Tuesday, April 26, 2016

E-Mental Health

The whole issue of e-mental health induces quite a bit of resistance in me, which causes me to pause and reflect.

The issue perhaps represents, somehow, a threat to the way I like to practice psychiatry.  Therefore, I may be prone to some biases, and simple resistance to change.

On the one hand, I love gadgetry, and I love technological innovation.  But I also love to practice psychiatry in a way which does not require any gadgetry of any sort.  I like, quite simply, to see my patients regularly, in person.  I am averse to a system which would make this type of practice less possible. 

There is no personal financial reason why e-mental health would need to be opposed.  Seeing patients in person, for an hour at a time, is financially disfavoured in the current system.   E-mental health certainly does not need to pose any threat to the financial well-being of therapists.   It may actually facilitate higher earnings for many therapists. In fact, if anything, there may be a bias towards using more e-mental health, as a therapist may be able to offer these types of services in a zero overhead environment, to large numbers of clients, therefore maximizing financial profit.

I have thought that various e-mental health resources are "impersonal," but I realize that I may need to be a bit more open-minded about this.  I am reminded of my own experience in university, many years ago:

I can think of many examples of courses I took in university, even in medical school, in which attending the lectures was not effective for good learning.  It was often a passive activity, involving a struggle to stay awake;  many professors may have been great experts in their fields, but were not effective, dynamic, or interesting teachers.  It would have been better for my learning to have skipped the lecture and just spent the time reading on my own.   Maybe in-person psychotherapy can be like this, in some cases.  

Nowadays, students often have opportunities to take courses entirely online.  Also, many teaching resources, such as lectures (including those done at famous universities) are available online.  While taking a course online could be less "personal" in many ways, it is not necessarily so.  Personal interaction with a professor or classmates may in some cases be easier online than in an in-person lecture.   It is only the medium which is different.

For many types of psychotherapy, there can be a sort of "curriculum" akin to the material presented in a university course.  This is especially true in CBT (cognitive-behavioural therapy).   In many cases, structured self-learning, possibly with an on-line "curriculum," could be more effective, engaging, and enjoyable than attending in-person appointments.

What are the variables that might determine this?  Individual factors relating to personal needs are obviously relevant here--in many cases of depression or anxiety, it is the CBT-like "curriculum" which is the most important element to be mastered, in order to have relief of symptoms.  It may not necessarily be the case that these patients have a particular need for interpersonal care from a therapist, at least not in an in-person setting.   The optimal way, and even the most enjoyable way, for a person to benefit from this "curriculum" may, just like a student in a university course, be through taking a "CBT course" online.   But, of course, in many cases, the "curriculum" does not really matter so much as the "therapeutic alliance" or the personal experience in a therapy setting. 

Another variable is the therapist's personal style.  This reminds me, once again, of professors I took university courses with long ago.  In some cases, the courses were wonderful, meaningful, engaging, energetic, and delightful experiences, with a professor who was full of love for the subject, enthusiasm, and personal care for the students.   This made the course a joy to attend, even if the subject matter might have been approachable in an on-line or indirect fashion.  

I suspect a similar dynamic can occur in therapy--in order for a one-on-one therapy experience to be worthwhile, or superior to an on-line substitute, there would have to be a meaningful engagement with a therapist, whose style would suit the patient's interest, and kindle the patient's motivations.

Unfortunately, in today's therapy environment, personal sessions are often in short supply.  Courses of therapy are often very time-limited.   There is often, as a result, an excessive focus on simple, trite therapeutic advice, with very little time allowed to form an ongoing therapeutic connection.  If this form of therapeutic encounter is compared with a computer app, I am not surprised that the app has similar effectiveness!  I do see that this type of simple, brief, limited therapeutic encounter is indeed helpful for many people (e.g. with stress-related anxiety or mild, transient depression), but I also see that such an encounter would be very frustrating and ineffectual for many who have a more complex or difficult psychological history.     

Here are some other dynamics to watch for:

1) "the Christmas gift effect."  Sometimes, parents will buy expensive gifts for their children, during the Christmas season.  These parents may not have had much time for the children during the year, and indeed the children may well have been asking for various expensive toys or gadgets.  The expensive gifts are appreciated excitedly -- but they don't really help the children feel better!  They are just more "stuff," and may even condition the children to become more materialistic.   What the children may really desire is to have parents who spend more time with them, attending to them, playing with them, and caring for them.  They don't really want gadgets -- they want care and love.  But in the absence of the care and attention, the children may only identify a wish for more presents or gadgets.  This is what Kahneman might call "miswanting," a distortion of identified desire caused by short-term materialistic reflexes, while longer term substantive needs are unmet.

I am concerned that various examples of e-mental health are a bit like expensive Christmas gift gadgetry.  Everyone is excited about it (not least the vendors who are selling the electronics required for it, or the researchers clamoring to publish journal articles about it), but in the midst of the fray, it may not be noticed that even less time, care, and attention is spent actually caring for patients directly.  More time in front of computer screens, less time in front of other people. 

2) The "curriculum" benefits of e-mental health could be obtained in a variety of other trivial ways.  If CBT curricula were widely available online already (which is ever more the case) or if they were introduced as health care programs during childhood, etc., then e-mental health curricula may have much less measurable impact.  It would be like taking the same university course (which you already passed) a second time.  For this cohort, a more direct, personalized form of care may be even more important.

3) Hidden costs.  While e-mental health ideas may indeed be effective in many situations, or may be equal in some measure of effectiveness to other established treatments, there could be hidden problems.  For example, suppose a cohort of therapists who love providing personalized, direct therapeutic care are compelled to spend their time supervising e-mental health activities (for example, sitting alone in an office, in front of a computer screen) for an expanding proportion of their time.  In this case, perhaps an equal (or greater) number of patients or clients could be seen and helped.  But--those individual clients who would have benefited most by seeing someone in person would not have been seen and helped, because the therapist was sitting in front of a computer screen instead!

Another hidden problem is the detriment to morale caused by compelling people to spend even more time in front of a computer screen, instead of in front of an actual person. An effective psychotherapist (or teacher, or musician, or worker of any type) is one who feels joy and passion and excitement and personal connection for the work. Imagine seeing a therapist or a teacher who appears disconnected, distant, or absorbed with an electronic gadget instead of with a person!   If joy of personal connection is deprived, through the use of supposedly efficient technology, then the effectiveness of the entire system is at risk. 

Furthermore, there could be a selection bias evolving in a therapists' population if this trend continues, favouring those who can tolerate more impersonal interactions as a norm.  Those who are most comfortable with simple personal connection, and less comfortable with technology, may feel more and more uncomfortable with entering into a therapy profession at all.   Yet, those with the highest comfort for personal connection are arguably the most valuable and talented therapists! 

The Golden Rule Question:

In trying to sort out this issue, I think we could ask ourselves a type of "Golden Rule" question:  if it was you yourself, or if it was your partner, your spouse, your mother,  your child, or your closest friend, who needed help for managing serious anxiety, depression, or some other psychological distress--how would you feel about an electronic resource being offered instead of a one-on-one therapist?

As I ask myself this question, I think that it ought not to be either/or.  I suspect, for me, that I would appreciate using various electronic resources.  And I suspect, for me, that it would also depend on the therapist who was available:  would I like that person?  Would that person seem compatible?  Would that person have the time and the  commitment to offer the help needed (possibly over a long period of time)?

If I was told that the use of e-mental health modalities would reduce the total amount of direct in-person time available for clients or patients, this might further demote my enthusiasm for them.  

In a system which is already failing to attend to providing adequate personalized care, I would be worried about a strategy in which even more time, money, and attention was given to a gadget, rather than to a human relationship.   The consequences of such movement away from personalized care affect not only clients or patients, but also the morale and health of the therapist community, and arguably the health of society as a whole. 

But, if e-mental health simply expanded the accessibility of therapy, allowed people trapped at home or in remote locations to access care, allowed playful educational engagement, while still allowing clients and therapists to have direct, personal time in a therapeutic framework, then I think this technology could be embraced in a way which is healthy for all.  

In subsequent posts on this subject, I would like to survey some of the literature on this.  Much of the recent literature is very positive and enthusiastic about e-mental health.  While I am curious, and am sometimes delighted, by some of the ideas, I am also wary about the lack of consideration for the issues described above.  There is a long history in psychiatry, and in medicine generally, of big enthusiastic trends of practice, sometimes following political motives, leading in retrospect to regrettable decrements in care.