By Samantha Denefrio, PhD
Background: Cognitive behavioral therapy (CBT) is a therapist-guided process by which an individual is asked to identify and then challenge their core beliefs about themselves, the world, and their future (Hoffmann, Asmundson, and Beck, 2013).
Developed by Dr. Aaron Beck, the theory behind CBT is that psychological distress can often be attributed to faulty thoughts that lead to disruptive behaviors. If a person can learn to recognize these troublesome thoughts, they can work to correct them and to adjust their behavior. Over time, these thoughts can be re-trained into healthier and more adaptive thinking patterns.
It is one of the most studied and empirically-validated methods of psychological intervention and therefore considered to be the gold-standard in the field of mental health (David, Crisetea, and Hoffmann, 2018). CBT is systematic with a standard protocol that requires regular visits typically over 10 to 20 weeks with targeted homework assignments each week (https://beckinstitute.org). This means that CBT is a significant time commitment for the patient and fitting in all necessary appointments during the therapist’s office hours may be a barrier to treatment.
Technology: With the advent of virtual medicine and health technology mobile applications, electronically-delivered CBT has become a growing and popular modality. CBT delivered in this way is guided by an experienced therapist and communication can be through a range of technologies such as video chat, text messaging, encrypted emails, and video tutorials.
When compared directly to traditional face-to- face delivery in a recent meta-analysis including 13 studies, both methods were proven to be equally effective at reducing psychological symptoms (Andersson et al., 2014) and significantly better than control conditions at reducing anxiety (Firth et al., 2017). In rural and remote areas where access to mental health counseling is limited, CBT delivered via telemedicine has significantly reduced symptoms of anxiety and depression (Griffiths, Blignault & Yellowlees, 2006). It has also been used as a successful supplement to enhance the effects of in-person therapy when part of treatment protocol (Lindner et al., 2014).
Population: Electronically-delivered CBT has been tried and proven successful in both children and adult populations, and across the full spectrum of psychological disorders included but not limited to social anxiety, depression, post-traumatic stress disorder, and eating disorders, and specific phobias (i.e., Ebert et al., 2015; Ye et al., 2014; Josephine etl., 2017; Juarascio et al., 2015; Dagöö et al., 2014).
One example, PTSD Coach is an app developed by the VA that has over 100,000 downloads, was tested in a group of trauma survivors for feasibility and found to have favorable reviews and modest effects on symptom reduction (Miner et al., 2016).
In a second example, one review of several studies using internet-based CBT to treat adults with insomnia found improvements in both sleep duration and quality in addition to less depression when compared to control conditions but not to in-person therapy (Seyffert et al., 2016).
In fact, the benefits of technology are not only specific to CBT, recent meta-analyses have shown that the benefits of multiple forms of therapy were improved when supplemented with mobile interventions (Lindhiem et al., 2015) and that smartphone applications significantly reduced depressive symptoms (Firth et al., 2017).
Conclusions: Taken together, these studies suggest that internet and/or video based CBT is a promising and effective option with the potential to reach larger numbers of people by reducing costs and increasing accessibility. Although, more research is needed to improve feasibility, delivery, and ensure high quality standards.
Keywords: CBT, smartphone, mobile technology, anxiety, depression
Key Learning Points
Search Methods: Articles were extracted from Google Scholar with results ranging from 2006 to present date and using the following search terms: “CBT and telemedicine”, “CBT and smartphone”,” CBT smartphone meta-analysis”, “what is CBT”.
Andersson, G., Cuijpers, P., Carlbring, P., Riper, H., & Hedman, E. (2014). Guided Internet‐based vs. face‐to‐face cognitive behavior therapy for psychiatric and somatic disorders: a systematic review and meta‐analysis. World Psychiatry, 13(3), 288-295.
David, D., Cristea, I., & Hofmann, S. G. (2018). Why cognitive behavioral therapy is the current gold standard of psychotherapy. Frontiers in psychiatry, 9, 4.
Dagöö, J., Asplund, R. P., Bsenko, H. A., Hjerling, S., Holmberg, A., Westh, S., … & Andersson, G. (2014). Cognitive behavior therapy versus interpersonal psychotherapy for social anxiety disorder delivered via smartphone and computer: A randomized controlled trial. Journal of anxiety disorders, 28(4), 410-417.
Ebert, D. D., Zarski, A. C., Christensen, H., Stikkelbroek, Y., Cuijpers, P., Berking, M., & Riper, H. (2015). Internet and computer-based cognitive behavioral therapy for anxiety and depression in youth: a meta-analysis of randomized controlled outcome trials. PloS one, 10(3), e0119895.
Firth, J., Torous, J., Nicholas, J., Carney, R., Rosenbaum, S., & Sarris, J. (2017). Can smartphone mental health interventions reduce symptoms of anxiety? A meta-analysis of randomized controlled trials. Journal of affective disorders, 218, 15-22.
Firth, J., Torous, J., Nicholas, J., Carney, R., Pratap, A., Rosenbaum, S., & Sarris, J. (2017). The efficacy of smartphone‐based mental health interventions for depressive symptoms: a meta‐analysis of randomized controlled trials. World Psychiatry, 16(3), 287-298.
Griffiths, L., Blignault, I., & Yellowlees, P. (2006). Telemedicine as a means of delivering cognitive-behavioural therapy to rural and remote mental health clients. Journal of Telemedicine and Telecare, 12(3), 136-140.
Hofmann, S. G., Asmundson, G. J., & Beck, A. T. (2013). The science of cognitive therapy. Behavior therapy, 44(2), 199-212.
Josephine, K., Josefine, L., Philipp, D., David, E., & Harald, B. (2017). Internet-and mobile-based depression interventions for people with diagnosed depression: a systematic review and meta-analysis. Journal of affective disorders, 223, 28-40.
Juarascio, A. S., Goldstein, S. P., Manasse, S. M., Forman, E. M., & Butryn, M. L. (2015). Perceptions of the feasibility and acceptability of a smartphone application for the treatment of binge eating disorders: Qualitative feedback from a user population and clinicians. International journal of medical informatics, 84(10), 808-816.
Lindhiem, O., Bennett, C. B., Rosen, D., & Silk, J. (2015). Mobile technology boosts the effectiveness of psychotherapy and behavioral interventions: a meta-analysis. Behavior modification, 39(6), 785-804.
Lindner, P., Ivanova, E., Ly, K. H., Andersson, G., & Carlbring, P. (2013). Guided and unguided CBT for social anxiety disorder and/or panic disorder via the Internet and a smartphone application: study protocol for a randomised controlled trial. Trials, 14(1), 437.
Miner, A., Kuhn, E., Hoffman, J. E., Owen, J. E., Ruzek, J. I., & Taylor, C. B. (2016). Feasibility, acceptability, and potential efficacy of the PTSD Coach app: A pilot randomized controlled trial with community trauma survivors. Psychological Trauma: Theory, Research, Practice, and Policy, 8(3), 384.
Seyffert, M., Lagisetty, P., Landgraf, J., Chopra, V., Pfeiffer, P. N., Conte, M. L., & Rogers, M. A. (2016). Internet-delivered cognitive behavioral therapy to treat insomnia: a systematic review and meta-analysis. PLoS One, 11(2), e0149139.
Ye, X., Bapuji, S. B., Winters, S. E., Struthers, A., Raynard, M., Metge, C., … & Sutherland, K. (2014). Effectiveness of internet-based interventions for children, youth, and young adults with anxiety and/or depression: a systematic review and meta-analysis. BMC health services research, 14(1), 313.