Internet studies, which typically have attrition rates of 35
percent to 90 percent, but also lower than the 25 percent to 50
percent attrition rate seen in face-to-face psychotherapy.
Now Mohr is seeking ways to provide that supplemental social
support even more cost-effectively. One idea is to harness the
power of online social networks to increase people’s adherence to
Internet interventions by engineering in principles of what Mohr
calls “supportive accountability.” Say a person is supposed to log
in to the intervention a certain number of times. “If a patient’s
network of peers can see a patients’s goals and their log-in activity
and the patient values his or her peers, the patient will be more
likely to meet his or her log-in goals,” says Mohr.
In another line of research, Mohr and psychologist Albert
“Skip” Rizzo, PhD, of the University of Southern California
are exploring ways of creating computerized versions of
interpersonal interactions once thought to require the presence
of a live therapist. They are developing programmable virtual
humans with whom users can role-play interpersonal skills.
Existing solely online, these “online instantiations of humans”
could play the role of a therapist who helps users practice
assertiveness or other interpersonal skills in the safety of a
virtual environment, Mohr explains.
Mohr is also looking at how to make sure each individual
gets the right treatment. “The effects are reasonable for Internet
treatment, but probably not as strong as face-to-face therapy,”
he says. “While we got large results in our trial, it was an initial
field trial, and those typically have larger effects.” A 2009
meta-analysis of Internet interventions published in Cognitive
Behaviour Therapy showed smaller result sizes, he points out.
As a result, Mohr says, psychologists might use Internet-based interventions for clients who respond to them and save
more intensive and costly face-to-face or over-the-phone
psychotherapy for those who do not.
Some people may not need the minimal contact such
interventions involve but can instead help themselves, says T.
Mark Harwood, PhD, a private practitioner in West Chicago
and co-author of “Self-Help in Mental Health: A Critical
Review” (2010, Springer).
Self-help includes books, 12-step programs, online support
groups, Internet-based programs and the like. While these
approaches can be part of or even the main focus of therapy,
they can also be used on their own by people whose problems
aren’t severe. (Self-help isn’t for everyone, Harwood emphasizes,
which is why he recommends that would-be self-help users seek
an evaluation from a therapist first to make sure they’re good
candidates for a primarily solo self-help approach.)
Of course, there are some approaches with no empirical
support behind them, either because the evidence doesn’t
support them or because they simply haven’t been studied
yet. But, Harwood says, there is ample evidence indicating
that some self-help approaches can be as effective as therapy
itself. He cites as an example a 2008 study in Acta Psychiatrica
Scandinavica that found that a self-help approach called
cognitive self-therapy was not only as effective as therapist-administered treatment but much more cost-effective.
Still, there’s some resistance to self-help approaches among
psychologists, says Harwood. He doesn’t think that should be
the case. After all, he says, in addition to helping individuals
working on their own, self-help can demystify and destigmatize
psychological interventions. That may make working with an
expert more palatable should the need arise in the future, he says.
One organization that’s already embracing alternatives
to traditional psychotherapy is the Department of Veterans
Affairs. Faced with a flood of service men and women
returning from Iraq and Afghanistan — an estimated one third
or more with mental health problems — the nation’s largest
health-care system is using all sorts of innovative strategies for
getting evidence-based treatment to veterans. These include
assessment and treatment via videoconferencing, self-help via
smartphone technology and the use of lay people like fellow
veterans to deliver care.
Such options allow access to care to patients who live too far
away from VA facilities and give veterans a choice about how to
access care, says Associate Director Denise M. Sloan, PhD, of the
Behavioral Science Division at the National Center for PTSD
at the VA Boston Healthcare System. These alternative options
can help patients overcome concerns about confidentiality and
the stigma associated with seeking help that are prevalent in the
military culture. And these strategies have the potential to deliver
services to large numbers of people quickly and efficiently.
“The more options, the more people you can reach,” says
Kazdin shares his vision
To watch a video of Dr. Alan Kazdin
discussing his take on how psychologists
need to retool their research, education and
training to reach those in need, visit our
digital edition at www.apa.org/monitor/