Research suggests that only 11 percent of individuals with anxiety disorders in the United States will seek care with a licensed provider within one year of experiencing symptoms. Further, the average delay of seeking treatment, among those who do finally seek it, is 23 years1. The many complex reasons for not seeking care include cost, access, time, stigma, as well cultural beliefs about mental health problems and healing processes, and the gap between need and use of mental health care remains wide. How can researchers and health care providers enhance access to quality mental health care and bridge this gap?
One Path to More Care
A potential pathway to reducing barriers to care is to utilize technology (such as smart phones, videoconferencing, and texting) to deliver psychotherapy. In the past several years, there has been an explosion of research on integrating technology into delivering evidence-based treatments for anxiety and mood disorders to increase access and flexibility for consumers2. But is this approach palatable to consumers? Recent evidence from a college student sample suggests that roughly 16 percent of respondents would be highly receptive to this approach to therapy3. However, less is known about attitudes toward online-assisted therapy in other demographic groups, such as middle-age and older adults and people without higher education. Another question: Do these treatments work?
Treatment by Internet
One recent study led by Dr. Sherry Benton examined the effectiveness of Therapist-Assisted Online, or TAO, a seven-week individualized treatment for anxiety delivered over the internet. TAO integrates brief therapist contact through videoconferencing. This online platform delivers psychoeducation about anxiety, text messaging, homework assignments, and weekly progress and symptom measures4.
The TAO sessions are centered on evidence-based principles from cognitive-behavioral and acceptance-based behavioral therapies and focus on self-monitoring of anxiety, relaxation skills, cognitive restructuring, mindfulness, and health behaviors (for example, exercise and sleep hygiene). Clients have a weekly brief videoconference with their therapist; and on the TAO online platform they review interactive online learning modules focused on the development of specific skills (relaxation or mindfulness); complete their assigned homework; and monitor their progress and symptoms .
Some Promising Results
Dr. Benton and colleagues compared the effectiveness of TAO to a “treatment as usual” condition (traditional in-person psychotherapy) in a large student sample. They compared the anxiety, life functioning, and well-being of a group of 72 students receiving TAO to the treatment as usual condition with a sample of 1,129 students at a university counseling center. Results indicated that the TAO condition performed significantly better in reducing anxiety and increasing well-being across the seven weeks of treatment. Both groups improved in all areas, but the TAO condition improved at a slightly higher level than treatment as usual.
More Answers Needed
These findings provide promising preliminary evidence for using TAO to treat moderate anxiety in a tech-savvy undergraduate population. However, some important questions and areas remain for future research. Most notably, the researchers do not detail what exactly the “treatment as usual” condition included. Were client sessions focused on same content delivered in TAO, or was treatment as usual more flexible? Also, was homework assigned at regular and consistent intervals as in the TAO condition? This study leaves the reader wondering: What exactly did they compare this intervention to?
Future research will require stricter comparison groups to determine with higher confidence if TAO is significantly better than traditional therapy, as well as if text messaging and other types of technology might have the same benefit when added to in-person therapy. In addition, results may be different with non-students or older clients. Finally, the measure used to assess anxiety and well-being outcomes is not a diagnostic measure, so from this data, we do not know how clinically or practically meaningful the changes observed are.
What About the Future?
This study does beg the question: Are online therapies the future? What is the future for traditional psychotherapy, given that evidence suggests most consumers still prefer it? The authors are very careful to note that the goal of TAO and other similar interventions is not to replace traditional psychotherapy. The goal is to provide more options when in-person therapy is not logistically, practically, or financially viable. It may be useful when clients in mild distress are not in need formal psychotherapy, but still could benefit from evidence-based care. TAO and other such interventions may be a helpful first line of support, while reserving in-person psychotherapy for clients in greater psychological distress or with more severe mental health problems.
In this rapidly evolving field, it’s likely that in a few more years, many additional advances will change the landscape of how evidence-based mental health care is delivered.
1. Wang, P. S., Berglund, P., Olfson, M., Pincus, H. A., Wells, K. B., & Kessler, R. C. (2005). Failure and Delay in Initial Treatment Contact After First Onset of Mental Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, 62(6), 603-613. doi:10.1001/archpsyc.62.6.603
2. Berger, T., Caspar, F., Richardson, R., Kneubühler, B., Sutter, D., & Andersson, G. (2011). Internet-based treatment of social phobia: A randomized controlled trial comparing unguided with two types of guided self-help. Behaviour Research and Therapy, 49(3), 158-169. doi:10.1016/j.brat.2010.12.007
3. Travers, M. F., & Benton, S. A. (2014). The acceptability of therapist- assisted, internet-delivered treatment for college students. Journal of College Student Psychotherapy, 28, 35–46. http://dx.doi.org/10.1080/ 87568225.2014.854676
4. Benton, S. A., Heesacker, M., Snowden, S. J., & Lee, G. (2016). Therapist-assisted, online (TAO) intervention for anxiety in college students: TAO outperformed treatment as usual. Professional Psychology: Research and Practice, 47(5), 363-371. doi:10.1037/pro0000097
Sarah Krill Williston is a PhD Candidate at the University of Massachusetts Boston, working in the Roemer lab. Her research centers on boosting mental health literacy and reducing stigma to encourage evidence-based care-seeking for anxiety and trauma-related disorders. Sarah specializes in offering evidence-based treatments like CBT and ABBT to individuals, particularly military families, active duty service members, and veterans with mood, anxiety, and trauma-related disorders.