Apps can put therapy in the palm of your hand. But what happens when they go haywire?
Spencer Greenberg and Eddie Liu just want to help people. “Both Eddie and I, we want to alleviate as much suffering as possible,” Greenberg said. “That’s both of our life’s mission.”
The suffering they’re targeting is mental health disorders, specifically depression. Greenberg is the founder and Liu is the CEO of UpLift Health Inc., a company that designs mental health apps. It’s a small, newish company: Their app, UpLift for Depression, debuted at the end of last year on the Apple App Store.
Its icon is a bright yellow sun peeking up through blue-outlined clouds. It’s billed as a proven program of cognitive behavioral therapy, which is itself perhaps the most effective and popular psychotherapy of the last 40 years.
The app itself is free but the program — 11 interactive sessions of around 45 minutes each — is $29.99 a month. The sessions were modified from existing cognitive behavioral therapy programs, giving users directed tasks and a “tool kit” to manage their thoughts. So far, they said, they’ve had a few hundred users, and they have a four-star rating in the App Store. Even more impressive is their evidence — in a pilot study of 80 UpLift users, those who kept with the program for a month saw a 50 percent reduction in their depression scores.
“We wanted to bring together the most effective techniques that we can find and package them in the best format we can. Bringing it into an app means [users] have in their pocket, they have it on the go,” said Greenberg. “There’s something really powerful to having that in your pocket.”
This, the therapist in your pocket, could be the future of mental health, a way to offer millions of underserved people access to mental health care at a fraction of the usual cost. And it has the potential to vastly expand the reach of cognitive behavioral therapy, a proven alternative to drugs. But cognitive behavioral therapy, like all therapies, can have side effects, some of them quite serious. And apps could vastly expand their reach — as well give rise to new ones we’ve never considered.
Right now, these apps live in a largely unregulated marketplace, where users self-treat away from the watchful eye of a therapist. So what happens if something goes wrong?
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FIRST PIONEERED in the 1960s by psychiatrist Dr. Aaron T. Beck, cognitive behavioral therapy is intended to make clear the link between thoughts and behaviors, and to show individuals how to disrupt harmful thought patterns. It’s gained traction among practitioners and patients as an effective, evidence-based, lasting therapy that doesn’t rely on psychotropic drugs, against a backdrop of increasing concerns about medication. It’s easy to train practitioners in how to do it; it’s easy to guide clients through using it; it has definable actions and measurable outcomes, and an appealing problem-solving ethos. It is often the first line of treatment for a host of mental health disorders, including post-traumatic stress disorder, anxiety, obsessive-compulsive disorder, and depression. It comes with a “strongly recommended” label from the American Psychiatric Association.
And it works — there is now substantial evidence that cognitive behavioral therapy is as effective, if not more so, than drug interventions, and can be very powerful when combined with medication. Christian Jarrett, a cognitive neuroscientist and editor of the British Psychological Society’s Research Digest, described the therapy in an article as having “revolutionized mental health care, allowing psychologists to alchemize therapy from an art into a science.” In an e-mail, he explained that one of its strengths is that it is “more formulaic” than other forms of psychotherapy, making it easier to study and optimize its effectiveness.
This focus on a reliable formula makes cognitive behavioral therapy a kind of app-maker’s dream. The way the therapy works lends itself very well to how apps work. Marrying cognitive behavioral therapy to modernity’s defining accessory, the smartphone, seems not only logical but inevitable.
But a lot of people — even therapists themselves — don’t realize that cognitive behavioral therapy can have side effects.
“There is a widespread belief that undergoing psychotherapy is worth a try. After all, [people think,] ‘It can’t do any harm,’” Jarrett said via e-mail. That assumption is wrong: Jarrett pointed to an article he wrote for the British Psychological Society’s journal in 2008, in which he noted that, on average, 10 percent of clients find their symptoms worsen through therapy. What was more surprising was that a 2006 survey of practicing psychologists in America found that 28 percent of them were unaware of the negative effects of psychotherapy. Even more recently, a 2014 study found that, though clinical trials of psychopharmacological medications considered the possibility of adverse side effects 100 percent of the time, similar trials of widely used psychotherapies, including cognitive behavioral therapy, considered adverse side effects only 60 percent of the time.
Michael Linden is a German psychotherapist and author of several papers exploring the adverse side effects of psychotherapy. In June 2018, he and his colleagues published a paper in Cognitive Therapy and Research exploring the side effects of cognitive behavioral therapy. They interviewed 100 German cognitive behavioral therapists about the incidence of negative side effects among their patients.
The results were, at least to individuals not versed in psychotherapy’s potential side effects, surprising: 43 percent of clients had experienced at least one unwanted side effect as a result of cognitive behavioral therapy, 21 percent rating their side effects as “severe” or “very severe.” These included increased distress, worsening symptoms, and stressed relationships, and were sometimes accompanied by suicidality, feelings of shame or guilt, and intensive crying.
“This is really the reality: Whatever you do in psychotherapy has side effects,” explained Linden. “This starts already when you start to talk to the patients. Psychotherapy starts with making patients unhappy.” Crucially, he says, he’s defining side effects as “negative effects caused by psychotherapy and, more importantly, appropriate psychotherapy” — that is, side effects not caused by malpractice or the misapplication of the therapy.
“Good therapists have side effects and know their side effects,” says Linden. “If a therapist thinks he has no side effects, he’s a bad therapist.”
But Linden’s research points to a large, somewhat muddled area in the science of psychology and psychiatry: What constitutes a side effect? In pharmacology, a side effect is an effect of the medication that is secondary to the medication, whether that’s adverse or beneficial or neither. It’s the outcome that wasn’t intended, but happens as a result of the treatment. But this is psychotherapy — what if the side effect is part of the treatment?
Psychologist Judith Beck, director of the Beck Institute, grew up with cognitive behavioral therapy. Her father, Dr. Aaron Beck, is the founder of the therapy. She says that cognitive behavioral therapy has “no side effects the way that medication has side effects,” but also that some, such as increased anxiety, can be a part of the process. For example, asking a patient who suffers from social anxiety to have a conversation with an officemate can increase their anxiety, but it’s essential to showing the individual that really, there’s nothing inherently dangerous or fearful about social interactions. “We need to get them to expose themselves to what they fear,” she explained. “We need to heighten the anxiety so that they can find out that actually it’s tolerable and they certainly can handle it.” That can be unpleasant. It can even be a side effect. But it’s also part of why cognitive behavioral therapy works. It’s the job of the therapist to mitigate and help manage those effects.
Which brings us back to UpLift and other mental health apps like it: In the absence of an actual person, a therapist to guide the client through the process, what then? If good therapists know that their treatment has side effects, can good apps?
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YES AND no. UpLift, for example, is designed to clock when a user’s mood is deteriorating and to potentially connect them with additional services. Other apps marry cognitive behavioral therapy sessions to text-based interactions with actual therapists; still others rely on artificial-intelligence chat bots to adapt to a user’s changing mood. But not all mental health apps come equipped with that facility, and some leave it in the hands of the user to monitor whether they need additional help.
At the same time, we don’t even know what kind of side effects we’re looking for. Some that accompany app-based cognitive behavioral therapy may be the same kind that accompany in-person therapy, but there are also likely new, unconsidered ones. And right now, the wave of mental health apps claiming to use cognitive behavioral therapy flooding the marketplace is swamping actual research.
One largely unexplored concern: how the apps’ delivery device, the smartphone, might aggravate or even create side effects. That’s a point raised by licensed clinical psychologists Drew Erhardt of Pepperdine University, and Edrick Dorian, the makers of MoodKit, an extremely popular cognitive behavioral therapy-based app. MoodKit provides “a suite of integrated tools aimed at helping users track their moods, identify and change unhealthy thinking habits, journal for self-discovery, and engage in a variety of mood improving activities,” they wrote in an e-mailed statement. Hundreds of thousands of people have used it, and its App Store rating is 4.5 stars; it, like UpLift, has also seen positive results in pilot studies.
However, describing the question of side effects from app-delivered cognitive behavioral therapy as “interesting, important, and complex,” Dorian and Erhardt said in their statement that adverse effects could come “from the very use of mobile apps as a modality through which to deliver mental health interventions (e.g., impaired sleep due to using the app at bedtime).” The apps, they continued, could add “to the already excessive time many of us already spend on our devices as opposed to engaging with other people or in healthy ‘unplugged’ activities.”
Other side effects might be related to the quality of the app itself. There are certainly some pretty egregious examples; for example, a 2015 Australian study assessing the availability and quality of apps for bipolar disorder found one app directing users to take a “shot of hard liquor” before bed to help them sleep during a manic episode. Another app claimed that bipolar disorder was “contagious” and “can transfer to another relative if they spend too much time with you and listen to your depressive life.” Ineffective apps might leave users feeling like they’ve wasted their time, or that they can’t be helped.
Some psychiatrists and psychotherapists have described the mental health marketplace as a kind of “Wild West,” a description that Dorian and Erhardt don’t dispute. “The proliferation of mental health apps is far outpacing efforts to adequately study their effects, both good and bad, and to evaluate or even regulate them on the basis of safety and effectiveness,” they wrote, noting that the FDA has taken a “hands-off” approach to regulating them. “This results in a landscape where clinicians and individuals are faced with a dizzying number of apps . . . with few options for adequately determining which are likely to be safe and useful and which might be poorly designed, unhelpful, or even dangerous.”
There have been some efforts to tame this landscape. In 2015, Dr. John Torous, a psychiatrist and director of the digital psychiatry division of Beth Israel Deaconess Medical Center, was asked to chair the American Psychiatric Association’s working group on app evaluation. One of the primary goals of the group, he said, was to establish criteria by which mental health professionals and patients could assess individual apps. Though Torous believes that apps have a “bright future,” he doesn’t believe they’re “ready for routine care,” nor does he see them yet having the impact they could. Despite the availability of thousands of mental wellness apps, he said, “we haven’t seen global mental health improve.”
If efficacy is a concern, so is privacy. In 2015, Britain’s National Health Service shut down its curated mental health app library after researchers determined that not only were many of the apps not scientifically supported, but several also sent users’ unencrypted private data over the Internet. Torous added that because most of these apps disclaim themselves from actually offering mental health treatment —
maintaining that they’re offering self-help, rather than therapy — they’re not covered by US patient confidentiality laws and could be selling data. “I often tell my patients, ‘The price of a free app is likely you,’” he said.
Then there’s the question of exactly what these apps are offering. Both UpLift and MoodKit come with the caveat that the programs are not substitutes for treatment from licensed mental health professionals. That disclaimer, however, substantially reduces the amount of responsibility app makers assume, Torous said. Because they insist they’re not delivering therapy, even though “reasonable consumers think they’re getting psychiatric treatment or intervention,” many have decided they don’t need to communicate the possibility of negative side effects.
UpLift and MoodKit do, but they certainly don’t have to — no one is making them. The makers of MoodKit and UpLift both agreed that more oversight of the apps could be useful, although Greenberg cautioned that overzealous regulation may impede innovation.
At the moment, there’s no consensus about how a cognitive behavioral therapy app should work — or even about what constitutes cognitive behavior therapy for the purposes of an app. That lack of definition concerns some experts.
“Both patients and clinicians would like there to be a little more certainty, evidence, and order in this space,” Torous said, adding that mental health apps are risking becoming like herbal supplements — potentially helpful, but also dogged by a lot of false advertising and hype. The fact that most of the evidence in support of app effectiveness comes from pilot studies, typically enrolling motivated people, undercuts its strength, he argued.
This is bad for patients, but it could also be bad for the mental health app space itself. “I think it would be a shame to see this digital mental health space fall, or miss out on an opportunity to deliver real mental health help to people, because there’s so much sleight of hand and marketing,” said Torous.
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WHEN SIGMUND Freud — father of modern talk therapy — unveiled psychoanalysis in the early 20th century, he couldn’t have imagined that a little over 100 years later, the couch you’d be lying on would be your own and your therapist would be an AI chat bot. Or that you’d be texting your therapist from your work desk in between bites of your lunch. Or that you’d earn “points” for completing therapy “tasks,” while your phone delivers cheery, buzzy reminders to fill out your “mood journal” four times a day. But neither did he know then, in a data-backed way, what kind of side effects psychotherapy — “just talking” — could have. We are now in a position to know better.
We know now that any treatment robust enough to have a positive effect has a potential to have a negative effect, too. We also know that new technology is subject to the law of unintended consequences. Digital mental health could transform how we treat people — just as long as we remember that it can do harm.
Linda Rodriguez McRobbie is an American freelance writer living in London.