Therapists have long consulted books like “The Heart and Soul of Change” to understand what works best in psychotherapy. Clinicians debate this basic question and use research, supervision and other ways to improve their skills. Yet we now have an assortment of digital tools for getting similar results. Was heart and soul unnecessary? Will a few therapeutic exercises lead to the same changes?
These questions concern me not only as a clinician, but also as someone who has consulted with digital health companies in recent years. These products are quite varied, and they can range from engaging and interactive clinical content in a digital format to real interactions with skilled people (licensed or not) in virtual formats like text, email, and phone or video conversations.
Investors have a bullish view of these products. Their benefits are clear-cut, despite some differences among them. They range in cost, but all are lower than face-to-face therapy, and they all improve much-needed access to clinical services. Each company cites published, peer-reviewed articles that show their clinical results to be similar to in-person services.
The actual comparability of these results will be unraveled by research over time. In any case, the comparison of group outcomes is only one test. It is not necessarily the most important clinical question. Whatever those analyses show, the replacement of therapy is not the goal for digital products. They offer alternatives for gaps in care rather than the elimination of therapists.
Behavioral executives should clarify that perspective with a comprehensive framework. A simple one is based on the idea of a continuum of services. Products across this continuum produce clinical benefits at a specific cost. Lower cost services must have some clinical value. The service continuum offers different combinations of clinical benefits and economic costs.
At the same time, we should ask a key question. Is an intervention currently working for the person receiving care? Michael Lambert’s landmark research on psychotherapy highlights this question. Patient-focused research is the name for this domain, and it means measuring progress to enable timely adjustments for the best results for each person. This applies to digital services and to therapy.
Patients care more about their own clinical improvement than the average change for treatment groups. Lambert’s work flags those who are not progressing as expected. We should know when interventions are off track, whether people are using digital tools or working with a therapist. We should know when a change in the type or intensity of the work is needed. We can then improve outcomes, one by one.
Digital products address this need by building in automated clinical alerts for people using their services. They might also offer coaches or clinicians for guidance and support. Some behavioral healthcare administrators decide to reinforce digital products with clinical backup from their own programs. They should know how each person is responding and have clinical alternatives when the response is poor.
This person-centered focus is being muted by some digital companies overly focused on group results. In this regard, there is an alignment between researchers and corporate marketing departments. Both are primarily interested in the comparison of group results, while service providers have an abiding interest in individual results. We should all be aware of these preferences.
This is not a theoretical difference. It could drive the industry in the wrong direction. For example, one digital CBT company gained FDA approval for its product. This entails submitting clinical trial data rather than real-world data for product approval. This differentiates the product but solves a problem that does not exist. Evidence is overwhelming for CBT both in-person and online. Getting FDA approval is irrelevant.
What do we need from executives? We need the continuum of services offered by each company clearly defined. Each service can be categorized according to parameters of cost, accessibility, empirical validation, and adaptability to the needs of the individual. This takes us beyond the usual marketing spin. Executives should promote how their spectrum of services can support an entire population.
What do we need from clinicians? They have developed many of today’s digital products. Executives need to rely on clinicians as subject matter experts and as architects of clinical protocols for poor responders. Clinicians are increasingly realizing that digital tools are far more effective when someone guides people to the resources most relevant for them. Products are still evolving.
What do we need from innovators? We need products focused on the top concerns of executives. For example, we need products better designed to target and manage people with poor responses to care. By contrast, the tangible benefits from third-party endorsements are unclear. We need executives to be active in shaping digital solutions to meet urgent business needs. We do not need passive buyers.
Ed Jones, PhD, is senior vice president for the Institute for Health and Productivity Management.