Computer-based training for CBT

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Maureen Fitzgerald
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Computer-based training for CBT

Does technology offer a way to expand use of CBT? See:
http://journals.psychiatryonline.org/article.aspx?articleid=99969

Michael Reynolds
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Joined: 06/06/2014 - 09:00

Technology offers a lot to expand CBT. Managed care is also getting on board. Many are offering wellness programs and smoking cessation programs based in CBT. In my opinion, these programs need to have each participant assigned to a counselor in case additional support is needed. Because I still haven't figured out how to do drug testing online. If you want to keep up with the latest research on technology assisted treatment check out the following. http://construct.haifa.ac.il/~azy/azy.htm and http://www.career.fsu.edu/documents/bibliographies/Dist_Counseling_Bibli...

outreach1
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Joined: 06/06/2014 - 10:45

I feel there many valid benefits to assisting one's recovery online. SMART Recovery being the first to come to mind. There are many exercises, assignments and literature that clients have access to. One of the problems is technology usually takes out the "We" and recovery can become an isolating experience.

jengoodwin
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Joined: 06/06/2014 - 12:03

I have not explored the SMART Recovery website and was unaware that you could use online resources for recovery through it. Thanks for the info!.

MaryJ
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Joined: 09/17/2014 - 13:08

I agree that technology has advanced CBT with online recovery, but there a still a great number of people that need to help that do not have access to computer, so face-to-face is still the greatest aid to recovery. Most clients appreciate a more positive "face" guiding them to recovery.

MaryJ
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Joined: 09/17/2014 - 13:08

Thanks for the resources, this forum has been very informative, I will continue to view this site.

outreach1
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Joined: 06/06/2014 - 10:45

SMART has been a helpful alternative to 12 step because it relies on EBP's and technology. Face to face would still be my first choice.

outreach1
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Joined: 06/06/2014 - 10:45

I just received an e-mail of local job offers. One was for providing CBT online. I guess people have faith in it.

MaryJ
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Joined: 09/17/2014 - 13:08

I can understand the need for those in recovery but have a very active lifestyle that take them away from their recovery home group and support systems

Ashley Koning
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Joined: 06/08/2014 - 16:05

Kia ora The New Zealand Drug Foundation recently developed an online self help treatment programme for cannabis use disorders that is based on CBT principles and this may be of interest: https://www.pothelp.org.nz/

Maureen Fitzgerald
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Joined: 06/04/2014 - 10:33

Great comments! Here are some other views (recent posts from the ATTC/NIATx Service Improvement Blog):

http://attcniatx.blogspot.com/2014/04/alcohol-awareness-month-and-techno...
http://attcniatx.blogspot.com/search?updated-max=2014-04-02T14:45:00-07:...

michael boyle
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Joined: 03/06/2012 - 12:23

There are several computer delivered CBT treatments that have undergone clinical trials demonstrating effectiveness. One is the Therapeutic Education System (TES) developed by Lisa Marsch at Dartmouth. It can be licensed for organizational use. See link below that contains published studies. http://www.addictionpro.com/article/smartphones-be-used-aiding-treatment...

TES is being combined with the A-CHESS mobile phone recovery support system in a NIDA clinical trial. See article below. http://www.c4tbh.org/technology-in-action/program-reviews/substance-use-...

Drinker’s Checkup is a web based program that provides screening, brief intervention, and optional CBT based treatment for either abstinence or moderation: http://drinkerscheckup.com

Kathy Carroll at Yale has also developed a web based CBT treatment called CBT4CBT but I do not believe it is available commercially.

eachdayagift
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Joined: 08/04/2014 - 11:33

Thank you for sharing these resources!

Kathleen Carroll
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Joined: 09/02/2014 - 08:41

Hi Michael-This is Kathy Carroll. As we've now completed 2 independent clinical trials, both published in AM J Psychiatry, we are making CBT4CBT available on a commercial basis through clinical providers. Information on the studies, a demo of CBT4CBT and contact information is available at CBT4CBT.com

There will also be a ATTC Blending Product that will cover both TES and CBT4CBT, not sure when that is coming out.

jengoodwin
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Joined: 06/06/2014 - 12:03

I think this is a really interesting conversation. Does anyone have any direct experience with its effectiveness? Are there clinical indications for use or are they primarily logistcial?

outreach1
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Joined: 06/06/2014 - 10:45

I don't know. There are so many recovery and social skills that cannot be learned by sitting at the computer. I would be hesitant to rely solely on computer based treatment unless there are restrictions to the person having real social interaction such as some rural areas or being home bound. In this sense treatment can be like learning a new language. If there is nobody else to talk with you tend to forget it. Recovery skills need not only to be learned but utilized.

IntheSpiritof89
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Joined: 06/09/2014 - 16:11

Very helpful and interesting information/resources; keep it coming.

Thanks

mjellison
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Joined: 06/06/2014 - 16:39

I have seen some success with this in Tobacco treatment. There are a few Apps that are being utilized on smart phones. The good thing about these is that we have a generation of adolescents that are internet/iphone savy and this may be a good way to approach/attract this population. I feel that getting on board with CBT in this way will not only engage clients but set a precedent for future treatment, wonderful way to keep up with changing times.
Smoking APP FYI

QuitStart APP
NCI QuitPal App
Quit Guide@Smokefree.Gov
MyQuit Coach App
Craving to Quit App

Kathleen Carroll
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Joined: 09/02/2014 - 08:41

Hi-This is Kathleen Carroll-the developer of computer based CBT, or CBT4CBT. I'd be happy to field any questions about CBT4CBT, which has been shown in 2 trials published in the American Journal of Psychiatry to be effective and durable. You can see a demo and contact us through CBT4CBT.com.

Just to clarify, we only allow use of CBT4CBT as a tool to enhance retention and outcome--its a 'clinician extender', not a substitute. Its a 7-module, web-based program that teaches CBT skills in an engaging and effective way. .

kim johnson
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Kathy, I'm wondering about how programs that used CBT4CBT in your studies integrated it into their service array. Was it something that people complete at home or while they are in the clinician's office? How did programs integrate the modules into their routine practice? For example, is it designed as homework that is then reveiwed and discussed in a session? Also, more generally, how do you see these tools as enhancing clinician efforts and what has been the response of clinicians to using it? We have had varying responses from clinicians about using ICTs with patients so I am wondering if you have faced any barriers at the clinician level.

Kathleen Carroll
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Hi Kim-Thanks for your question. In the studies, it was evaluated as an add-on to the standard service array provided by the clinic. Clients generally did the modules at the clinic at the time of their weekly visits, but were free to do it at home if they had a computer or tablet set up. Clinics saw it as a way to provide one extra individual session of CBT to the clients. Clinicians who are CBT-focused often reviewed homework with the client, and some clinicians even went through the modules in group. We started this in 1992, and clinicians were a little skeptical at first, but the reactions we've gotten are very positive--clinicians see it as a way to enhance their relationship with the clients and give them 'more' in the limited time they have. A few have shared that they think its improved their own CBT skills. Clinicians who aren't very familiar with CBT for addiction really like it because the program helps them feel that they are addressing addiction-related problems in a positive appropriate way.

Thanks! Kathy

tw_telehealth
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Joined: 06/06/2014 - 09:34

Kathy, can your program be adjusted to provide a different "dosage" of treatment matched to the severity of disorder, with lower risk subjects getting less intensive treatment while more severe subjects receive more intensive or more frequent treatment?

Kathleen Carroll
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Yes, as its available 24/7 and the user decides how to use it--everything from the order of the modules, how fast or slow to go, what sections to repeat, and quizzes and exercises to practice. We usually do it over 8 weeks. Our first study took 'all comers' and did well with a wide range of severity. Our second study, in methadone maintenance, also did well with a more severe population with a higher level of psychiatric problems. Kathy

michael boyle
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Hello Dr. Carroll:

Thank you for participating in the ATTC Network of Practice. I have a couple questions regarding your CBT4CBT treatment approach.

What is the optimum role of a clinician in implementing the CBT4CBT computerized treatment? I heard you present a few years ago regarding a motivational interviewing study you had completed. The clinicians providing MI and those providing treatment as usual all taped their sessions that were rated for content. As I recall, a large percentage of the time spent by the TAU group was coded as “chat” composed of general conversation rather than treatment approaches such as assessment, problem solving, skill training or homework assignment. My guess is that clinicians working with CBT4CBT have a very refined and focused role. Are clinician sessions provided in person, telephonically or both? Id there a recommended frequency or duration for clinician delivered services?

Have you conducted any cost studies on the use of CBT4CBT? As funding is anticipated to move from fee-for-service to using episode of care or case rates with performance incentives, it appears the adoption of technological treatment and recovery supports that can achieve the same or better outcomes than services entirely delivered by clinicians have significant potential for cost savings within treatment organizations.

Michael Boyle
CHESS/NIATx

Kathleen Carroll
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Thank you and CHESS/NIATx for great questions--keep 'em coming!

The optimum role for a clinician can vary-we designed CBT4CBT to be compatible with 'all comers' in terms of clients, but I think that's true for clinicians as well. For example, at one end you might have a very experienced CBT clinician who uses CBT4CBT to provide more opportunities for practice of skills outside of sessions, or 'boosters' for clients whose skills may be getting rusty. In this case, the clinician might watch a module or two together with the client, discuss homework responses, and so on.

At the other end of the spectrum, since CBT4CBT makes the concepts and skills so easy to understand, it can be used where the clinician may know very little about CBT or addictions. For example, a mental health counselor who knows their depressed/anxious/PTSD client also has substance use problems, but is not confident about handling those problems could 'prescribe' CBT4CBT as a means of addressing the substance abuse problem in a responsible way (compared to ignoring it!).

Novice clinicians who who don't know a lot about CBT would also find it useful--its a great means of providing a way for their clients to get CBT while they build a relationship, manage crises, and so on. Some state probation programs are thinking about using it in this way too; the data from our most recent study indicated that participants assigned to CBT4CBT were significantly less likely to be arrested/sent to jail than those that got standard treatment alone!.

The bottom line is, provided the clinician monitors the patient regularly and provides adequate clinical management, CBT4CBT can be used in just about any situation. By the way, we also have a lot of new clinicians telling us that they've learned a lot about CBT by watching CBT4CBT!

As for cost, we have done cost-effectiveness studies, published in Drug and Alcohol Dependence (Olmstead et al., 2010; free PubMed Central download: PMCID: PMC3033701). The study shows that taken to scale, CBT4CBT 'dominates' standard treatment, meaning its more effective at lower cost. However, the problem is that as low-cost as CBT4CBT is, it is not yet reimbursable through CMS.

You've nailed the cost issue--it's complicated to pay for through fee-for-service (most clinics pay for site licenses or use-per-patient). However, as the system moves toward monitoring and reporting outcome data, it's a no-brainer. Thanks! .

melissat
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Joined: 09/11/2014 - 19:04

Hi. I am in the process of researching computer based modules to supplement our services. We have a detox/residential facility with step-down to DIOP, Day Tx, IOP and Outpatient. CBT4CBT would be, I think, a great fit. Is there information you can provide regarding the cost and where I can purchase it? I am also writing an innovative grant and would love to have the cost and use this program. Thanks.

Kathleen Carroll
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Joined: 09/02/2014 - 08:41

Hi Melissa-Thanks for your interest! You can access the demo and lots of information through CBT4CBT.com. Click on the 'contact us' button. The cost depends on the number of patients you want to run through. We can do site licenses; we're working to make it affordable until reimbursement is available. Same thing for grants-depends on the size of the sample and how much (if any) programming you'd need done. Kathy

melissat
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Joined: 09/11/2014 - 19:04

Thanks, Kathy! I will do that right now.

Marg Brawner
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Joined: 10/16/2014 - 16:28

Looking forward to CBT4CBT becoming a widespread tool. Thanks for the information.

tw_telehealth
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Joined: 06/06/2014 - 09:34

Kathleen,
I would like to try this program out in my practice (I am Telehealth-based). I sent Geoff White a message for contact, wondering if I need to do anything else to discuss terms of use?
Thanks,
Tom Wilson.

tw_telehealth
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Kathleen,
Geoff gave me an opportunity to try our CBT4CBT, and found it to be very engaging and a great way to teach CBT skills to clients with SUD disorders. I might add that it would make a great professional development tool for clinical staff who need to learn CBT or need a refresher course.
Regards,
Tom

ZMALOTT
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Joined: 09/20/2014 - 09:52

Hello Tom, I'm a substance abuse counselor interested in the future of internet-based counseling as a means of working with a widely separated population in rural and fronterr areas of the Southwestern United States. Could you contact me at zmalott (at) liberty (dot) com in order to open a line of communication around this subject?

Thanks,

Zach

ZMALOTT
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Hello Tom, I'm a substance abuse counselor interested in the future of internet-based counseling as a means of working with a widely separated population in rural and fronterr areas of the Southwestern United States. Could you contact me at zmalott (at) liberty (dot) com in order to open a line of communication around this subject?

Thanks,

Zach

tw_telehealth
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Hi Zach, Your email shows you in Hawaii. Is that where you are licensed?
Tom

Kathleen Carroll
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Thanks, Tom! We've had a lot of clinicians say that--always nice to hear. Best of luck with your work! Kathy

Bob Muscala
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Joined: 09/17/2014 - 16:14

I actually think CBT/RET is way over-valued and that we might be better off teaching others how to protest and complain better
http://www.muscala.com/complainingforgood.htm

Molly
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Joined: 09/17/2014 - 23:12

Well, I've used CBT for several years with my adolescent substance using clients. That being said, I'm always looking for new ways to reach them and electronic media definitely has their attention! Getting them to put their phones away is always a challenge, so maybe we can meet them where they're at with this!

Michael A. Ellis
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Joined: 09/18/2014 - 08:29

I think we can underestimate the power of social media, the internet, personal communication devices. They are omnipresent and the more we work to take advantage of this new technology, the more we are able to speak the language of young people. By young people I mean most anyone, especially those under 65!

Kathleen Carroll
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Same for us--in our randomized studies, we take 'all comers". We've looked, and can find no differences in outcome or feasibility by gender, age, ethnicity, and people with no experience with computers do just fine.

I think we all underestimate the number of people who don't have access to solid, evidence-based treatments....there just aren't that many trained CBT clinicians out there to meet demand!

michael boyle
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Mike - in all the CHESS studies U. Wisconsin has conducted using computers and smart phones, they have found no difference is use among age groups. Even people who have never used the internet or a smart phone learn and use the tools effectively.

crosa@admhn.org
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Joined: 09/18/2014 - 10:51

Using the computer is new for me, yet it is a new generation that is frequently glued to their smartphone. We often recommend MyStrength as an additional support for clients. Why not offer them one more tool. I, too, believe face to face is better, but more tools are more tools. Let's give them all!

Molly
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Joined: 09/17/2014 - 23:12

So, this is a computerized program that clinicians can use? I'm a little confused here. I don't know where the original post is.

Molly
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Joined: 09/17/2014 - 23:12

what is the reading/comprehension level required for this program?

Also, is there somewhere to view this program?

Kathleen Carroll
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Hi Molly-We designed CBT4CBT so that only a 1-2 grade reading level is required; its audio-driven and doesn't require prior experience with computers. You can see the demos at CBT4CBT.com. Let me know if you have any questions. Kathy

Michael A. Ellis
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Joined: 09/18/2014 - 08:29

and the demos are excellent!!!