Putting Care Back into E-Therapy

Dr Simon Hatcher

Advocates of computerised therapies currently promise a great deal, but to date the delivery of these therapies has been disappointing. For example, the largest trial of computerised therapies in routine clinical practice, the REEACT trial, found no difference between those offered one of two guided computerised Cognitive Behavioural Therapy (CBT) programmes, and usual care by UK family doctors[i]. Similarly, trials of “telehealth,” typically including regular monitoring and advice, have shown no or very little improvement over routine care[ii], [iii]. So while individual randomised clinical trials show that using technology can improve outcomes, there remains a problem with implementation outside of controlled settings.

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One of the reasons for the disparity between promise and implementation may be found in qualitative studies of computerised CBT programmes. Here we see consistent findings around the level of respondent “relatedness” or “connection” with the technology, revealing a core issue for users. In our own work qualitative studies on this topic, “trust” in the technology has also shown itself to be a something that is easily damaged by bugs or difficulties with logging on to the technology. Trust in the program or application thus appears to be an important component of therapeutic connectedness, in many ways similar to the trust that is invested in a therapist.

Why should connection, relatedness and trust be such important issues? After all isn’t the relationship with a piece of technology? I think one of the answers is that, as a clinician, I spend most of my time providing care for people rather than diagnosing conditions or relieving their symptoms.

Though from the outside, it may seem that the work of healthcare is mostly that of matching a treatment to a diagnosis in order to relieve symptoms, the “care” of healthcare is something that must be given more emphasis. Care is rarely talked about, and the design of health apps or online therapies seems to reflect this. So while many of these interventions offer assessment and diagnosis, with treatments focused on symptoms, little attention is paid to the way that care as a medical practice is affected. Diagnosis in modern medicine is relatively straightforward, and the treatments that we offer help, but people are often left with residual symptoms, and this is where care becomes crucial. The disparity between the different aspects of medicine has long been recognised, with aphorisms such as, “To cure sometimes, to relieve often, and to comfort always,” or as Freud said, “much will be gained if we succeed in transforming your hysterical misery into common unhappiness”.  

More pithily, the central task of medicine may be to help people suffer more successfully. Without the relationship of care made more prominent in the development of new health technologies, this gap between promise and implementation will continue to remain unaddressed.

[i] Simon G, Littlewood E, Catherine H, Gwen B, Puvan T, Ricardo A, et al. Computerised Cognitive Behaviour Therapy (cCBT) as Treatment for Depression in Primary Care (REEACT Trial): Large Scale Pragmatic Randomised Controlled Trial. BMJ. 2015 351:h5627.

[ii] Salisbury C, et al. Telehealth for Patients at High Risk of Cardiovascular Disease: Pragmatic Randomised Controlled Tiral. BMJ. 2016 353:i2647.

[iii] Pinnock H, et al. Effectiveness of Telemonitoring Integrated into Existing Clinical Services on Hospital Admission for Exacerbation of Chronic Obstructive Pulmonary Disease: Researcher Blind, Multicentre, Randomised Controlled Trial. BMJ. 2013 3476:f6070.

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