Can Computers Assist Us in Delivering Evidence-Based Interventions with “Computer Assisted Therapy”?

computer-assisted therapyHow can the billions of people needing behavioral care be served by evidenced-based interventions? We don’t have enough funding or clinicians to serve everyone wanting behavior change guidance, support or direct intervention. If we look at the need in rural and frontier areas alone, we can do much more. In a paper outlining the need for telehealth technologies in rural and frontier areas, the National Frontier and Rural Addiction Technology Transfer Center Network (ATTC) states:

Over half of the country’s land mass is designated as frontier or rural, which is defined by low population density and geographic remoteness to Census Bureau-defined Urban Areas [1]. Frontier/rural areas are characterized by small population centers that cannot support the type of healthcare services available in more densely populated centers, including substance use disorders (SUDs) treatment [2]. Approximately one quarter of the U.S. population (62 million people) lives in frontier/rural areas, with an estimated 16-20% (15 million) of those individuals experiencing substance dependence, mental illness, or co-morbid conditions [3].”
Although individuals residing in frontier/rural areas may have similar prevalence rates of drug/alcohol dependence as their urban colleagues, their mortality rates and risks for suicide are higher [4] and in general their alcohol/drug problems more severe [5].The most significant issue facing individuals with SUDs in frontier/rural areas is access to treatment/recovery services. A 2009 workforce study reported that the lowest concentration of mental health professions was found in frontier/rural areas, especially those counties with less than 10,000 people [6]. Furthermore, the health professional shortage areas (HPSAs) definition of frontier specifies that ‘the time and/or distance to primary care is excessive for residents,’ which includes lack of consistently accessible roads to a healthcare access point [2]. This means that patients may have to drive over 60 minutes one way to receive treatment services. With little or no public transportation in these areas, attending treatment is difficult if not impossible. Consequently, many clients may never receive SUDs treatment.
In addition to accessibility, availability and acceptability of services are issues that prevent or delay individuals with SUDs/mental health disorders from receiving treatment [7]. Availability refers to the presence of treatment and recovery services; acceptability refers to clients’ attitudes towards entering treatment and the perceived or actual lack of confidentiality and community support. Addiction treatment/recovery services in frontier/rural areas also are difficult to sustain due to high delivery costs, a shortage of trained counselors, and in some cases public opposition to drug/alcohol treatment programs related to fear that programs will draw more individuals with SUDs into the area [8]. Remote healthcare services have been shown to provide an excellent vehicle for expanding access to and availability of medical and mental health services in frontier/rural areas, and holds great promise for helping address some of these barriers to SUDs treatment.

Yet Another Form of  Telemental Health 

Let’s consider the possibility that computers can do the bulk of behavioral interventions to reach more people at a lower cost if properly directed by well-trained behavioral health clinicians. Such interventions have already been designed for mild to moderately impaired groups of people who don’t need or cannot access a full course of in-person or telehealth care. Called “computer-assisted therapy,” these telehealth interventions have been evolving for more than a decade to provide the early levels of “stepped care” prior to the need for direct care by trained therapists. This week’s news brought a statement about the availability of computer-assisted therapy programs from Terra Hamblin, project manager at the National Frontier and Rural Addiction Technology Transfer Center Network (ATTC). Cited in Behavioral Healthcare, Ms. Hamblin stated that “more than 100 different computer-assisted therapy programs have been developed for a range of mental disorders and behavioral health problems to date.”

Therapist-Assisted Online

You might recall that last January, the TMHI blog reported the related pioneering work of Dr. Sherry Benton at the University of Florida. In that article, Telemental Health in the University Setting Report of High Success Rates Compared to In-Person Counseling, Dr. Benton revealed the power of her Americanized version of computer-assisted therapy, called “Therapist-Assisted Online or the “TAO” program. Treatment involved a series of 12-videotaped self-help, depression and anxiety modules made available through the school’s counseling office to students in addition to shorter periods of distance care via videoconferencing.  In her presentation of TAO’s outcome data at the August 2014, American Psychological Association convention in DC, Dr. Benton enthralled more than 60 psychologists with the details of her study in the Telepsychology Best Practices: Maximizing Opportunities in Health Care Reform workshop. She reported a 75% reduction in overall counseling staff time, paired with better outcomes in depression and anxiety when compared to the in-person students treated in person at the University’s counseling center.  

Similar results are sparking interest in not only counseling offices, but governmental groups, primary care clinics, payors and many more groups who see a need for care to be delivered across the entire spectrum, and not just people with severe disorders seeking acute care. A substantial body of research also exists to guide our decisions in this rapidly evolving area. While similar programs are evolving in United States, the US isn’t the leader in this arena. 

International groups have researched and reported the advantages of automating behavioral health care for well over a decade. For example, the International Society for Research on Internet Interventions (ISRII), founded in 2004, promotes the scientific study of information and communication technologies targeting behavioral, psychosocial, health and mental health outcomes. Their website explains that, these “Internet interventions” are broadly inclusive of existing and emerging technologies, including, but not limited to, the web, mobile and wireless devices and applications, digital gaming, virtual reality, remote sensing, and robotics.  ISRII members include researchers, clinicians, engineers and computer scientists, informaticists, software developers, economists, and policy experts across the public and private sectors, who are committed to fostering excellence in evidence-based eHealth interventions.”

From telephone, to text messaging to video-conferenced behavioral telehealth interactions, clinicians today have unprecedented options. If you haven’t begun to think about this world, consider taking one of TMHI’s training modules to expand your thinking. See our TMHI homepage, where Dr. Benton explains how she was inspired to consider various telehealth options by training at TMHI.


  1. USDA. Frontier and Remote Area Codes. 2000; Available from: http://www.ers.usda.gov/data/frontierandremoteareas/documentation.htm. 
  2. NRHA (2007). National Rural Health Association Policy Brief: Designation of Frontier Health Professional Shortage Areas, G.A. Office, Editor: Washington, DC. 
  3. NRHA (2008). Workforce Series: Rural Behavioral Health. G.A. Office, Editor: Washington, DC.
  4. Goldsmith, S.K. et al. (2002). Reducing suicide: A national imperative. Center for Rural Affairs. Washington, DC: National Academy Press.
  5. Baca, C.T. et al. (2007).Telecounseling in rural areas for alcohol problems. Alcoholism Treatment Quarterly, 25(4), 31–45.
  6. Ellis, A.R. et al. (2009). County-level estimates of mental health professional supply in the United States. Psychiatric Services, 6(10), 1315–1322.
  7. New Freedom Commission on Mental Health, Subcommittee on Rural Issues: Background Paper, 2004, New Freedom Commission on Mental Health: Rockville, MD.
  8. Johnson, M.E. et al. (2005). Rural-urban health care provider disparities in Alaska and New Mexico. Administration and Policy in Mental Health, 2, 1–4.

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