Mental health and the balance between technology and the human touch [PODCAST]

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“The reality of the last two years is that almost all of us have experienced some mental health disorder symptoms, and that mental and physical health are equally important components of overall health. We call these subclinical symptoms, or symptoms that are there but that don’t meet full criteria for a disorder. Most of us have experienced subclinical symptoms, or psychosocial stressors, since the start of the pandemic due to the stress that we’ve been under. These can include things like divorce, illness, job loss, and even things like stressful homeschooling. If you get enough of them, you’re more likely to tip over into subclinical or clinical levels of symptoms, including increasing the risk for many types of physical health problems, particularly long-lasting conditions like diabetes, heart disease, and stroke. The setpoint of our average well-being levels has shifted down the spectrum over the last few years. That means that almost all of us can benefit from seeing a provider and getting professional mental health support, whether through a digital tool or via face-to-face therapy.

It’s important to think about the total person, and all of the facets that may need treatment. Using technology that integrates siloed services into one ecosystem has the advantage of being able to provide highly coordinated care, whether that’s for mental health, chronic condition management, substance use monitoring, managed behavioral health, or other needs.”

Jay Spence is a psychologist.

He shares his story and discusses his KevinMD article, “Mental health and the balance between technology and the human touch.”

Reflect and earn 1.0 AMA PRA Category 1 CME for this episode.

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show we have Jay Spence. He is a psychologist and health care executive. He wrote the KevinMD article “Mental health and the balance between technology and the human touch.” Jay, welcome to the show.

Jay Spence: Thank you for having me.

Kevin Pho: We’ll get to the article in a little bit, but first off, can you share your story and journey to where you are today?

Jay Spence: Sure. So I originally started out my career as a clinical psychologist. I started in private practice, and as part of being in private practice, I think there’s a trend over time that you see: You end up with patients that you’re seeing for longer than I thought I should be seeing them. I think I came out of university thinking that there were the treatments that I’d been giving to be able to get people better in a certain amount of time. And two, three years into treatment, sometimes some of my patients were still coming back, even though I think I’d tried every treatment under the sun that I knew I had to get them better. So I got curious about what was going on there.

I headed back to go and do some research at a local hospital clinic and ended up just being in the right place at the right time. There was a guy there who was a maverick psychiatrist. He was kind of your bow-tie-wearing, odd-socks, ready-to-take-on-the-world psychiatrist. He was at the end of his career, and he had kind of changed several things within the health care system in Australia, and the thing that he turned his mind to at the very end was virtual treatment. This was in the kind of early 2000s, or actually, mid-2000s, and he was showing us data that he was getting people better by putting tech stuff onto a website, forcing them to read it by calling them up and telling them to read it.

And he challenged us, just by saying he could beat any of our outcomes in the outpatient clinic that we were working at, at the time. We and some of the other psychologists didn’t believe him, and so we kind of went back in to start doing research with him, and later realized that was his trick to recruit PhD students. That’s how he got us in. So he got us into a PhD, and it was very fortuitous, in a sense, that we just stumbled into being in one of Australia’s really early virtual clinics. And obviously, the virtual treatment industry has blossomed into telehealth and is now a thriving industry. So we were just in the right place at the right time with a clever guy who saw the way it was going to be.

Kevin Pho: So tell me about that transition from clinical psychology into the health tech space. What was that journey like for you?

Jay Spence: It was a very steep learning curve. So I started by getting into a business accelerator that was run by a large telco in Australia. It’s kind of the equivalent of AT&T. I didn’t realize that almost none of the skills that I had from doing my master’s and my PhD were going to be helpful or useful in starting a business, and that’s what the business accelerator was for.

But really, I kind of went from having a mindset which was very focused on doing things at a slower pace, understanding that things needed to be done well in order to be taken seriously by the scientific community, to realizing that I needed to move at some type of pace and be willing to take a lot more risk. So I took off the scientist hat, or kind of put it down for a while, and had to put on the marketing hat, the accounting hat, the sales hat, and all the other things that go along with starting a business. There were some sleepless nights, but I think in the end we kind of got through that period, got the commercialization of the research that I’d done as part of my PhD set up, and then took it from there.

Kevin Pho: So we have a lot of clinicians, physicians, and psychologists who make that transition from the clinical world into the business world. What kind of advice do you have for them?

Jay Spence: I’d say the first would be just to be very conscious that entrepreneurship is a new career. I had originally thought that this was something that I could balance with my old career, and I tried very hard. I tried to keep my private practice running; I tried to kind of keep one foot in there. The commercialization of a startup, especially one that moves quickly, becomes all-consuming, and it is really about having to take a master’s degree in all of those areas that I said before. You need to become a marketer, you need to become a salesperson, and you need to be able to understand aspects of touching everything lightly, from finance through to customer service. If that doesn’t appeal to you, I don’t know whether the sleepless nights are really worth it.

But the thing that I noticed for the entrepreneurs who had come from a scientific background, who did push through the initial phases of discomfort, is that they had two things. They had that kind of mindset of, “The system has to change, and I don’t really care what happens. I’m just going to bulldoze through this, because I can see something’s going to change here.” So there’s that visionary, values-based visionary; I think he’s kind of this section. And there was another group that was just incredibly resilient. It went a bit slower for them; they’re smart people, they worked through it, and they weren’t as rocked by the different buffers that came through. But either pure resilience or pure visionary, either one of those two, is necessary to go through the stress of needing to learn lots of things within a short period and make it work.

Kevin Pho: Now, let’s talk about the KevinMD article that you wrote. It’s titled “Mental health and the balance between technology and the human touch.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Jay Spence: Yeah. What we’re seeing at the moment is that there’s a transition, obviously, into lots of different forms of digital treatment for what is historically a very human and relational form of treatment. And the changes that we’re seeing are happening really rapidly, and some of these things mean that there needs to be this consistent awareness of how we might be able to retain the components of human treatment within a digital world.

To give you an example, one of the trends that we’ve seen has been a really strong transition towards people using chatbots, which is essentially just chatting with an algorithm that doesn’t have any human element whatsoever. And there’s been uptake of those types of treatments from lots of different demographics. I think we’re still understanding who, what, where, and when we need to use those types of interventions with. But one of the things that we’re seeing also is that there need to be really clear off-ramps to be able to access human care at the right time.

Digital interventions are great ways to get started, obviously, but for a lot of people, I think that there’s a sense that perhaps that’s the be-all and end-all of the interventions, especially if you’re growing up in an era of being a younger person, where you might not have had the experience of doing therapy or the experience of doing coaching. Digital is safe, and digital is what a lot of people know, especially if they’re younger.

But what we’ve really seen is that there’s this need to do two things really well. One of them is to be able to understand how we facilitate care towards a real person in a way that’s titrated: having low-intensity treatments for people that are able to just come in and get what they need, who might be a bit more towards the well spectrum; moderate-intensity treatments like coaching, telehealth coaching, those types of interventions, for when it’s needed by the group that might be at risk; and more high-intensity treatments like your therapy, counseling, telehealth, and face-to-face, and case management for people who are starting to drop off. So digital systems need to allow for that.

And I think that’s what we’ve seen more recently with the merger between Ginger, which is a coaching company, and Headspace Health, which is traditionally a meditation app. Because I would imagine that what they’ve seen is you can’t go for a purely digital play. It has to have the human touch, which is the coaching element that Ginger has, and the combination of those types of entities, where you can say, “This is the best-practice meditation app, and this is a great organization that provides coaching.” So how do we actually manage to provide the human touch within the digital and make sure that these systems function well over time?

Kevin Pho: Are there specific behavioral health conditions that are more amenable to a digital solution?

Jay Spence: Yeah, I think it’s more about the severity rather than the condition. So digital health interventions have been tested in lots of different conditions. And the really interesting thing to me about digital interventions, and what I mean by that is usually a digital course, an evidence-based digital course that teaches a skill like cognitive behavior therapy through videos on an app or something like that, and it has some type of phone coaching element or video coaching element to it. Those are the ones with the strongest evidence, but they’re quite brief, and the phone coaching element can be quite short. Those interventions have been tested across a wide range of presentations, so there are interventions to say that they can work with conditions as severe and problematic as schizophrenia.

But really, where the evidence sits for this is: The lower the person’s symptoms are, the more that they’ll be able to recover from digital methodology. The more severe their symptoms become, the more they’re likely to need some type of phone coaching or video coaching methodology. Or sometimes it’s about a combination of a face-to-face treatment with a digital treatment. So a therapist sees the person in their office, but they recommend a digital treatment as part of their therapy, so that they can essentially get the self-help, or the training, doing CBT on your own through the app, while you focus on the more relational principles of treatment with the therapist in the office.

Kevin Pho: So you mentioned digital therapy a couple of times. So what exactly would that entail? You mentioned things like chatbots; you mentioned CBT, cognitive behavioral therapy. You know, is it just video one-on-one? So specifically, what kind of digital therapies are you talking about?

Jay Spence: Glad you asked. It’s a growing area, and even I find it hard to understand what’s in that box sometimes. So digital therapy, at its kind of highest parent term, probably encompasses something which is referred to as an e-health intervention, and an e-health intervention has lots of subcategories sitting underneath it. There are interventions that I spoke about, like chatbots. That’s usually a purely digital intervention that’s delivered via an app or a web page, where somebody’s talking to an algorithm that’s just a large decision tree, things that they can explore into. And each of those decision trees might be something like, “Are you feeling stressed today? Would you like me to give you some information on how to handle that stress?” Then the person is presented with best-practice information via text or video.

Then you move into things like computerized CBT. It’s also called iCBT, and those interventions are the digital courses, with or without phone coaching, that I was talking about. So there are lots of versions of this, and these are the interventions that are very strongly supported by evidence, because what they’re doing is delivering an evidence-based course, like delivering doses of cognitive behavior therapy with the support of a coach. And that coach can be a layperson, somebody who’s had minimal coaching training, or they can be a specialist, like a psychologist, clinical psychologist, or psychiatrist, who phones them up, talks to them about the content, and moves them through the content. And the dosage is essentially moving through those modules within the course.

Then also under e-health interventions, you’ve got a raft of different telehealth-style interventions, so chat-based therapy and video-based therapy. And the evidence for those styles of therapy is growing over time, to the point where video-style intervention is now a fairly established intervention. It needs to be, and the outcomes are similar to face-to-face in some settings.

Kevin Pho: So walk us through a real-world success story or a case study. Tell us about a typical patient, what kind of condition he or she would have, and what kind of digital interventions you could offer this patient.

Jay Spence: Well, I mean, the good news is there have been lots, because these interventions have been around for some time. So I’ve seen success across the spectrum with lots of different types of people. But I might take you back to the beginning, which is where I really saw it starting to work. So this is in about 2008, 2009. We were running a research trial for people who were socially phobic and also had symptoms of panic, and most of that group were housebound. They hadn’t come out, you know, really, to go outside to put the washing on the line in quite some time. Obviously, there’s some depression that’s emerging in that context as well. So you’ve got a group that is not well suited to coming into a doctor’s office to be a patient.

I think it was maybe my second or third research trial that I’d been involved in as part of this lab, and I was one of the clinicians that was doing the phone coaching. And so when we were creating our hierarchies of steps to start to get them back going, step number one was really, “OK, what could you do today to try to get out of the house?” And they’d watched a video online, maybe two videos, that explained basic principles of doing graded exposure, which is a treatment for being able to help people take steps to overcome anxiety.

Normally, with someone with that level of severity, if they even managed to come into my office, I knew that I was really looking at what I would say is probably a 12-month treatment period to start to get them back up and running, and that’s honestly if they’re lucky to get in. In the interventions, having watched a couple of videos, they were coming in much more prepared and much more settled, because they’re at home and they’re less anxious at home. And they were able to see, “OK, the purpose of this call is I’ve got to create this hierarchy,” and I have to kind of scaffold them up to get to that point. I’ve already skipped four sessions to get to that.

Then I was noticing, hang on, the next time I called that person back, they haven’t just gone outside; they’ve done three more steps down their stepladder, and they’re off down the shops talking to people. That never used to happen for me when I was in face-to-face. It was very, very slow steps, taking it slow, making sure that they weren’t going to relapse.

What I saw from doing that style of intervention was that, especially for some of these groups, it was working much more on self-efficacy, because they had the tools they needed. They could go through the video library and say, “OK, I can see step one, I can see step two, I can see step three. I’ll watch these videos now. I can take these steps when I feel ready.” I think that was a very clear shift in the balance of power that I’d been used to in my therapy sessions, where it was much more didactic. I had taken a style in my sessions of saying, “Let’s take this slow. Follow me through this, and I’ll show you how to get better.” Whereas they said, “I’ve got this tool, I’m ready to get better, I’m going to take this step,” and it was just me calling up and saying, “Great, well done, keep going.” And that really impressed me, to be able to see that those types of results were possible through digital interventions where it was a very light touch for a clinician.

Kevin Pho: We’re talking to Jay Spence. He’s a psychologist and health care executive. He wrote the KevinMD article “Mental health and the balance between technology and the human touch.” Jay, what are some of your take-home messages that you want to leave with the KevinMD audience?

Jay Spence: It’s the same message that I always ask everybody for whenever I’m talking to people. We’ve seen some massive changes in the destigmatization of mental health across the last couple of years, since the pandemic. I would just really ask that everybody keep doing that great work. We’re starting to see the outcomes of it already, in terms of people feeling a lot more comfortable about talking about mental health in their workplace, with their friends, and with their family.

I still think we’ve got a really long way to go. The best way to be able to do it is to always be reflecting about whether or not you’re talking about mental health with your patients in the same way that you would talk about a physical illness or an injury. Because I think that’s the way that we’re headed, to be able to understand that it’s the time for mental health to be seen with a lot less stigma than it has been. And so I appreciate all the good work that everybody’s doing in order to have that happen.

Kevin Pho: Jay, thank you so much for sharing your time and insight. Thanks again for being on the show.

Jay Spence: Pleasure. Thanks, Kevin.

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