Research has shown that digital therapeutics (DTx) platforms using tools derived from therapies like Cognitive Behavioral Therapy (CBT) promote clinical change (Brown et al., 2020). Decades of research also demonstrate the importance of social supports and well as the relationship with the therapist in psychotherapy outcomes (Barker & Pistrang, 2002; Lindfors et al., 2019; Wampold & Imel, 2015; Zimmerman et al. 2021). It remains an open question what types of additional social support can improve those results. One such digital product, Learn to Live, has demonstrated improvement with personal coaching (Brown & Jones, 2021) and with automated text message support (Brown & Jones, 2022). The current study examines potential benefits from another type of support, specifically friends and family, who are notified by the digital user of their platform use.
Learn to Live offers this option to people at the time of enrollment to engage support from family and friends as “Teammates.” New users are offered the option of providing up to two email addresses for individuals who will be on their “team.” Learn to Live has no mechanism for knowing how much support any teammate provides a user of the platform. Teammates are contacted after the user enrollment process to notify them that their friend or family member will begin using one of the therapeutic modules. They are also contacted when lessons within the module are completed.
The Learn to Live database has an indicator of whether the user included the teammate option. This permits evaluation of the outcomes for those choosing this option, and it allows investigation of the degree to which this option is associated with a larger effect size for those users who also engage other support options. For example, the coaching option was previously shown to be associated with larger effect sizes (Brown & Jones, 2022). Any additive effect would be a unique pathway to increase effectiveness.
As in our previous articles, the magnitude of improvement is reported using the effect size statistic. This statistic is routinely reported in studies of outcome and meta-analytic studies of outcome. Brown & Jones (2022) provides a detailed description of the methodology used to compute this statistic for Learn to Live questionnaires as well as data on outpatient psychotherapy from the ACORN Collaboration.
Analysis of variance is used to determine how much of the variance in outcome is explained by each of the four conditions studied. The conditions identified for analysis are: a) use of the program without any additional support; b) use of the program with coaching support; c) use of the program with automated texting support (“mindfulness moments”), and d) use of the program with teammate support. Analysis of variance permits evaluation of the relative contribution of each condition independently and additively.
The sample employed (n=5628) includes users of the platform in calendar years 2019 through 2021 who had at least two self-report measures in the system permitting an analysis of change.
Analysis of variance found that two of the support conditions, coaching and teammates, had outcomes significantly greater than use of the platform without support (p<001). Mindfulness text message support did not differ significantly from the no support condition (>.10).
The following table presents the results for each of the conditions and for the ACORN psychotherapy sample which has been used in the previous Learn to Live studies as a reference point.
|Mean Effect Size and last session number by treatment condition|
|Condition||Mean Effect Size||Last lesson number|
|All Learn to Live cases (n=5628)||0.58||4.1|
|No coaching or teammates (n=4131; 73%)||0.44||3.9|
|Teammates but no coaching (n=276; 5%)||0.81||3.9|
|Coaching but no teammates (n=1072; 19%)||0.86||4.9|
|Coaching and teammates (n=149; 3%)||1.09||4.9|
|ACORN sample (n=116,854)||0.74|
The following graph displays the effect sizes graphically. It appears that the effect for teammates support is independent of and additive to the effect for coaching, and this is confirmed by the ANOVA. The effect size for combined coaching and teammates was significantly larger than for either the coaching or teammates condition alone.
The mediating effect of lesson utilization was analyzed. Interestingly, coaching was associated with completing more lessons, while teammates appeared to add to the effect size without increasing the number of lessons.
The results further reinforce the importance of various forms of social support either from a counselor or friend. They may have separate mechanisms of action, as indicated by the apparent additive effects of combining coaching with teammates. Understanding the relative contributions of therapist support and other social supports is an ongoing topic of psychotherapy research (Winefield, 1987; Barker & Pistrang, 2002).
The results are intriguing but should be interpreted with some caution. First, it must be stressed that correlation is not causation. One plausible explanation for the results is that users choosing support are more motivated and/or ready to accept help than others. User factors (much like patient factors) are likely to be contributing to the results, if not explaining them in totality. Something is likely to be different about these users selecting support.
These results are generally consistent with research on psychotherapy highlighting the importance of the therapeutic relationship in driving clinical change as well the evidence for the importance of social support. The emerging modality of DTx is generally limited to providing therapeutic techniques without an element of personal support. People who select some type of personal contact or support have been found in three studies (Brown & Jones, 2021; Brown & Jones, 2022, and the present study) to have superior outcomes over those who only utilize the online therapeutic tools.
In all, 26% of users opted for coaching and/or teammates support. From a quality improvement perspective, the next step would be to find ways to increase participation in both program options. However, the coaching support requires hiring staff to meet increased demand, while the teammates option has minimal additional expense. This is an important business consideration, and so the current results merit further study of larger samples before business decisions are based on them.
Cite This Article
Brown, J., & Jones, E. (2022, July). Improving results for digital therapeutics with social support. [Web article]. Retrieved from http://www.societyforpsychotherapy.org/improving-results-for-digital-therapeutics-with-social-support
Barker, C., & Pistrang, N. (2002). Psychotherapy and social support: Integrating research on psychological helping. Clinical Psychology Review, 22(3), 361-379.
Brown, J. S., Jones, E., & Cazauvieilh, C. (2020, May). Effectiveness for online cognitive behavioral therapy versus outpatient treatment: A session by session analysis. [Web article]. Retrieved from http://www.societyforpsychotherapy.org/effectiveness-for-online-cognitive-behavioral-therapy-versus-outpatient-treatment
Brown, G. S., & Jones, E. (2021, March). Improving clinical outcomes for digital self-care. [Web article]. Retrieved from http://www.societyforpsychotherapy.org/improving-clinical-outcomes-for-digital-self-care
Brown, J., & Jones, E. (2022, May). Improving results for digital therapeutics. [Web article]. Retrieved from http://www.societyforpsychotherapy.org/improving-results-for-digital-therapeutics
Lindfors, O., Ojanen, S., Tuija Jääskeläinen, T., & Knekt, P. (2014). Social support as a predictor of the outcome of depressive and anxiety disorder in short-term and long-term psychotherapy. Psychiatry Research, 216(1), 44-51.
Wampold, B., & Imel, Z. (2015). The Great Psychotherapy Debate: The evidence for what makes psychotherapy work. Routledge.
Zimmermann, D., Wampold, B. E., Rubel, J. A., Schwartz, B., Poster, K., Schilling, V., Deisenhofer, A., Hehlmann, M. I., J Penedo, J., & Lutz, W. (2021) The influence of extra-therapeutic social support on the association between therapeutic bond and treatment outcome. Psychotherapy Research, 31(6), 726-736.