Low Intensity Intervention Resources for Patients Waiting for Therapy
Psychotherapy Bulletin Editors’ Note: Long wait lists for mental health treatment are a major barrier to accessing care and have been associated with symptom worsening and dropout. Individuals who are waiting for treatment may be particularly well-suited to receive low-intensity resources while awaiting a therapy appointment.
Long wait lists for mental health treatment are a major barrier to accessing care and have been associated with symptom worsening and dropout. Despite this, individuals who are waiting for treatment represent a unique opportunity for intervention as they have already overcome significant barriers (e.g., stigma) that are involved in reaching out to mental health services. Patients placed on treatment waiting lists may be particularly well-suited to receive low-intensity resources while they wait for therapy. In this article, we summarize literature on low-intensity resources for common mental disorders (e.g., depression, anxiety), focusing on their potential for use with individuals waiting for treatment. We include descriptions of various resources that providers could recommend for patients to use while waiting for mental health treatment.
Depression and anxiety are two of the most common mental disorders and are leading causes of disability worldwide (James et al., 2018). More recently, the prevalence of depression and anxiety has increased by 25% worldwide during the first year of the COVID-19 pandemic (Bueno-Notivol et al., 2021). This increase in mental health need was accompanied by an increase in treatment seeking (Canady, 2020), indicating an unmet increase in demand for therapy. Prior to the COVID-19 pandemic, reported waiting times for therapy varied in the literature, with averaged reported waiting times including 2-3 weeks or up to 2-3 months. In a recent survey, mental health providers who maintained a treatment waiting list reported that these waiting times have increased since prior to the pandemic from a wait time of about 9 weeks to wait time of about 13-weeks (Peipert et al., 2022).
Maintaining a treatment waiting list is common practice for mental health providers, as logistically most providers cannot see all patients who are seeking treatment at the same time. Though waiting lists are common, practices and standards for treatment waiting lists may vary between providers (Brown et al., 2002). Patients themselves also identify waiting for treatment as a barrier for mental health treatment seeking (Punton et al., 2022), reporting negative psychological and behavioral outcomes after being placed on a waiting list for mental health care. Research on therapy outcomes suggests waiting times for mental health treatment may impact future treatment engagement (Krendl & Lorenzo-Luaces, 2021; Reitzel et al., 2006), and gains during treatment (Cuijpers et al., 2021; Steinert et al., 2017). Though treatment waiting lists are common practice, there is the opportunity for providers to suggest resources to patients while they are awaiting therapy.
Low-Intensity Treatments (LITs)
Even prior to the COVID-19 pandemic, researchers suggested turning to low-intensity modalities, like self-help books or apps, to address the burden of untreated mental illness. Low-intensity treatments (LITs) include treatments that are used with a little guidance from a professional (e.g., therapist) or paraprofessional (e.g., coach, student). In some cases, LITs are entirely self-guided, without the help of another individual. This allows users to engage with LITs without many of the burdens that are present with face-to-face care, such as costs, insurance barriers, transportation, and time off from work, among others (Andrade et al., 2014). Guided and unguided forms of self-help are shown to be effective in research studies, with guided self-help being about as effective as face-to-face therapy for depression and anxiety disorders (Cuijpers et al., 2010). For depression, self-guided LITs appear to be less effective than therapist-guided LITs but are still more effective than being on a waiting list with no LIT provided. For anxiety, self-guided and therapist-guided LITs appear to be equally efficacious (Titov et al., 2016).
Low-intensity treatments are available in the form of books (“bibliotherapy”) and online tools, like apps or websites. The development and use of well-being apps in particular has increased substantially in the past few years. In 2017, it was estimated that over 325,000 apps are publicly available for mental health and well-being (Neary & Schueller, 2018). Despite this large expansion, six of the most popular apps account for 90% of all downloads and active users of mental health apps (Wasil et al., 2020). Many of these more popular mental health apps emphasize mindfulness and meditation practice but many do not contain aspects of evidence-based practices for mental health like behavioral activation or cognitive restructuring (Wasil et al., 2021). Many forms of internet-based treatments that have been widely researched in clinical trials are not made accessible to the public. Indeed, in a recent systematic review of internet cognitive-behavioral therapies (iCBTs) that have been studied in at least one randomized controlled trial, only 14.6% of these iCBTs were made available to the public (Buss, 2020).
In a survey of 141 providers, nearly 85% reported maintaining a waiting list for their clinical practices or scheduling patients months in advance. However, only 16% of providers reported recommending books to patients while they wait for treatment, and even fewer reported recommending apps (Peipert et al., 2022). There are several reasons why providers may not currently be recommending LITs for patients waiting for treatment, including some misconceptions about LITs in practice.
Common Misconceptions About LITs
Patients will prefer apps over books. We have heard from colleagues that they have great interest in the use of apps and other digital tools. However, books and other print media can be helpful for people with common mental disorders. In a recent survey of nationally representative adults, participants reported a greater willingness to engage with print-based materials over digital mental health interventions (De Jesús-Romero et al., 2022). Though preferences may vary, this survey suggests that, contrary to some popular beliefs, inidividuals may prefer working from a book format rather than a digital (computer or phone) format.
Books and apps are only for people who have mild concerns. Another common concern we have heard is that LITs may only be appropriate for patients with rather mild symptoms. This assumption has not been supported in research. In fact, studies of self-guided internet-based treatment found that the effects were more pronounced with more severe symptom presentation (Bower et al., 2013), and this effect may even be more pronounced with added guidance component. Indeed, research on digital interventions has tended to use more lax study entry criteria leading to more heterogenous patient presentations (Lorenzo-Luaces et al., 2018). For example, it is less common for studies of digital interventions to exclude patients on the basis of substance use, psychosis, or personality disorders than compared to face-to-face psychotherapy trials.
Patients waiting for treatment can’t benefit without a comprehensive assessment. Many of the LITs described in the included resources are based in cognitive behavioral therapy (CBT) and include CBT skills that are on principle transdiagnostic, such as identification of maladaptive thinking and values-based behavioral activation. CBT has demonstrated efficacy across a number of common mental disorders including depression, anxiety, OCD, and insomnia (Hofmann et al., 2012), and overlaps in many content areas with other transdiagnostic interventions such as the Unified Protocol (Barlow et al., 2017). Indeed, existing evidence suggests that CBT skills for depression also lead to reductions in anxiety and vice-versa (Cuijpers et al., 2016; Weitz et al., 2018).
Patients can’t benefit without personal contact. The therapeutic alliance is known to be a reliable process of change in all psychological interventions. Thus, a concern for seasoned therapists may be that symptom change is not possible without some degree of therapist guidance. However, self-guided interventions have been shown to be effective compared to waitlist controls or treatment as usual (Cuijpers et al., 2011). In fact, many individuals report a preference for dealing with mental health problems on their own without the support of a therapist (Mojtabai et al., 2011). Though this is likely not the case for all patients who seek out mental health providers, there may still be a benefit to using a LIT while waiting for treatment as opposed to receiving no care at all.
Patients won’t engage LIT materials. Engagement in LITs is a well-documented limitation in the literature. However, some research suggests engagement in self-help modalities might not be that different from psychotherapy. In a meta-analysis comparing internet-based CBT to face-to-face psychotherapy, drop-out and non-compliance rates were comparable (Carlbring et al., 2018). Moreover, patients waiting for treatment will not have the option to engage in materials if they are not made aware of them to begin with.
LITs are meant to replace face-to-face therapy. Though many LITs attempt to mimic face-to-face therapy, they are not intended to replace face-to-face therapy. Rather, there is a known disparity in access to evidence-based mental health care such that there are not enough trained psychotherapists for everyone with a common mental disorder (Kazdin & Blase, 2011). The prevalence of mental health concerns suggests that treatment ought to be scalable and accessible. This cannot be done exclusively using face-to-face modalities.
One barrier we have encountered to psychotherapists using LITs in their practice is the belief that evidence-based LITs are not easily available. Here, we concur with individuals expressing this belief. Many of the mental health apps available to the public have not been studied in clinical trials nor do they contain components of evidence-based practice. Furthermore, research based LITs are often not made publicly available. This is part of a larger research-practice gap that is prevalent in clinical psychology. Despite this, there are LITs that include elements of evidence-based practice or that have been studied in clinical trials. Given the vast number of resources available, it can be difficult to sift through and find evidence based LITs. To address this barrier, below we provide descriptions of evidence-based LITs, including print- and internet-based resources, that providers could recommend to patients while waiting for treatment. Additionally, resources such as Psyberguide.org collates the evidence-base for many web- and app-based LITs.
Resources for providers
- Doing What Matters in Times of Stress (DWM): DWM is a publicly available self-help book published by the World Health Organization to target distress. DWM has 5 sections, each with a specific component for handling stress. The skills are based on Acceptance and Commitment Therapy (ACT), an evidence-based therapy for anxiety, depression, chronic pain, obsessive-compulsive disorder and other diagnoses. DWM is meant to provide skills that can be used across situations to help manage stress. One notable advantage of DWM relative to other LITs is that it is written at a 4th-grade reading level and can be downloaded in several languages for free online (https://www.who.int/publications/i/item/9789240003927). We conducted an open trial of DWM for individuals in the United States and found it was an acceptable intervention for depression and anxiety (Lorenzo-Luaces et al., 2022).
- Centre for Clinical Interventions (CCI): The CCI is a specialist clinical psychology service in Perth, Western Australia. Their website includes several self-help tools and resources under the section “Looking After Yourself”. The materials include workbooks, worksheets, and psychoeducation materials for a range of diagnoses, including anxiety, depression, panic disorder, and disordered eating. They also include materials targeting transdiagnostic health-related behaviors, like sleep, distress tolerance, worry and rumination, and perfectionism. The resources are freely available to download online (https://www.cci.health.wa.gov.au/Resources/Looking-After-Yourself)
- Treatments That Work Series: Oxford University Press publishes a series of treatment manuals and patient workbooks based on evidence-based treatments for a series of disorders (e.g., anxiety, depression, chronic pain) and transdiagnostic factors (e.g., stress). The workbooks include psychoeducation material, exercises, and worksheets to teach coping skills.
- e-couch: e-couch is an online, interactive self-help program which provides evidence-based information to help users understand and manage symptoms of common mental disorders. e-couch offers five programs: Depression, Anxiety & Worry, Social Anxiety, Divorce & Separation and Loss & Bereavement. Each program includes information, as self-help modules with exercises and workbooks. E-couch has been studied in cluster-randomized trials and randomized controlled trials within schools (Powell et al., 2020). More information on e-couch can be found online (https://ecouch.com.au/).
- IntelliCare: IntelliCare is a suite of apps developed by Northwestern University’s Center for Behavioral Intervention Technologies (CBITs). The apps are all meant to help people with depression, anxiety, and stress. IntelliCare apps were found to reduce depression and anxiety symptoms in randomized controlled trials (Mohr et al., 2019; Mohr et al., 2017). IntelliCare apps include:
- The Hub: A home app which allows users to track progress and recommends additional apps to download based on the individual’s goals.
- Daily Feats: Celebrates user accomplishments and daily activities
- Thought Challenger: Teaches cognitive restructuring skills through a step-by-step process.
- My Mantra: Allows users to create meaningful mantras and add virtual photos to serve as encouragement and motivation throughout the day.
- Day to Day: Encourages application of new skills each day, including gratitude, problem solving, and cognitive restructuring.
- Worry Knot: Worry Knot provides strategies and techniques to help manage worry.
- More information on the IntelliCare apps can be found online (https://www.adaptive-health.com/intellicare)
- SuperBetter: SuperBetter is an app and website designed to apply positive psychology principles, social interaction, and “gameful” design, aspects of game play like optimism, creativity, courage, and determination, to personal life challenges. App users are able to choose between a multitude of modules that tap into different skills (e.g., cognitive restructuring, behavioral activation, expressive writing). SuperBetter was found to be effective in reducing depression symptoms in a randomized-controlled trial (Roepke et al., 2015).
- MoodKit: MoodKit guides users through modules based on principles of CBT: behavioral activation, cognitive restructuring, mood monitoring, and journaling. MoodKit was found to be effective at reducing depression symptoms in a randomized trail (Bakker et al., 2018). MoodKit is available for download on the Apple App Store for a one-time fee of $4.99.
- Beating the Blues: Beating the Blues is an online CBT program for individuals with depression and anxiety. The program includes exercises and information to allow users to learn about and apply CBT principles. Beating the Blues was found to be effective at reducing depressions symptoms in a randomized-controlled trial (Forand et al., 2018). Beating the Blues is available online (https://www.beatingtheblues.co.uk/) for a one-time fee of £59.95 ($78.28).
- Moodgym: Moodgym is an interactive web-based program designed to provide information about and skills to cope with anxiety, depression, and stress. It covers many CBT principles including cognitive restructuring, behavioral activation, and problem-solving techniques over the course of 5 modules: Feelings, Thoughts, Unwarping, Destressing, and Relationships. Along with the modules, the program offers a “workbook” for quizzes, exercises, and journal entries. Moodgym was found to be effective at reducing depression and anxiety symptoms in a meta-analysis of Moodgym studies (Twomey & O’Reilly, 2017). Moodgym is available online (https://moodgym.com.au/) for a 12-month subscription fee of $29.95.
For children and adolescents
- Coping Cat: Coping Cat is a workbook with computer-assisted programs tailored for children with anxiety. The workbook is based in CBT and contains 4 major components: Understanding and recognizing reactions to anxiety, thoughts and feelings in anxious situations, plans for effective coping, and evaluating performance and self-reinforcement. Coping Cat is designed for ages 7-13, but there is also an adolescent version (the C.A.T Project) for ages 14-17. In a meta-analysis of randomized-controlled studies, Coping Cat was found to be effective at reducing anxiety symptoms (Lenz, 2015).
- New Harbinger Instant Help Books: New Harbinger publishes a series of “instant help” books for teens, including books for anxiety, emotion regulation, mindfulness, self-esteem, and others. The books incorporate aspects of evidence-based programs, including CBT, dialectical behavior therapy, and acceptance and commitment therapy. These can be found online at https://www.newharbinger.com/about-us/instant-help/
Summary and Conclusion
In the context of our current mental health system and level of public health burden, LITs may serve as a useful tool for engaging patients prior to entering the therapy office and providing a resource while they may have to wait weeks or months for therapy. There is a growing body of literature that supports the efficacy of LITs even with little or no guidance from a professional. Current practice appears to be receiving no intervention or few resources while on a treatment waiting list, and this can be detrimental for patients. Rather, suggesting LITs may allow patients to initiate the treatment process, learn about therapy tools, coping skills, and other aspects of evidence-based practice prior to their time in therapy.
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