March/April 2015 Issue

Behavioral Health Technologies: Clinician Extenders
By Sue Coyle, MSW
Social Work Today
Vol. 15 No. 2 P. 16

The Center for Technology and Behavioral Health is researching, developing, and implementing effective interventions that promote behavior change and expand access to those tools inside and outside systems of care.

The link between behavioral health care and technology is nothing new. Sarah Moore, PhD, LCSW, senior researcher at the Center for Comprehensive Pain Management & Palliative Care in Pennington, NJ, and a consultant for the Center for Technology and Behavioral Health (CTBH) in New Hampshire recalls the use of technology in her work with children with autism spectrum disorders decades ago. "This was in the '90s," Moore says, "before most of us had cellphones. The children had handheld devices to help them communicate."

And Sarah Lord, PhD, director of the Dissemination and Implementation Core at CTBH, remembers the first tools she worked on when entering the field of behavioral health technology 16 years ago. "When I started, the technology was in its infancy. It involved developing interactive CD-ROMs."

Today, the technology has changed a bit from CD-ROMs to interactive websites and mobile applications, but the intent is the same: to help further behavioral health treatment. "Technology will be a clinician extender," Moore says.
Working to make that statement a reality are innovators such as Moore and Lord and many others at CTBH.

The Benefits
Before glimpsing the work being done and the tools being developed at and through CTBH, it is important to understand why behavioral health technology is and will continue to be a valuable asset to behavioral health treatment. For one, the varying tools provide clinicians with support to expand their services.

"I believe that current social work practitioners have a growing pressure to be both generalists and specialists in their chosen fields," says Joelle Ferron, PhD, MSW, an adjunct assistant research professor in the department of psychiatry at the Geisel School of Medicine at Dartmouth College and an investigator at CTBH. "And increasingly, both practitioners and clients are approaching the Internet and mobile applications for answers to questions about best practices and the most up-to-date knowledge. I see most of the work that I do as a resource for clinicians and their clients—so clinicians do not have to know all the cutting-edge information in smoking cessation research, but can access a resource that informs and motivates their clients to use treatments that work."

Lisa Marsch, PhD, director of CTBH, agrees, citing the need for additional resources and information as one of the reasons she entered the behavioral health technology field. "There are often really effective interventions that can promote behavior change, but there are so many challenges to pushing … approaches that work," Marsch says.

For clients, the technology creates greater access. A large number of individuals in the United States with substance use and mental health issues are not in our systems of care, Marsch says. Different tools and technological approaches can help change that.

Take, for example, individuals struggling with chronic pain. "People with chronic pain are incredibly isolated," Moore says, explaining that many are physically unable to attend in-person treatment or support groups, even when such services are as few as two blocks away. "Technology is an amazing tool that builds communities for those who are unable to connect in person."

Similarly, Moore describes how technology can help clinicians connect with adolescents struggling with opioid addiction. "We can literally meet the kids where they are. They are buried in their online social networks. Technology gives us the opportunity to help shape the choices to, for example, use or not use."
In connecting with adolescents and adults technologically, clinicians also have the chance to ease more reticent clients into sharing. "People have many different comfort levels of sharing intimate details of their life," Moore says. "To have the opportunity to talk with peers in a remote way could be amazing. The isolation would be so easily remediated."

The Center
A key factor in maximizing the benefits of behavioral health technology is having a place that works to create, implement, and evaluate such tools; CTBH is just such a place.

Funded by the National Institute on Drug Abuse, as well as other federal departments and institutes, CTBH strives to promote research and innovation that will transform behavioral health treatment. For professionals such as Ferron, CTBH provides great opportunities. "The Center offers comprehensive research support for investigators," Ferron says. "There are monthly seminars, a network of experts in technology, and pilot grant monies for new projects that support growth. I have been a recipient of a pilot grant and that funding was critical to my current development of a smoking cessation mobile application for adults with severe mental illness."

One of the most impressive aspects of CTBH is its integrative/collaborative approach. Professionals from a variety of backgrounds work together in the research and development processes—connecting clinicians who may know a great deal about direct service, treatment models and research with those who can manufacture tools, Moore explains. "[Through CTBH] the people who have a lot of the evidence-based content on substance abuse and mental illness are joining forces with engineers," she says.

"We work with computer scientists; we work with graphic designers and marketers and programming professionals," Lord adds. "And we here are psychologists and psychiatrists and anthropologists. We all bring something—a lens—that hopefully carries through into the products."

For instance, graphic designers and marketers help make the tools more desirable for users. "We're trying to use strategies that are used in other areas of business, be it colors and fonts or interactivity, to make the tools personally relevant," Lord says.
Another vital collaborator? The clients. "It's pro forma to engage the end users in the early stages [of development] through the entire process," Moore says. "It's really empowering, a very exciting development process."

And to further maximize the effectiveness of CTBH's work, it is not relegated to one location. While CTBH is based in New Hampshire, research is completed throughout the country and the world. "The majority of our work is not done in the Dartmouth community," Marsch says. "We have a wonderful team all over the country. We have a few international projects."

Research and Development
The projects being completed by the teams at CTBH vary greatly. Ferron is focused on smoking cessation. "I have been working with Mary Brunette, MD, on the development and testing of a Web-based motivational support program to help people with mental illness engage in smoking cessation treatment," Ferron says. "Over the past few years, I have also begun developing a mobile application to help these same individuals quit smoking and remain abstinent."

Moore, as a consultant, has contributed to several projects, including a program review of technology-based interventions for substance abuse, as well as the construction of a "roadmap."

"The idea of the roadmap," Moore says, "is to help others implement Web-based tools into community-based/real world settings. [We are developing] an implementation roadmap or guidelines for a mobile recovery support app." Lord is involved in both programs.

With Marsch, Moore is also working on a project to develop a Web-based tool for individuals with chronic pain who are opioid treated.

Additional research spans all populations. "There are multimedia games for kids focusing on prevention," Marsch says. "[There are] tools for people with HIV and all kinds of populations. We've been heavily focused on developing systems that can be available to be responses to whatever needs patients may have around depression, trauma, drinking. It's exciting."

Implementation
An important part of development is implementation and analysis. Without it, there is no way to know, or prove, that a tool is effective. This step, however, is one that some (outside of CTBH) are apt to skip. "There's an enthusiasm to get the tools into the field," Lord says. "Technology advances really quickly and there's a lot of energy behind it. It's kind of sexy. People want to start using it. But they are quick to use it before they know that there's benefit."

Lord prefers to ensure that the tool will be as useful as possible to the clinicians and clients. "We try to identify early on what the barriers to implementation would be, so we can come up with strategies to overcome those barriers and strategies to facilitate implementation of these tools in different settings," Lord says.

"You have to develop something that is going to be beneficial for clinicians and not create more work for them. If it's something that creates more work, it's going to be dead in the water," Lord continues. "As you develop these tools, you need to get feedback from clients, from clinicians, and from leadership around how best to develop these tools in ways that can be beneficial.

"We look at what kind of information [the clinician] would like to actually help guide in the care of clients. That could be presentation of different types of data that are collected from the various tools, how often the clients are using the tools, and the clients' perceptions and ratings of the tools."

The clinicians aren't the only ones they look to for implementation answers. The clients are equally as important. "Everything that we develop, we are developing with clients or whoever the end users are going to be in mind. Everything that we develop is user centric," Lord says.

"Sustained engagement is an important question that a lot of us are focused on. How do we make it initially engaging but also something folks would keep turning to? That's really important."

Barriers
In doing the implementation and analysis, researchers often do find barriers—but not necessarily the one(s) many initially consider.

Resistance, for example, is a topic often discussed in conjunction with advancing technology. And while some resistance does exist, it is not pervasive. "Some people worry that technology could replace their jobs," Moore says. "But good clinical work is never going to be outsourced by a computer, and there does not seem to be a pattern of reluctance [among clinicians] in my experience." Moore reports the opposite, in fact, stating that clinicians are often eager to use the tools at hand.

The same can be said for clients, provided tool development is appropriate. "If you develop something that is really relevant and has value to the end user, you will not see increased skepticism," Marsch says. "We work with people with active schizophrenia, who are hearing voices. We develop tools with very linear paths and concrete content." For older adults—a population one might not associate with social media—the developers work to create tools that may not look the same as Facebook and Twitter but still connect. "They welcome social media, especially if they aren't able to get out of the house. They have a network now and people really welcome that," Marsch says.

What, then, are the barriers to continued technological development? "Some of the barriers include common sense ones, such as a lack of awareness of the research," Lord says. "We're not always as good as researchers at translating or conveying the information on research to folks other than ourselves."

Another barrier is technology access. "There is still some disparity in terms of access, be it access to good Internet connections, wireless technology, or smartphones," Lord adds.

Moore agrees, citing a project reliant on a mobile phone. "A lot of the programs had not thought of the fact that many people did not have smartphones. The folks without the phones were feeling very left out."

And then there is time. "Technology develops ahead of the science," Lord says. "That is a challenge that we are constantly up against. So we're thinking about how we can adapt our research models to keep up with how quickly technology advances. We are constantly focusing on emerging research models that we can use to test these tools more quickly, before the technology gets so far ahead and changes. It is a dynamic field," she adds.

The Future
With such a thorough and verdant field of research being completed at CTBH, it's difficult not to look to the future and what may be next. Ferron, Marsch, Lord, and Moore are all enthusiastic about where the research will lead them and their cohorts.

"Right now, we see a lot of great programming that integrates sensors with smartphones," Ferron says. "For example my CTBH pilot grant focused on an electronic cigarette pack that communicated via Bluetooth to an application on the client's smartphone. When the user opened the electronic cigarette pack, the phone would [send a message asking the user] to answer questions about their moods and thoughts about smoking. Similarly, many physical activity sensors are mass marketed. We know that they are socially acceptable but we don't know the impact. I'm excited to see how these interventions develop to increase targeted behavioral change."

"One thing I am particularly excited about is more integrated tools," Marsch says. "There's a lot of exciting work focused on very specific topics. There is a tool for depression, for anxiety, etc. But a lot of the fundamental aspects of how these things work apply to all different kinds of problems."

And on a more general scale, Moore is excited by the possibilities for research and development that exist within CTBH, noting that real genius comes from great curiosity. "That's what's happening at the Center for Technology and Behavioral Health," she says.