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Annual Review of Cybertherapy and Telemedicine 2012

B.K. Wiederhold and G. Riva (Eds.)
IOS Press, 2012
2012 Interactive Media Institute and IOS Press. All rights reserved.
doi:10.3233/978-1-61499-121-2-32

Adapting Computerized Treatments Into

Traditional Psychotherapy For Depression
a

James OVERHOLSERa,1
Case Western Reserve University, Cleveland Ohio USA

Abstract. Recent developments in technology have helped to improve the process

of psychotherapy. Unfortunately, many therapists lack the computer skills or
financial resources needed for the newest technology. Nonetheless, even basic
advances in technology may help to improve the treatment of depression. Method:
The literature is reviewed for journal articles on the treatment of depression
published during the past seven years in which treatments have been guided by
technology. Results: Six novel findings are summarized that may be helpful even
when the therapist lacks skill or resources for advanced technology. 1) The
efficient assessment of depression can be facilitated by technology, whether using
standardized measures or simple daily ratings of mood. 2) Technology tools can be
used to send semi-automated daily reminders to help clients develop more adaptive
habits in thoughts or actions. 3) Depressed clients can begin to confront their
negative view of self, often triggered by some form of loss, failure, or rejection,
whether real, imagined, or anticipated. 4) Clients can confront their problems
through therapeutic dialogue, whether conducted in person, over the telephone, or
via video conference. 5) Clients can use writing assignments to identify, label,
explore and express their thoughts and feelings. These writing assignments can be
conducted via paper, email, or internet forms. 6) Clients value rapport with a
therapist, and this bond seems important to ensure participation and adherence
with treatment. Conclusion: Even low-tech therapists can strengthen the treatment
of depression using basic technology tools to replace, extend, or supplement
traditional sessions. However, it is important to protect the rapport needed for
sustained participation in therapy.
Keywords. Depression, Psychotherapy, Technology

Introduction
Recent developments in technology have helped to improve the process of
psychotherapy. Technology-assisted therapy has included virtual reality exposure
simulations, internet web sites with psycho-educational resources, dialogue over videoconferencing, or daily emails with a therapist. Some computer applications can allow
for personalized experiences that feel vivid yet safer than other options.
Technology has improved tremendously over the past 20 years. All therapists and
most clients now rely on computers, email, internet searches, and text messaging.
However, some therapists may lack the computer skills or financial resources needed
for the newest technology. More mature therapists may have been raised (personally
and professionally) before the boon of technology. It may not be second-nature to use a
1

Corresponding Author: James Overholser; E-mail: overholser@case.edu.

J. Overholser / Adapting Computerized Treatments into Traditional Psychotherapy for Depression

33

smart phone for email and other applications. Some clients lack education, training,
computer savvy, or personal finances needed to remain current with the latest
technology. Some older adults do not use computers or the internet except on an
infrequent basis. In addition, many clients are struggling with the weak economy,
widespread unemployment, and risk of home foreclosure (27). Suddenly home access
to the internet may be a luxury that cannot be afforded.
It is hoped that even basic advances in technology may help to improve the
treatment of depression. Therefore, the present review will seek to identify strategic
changes in therapy that have been learned through the latest technology-assisted forms
of treatment. The goal is to identify various goals for therapy or mechanisms of change
that might be adapted for use even when the therapist does not rely extensively on
computers, internet sites, or virtual-reality technology.
1. Method
The psychotherapy literature is reviewed for journal articles on the treatment of
depression published during the past seven years in which treatments have been guided
by technology. Although the primary focus will be on studies pertaining to the
treatment of depression, the review will also include several useful studies on the
treatment of anxiety disorders or other forms of mental illness. A comprehensive search
was used to find all recent journal articles. PsychInfo, PsychArticles, and Google
Scholar were the search engines used to identify the latest publications in the field.
Although the review is focused articles published during the past 7 years, where
relevant, the review will extend further back for a comprehensive review.
2. Results
After an extensive review of the published literature, six novel findings were identified
that could be adapted onto more traditional forms of psychotherapy for depression. The
six strategies are summarized that may be helpful even when the therapist lacks skill or
resources for advanced technology.
2.1. Conduct an Efficient Assessment of Depressive Symptoms
The assessment of depression can be facilitated by technology, whether using
standardized measures or simple daily ratings of mood. A simple framework can guide
the assessment to include the "ABC'S of symptomatology": (A) Affective reactions,
(B) Behavior changes, (C) Cognitive distortions, and (S) Social functioning (26).
Assessment strategies can help increase awareness of emotional reactions. Using
mobile phone applications, clients can report their mood several times a day for one
month, and record their mood and negative cognitions (24). Even simple ratings of
mood can be quite useful to guide therapy and monitor progress (34). Clients can learn
to record their mood and daily activities (10), and begin to identify patterns in daily
fluctuations of depressive symptoms.
2.2. Help clients to develop adaptive behaviors
Most forms of technology provide a fair amount of structure. Online educational
materials can be used to enhance a person's knowledge of common symptoms and

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J. Overholser / Adapting Computerized Treatments into Traditional Psychotherapy for Depression

various treatment options (9). Technology tools can be used to send semi-automated
daily reminders to clients to help them develop more adaptive habits in their thoughts
or actions. Daily reminder notes can be sent via email or text messages to promote
adherence to therapy and cooperation with behavioral activities between sessions.
Behavioral activation strategies can be easily incorporated into online treatments (22).
2.3. Cultivate effective problem-solving skills
Problem-solving therapy can provide a simple framework for psychotherapy sessions.
Many depressed clients have struggled because of recent stressful events. They may not
know how to respond effectively, or they may be limited by maladaptive habitual
responses. Brief, structured training in problem-solving skills can be effective in the
treatment of depression (11), and has been more effective than many other types of
treatment (20). Even when provided through a training videotape, problem-solving
training can help to reduce depression and suicide risk (13).
2.4. Restructure negative attitudes and pessimistic expectations
For most depressed clients, cognitive restructuring is essential for effective therapy.
Clients can be helped to identify, clarify, challenge, and change negative interpretations,
attributions, and expectations. Internet modules (completing one module each week for
5 weeks) can be used to increase the person's awareness of negative automatic thoughts
and to confront and change these negative attitudes (6). Computerized therapy can help
clients to reduce tendencies for a negative attributional style (30).
2.5. Use writing activities to explore and express negative emotions
A therapist can use a series of written assignments structured to help clients (a) identify,
(b) label, (c) explore and (d) express their thoughts and feelings. These writing
assignments can be conducted via paper, email, or internet forms. A therapist can
develop a series of templates that guide the client through thoughts and recollections.
The client's responses can be emailed back to the therapist once a week or more often.
Clients can be guided through a series of writing projects, to explore positive memories
and move forward with a more positive attitude (35).
2.6. Protect the therapeutic relationship
Clients value rapport with a therapist, and this bond seems important to ensure
participation and adherence with treatment. Without a sound therapeutic alliance,
therapy is unlikely to be successful (28). An inquisitive exchange of questions usually
guides the more productive therapy sessions (25). Even though weekly telephone calls
from a therapist do not enhance the potency of internet treatment for depression (12),
clients tend to drop out from internet based treatments because of the lack of face-toface contact as well as other concerns (8, 17). Computerized treatments should be
designed to extend, not replace, the role of the therapist (1, 29, 33). Computer therapy
with support from a therapist has been found to be much more effective than computer
therapy without personal support (3, 5, 31). Pre-scheduled telephone contacts can help
to supplement the computerized interventions (19). In addition, clients tend to prefer
working with therapists who self-disclose issues about their own life and concerns (18).

J. Overholser / Adapting Computerized Treatments into Traditional Psychotherapy for Depression

35

3. Conclusions
Even low-tech therapists can strengthen the treatment of depression using basic
technology tools to replace, extend, or supplement traditional sessions. Computerized
forms of treatment can provide many novel strategies for education, training,
supervision and therapeutic change (4). The latest treatments can provide novel
strategies, simple reminders, and vivid examples. Internet-based treatments are valued
as convenient and anonymous (16), helpful, logical, and useful (7). Similar to weekly
scheduled outpatient sessions, clients can be encouraged to complete one module each
week (24).
There are many skilled therapists who were raised after the technology boom who
may benefit from strategies for therapy that can be enhanced through simple
technology tools. Some clients may need computer training (36). Ideally, computerized
treatments should avoid becoming overly complicated in the technology sophistication
needed (2). Research has found that internet-based treatments can be effective for
adults over age 50 (32).
With the use of technology, it can become easier to provide treatment to clients in
rural settings, as well as patients who have medical problems that might limit their
mobility (23). Internet forms of therapy can be effective, convenient and affordable (14,
15). Computer assisted therapy is viewed as logical, useful, and acceptable by most
clients. With adequate computer safety features, Internet therapies can be convenient
and confidential (21).

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