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Cognitive and Behavioral Practice 22 (2015) 359-366
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Commentary

Technology-Based Interventions and Reducing the Burdens of Mental Illness:

Perspectives and Comments on the Special Series
Alan E. Kazdin, Yale University

This series illustrates excellent advances in the use of technology to deliver psychological treatments. My comments place technology-based
treatments in the context of current evidence-based psychotherapies and focus on the extent to which technology can expand the reach of
psychosocial interventions. I discuss criteria for the development of novel treatment methods so that our interventions can reach
individuals who could profit from psychological services but who currently receive no formal help. Technology-based methods of delivery
have excellent benefits and as they continue to be evaluated it would be valuable not only to collect the usual outcome data for individual
clients but also to examine system-level outcomes to see whether our interventions in fact reach more of the underserved who are in need of
psychological services.

T HE use of technology in everyday life is remarkable.

Our social and nonsocial lives are dominated by
technology in some way, whether we are talking, texting,
listening to music, reading, watching, sharing, exercising,
playing games, handling our calendar and to-do list, and
monitoring (e.g., our pets, babysitters, eating, sleeping,
steps we take walking), and more. All is made easy with
our smart phones, watches, wristbands, and bracelets and
cross-platform computing that goes with them. These are
quickly moving to brilliant phones and watches, and smart
clothing that read physiological states as markers for
psychological states. Robotics are in the mix as they play a
role in so many ways and already have entered into
physical and mental health care (e.g., Rabbitt, Kazdin &
Scassellati, 2015). People now over 25 years of age soon
will be telling stories, revealing their “age,” of what it was
like when there were laptops. Like many who tell stories of
how things were, they will get vacuous nods of feigned
interest about their stories and then annoying questions
like, “Wasn’t laptop a kind of dancing?” With young
children in the home, technology is routine if for no other
Keywords: Technology; Interventions; Treat mental illness
1077-7229/12/© 2015 Association for Behavioral and Cognitive
Therapies. Published by Elsevier Ltd. All rights reserved.
reason than Skype experiences with distant relatives.
Increasingly accidental phone calls are made by young
children handling a smart phone. And it is not a shock to
learn that a 9-month-old infant accidentally rented a car
online (Kim, 2015). The overall point is clear. Technology
even if at some early stage, is central to our everyday lives
and awaits newborns as they enter the world. (Actually,
there are many apps parents can use to monitor and bond
with the fetus so the fetus can begin exposure to technology
early.)
The series of articles illustrates different types and uses
of technology to deliver psychological treatment. This
series illustrates advances in treatment by researchers
whose contributions to evidence-based treatments are
already outstanding. The articles encompass diverse
technologies and clinical foci and highlight research,
practical, and clinical issues that the applications raise. Use
of technology in general and for treatment in particular
raises novel ethical, legal, and regulatory issues and these
too are covered in the series. As we learn from the series, the
use of technology in mental and physical health care is
not new (Comer, 2015–this issue). Telemedicine, telehealth,
and telepsychiatry have been around for a long time in some
form—at least 40 years (www.americantelemed.org/). At the
same time, technology has made qualitative leaps in the past
few years and these are likely to accelerate as many new
options in both hardware and software evolve and more
360
clinical assessment and treatment can be provided in real
time in the lives of the clients. My comments raise issues
about the extent to which technology will expand the reach
of psychosocial interventions and do so in palpable ways that
will reduce the burdens of mental illness.
Technology as a Way of Extending the Reach of
Therapy
Overview of the Challenge
Many of the articles underscore how technology will
extend treatment to reach more people or to reach
people in better ways. In principle and practice, online,
mobile, and other forms of technology-based treatment
can go anywhere as long as a client has access to the
equipment (e.g., phone, tablet) and to the Internet. The
reach is obviously a huge benefit and the range of
technologies that can deliver treatment adds to that. Yet,
will technology reach those people in need and meet key
features of the challenge of extending treatment in such a
way as to have impact on the burdens of mental illness?
There may be proof of concept studies (showing what
technology could do in principle), demonstration projects
(randomized controlled trials [RCTs] with meticulous
controls demonstrating the efficacy or effectiveness of
treatment), and the usual meta-analytic reviews showing
treatments are doing great, at least if effect size is the metric.
These steps with be the easy part and very much business as
usual. Yet, there are challenges that technology could
address well beyond what we are currently doing.
The broad challenge is reducing mental illness both at
the level of individuals and society. We begin with the
scope of clinical dysfunction in the population. In the U.S.
approximately 25% of children, adolescents, and adults in
the community meet criteria for at least one psychiatric
disorder (Kessler et al., 2009; Kessler & Wang, 2008). With
a U.S. population of approximately 320 million people,
that would amount to approximately 80 million people
currently with a psychiatric disorder at a given point in
time. Meeting criteria for a diagnosis may be a high bar to
use as a measure. Subclinical dysfunction and stress that
do not rise to that level may deserve attention as well.
Approximately 11% of the U.S. population experiences
serious psychological distress (Substance Abuse and Mental
Health Services Administration [SAMHSA], 2014a). This
distress encompasses problems with anxiety and mood and
is associated with increased risk for physical health
problems (e.g., cardiovascular disease, diabetes, arthritis,
cancer) and reduced life expectancy (Kiecolt-Glaser et al.,
2002; SAMHSA, 2014b).
Let us go beyond the U.S. for a moment because on a
worldwide basis, mental illness is prevalent, mostly
untreated, and on par with physical disease in terms of
impact. For example, in 2004, the burden of depressive
disorders (e.g., years of good health lost because of
Kazdin
disability) was ranked third among the list of mental and
physical diseases worldwide (World Federation for Mental
Health, 2011). By 2030, depression is projected to be the
number-one cause of disability, ahead of cardiovascular
disease, traffic accidents, chronic pulmonary disease, and
HIV/AIDS (World Health Organization [WHO], 2008).
Whether narrowly focused on the U.S. or world platform,
the need for services to treat and prevent dysfunction is
enormous.
The development of evidence-based psychotherapies
(EBPs) reflects a significant advance that could address
the treatment needs. Currently, over 340 evidence-based
psychosocial interventions have been identified, and the
list continues to grow (U.S. Department of Health and
Human Services [USDHHS], 2015). 1 There also exist novel
variations with an evidence base, including transtreatments
(e.g., unified and enhanced cognitive behavior therapy;
Barlow et al., 2011; Fairburn et al., 2013) and modular
treatments where a small set of components of EBPs can be
applied to the majority of referred cases (e.g., Weisz et al.,
2012). Along with treatment development have been major
efforts to disseminate these treatments so that they are used
in clinical practice, including dissemination via telehealth
(e.g., Karlin et al., 2010; Lindsay et al., 2015).
The vast majority of treatments, whether evidence-
based or not, transtreatments or modules, usually are
delivered by a now “standard” therapy model in which
treatment is provided one-to-one, in person, by a mental
health professional at a clinic, office, or larger health-care
facility. The model has been very successful, as witnessed
by the many EBPs developed in this fashion. Yet, we know
that among the many individuals in need of psychological
services, only a small portion (approximately 20% – 30%)
actually receive services (Kessler et al., 2005). And these
services include virtually any effort to remedy their problems,
leaving aside psychotherapy, not to mention EBPs.
The dominant model of treatment delivery is likely
to limit the impact of EBPs and dissemination efforts.
If all professionals providing services switched to EBPs
tomorrow and executed the treatments with fidelity, it
would not really affect the majority of individuals in need
of services. (Permit me to gloss over picky practical
obstacles [e.g., the majority of graduate training programs
in clinical psychology, counseling, social work, and
required internships rarely include EBPs] or tiny decisions
we would need to make [e.g., of the 340 plus interventions,
1
Different terms have been used to refer to psychotherapies with
evidence on their behalf including empirically validated treatments,
empirically supported treatments, evidence-based treatments, evidence-
based practice, and treatments that work. Evidence-based psychotherapy
is adopted here and will be used throughout. The term “evidence-based”
is in keeping with a broader movement that pervades many disciplines
(e.g., evidence-based medicine, public health, agriculture, law, social
work, social policy, among many others).
 Commentary: Technology to Reduce the Burdens of Mental Illness
which ones should we train?]). Let us assume all the
clinicians are practicing EBPs; the people in need of and
who actually receive care presumably would be receiving
better care. All to the good, of course, but not very helpful
for the untreated. The answer is not simply adding more
mental health professionals so there is a larger workforce
(Hoge et al., 2007). Mental health professionals in the U.S.
tend to be concentrated in urban areas, underrepresent the
diverse ethnic and cultural groups in need of treatment,
and underrepresent key areas of services (e.g., children,
elderly) that are needed. Adding more professionals to
administer treatment in the dominant model is not likely to
reach the millions in need.
There are many barriers to seeking, providing, and
receiving treatment. One of the barriers that we as
professionals and scientists may control is the model of
treatment delivery. The dominant model of delivering
treatment will not be sufficient by itself to reach most
people in need and reduce the burdens of mental illness.
This is not an argument “against” individual therapy.
There is no “argument”; there is only the realization that
if the goal is to reduce the burdens of mental illness at a
personal level (e.g., reaching many individuals) and social
level (e.g., having population impact) in the U.S. and of
course worldwide, much more is needed than developing
and disseminating EBPs delivered in the dominant model.
New Ways to Deliver Treatment
Perhaps technology can rescue this situation or at least
be a significant part of the solution. In some instances,
technological applications of treatment continue key
features of the dominant model, with one-on-one individual
treatments with a mental health professional. The advan-
tage here includes extending treatment to remote locales
(e.g., rural areas) that might not otherwise have resources.
And of course, other applications require no therapists at all
(e.g., self-help) and there are many variations in between.
Many applications of treatment that draw on technology
are extensions of EBPs and investigators have modified the
treatments so they can be provided online or aided by
technology in some other way. This approach begins with
existing treatments and seeks different ways of delivering
them. A complementary approach might be considered as
well. Rather than beginning with treatments, we might
begin by considering the characteristics of treatment that
are needed to reach people in need of psychological
services. Consider for a moment criteria to guide our
treatment development with this goal in mind. For starters,
I believe we need treatments that have these characteristics:
• Reach: The ability to serve many individuals,
including those who ordinarily would not seek or
receive treatment;
361
• Scalability: The capacity to be applied on a large
scale or at least larger scale than individual therapy;
• Affordability: Relatively low cost compared to the
usual treatment;
• Convenience: More seamless integration of the
intervention with an individual’s everyday life;
• Expansion of settings where interventions are provid-
ed: Bring interventions to locales and everyday settings
where people in need are likely to participate or attend
already;
• Acceptability to consumers (potential clients and as
relevant therapists): Views that the treatment is
appropriate and reasonable as an intervention;
• Flexibility: Options or choices for how services are
delivered and provided because there will be no single
model of delivery that will be suitable for all; and
• Use of a nonprofessional workforce: Increase the
number of providers who can deliver treatment.
Consider how technology maps on to some of these
criteria. Many of the criteria are interrelated and so I will
highlight them together. First, reach and scalability may be a
huge benefit of technology-based interventions. A promising
example conveys the potential in relation to cigarette
smoking, often a target of psychological interventions. In
one program, a Web-based intervention for smoking
cessation was developed in English and Spanish (Muñoz
et al., 2006). An individualized, password-protected Website
provided access to the smoking cessation intervention to
consenting eligible individuals and was used to obtain
assessment data throughout the intervention. Initial applica-
tions of the program reached more than 4,000 smokers from
74 countries and was carefully evaluated (e.g., RCT, follow-up
assessments, and impact on smoking-termination rates).
A recent extension of the online program conveys reach
and scalability even better. The program, again available in
Spanish and English, was visited by over 290,000 individuals
from 168 countries (Muñoz et al., in press). Data reported for
over 7,000 participants revealed smoking quit rates ranging
from 39% to 50% at different points of assessment up to an
18-month follow-up. This particular program advanced the
notion of Massive Open Online Interventions (MOOI) as a
model for reaching many people in need of services and for a
variety of clinical problems. This model follows the familiar
Massive Open Online Course (MOOC) system that provides
open access to college and university courses on the Web.
Another online program focuses on depression
(MoodGym, https://moodgym.anu.edu.au/) and notes
explicitly it is not designed to treat clinical levels of
dysfunction but rather to provide information and skill
development (using cognitive behavioral procedures).
The program is free and available worldwide in several
different languages. Evidence indicated the program is no
more effective than providing information alone, both of
362
which surpassed an attention-placebo control (Christensen,
Griffiths & Jorm, 2004). I mention the program here
because of its reach. Since its inception in 2004, the Website
notes that there are over 850,000 registered users worldwide
and with many countries using the program including
Australia (where the program was developed), China,
Denmark, Finland, the Netherlands, and Norway.
In mentioning reach, comments are warranted for
especially underserved populations. I note “especially” in
the context of having mentioned that in the U.S. the vast
majority of individuals in need of services are under-
served. However, subgroups within our populations have
special difficulties in receiving services. These include
individuals of ethnic minorities, children, the elderly,
individuals in lower income groups, single parents, and
individuals with dysfunction associated with traumatic
experiences (e.g., child abuse, domestic violence, and
sexual abuse). My list is not exhaustive but need not be to
make the point. Does technology reach the special
populations that suffer from higher rates of neglect
than the general population? Yes, in some cases. Rural
populations can be better served by online treatments,
apps, telepsychiatry, and the like. Yet it is useful to begin
in the conceptualization and development of treatment
by considering the means through which treatment will
reach individuals who are not otherwise served.
Affordability, convenience, and expansion of settings
are other criteria I have suggested as a point of departure
for designing or evaluating treatments, and each of these
can be readily achieved with technology. Technology-
based treatments often do not require a mental health
professional or require reduced time with one. Many
online versions of treatment can be put into place and
made available to all seekers. Once a treatment is
developed, it can be accessed as needed. Also, if help is
needed by the client, this may not require a mental health
professional but an individual trained to help the client
traverse the activities promoted by the Website. If a
problem emerges that is clinical rather than computer
troubleshooting, a professional can be available.
Convenience and expansion of settings occur when
individuals can receive treatments in their homes or on
their smart phones, tablets, and so on as they negotiate
their daily lives. Online treatments of course can be
accessed 24/7 and that is flexibility in the ideal extreme
perhaps. That same 24/7 availability encompasses expansion
of settings, another criterion I mentioned. By expansion of
settings I had meant bringing treatments to individuals
rather than bringing individuals to treatment (e.g., clinic).
Online interventions and software apps are among inter-
ventions that do exactly that.
Affordability, convenience, and expansion of settings
have excellent models in physical health care (Kazdin &
Rabbitt, 2013; Rotheram-Borus, Swendeman & Chorpita,
Kazdin
2012). Medical services are available in shopping malls and
drug stores or local urgent-care facilities, all with back-up as
needed for serious medical conditions that may be
identified. If we are going to reach people, we must be
able to—well—reach people and not ask them to come into
a clinic. Technology offers many opportunities for that.
Acceptability of treatment may be a strength of
technology-based treatment. Treatment acceptability
refers to judgments by laypersons, clients, and others of
whether the intervention procedures are appropriate,
fair, and reasonable for the clinical problem (Kazdin,
2013). Individuals (e.g., children, parents, mental health
workers) can readily distinguish treatment procedures in
terms of their acceptability and independently of outcomes
those treatments produce (e.g., Kazdin, 2000; Kazdin,
French & Sherick, 1981). Acceptability influences the
extent to which clients are likely to seek treatment, adhere
to treatment once they begin, and perceive barriers to
participation in that treatment (e.g., Kazdin & Whitley,
2006; Reimers et al., 1992). Acceptability also influences the
likelihood that mental health professionals will refer cases
to a given treatment as well as the quality and fidelity with
which they implement a particular treatment (e.g., Allinder
& Oats, 1997; Arndorfer, Allen & Aljazireh, 1999). The
acceptability of alternative ways of administering treatments
using technology is not well studied. Yet, one can assume
from how often individuals routinely use technology that
this will be an increasingly natural and acceptable way of
obtaining services. We do not need to go to stores to shop
(e.g., Amazon) or to chat with our friends (e.g., texting,
Skype, FaceTime). We do not need to go to clinics to
receive mental health services!
Flexibility of delivery also is excellent among technology
options. Interventions can be delivered in many ways
(e.g., texting, apps, online) and people can select among the
options or will be able to as more of these develop. Treatment
can be scheduled in a fixed or flexible way and be delivered at
work, home, or in everyday life in real time. Contrast this with
the traditional and still dominant model of individual
therapy with a mental health professional where conve-
nience at best means meeting at an appointment time that
both parties have available. To provide services, we want
many options so that more clients can be reached and so that
options can match different circumstances (e.g., geograph-
ical, schedule, preferred mode of being connected).
Finally, I have noted expansion of the workforce by
increased used of nonprofessionals. This is a sensitive
issue professionally given natural interests in protecting
who can provide services and with what qualifications. We
know that lay individuals and counselors can effectively
administer mental health (and physical health) services
and that use of such individuals greatly expands the reach
of these services (Kazdin & Rabbitt, 2013; WHO, 2008).
For example, well-controlled studies have shown that lay
 Commentary: Technology to Reduce the Burdens of Mental Illness
individuals can deliver effective treatment for significant
clinical problems (e.g., depression, anxiety, and schizo-
phrenia; e.g., Balaji et al., 2012; Patel et al., 2010).
Technology-based interventions may partially skirt the
issue of who administers treatment. Many treatments are
self-help and so no mental health professional is needed.
Yet several of the computerized and mobile treatments
might well require some assistance. As we have seen from
articles in this series, the software carries the treatment
procedures and lay individuals may be needed to help
individuals use them. It is true of course that when lay
counselors are used, invariably back-up is needed so a
mental health professional is available to handle mental
health crises (e.g., suicide risk, more severe clinical
dysfunction than the program has been designed to
address). Using professional resources for back-up rather
than as the initial point of contact would be a major
change and could allow other criteria (e.g., reach,
scalability, affordability) to be met more readily. My
comments here do not pertain to eliminating mental
health professionals or their training. Rather, there is no
need to begin with the most expensive resource that is not
available to most as a first line of attack.
New and Not Just Improved
At this point, much of technology-based treatment
focuses on new ways of administering interventions.
Plainly, that is valuable because of the challenges I have
mentioned and our apparent inability to provide our
evidence-based and nonevidence treatments to people in
need. In psychotherapy research, treatment as usual
(TAU) is a familiar term to denote the interventions in
place at a particular clinic or in the community. Typically,
TAUs serve as control conditions to rigorously evaluate
the impact of some other treatment. In the world, TAU
actually is no treatment (i.e., what most people get most of
the time). Technology can go far to improve that situation.
To stretch our thinking of what technology can do, let us
go beyond improved ways of reaching people to entirely new
interventions. A useful distinction has been noted in a
discussion of the physical Internet, which is an active area of
work in industry, engineering, and manufacturing. 2 As one
2
The physical Internet refers to a way of transforming how physical
objects (e.g., manufactured goods) are transported, stored, supplied, and
used to achieve greater efficiency as well as sustainability. Achieving this
transformation requires collaboration and standardization of manufactur-
ing, shipping, retailing, regulating, and the movement of goods across
many boundaries (e.g., geographical, industry, proprietary). This is
referred to metaphorically as an Internet to emphasize the standardization
and communication that characterizes the more familiar digital Internet. In
manufacturing, there are enormous differences among industries,
companies, countries, and so on that limit efficiencies and these not only
influence costs, but also sustainability of resources and utilization of the
work force (see Montreuil, 2011; www.physicalinternetinitiative.org/.
363
researcher noted in that context, “It’s [the physical
internet] not about a better way of doing what you now
do. It’s about doing things you’ve never thought of doing
before” (Gue, as quoted in Wible, Mervis & Wigginton,
2014, p. 1106). The comment is instructive by keeping both
facets in mind. We want to do things better (e.g., deliver
therapy better, more broadly, with greater reach, and so
on). We also want to rethink all facets of treatment and what
technology offers that is not just novel ways of delivering
what we have available now.
The distinction is not dichotomous but sensitizes us to
options to consider and foster truly novel ways of helping
people that do not follow from standard treatments
(i.e., what we do now). For example, for both treatment
and prevention large-scale and fully automated and
individualized interventions can be designed to promote
exercise (e.g., Hurling et al., 2007). Also, for individuals
with stress, psychosocial symptoms, and impairment,
support programs could be made routinely available
and alleviate both mental and physical health problems
(e.g., Bouma et al., 2015). Or let us be much more ambitious.
A huge problem in physical and mental health care is
treatment adherence. For example, for major (and minor)
diseases getting individuals to follow through on treatment
(e.g., activities, taking medication, monitoring biological
states, getting follow-up checkups, filling and refilling
medication prescriptions) is an issue with direct impact on
disability and mortality (e.g., cardiovascular disease, cancer,
diabetes, HIV/AIDs). Psychological science with the use of
technology might be a perfect combination to address this
in pervasive ways that influence health. This would be one
example of going beyond doing what we are doing now.
Technology-based interventions that addressed a pervasive
limitation of many treatments for many diseases and
dysfunctions could change what we do and of course
would go well beyond diseases and dysfunction and address
lifestyle changes.
I raise the above real and hypothetical examples
merely to encourage us to begin with needs of society
and to think of new ways of reaching people, including
not just technology but the types of interventions that may
be provided. There are many ways of reducing mental
illness and its burdens in addition to psychotherapies and
the technology may be useful in providing those too (see
Kazdin & Blase, 2011; Kazdin & Rabbitt, 2013). We will
need a portfolio of models of delivering treatment
because of the diversity of individuals in need of services
and ways in which they may need to be reached.
Conclusions
Technological advances are changing the nature of
treatment and its delivery. Treatment can be “with us” full
time as we connect to the Web or if we downloaded the
program in some way, we do not need to be connected.
364
Perennial clinical-research concerns about treatment—any
treatment—emerge with technology-based treatments but
with new answers. For example, will therapeutic changes be
maintained after treatment is terminated? Maybe we do not
have to worry so much about that—there is no reason to
terminate treatment because maintenance programs and
treatment-related exercises can be accessed, activated, or
provided after a more intensive or concentrated period of
treatment has been completed. Some disorders and sources
of dysfunction are chronic, episodic, or low grade with
periodic blips (mini-episodes) that could use a little help
(e.g., during periods of stress). For these, we ought not to
even expect maintenance if treatment is given and ended.
Technology offers many models of maintenance that can
be assigned pro re nata. As another concern, what if people
drop out of treatment? Well they can drop back in as
needed and maybe we should worry about that less or
differently too.
The directions that therapeutic applications of technol-
ogy will take are hard to predict but exciting to imagine.
Technology development for medicine, space exploration,
astronomy, business and industry, and military, among
other domains, fuels continued advances. Psychosocial
interventions will profit from the advances. Even with what
we have now, amusing scenarios are easy to envision.
For example, we have smart cars that drive themselves.
Perhaps it will be only a little while before the public finds
these acceptable. Once smart cars are acceptable, a
psychologist and computer scientist no doubt will collaborate
to develop a module for that car that provides psychotherapy
of some kind (e.g., traditional talk therapy may be standard;
dialectical behavior therapy or mindfulness may be options
for a little extra cost, and at the luxury end there may be a
special comorbidity package that includes all EBPs and a
couple of TAUs). Perhaps the car will be able to detect
cues from the passenger (e.g., electrical, physiological, or
olfactory—now with sensors already in clothing) and based
on data derived from these sources, a warm and friendly
computer voice (while the car is self-driving) begins. (The
passenger gets to select the language, accent, and gender of
the voice.) The computer voice begins in a mellifluous and
comforting tone, “Sidney [name of the passenger], I can tell
you are tense. Are you still having problems with your [boss
at work, relationship, golf swing]? We have 12.37 minutes
until we at arrive at our destination; perhaps we could talk
about it or at least cover one self-defeating cognition.” We
are years away from a holographic therapist in the car but a
client could put on one of those helmet-mounted display
systems that fighter pilots use and have the image of a virtual
talking therapist right there! All the technology I note is
available now. I am not advocating because most people in
the world do not have cars and there is still social stigma,
including novel sources of that too. (I routinely get
disapproving looks when I wear my helmet-mounted
Kazdin
display system while I am driving.). I mention this merely
to convey possible qualitative changes that may be
forthcoming. Now we provide cognitive behavior therapy
by computer or Web. My frivolous example conveys a
different level that changes the scenarios of treatment even
more.
With the technology-based treatments we have now, it
would be helpful to expand how they are evaluated.
Rather than just therapy outcome, obviously important,
the benefits, costs, impact, and possible tradeoffs of
treatment might be given much more attention. There
are interesting possibilities that emerge if technology in
fact helps to scale up treatment. For example, it is possible
that attrition might be very high from a self-help online
treatment or treatment with minimal human assistance.
If attrition from some technological version of treatment
is as high as 50% or 75%, that might sound disastrous
(i.e., half or three quarters of people who start just quit!).
We need metrics that allow evaluation of treatment in a
more thoughtful way than merely looking at dropouts
or dropout percentages (leaving aside nuances such as
dropouts often show sudden treatment gains). For example,
if 500,000 accessed and receive treatment via some app in a
given year and 50% dropped out quickly, we have 250,000
who received treatment. Consider the “same” treatment
delivered in a way that reached 2,500 individuals in a year
but with no dropouts. We want to know of these differences
and look at cost-benefit and overall impact on the
population. Similarly, assume for a moment that a
computer-based treatment were slightly less effective than
that same treatment delivered by a mental health profes-
sional. (At this point, much of the evidence suggests the
treatments delivered in these different ways produce similar
outcomes.) A computer-based treatment might reach 1,000
times as many clients as an individually administered,
in-person therapy. The slightly reduced outcome effects—if
in fact that were the case—would not at all diminish the
importance and significance of reaching so many people in
need. We ought to keep in mind the challenge before us
and the unmet needs of society.
As I mentioned, a promise and hope of technological
advances in therapy are to extend treatment in ways that
surpass the traditional model of treatment, one-to-one,
in-person therapy, with a mental health professional. Clearly
that is already evident. Yet, it would be useful to be more
systematic in demonstrating what newer treatments are
accomplishing. Some of the articles in this series, including
mine, have hailed the potential of technology-based
treatment in reaching people in need, extending services,
and redressing the burdens of psychological dysfunctions,
broadly conceived. It would be an enormous contribution to
provide data to see if in fact we actually are accomplishing
any of this. For example, I mentioned that some subgroups
of our society are especially unlikely to receive services.
 Commentary: Technology to Reduce the Burdens of Mental Illness
Demonstrating that we in fact can reach more underserved
in general and special groups in particular would be a great
contribution. We already collaborate (e.g., with computer
scientists, artists, animation experts, media people) to
develop technology-based treatments. Perhaps we can
extend these collaborations (e.g., with public health, policy,
and population researchers) to incorporate system and
population-based measures. Are we reaching more people
in need and reducing the burdens of mental illness,
emergency room visits, utilization of health care, and so
on? We ought to draw on technology and collaborators not
only to deliver treatments in novel ways but also to measure
the impact as well.
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Address correspondence to Alan E. Kazdin, Ph.D., Department of Psychology,
2 Hillhouse Avenue, Yale University, New Haven, CT 06520-8205; e-mail
address: alan.kazdin@yale.edu
Received: April 7 2015
Accepted: April 23 2015
Available online 12 May 2015