Technological Advances in Cognitive-Behavioral Therapy and Clinical Practice: Challenges in an Evolving Field

Studies have shown that mental health clinicians across disciplines (psychiatry, psychology, social work, nursing) use cognitive-behavioral therapy (CBT) in their clinical practice more than any other treatment modality (1). CBT offers mental health clinicians a wide spectrum of relatively brief, cost-effective, and empirically supported treatments to provide effective mental health services to their clients. CBT is internationally recognized as a first-line, evidence-based treatment for a range of conditions, including anxiety disorders, mood disorders, and substance use disorders (2, 3).

Over the past three decades, the use of technology to deliver CBT has expanded into all aspects of the therapeutic process, including assessment; symptom and homework tracking; cognitive, behavioral, and functional skills training; and relapse prevention (4). Examples of technology innovations for CBT include online self-help tools, smartphone applications for skills practice and tracking (cognitive restructuring, behavioral activation), virtual reality (VR) programs for exposure therapy, and computer-based and Internet-based CBT (4).

Advances in CBT technology also aim to expand access to CBT among marginalized and diverse communities (5). Technology-assisted CBT can mitigate barriers to treatment utilization that often plague traditional CBT by eliminating transportation challenges for people in remote locations or with physical limitations, enhancing privacy, increasing the convenience and flexibility of scheduling, and improving engagement with youths (4, 6). However, these developments raise important methodological, legal, and ethical challenges that all mental health clinicians must consider. This brief report explores the challenges that emerge from technological advances in CBT in relation to clinical practice, specifically among marginalized populations.

Challenges to the Use of CBT Adaptations

As with the development of any new treatment, advances in CBT come with emerging challenges that are important to consider when delivering treatment and identifying areas for future research. Understanding and engaging these challenges is especially relevant for mental health clinicians, who have an ethical responsibility to maintain clinical practice standards consistent with their field’s code of ethics and values (e.g., National Association of Social Workers, American Nurses Association, American Psychiatric Association, and American Psychological Association); such challenges have the potential to compromise the underlying values of a clinician’s practice. The topic of technological advances is of particular importance, because the mental health field has rapidly become more reliant on the use of technology in response to the COVID-19 pandemic. We identified five key challenges and brief recommendations related to each challenge, a summary of which can be found in Table 1.

Challenge 1: The Therapeutic Alliance

Technology-delivered CBT often reduces and sometimes eliminates the role of clinicians in delivering treatment, which may compromise the development of a sound therapeutic alliance, a key element associated with enhanced treatment outcomes with CBT (7). The therapeutic relationship in CBT has been described as a fundamental principle based on collaboration and trust (7). It is within the context of this collaborative alliance that the client and clinician identify available options to address the client’s issues and work together to bring about changes that will improve the client’s quality of life.

Mental health clinicians, who are committed to building a collaborative therapeutic relationship to promote self-determination, are challenged by the limited research examining the therapeutic alliance across different versions of technology-assisted service delivery. One study of 48 individuals receiving Internet-based CBT for a past traumatic event found low to modest associations between the quality of the therapeutic alliance and treatment outcomes that were much lower than for traditional CBT (8). Another study found an equivalent quality of therapeutic alliance between Internet-based CBT and traditional face-to-face CBT treatment groups; the strength of the alliance in both groups predicted positive therapeutic outcomes (9). Similarly, a meta-analysis examining the therapeutic alliance within Internet-based psychotherapy found a small but significant effect between Internet-based psychotherapy and treatment outcomes, as well as a slightly larger effect between the therapeutic alliance and face-to-face psychotherapy outcomes (10). It is important to note that the meta-analysis did not focus solely on CBT but included other psychotherapeutic interventions as well.

Further research is essential to guide clinicians on how to achieve a sound therapeutic alliance when using technology-adapted CBT, whether alone or in combination with traditional CBT. In addition, more research is needed about the strength of the therapeutic alliance across different technology platforms and ways to preserve it. At present, clinicians can dedicate time, including time with colleagues and supervisors, to practice using different technology platforms and tools to improve self-efficacy, thereby mitigating a barrier to therapeutic rapport. Clinicians can also familiarize themselves with existing literature on the therapeutic alliance specific to the technology platform they plan to use. In addition, clinicians can focus on cultivating their core clinical practice skills for use with technology-based formats.

Challenge 2: Potential Fit for Diverse and Marginalized Populations

Technology-delivered CBT, particularly computer-delivered treatment, may warrant special consideration for clients with marginalized identities. For example, without face-to-face interactions, accurately assessing clients in terms of body language, eye contact, posture, grooming, and general appearance may be challenging, and this challenge may even hinder appropriate cultural and life-context considerations. Clients with suicidal behaviors may be at greater risk where suicide assessment and emergency intervention may be difficult to find or access (11). In addition, further research is needed to determine which groups are most likely to benefit from technology-delivered treatment. One study surveying licensed mental health professionals in the United States examined predictors of continued teletherapy use 1 year after the onset of the COVIID-19 pandemic and found that clients from rural areas, clients from younger and older adult age groups, clients utilizing Medicare, and clients with marginalized gender and religious or spiritual identities were more likely to continue teletherapy. In contrast, those of lower socioeconomic status, Medicaid beneficiaries, and those seeking couples or family therapy were found to be less likely to use teletherapy (12). These findings suggest that access to the Internet, secure housing, and child care may be important for the successful provision of teletherapy to clients.

Further, older clients and clients with intellectual disabilities may not possess strong technological literacy, although some results have shown that individuals from these groups are able to learn computer skills through effective training programs (13, 14). Technology adaptations may improve treatment access and outcomes for some individuals, especially during a time when traditional treatment is unavailable or limited. However, clinicians must first determine whether the use of technology is an appropriate fit for their client through assessment and knowledge of extant literature, and then determine the client’s readiness for use. In addition, clinicians must consider which forms of technology (e.g., clinical apps, live Zoom sessions, VR) would be most appropriate for their clients. To support the provision of competent services (i.e., the validity and goodness-of-fit for CBT delivery among diverse groups), future CBT research should include technology-delivered intervention studies specifically designed for the needs of these populations. Finally, efforts must be made to identify ways to provide financial support to individuals from marginalized groups who have minimal or no health insurance coverage.

Challenge 3: Geographic and Economic Access

Adapted CBT has the potential to increase access to effective treatment in remote and resource-limited areas, yet access to such innovations often remains unavailable to those who need them the most. Adaptations developed at academic institutions can take up to two decades to be widely disseminated, and many remain solely in academia (15). Although Internet access and smartphone use are rapidly growing, some populations have greater access and different technology preferences than others. For example, although White Americans (80%) are more likely to use the Internet than Black Americans (72%) or Hispanic Americans (61%), Black Americans are the most active users of the Internet by means of mobile devices (15). Understanding these differences in technological use is essential for offering the platforms that are most frequently used by various populations.

Disparities in the availability of smartphones and access to the Internet raise concerns about inequity in the use of technology-delivered CBT. For example, ownership of smartphones among individuals with severe mental illness (e.g., bipolar disorder, major depressive disorder, generalized anxiety disorder) in an Atlanta community clinic was found to be 31.4%, which was less than half of smartphone ownership by the general public (16). In addition, 22.3% of Americans in rural areas, 27.7% of Americans in tribal lands, and 39% of farmers lack coverage by broadband Internet, compared with 1% of urban Americans (17). In addition, VR technology is costly and typically not readily available in community mental health or community-based organizations.

Clinicians promote a social justice perspective when they advocate for services to address clients’ disadvantages related to power, privilege, and oppression that can negatively affect their treatment (5). Through research, policy changes, and practice guidelines, clinicians can ensure that effective treatments, including CBT adaptations, are affordable, available, and accessible to individuals who otherwise would not have access to them.

Challenge 4: Legal and Ethical Issues

Legal and ethical implications have quickly emerged because of the burgeoning reliance on technology-delivered treatment. Perhaps the most important consideration with technology use is that sharing private and personal and identifying information via platforms such as Internet-based CBT, mobile applications, and teletherapy (e.g., Skype, Zoom) poses a great risk to maintaining confidentiality for both clients and mental health clinicians (18). Not all technology-based interventions are designed to ensure the privacy of users (i.e., data encryption), and both clients and clinicians may not be sufficiently informed of these risks (18). Clinicians need to provide clear information to clients about the parameters of privacy and confidentiality and acknowledge the risks and protections related to the use of technology. To support their efforts, clinicians must be familiar with the legal and ethical standards, as established in their fields, for the role and use of technology with clients.

As availability of and access to smartphones increase, so does the use of mobile applications for the delivery of CBT treatment. There has been tremendous growth in unregulated mobile applications that deliver specific components of CBT, including skills training for breathing exercises, relaxation exercises, mindfulness techniques, thought diaries, and mood tracking (16). However, mobile application growth far surpasses the rate of research examining these applications’ adherence to CBT principles and effectiveness compared with control conditions and traditional CBT. Although mobile applications have been found to be helpful in the reduction of depression and anxiety symptoms among various populations, with moderate effect sizes (16, 19, 20), the evidence is limited. Thus, therapists must be thoughtful when considering with whom these apps should be used, whether they can serve as stand-alone treatments, when they should be used in conjunction with face-to-face therapies or other technology-delivered therapies, and how to effectively integrate them into practice.

Further, mental health clinicians must respond to the legal issues that can arise when they use technology to deliver CBT across jurisdictions. This response involves determining whether the clinician has proper licensure to practice across different regions or states, conforming to laws that govern practice in areas where the clinician and client are located, and identifying the guidelines for how to determine eligibility for insurance and to bill for services when delivering CBT through telemedicine or by using a personal computer. Professionals in various mental health fields (psychiatry, psychology, social work, nursing) have a responsibility to develop up-to-date information via practice guidelines for these issues and to make that information readily available to their peers.

Challenge 5: Competency in Technological Advances

Having proficiency in the delivery and training of traditional CBT does not presume proficiency in technology-driven CBT; clinicians have an ethical obligation to demonstrate competency and proficiency in the use of adaptations they utilize when providing services. To ensure competent practice of adapted CBT, experts who provide supervision and training to students and early-career mental health professionals are responsible for administering proper training for both traditional and technology-delivered CBT. In addition, the use of CBT in non–mental health settings (e.g., primary care provider offices, churches, schools, community centers) is growing considerably. These settings are often more accessible than traditional mental health centers and, for some, less stigmatizing (21). Therefore, mental health clinicians who train nonclinical professionals such as teachers, vocational specialists, and religious leaders have an obligation to provide proper education and training about technology-delivered CBT to these community providers.

Conclusions

Adapted versions of CBT offer promise for reaching many individuals with diverse backgrounds or from underserved communities. However, multiple challenges across the domains of research, practice, policy, education, and training have the potential to compromise the competent delivery of these treatments. In light of these challenges, and empowered by the values and ethical standards that guide all mental health disciplines, clinicians are uniquely positioned to take greater ownership of and responsibility for the research and development of CBT interventions that utilize technology assistance, cultural knowledge, and nontraditional treatment settings; form stronger collaborations between researchers, educators, policy makers, and practitioners to improve the flow of information; and commit to a comprehensive, career-long training process that extends beyond higher education. Engagement of these strategies will continue to increase access to and affordability of effective and culturally responsive mental health treatment, especially for individuals from marginalized communities, and will ensure that the best available CBT evidence, pedagogy, and forms of intervention delivery are being integrated into all aspects of mental health practice.