A client suffers from one of the oldest and most common fears: arachnophobia. The mere thought of a spider causes her anxiety, and she often has a friend check a room for spiders before she enters. She wants to get help, but she lives in a remote area without access to a clinical expert. Could the use of augmented reality help the client overcome this phobia and actually touch a tarantula?
Arash Javanbakht, an assistant professor of psychiatry and director of the Stress, Trauma & Anxiety Research Clinic (STARC) at Wayne State University in Michigan, has found that it can. At STARC, Javanbakht uses augmented reality along with telepsychiatry as a method of exposure therapy for clients with phobias.
The client with the spider phobia, for example, would put on the augmented reality device and connect with the therapist through a wireless telepsychiatry platform. The therapist, who has full control of the augmented exposure scenario, sees a map of the client’s environment on a computer monitor. At first, the therapist places a small spider across the room in front of the client. Then, the therapist adds a larger spider that crawls across the wall. The therapist notes what the client sees and asks how she is doing. By the end of the session, several types of spiders — all moving around — and spider webs surround the client. In this safe, controlled environment, the therapist and client work together to help her overcome her fear.
The impressive part is how quickly this method can help clients. For Javanbakht, the ultimate goal is to have clients touch a real-life tarantula (or a tank containing one). Comparing traditional therapy with the augmented experience, Javanbakht discovered that what would take on average six face-to-face sessions could often be accomplished in 40 minutes with the use of augmented reality. He contends that pairing technology such as this with traditional therapy approaches can significantly improve treatment efficacy for other phobias, anxiety disorders, obsessive-compulsive disorder and posttraumatic stress disorder.
Despite the possibilities that new technologies offer, however, counselors are often reluctant to use them. Many prefer face-to-face counseling and question the impact that technology may have on the therapeutic relationship. Others are unsure of what technology to use or how to use it. Most counselors worry about possible ethical implications. For some, the overarching counseling principle of do no harm translates into do not use tech.
Olivia Uwamahoro Williams, an assistant professor of counselor education and college student affairs at the University of West Georgia, says this hesitancy to embrace technology is understandable because counseling is a person-centered profession. However, counselors shouldn’t think about technology as a means of removing the person completely, she argues. Instead, they can use technology to enhance mental health and counselor training outcomes, she says.
“There’s a general lack of understanding in the counseling community about high technology such as artificial intelligence [AI] and how it will impact the field,” adds Russell Fulmer, who is part of the core faculty at the Counseling@Northwestern program with the Family Institute at Northwestern University. Some counselors incorrectly assume that they have to be well-versed in the inner workings of technology or must learn how to code, and many counselors even fear losing their jobs to high technology such as AI, he says.
However, Fulmer, a licensed professional counselor (LPC) and a member of the American Counseling Association, doesn’t believe that counselors’ livelihoods are in jeopardy from technology in the short term. The jobs most in danger of becoming obsolete are ones that are repetitive, he says. Thus, occupations such as counseling that involve social and emotional intelligence are better positioned in the long term, he explains.
Holly Scott, an LPC and the owner of Uptown Dallas Counseling in Texas, used to be adamantly against using technology in counseling. Now, however, she is a technology convert, citing at least five ways that counselors can use technology in their practices:
- Helping clients find mental health practitioners who are a good match for their presenting issues
- Finding and disseminating evidence-based information
- Improving clients’ mental health through the use of virtual or augmented reality
- Encouraging clients to follow up on treatments and the skills they learn in session through the use of mental health apps
- Reaching a broader range of clients through telehealth
Meeting clients where they are
Younger generations have a difficult time imagining a world in which libraries and encyclopedias were the only means of researching school projects. Today, they simply pull out a smartphone and Google it — sometimes while still sitting in class. According to the Pew Research Center, in 2018, 95% of teenagers reported having a smartphone or having access to one, and 45% said they were online on a near-constant basis.
Technology is not just for the young, however. Pew also found significant growth in tech adoption in recent years among older generations, particularly Gen Xers and baby boomers. In fact, boomers are significantly more likely to own a smartphone today than they were in 2011 (67% in 2018 versus 25% in 2011), and the majority (57%) now use social media.
James Maiden, the assistant dean of student affairs and an assistant professor of counseling at the University of the District of Columbia (UDC), finds that clients are outpacing counselors in terms of technology. Counselors need to do a better job of meeting clients where they are, he says. “Don’t think [technology] is going to replace you,” he argues. “Think of how [it] can extend the good work that you’re doing.”
In fact, Maiden, an LPC and an ACA member, views technology as “a gateway into seeking a professional [counselor].” Counselors can begin by providing peer-reviewed, factual information and tools online for people who search the internet for help, he says. Making this information readily available to the public will help lessen the stigma around mental health and open the door for more individuals to eventually take the next step of going to see a counselor, he explains.
Scott says most clients find her private practice in Dallas through her website or by Googling “anxiety” and “Dallas.” She acknowledges that this is a more “selfish” use of technology — one that helps counselors get their names out there. However, if counselors share with the public their specialties and what they offer, then it’s a win-win for both the counselor and the client, she says.
Part of the purpose of Scott’s website is to remove as many stressors for potential clients as possible. The information it provides can help address people’s fears and concerns and normalize the counseling experience, she says. For example, a counselor’s website can include pictures of the office and address common questions that first-time clients might have: Where do I sit in session? Are people going to see me in the waiting room? What do I say to people if they see me sitting there? How much does counseling cost? Where do I park?
Of course, the counseling profession has made some strides in meeting clients where they are through the use of technology. For example, distance counseling and telehealth remotely provide services to clients who may not be able to see a counselor in person because of location or limited mobility.
More widespread use of telehealth has led to a significant decrease in the number of psychiatric admissions among those residing in geographically isolated areas, according to Panagiotis Markopoulos, the clinical lab director and a faculty member in the counselor education program at the University of New Orleans. He touts several benefits to using distance counseling:
- Safety (clients can express themselves more freely)
- Less social stigma (clients can avoid public encounters)
- Accessibility (clients can receive help regardless of their geographical location or daily schedule)
- Affordability (clients can receive counseling services at a lower cost than with face-to-face counseling and save on transportation costs)
For clients who prefer or need to use distance counseling, Markopoulos, an LPC in private practice in New Orleans, recommends video- and text-based communication tools such as My Clients Plus and Zoom. In addition, Second Life, a 3D virtual game, offers an encrypted way of communicating, Markopoulos says. If clients value anonymity yet want to be present with a counselor, they can create avatars, enter the “virtual session” and talk through a headset or text-based chat, he explains.
Counseling: There’s an app for that
The high cost of some technologies prevents private practitioners from using them, but mental health apps are an affordable way for counselors to incorporate technology into practice. In addition, these apps can allow people who face barriers to traditional mental health services to access help.
According to Psycom.net, health experts predict that apps will play an important role in the future of mental health care. In particular, mobile apps for cognitive behavior therapy (CBT), relaxation and mindfulness interventions are gaining momentum as supplements to in-person therapy.
Scott, who serves on the board of the National Social Anxiety Center, personally knows the power of using CBT apps with clients. When a client comes to Scott, she offers to use either paper handouts of CBT activities or MoodKit, a CBT app developed by two clinical psychologists. She’s noticed that most clients 35 years and younger prefer to use the app. “For a certain population, [the MoodKit app] really increases the speed of the change and the efficacy of the therapy,” she adds.
Scott has also observed that when she asks clients to record their moods between sessions, those who do it manually often wait until the last minute — sometimes in the waiting room — to complete the assignment. Clients generally respond better to the app, she says, perhaps because it lets them easily chart their moods and provides them with a visual diagram.
When Scott introduces MoodKit, both she and the client open the app on their phones, and she walks the client through all the activities such as daily mood tracking, thought records and behavior activation. With thought records, the app guides users through all the important questions and helps them label the cognitive distortion with prompts such as “Is this all-or-nothing thinking?” Scott also thinks the app’s section for behavior activation is brilliant. With a client who has social anxiety, for example, the app provides a choice of therapeutic activities such as introduce yourself to a stranger. After the client selects an activity, the app prompts the individual to select a day and time to complete this activity.
Incorporating a CBT app with regular counseling also encourages clients to put the CBT skills they are learning in session to use in their everyday lives, Scott continues. The outcome is best if counselors follow up with clients about the app and the progress they are making, she notes. For example, counselors can ask: What do you like about the app? What activity did you complete this week? When you did that activity, what did it feel like? “The therapist’s input … is what will change [the app] from just something [clients] play with on their phones into a real therapeutic, mental-health-changing application,” Scott says.
Scott, who volunteers as a crisis counselor for Crisis Text Line (which provides free crisis intervention via text messaging), has also discovered that several of her clients already use the meditation/mindfulness app Headspace. If clients are using an app, counselors can see if the app works with their therapeutic goals before using it in session with them, she advises.
Before meditation apps, Scott would play a recording (such as background noise at a bar) and have clients focus on the conversation. Then she would tell clients to do the same thing outside of sessions, starting with 10 minutes a day and working up to 30 minutes. Clients often felt too busy to set up a place where they could play a recording and work on meditation, but the app creates the environment for them, increasing the likelihood they will practice the skill outside of session, she says.
Maiden, like Scott, is a technology convert. He started learning more about incorporating technology into counseling while serving as the principal investigator for UDC’s Verizon Innovative Learning program, which provides educational experiences that promote and support the involvement of ethnic minority boys in science, technology, engineering and math. The program included free summer sessions, led by counselors-in-trainings, that discussed how to maintain one’s mental health. Afterward, the boys created apps that featured information on mental health stigma, stress prevention, anxiety, depression, suicide awareness and local mental health resources (such as counseling centers). Participants also received a year of mentoring and follow-up workshops.
Through their involvement in the program, the students learned the importance of seeking help when dealing with issues such as bullying, death and violence. They grew more likely to reach out to mentors or parents or to access the local resources included in the apps, according to Maiden, who presented at the 2019 ACA Conference on using technology to increase mental health awareness.
Through his involvement, Maiden realized the potential apps have for functioning as counseling tools that supplement the face-to-face work. Tech tools such as those created in Maiden’s program also allow people to share information with others who may not be inclined to discuss their mental health, he continues. For example, when the friend of one of the boys who had participated in the program joked on the phone about killing himself, the boy quickly informed his friend that suicide was not a laughing matter and that he was going to tell his mother, who would tell his friend’s parents. The boy also provided his friend with local resources from the app. As a result of his actions, the friend’s parents sought help for their son.
Exposing clients to a virtual world
As Scott points out, exposure therapy can be time-consuming and expensive to do when using real-life props and scenarios. As Javanbakht’s impressive results demonstrate, however, virtual and augmented reality can allow therapists to remotely expose clients to feared objects or situations. This approach is more time- and cost-efficient and provides a safe, effective outcome, Scott says.
Markopoulos finds the immersive quality of virtual reality particularly helpful for clients with autism spectrum disorder (ASD). Research indicates that individuals with ASD are drawn to technology, and they often learn and understand visually, he says, so using virtual reality with this population makes sense. “The higher the immersion, the more likely the child who has been diagnosed with autism will be able to apply the social skills that he or she has been taught in a real-life situation,” Markopoulos explains.
Markopoulos, an ACA member, has received several awards, including the 2018 Graduate Student Research Award from the International Association of Marriage and Family Counselors and the 2017 Make a Difference Grant award from the Association for Humanistic Counseling, for his work with virtual reality in the treatment of children with ASD. He also presented on the topic at the 2018 ACA Conference.
Markopoulos developed a virtual mall for individuals with ASD and for those who present with social anxiety. Both Markopoulos and the client put on the head-mount display (box-shaped glasses that allow the user to see the virtual/augmented scenario) and enter the virtual mall, which is busy and noisy. The client will see and hear coins falling from the ATM and televisions playing, see flashing lights from a photo booth in the center of the mall and see avatars constantly walking past. All of these visual and auditory elements serve as checkpoints to figure out the source of anxiety for the client.
As the client passes by a large television producing a high-pitched frequency, the client pauses and stares at it, and Markopoulos takes note. Markopoulos has attached a heartbeat sensor to the client, and upon hearing the television, the client’s heart rate escalates. At this point, the client says the mall is overwhelming and removes the head-mount display.
Through the use of virtual reality, Markopoulos has identified what is causing the client’s anxiety — the high-pitched frequency he programmed into the television. With this information, he creates a new scenario with checkpoints focused on the same high-pitched frequency, and he allows the client to control the volume. Upon entering the virtual world again, the client reports the sound is loud and overwhelming, so the client lowers the volume. Slowly, with Markopoulos’ help, the client is able to cope with the sound at a low frequency. Then Markopoulos gradually increases the sound, helping the client slowly build capacity for handling more noise.
Scott and Maiden are excited about the possibilities of incorporating virtual reality into counseling practice. In fact, Maiden plans to use virtual reality in the Verizon Innovative Learning program at UDC this summer. He wants the boys who participate to create virtual safe spaces so they can process and cope with all the stressors they experience. He hopes these safe spaces will be tools the boys can use at home until they are able to make it to their next counseling sessions.
Mental health chatbots
Fulmer doesn’t think that AI will eclipse the human need for face-to-face interaction that counseling provides. Instead, he equates AI to a multivitamin — one that will serve as a supplement to counseling.
To learn more about the intersection of AI and mental health, Fulmer reached out to X2AI, an AI startup in Silicon Valley that is, according to language on its website, “building an AI that will … make the lives of people suffering from various forms of mental illness much better.” Fulmer offered his services and now serves as a consultant and on the company’s advisory board.
As Fulmer explains, Tess is X2AI’s largest and most versatile mental health chatbot. She provides psychological support for people using automated chat conversations through text-based messaging apps that are compliant with the Health Insurance Portability and Accountability Act (HIPAA). When a person talks to Tess, she not only analyzes the conversation but also remembers details and learns from what the person says.
Along with X2AI, Fulmer conducted a randomized controlled trial to test the efficacy of using Tess to reduce symptoms of depression and anxiety in college students. Depending on the group, participants received unlimited access to Tess for either two weeks with daily check-ins or four weeks with semiweekly check-ins. The college students used Facebook Messenger (a text-based communication) to interact with Tess. She provided psychoeducation and interventions to help the students cope with their depression or anxiety.
Fulmer and his colleagues found that having access to Tess resulted in a significant reduction in symptoms of anxiety and depression among the students. In addition, the participants said they felt comfortable and satisfied with the therapeutic experience. One student said it felt like talking to a real person and noted the benefits derived from the specific tips Tess provided for ways to improve mental health. Another student reported learning new ideas for making small changes.
Fulmer points out that this study and the students’ feedback suggest that chatbots can help with two of the most common counseling issues — anxiety and depression. Thus, counselors might want to explore the use of mental health chatbots such as Tess, in conjunction with traditional therapy, to see if it improves the mental health of some clients.
Mental health chatbots can also reach a wider, more diverse group of clients, Fulmer says. For example, X2AI has developed a chatbot (Karim) to help Syrian refugees and a chatbot (Sister Hope) designed for clients who are Catholic. Fulmer also notes that rural populations that don’t have much access to mental health care and older adults who often experience loneliness could benefit from mental health chatbots.
“AI is the biggest opportunity that humankind has ever had,” Fulmer says. “When there’s opportunity and the potential of power and influence, it must be monitored. It must be crafted, and it … must evolve appropriately. And counselors can play a role in … the evolution of psychological AI.”
In graduate counseling classes, students often engage in role-play, with one student playing the role of the client — including assuming the client’s mannerisms and personal history — and the other student embodying the role of the counselor. This traditional training method offers several benefits, including helping students develop empathy and experience what it takes to be vulnerable in a session, Williams points out.
However, because students would often “break” from their role-playing if they were caught off guard, Williams, an ACA member and LPC at the Healing Center for Change in Georgia, felt the immersion aspect was not as authentic as it could be. To make the experience more immersive, she started using virtual simulation to create these role-playing scenarios — a topic she presented on at the 2019 ACA Conference.
With virtual simulation, students go into a virtual lab and interact with avatars. The scenarios are limited only by counselor educators’ imaginations, she says. It could be a client with bipolar disorder or a family session with two adults and three children. She points out that a virtual space is also less stressful for students because it allows them to focus on the counseling role.
Another major benefit is that counseling instructors can easily manipulate or alter the student–avatar interactions and virtual scenarios to further challenge students and prepare them for real-world counseling sessions, Williams says. Instructors can also pause the simulations when students are feeling frustrated and process with them, she says.
For example, recently, when an avatar’s voice became low and choked, the counseling student doing the simulation did not pause to address the emotional change but just kept processing the client’s story. Williams wanted to check this, so she stepped over and asked the person managing the equipment to make the avatar cry. When the avatar started crying, the student froze, not knowing how to respond. Williams paused the session to process this issue with the student, who admitted that she didn’t handle it well when people cried. The other students who had been observing and taking notes on the virtual session acknowledged that they wouldn’t have known how to respond either.
This virtual experience made the counselors-in-training realize that they needed to work on handling clients’ emotions and led to a class discussion on strategies. Williams says she wouldn’t have been able to recreate the same scenario in a traditional role-play because she can’t easily walk over to a student and whisper, “Start crying.” That wouldn’t create the same effect, she says.
Because students know the avatar is not a real client and recognize that the virtual simulation is a safe space, they are also more willing to take risks, Williams adds. A year ago, a student went into the virtual lab and started asking the avatar close-ended questions, which every counseling textbook and instructor advises against. When the student came out 10 minutes later, Williams asked her why she had used those questions. The student replied that she had been curious about what would happen; now she understood that it resulted in the counselor and client going around in circles.
Providing a safe space to role-play often gives counselors-in-training the courage to “mess up,” Williams says. “They can get it wrong — really wrong — and that’s fine because you can stop the simulation, give them feedback, assess how they’re doing, and start it back over and give them an opportunity to practice that skill again.”
Williams still recommends blending traditional role-play with virtual role-play. She uses the traditional method when students are learning the basic counseling skills, such as listening and developing a therapeutic alliance. Then later in the class, she uses virtual simulation to have students practice those skills and experience more complex scenarios such as crisis intervention, a client with psychosis, or couple and family sessions.
Counseling students can also use avatars to learn how to talk with clients’ families and caregivers, she adds. For example, the virtual scenario could involve a school counselor discussing with a child’s parents how the child mentioned having suicidal thoughts. The counselor-in-training can practice having that conversation with the parent and figuring out how to work together to create a safety plan, she explains.
“As educators, we need to be mindful of the students that we’re teaching,” Williams says. “The millennial generation … [is] exposed to a level of technology that is beyond what any of us were exposed to over the course of our lifetime. It’s naïve to think that we can continue to teach effectively these new sets of students and keep their level of excitement and keep their level of enthusiasm without incorporating more exciting technologies in their learning experiences.”
Because technologies change so quickly, counselors may find themselves in uncharted waters when debating whether to incorporate things such as virtual reality therapy or mental health apps into their counseling practice.
The first questions Scott typically hears related to counseling and technology revolve around ethics. She acknowledges that a lot of misinformation tends to circulate about using technology within one’s counseling practice, so she advises counselors to continually check the ethics codes of counseling organizations such as ACA and state-level regulations to see if new guidance or rules have been put in place.
The ACA Code of Ethics doesn’t specifically mention chatbots or mental health apps, but as Joy Natwick, ACA’s ethics specialist, points out, the decision to make the code a general set of guidelines and principles for using technology was intentional. “If we were to write a code that specifically names types of technology, it would be out of date before we printed it,” she says.
Natwick encourages counselors to pay special attention to Section H of the ACA ethics code, which discusses distance counseling, technology and social media. “If you feel like you can’t find [an answer in that section], go to the preamble of the code because that’s where the [professional] values are, that’s where the principles [of professional ethical behavior] are,” she advises.
When counselors encounter a new technology or have ethical questions about technology, Natwick suggests they use an ethical decision-making process such as Holly Forester-Miller and Thomas Davis’ “Practitioner’s Guide to Ethical Decision Making.” (ACA members can access both an infographic and a white paper on the seven-step model at counseling.org/knowledge-center/ethics/ethical-decision-making.) ACA is also in the process of creating tip sheets to provide practical guidance regarding social media and distance counseling, she adds.
“Technology becomes more and more ingrained in everyday life and, therefore, we as counselors need to keep up,” Natwick says. “We don’t want our profession to get left behind.” She hopes the practical guidelines provided by ACA will serve dual purposes: 1) Encourage those eager to use technologies in counseling to pause and consider the ethical implications, and 2) encourage reluctant counselors to engage more with technology.
Natwick also stresses the importance of competency, privacy and confidentiality when it comes to technology in counseling. “Technology is another way we are supplementing therapy or interacting with our clients,” she says. “[As with] anything we introduce to our clients, we need to really educate them about the risks and benefits.”
Scott is well aware of privacy concerns online, so her informed consent document explicitly details her online and social media policies and lets clients know appropriate ways to contact her. For example, she will not friend clients on Facebook, but they can follow her on Twitter. Clients can also contact her through a form on her website or by posting comments on her blog (which require her approval). She also addresses these issues during her intake session
“Tech privacy means something very different in the tech space than it does in the health care space,” Natwick warns. For this reason, she recommends that counselors use technologies created or informed by mental health professionals because these vendors should share similar values with counselors and understand the HIPAA privacy rule.
Teaming up with tech
Of course, professional counselors can also benefit from technology apart from using it with clients. Scott often turns to Twitter to find information and to get practical suggestions from fellow mental health practitioners by using hashtags such as #CBTworks and #SoMePsychs. For example, she recently saw a Tweet asking other mental health practitioners for their favorite clinical handouts for doing cognitive restructuring with clients with anxiety or depression. Several people replied with resources, including handouts, infographics and links.
Scott discovered MoodKit, the CBT app she uses with clients, through the Academy of Cognitive Therapy Listserv. A quick search on the Listserv led her to a research study on three CBT apps. The study found that MoodKit was effective in decreasing depression and increasing mood.
All of this reveals that technology is changing the way that clients and counselors communicate and form relationships. This suggests that counselors will need to be open to finding new ways to build relationships, and it may mean that some of the initial relationship building will happen in different ways than they are used to, Natwick points out.
Smartphones already have built-in sensors that record users’ movement patterns, social interactions, behaviors, and vocal tone and speed. According to the National Institute of Mental Health, apps in the future may be able to analyze the data to determine a user’s real-time state of mind and alert mental health professionals that help is needed before a crisis occurs.
In fact, AI has already made great strides in medical diagnoses. New Scientist magazine recently reported that human doctors annotated medical records (including text written by the doctors and lab results) to help train AI. This partnership resulted in AI that could diagnose children’s illnesses in unseen cases with 90% to 97% accuracy.
Fulmer believes a type of symbiotic relationship could also form between counselors and technology. He sees technology such as AI working alongside counselors in the same way that counselors often work in multidisciplinary treatment teams. For example, a chatbot could detect a person’s emotional or behavioral state and provide the counselor with the client’s data and a possible diagnosis.
“Rather than just one counselor meeting [clients] during their initial interview and having to write down a provisional diagnosis, it might be pretty helpful to also meet with an AI and get their input on the diagnosis,” Fulmer says. “That could probably enhance reliability and even validity.”
The partnership aspect is key. Technology is most likely to assist mental health professionals, not replace them. Fulmer is an optimist about the intersection of technology and counseling and believes “that if done the right way, everyone can benefit.”
Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at email@example.com or through her website at lindseynphillips.com.
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