To better involve patients in their therapy, researchers at the Berkeley School of Social Welfare of the University of California have developed an algorithm-based text messaging service. The service is designed to help improving the treatment of depression in members of ethnic minorities and social strata with a lower income. This way, patients are supported with their homework, regular attendance of therapy sessions and medication intake. We have asked Adrian Aguilera, head of the program, about his experiences with using digital support for psychotherapy.

Why has your team developed an algorithm and a mobile application to support psychotherapy?

Dr. Adrian Aguilera (Foto: privat)Aguilera: “Real and sustained psychological and behavioural change occurs in one’s daily life, not merely during 1 hour therapy sessions. We wanted to help people to continue to remember and practice the cognitive behavioural therapy skills that they learn throughout their lives. We also want to improve the rates of attendance and completion in psychotherapy which are a general problem that is more marked among low-income populations.”

In what ways does such a digital solution support psychotherapy?

Aguilera: “We developed an automated text messaging platform that asks about patients’ mood on a daily basis and provides some feedback about their mood and tries to reinforce efforts by individuals. We also send messages encouraging them to practice the skills that we have learned that week. For example, if we are learning about engaging in new activities as a way to overcome symptoms of depression, we might encourage an individual to go out for a walk or find a partner to engage in a new activity.”

Have there been cultural differences in using the application and if so, why?

Aguilera: “We work mostly with Spanish speaking Latinos in the US but have also work with some English speakers. In looking at the reasons for each group liking the intervention, Spanish speakers often comment about how the program helps them feel cared for and supported. English speakers tended to emphasize the benefits of introspection and self awareness. This was an interesting finding which makes sense given what we know about the dominant individualized focus of Euro-American cultural orientation compared to a more collectivist and relational Latin American cultural orientation.”

Are there obstacles that should be addressed to make digital solutions more widely available in psychotherapy?

Aguilera: “We believe that technology should be leveraged to expand the reach of mental health and psychotherapy solutions. Psychotherapy is still relatively expensive and tends to be utilized by people with higher incomes. Digital technologies could offer a way to both offer more tools to more people and to improve existing interventions, which are often of lower quality in lower income and public sector settings, particularly in the US.”

Based on your experience and research, what are the reasons that digital solutions seem to work well in psychotherapy?

Aguilera: “The main benefit for pairing digital solutions with psychotherapy is to extend the work being done in face to face sessions. An added benefit is that digital solutions can also extend the supportive relationship which is key in successful therapy. The more that these digital tools are automated, the greater the reach of an individual therapist to reach out to more patients with less time beyond the face to face time. As mentioned previously, psychological and behaviour change must occur in one’s daily life and digital tools are an integral part of most people’s lives today.”

Where would you say are the limits for the use of digital solutions in psychotherapy?

Aguilera: “We know that digital tools that are utilized without any human contact or support work, however, people stop using them at very high rates. Therefore it is important to find ways to integrate humans in the loop so that digital solutions can be sustainable. Algorithmic tools also have promise because they are more flexible and can be individualized but some individuals can be turned off by the fact that they are not sent by a real person. This drawback can be mitigated by clearly integrating a therapist or other supportive person into the digital intervention. The key in my mind is finding an efficient blend between the technology and the human.”

Further reading

  • Aguilera, A., Bruehlman-Senecal, E., Demasi, O., & Avila, P. (2017). Automated Text Messaging as an Adjunct to Cognitive Behavioral Therapy for Depression: A Clinical Trial. Journal of medical Internet research, 19(5).
  • Aguilera A, Berridge C. Qualitative Feedback From a Text Messaging Intervention for Depression: Benefits, Drawbacks, and Cultural Differences. Eysenbach G, ed. JMIR mHealth and uHealth. 2014;2(4):e46. doi:10.2196/mhealth.3660
  • Aguilera, A. Digital Technology and Mental Health Interventions: Opportunities and Challgenges, ARBOR Ciencia, Pensamiento y Cultura, 2015; Vol. 191-77. doi:

Dr. Adrian Aguilera (@draguilera) is associate professor at the School of Social Welfare of the University of California, Berkeley. Dr. Aguilera’s current research interests focus on utilizing digital health and mobile technologies to improve health and mental healthcare of low-income and ethnic minority populations, with a focus on Latino and Spanish speaking populations.

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