An international meeting as close as your computer keyboard.
After the 2020 iaedp conference planned for Orlando, FL, was cancelled due to the COVID-19 virus, the iaedp Foundation quickly went into action and turned the meeting into a virtual conference. Using virtual reality, members and other registrants were are able to take study sessions, visit the virtual exhibition hall, participate in Spanish sessions, complete classes for CME credits, and also to hear outstanding presentations by keynote speakers.
Here are three presentations by keynote speakers at the 2020 iaedp virtual meeting. Topics ranged from the power of laughter and hope, and uses of new technology to improving care for eating disorders patients. Here are a few highlights:
Humor Really Is the Best Medicine
Author, columnist, and educator Gina Barreca, PhD, told her audience that humor can be a powerful therapeutic tool. Detailing her own childhood in a large Italian family that had two sets of rules, one for men and another for women, Dr. Barreca described how the use of humor helped her establish her independence and enabled her to break out of restrictive patterns for women. According to Dr. Barreca, the traditions she grew up with dictated that women weren’t supposed to take up much space—this went not only for female bodies but other areas as well. Beginning in childhood, females were taught to not be too loud, not to want too much, and their assigned role was primarily to take care of everyone else. Taking care of everyone else all the time leaves little space for psychological real estate for ourselves, she said.
Dr. Barreca told the audience that humor enabled her to break out of the mold of her upbringing of Barbie dolls and her family’s expectations of her. As females, “our first mistake was learning to be “good girls,” she said, adding that as good girls, women are taught never to trust themselves or their own reactions. She also noted that ideals of beauty are always in flux. Beauty is a sort of compact between the beautiful being and the perceiver of that beauty, and the reflective surface can shift, shake, or reshape itself. She added that women’s worth historically and culturally has been based on beauty and youth rather than accomplishments or talents. Why, she wondered, have women been made anxious about aging and experience while men, at least historically, have been rewarded for precisely those same attributes?
Humor and the way that it is therapeutic allow us to tell our stories and to give some space around it, she noted. One of its benefits is helping the individual learn to answer back and to defend oneself. She offered the example of Liz Carpenter, former Press Secretary to Lady Bird Johnson and assistant to Vice-president Lyndon B. Johnson. Carpenter wrote a very popular book and at one of her book signings historian Arthur Schlesinger, Jr. said he had heard that her book was selling well, and asked, who had written it for her. Without a pause, Carpenter answered, “Glad you liked it, Arthur; who read it to you?”
If we don’t know what we want or desire, it is hard to figure out what we need, she said. The struggle with identity is wrapped up in body image, she added. Women have “selves” that include the mother-nurturer, the girlfriend, the pal, supporter, encourager, and the delight of other people, she added. Dr. Barreca shared that she learned that anxiety was the motivating factor for most of what she did in her earlier life, even though she did not want to acknowledge it at first.
She told the audience about the power of writing or telling your own story so you can make sense of the world. This happens because you are putting yourself into the story, and with your own point of view you can control the story, she said. She added that by writing your own story things don’t just happen; you become not the victim or the object, but instead you become the subject of your own story. You become the narrator. She said that we are not just talking about what is happening or what has happened; instead, one gets to tell the truth. One possesses his or her life in a meaningful way—a story of what made you what you are.
Dr. Barreca said that laughter really is the best medicine because it detoxifies. “It is something that allows us to wash away the things stuck into us, and cleans out and rewrites some version of what has happened to us,” she said. A person can rewrite some version of what has happened, making things better. You can reset things in a different framework, she noted, and this can be done with love. It keeps baggage moving and one can learn to repack things. By writing things down, one can make herself or himself laugh. The truth is funny, she said, and it cleans things out and enables an individual to re-write some version of what has happened, and can make things better. Using the truth can reset things in a different framework. Humor is an act of welcoming, and laughter can make a community of people come together, said Dr. Barreca. It provides a moment of deep intimacy. Even if everyone doesn’t get it, it is a start, she said. If you have to rewrite, it makes you affirm and enjoy what you were.
[Gina Barreca, PhD, is the author of 10 books, including the bestselling book They Used to Call Me Snow White, But I Drifted: Women’s Strategic Use of Humor, Babes in Boyland, Perfect Husbands (and Other Fairy Tales), and It’s Not That I’m Bitter, and has edited 18 others. Dr. Barreca is a syndicated weekly columnist for The Hartford Courant and is Board of Trustees Distinguished Professor at The University of Connecticut. Her blog at Psychology Today has over 6.5 million visitors.]
Cultivating Hope Through Strength-Based Practices
Daniel Tomasulo, PhD, MFA, MAPP, told the audience that hope is the greatest advancement in positive psychology since the science of psychology was discovered. He added that most of the science and practice of psychology has been about reducing depression and anxiety. In contrast, positive psychology provides a way to enhance the positive, not only reduce the negative. It is a way to understand that your signature strengths are the way forward, and a means to have a positive perspective that tips the scale in factor of greater wellbeing.
Dr. Tomasulo described a new theory of well-being termed PERMA (Positive Emotions, Engagement, Positive Relationships, Meaning, Accomplishment)( Seligman, ME. Handbook of Positive Psychology. 2002. 2:3-12). The PERMA approach is a way of thinking about the five pillars of psychology and sustainable well-being, he explained. He noted that a change in one habit usually has a ripple effect on another. Positive emotions are like nutrients, feedback into thoughts and behaviors. Where does hope fit in? He noted that most of us are looking for problems all the time. Once we find them, a downward spiral starts, which makes it more and more difficult to pull out of anxiety and depression.
The answer to such a downward spiral is through positive interventions, he said. A group he termed “high hope people” use positive interventions to get past such downward emotions. In the past most psychology has been focused on the negative parts of depression or anxiety. Dr. Tomasula said what is needed is different tools and science to approach well-being, quoting pioneering psychologist William James, who wrote, “My experience is what I agree to attend to.” The true nature of hope is that you can decide what you focus on and spend time on, said Dr. Tomasulo. He asked, “What do your clients need to know? What are they going to focus on and attend to?” We have an extraordinary power and ability that we don’t recognize, he said, and added that negative emotions limit us, and physiology shows this. For example, when there are negative emotions, the digestive system reacts and peripheral vision narrows. With positive emotions, however, one tends to broaden and to build greater creativity and more dynamic resources.
Dr. Tomasulo provided a number of statistics about depression and anxiety prior to the onset of COVID-19. For example, 80% of those with depression relapse; 40% of Americans report being lonely; 10 times more people are depressed today versus during 1945; in the last 3 decades, 15- to 26-year-olds report twice as much anxiety, depression, and behavioral problems as their predecessors. Suicide is the leading cause of death in this age group, and between 2009 and 2018 the U.S. had more school shootings than 27 other countries combined.
Such data point to a sharp rise in society’s symptoms in a relatively short time, he said, which shows that the root cause of most depression isn’t a chemical imbalance, and human genes are not the cause. Rather, people are losing hope—and doing so faster than at any time in history.
Hope is not the same as faith, Dr. Tomasulo said. He gave an example of this from professional baseball pitcher James Augustus “Catfish” Hunter. When Hunter described all the ways he prepared for pitching a game, including striving to increase his strength and grip, for example, he said at some point he just had to let go of the ball and throw it, and didn’t have any control over it any more.
Calibration and correction through micro-goals
Giving patients a micro-goal is an important and powerful way to shift goals, he said. The current pandemic has challenged whatever goals existed before the virus attacked. For patients, the challenge is to form micro-goals, such as walking the dog, preparing dinner, making phone calls, or answering three e-mails, for example. Dr. Tomasulo added that these small goals allow one to see progress and the larger goal comes into sight again. Having a group of micro-goals, and agreeing not to plan further than 4 hours at a time can be very useful for helping patients engage.
It is a myth that one either has hope or not, he said. It can start with small acts of kindness, or as comedian Marty Feldman has said, the fastest way out of depression is to do something kind for someone else. Dr. Tomasulo said that while this seems like an incredibly simple and small step, it can take a person out of his or her own head and into a more positive direction. Using himself as an example, Dr. Tomasulo also recommended performing a gratitude review by stopping and thinking about three good things he is grateful for. This could be a beautiful day, seeing a friend after a longtime absence, a check in the mail, or seeing a grandson. These small good things are to be celebrated. He urged all to celebrate the positive. We all have a choice, he said, and can change our personal biographies by making such choices.
[Daniel Tomasulo PhD, MFA, MAPP, is a core faculty member for the Spirituality Mind Body Institute (SMBI), Teachers College, Columbia University, and holds a PhD in psychology, MFA in writing, and Master of Applied Positive Psychology from the University of Pennsylvania. He writes the daily column, “Ask the Therapist,” for PsychCentral.com, and developed the Dare to be Happy experiential workshops for Kripalu Center for Yoga & Health. He was honored by Sharecare, a digital health company, as one of the top 10 online influencers on the issue of depression. He is the author of American Snake Pit and a newly released book, Learned Hopefulness. The Power of Positivity to Overcome Depression.]
How Technology Can Enhance Mental Health Care
Dr. Sabine Wilhelm, Chief of Psychology at Massachusetts General Hospital, Boston, outlined the ways in which modern technology is helping attack the current global mental health crisis. Internet-based treatments, smartphone applications, sensors, and virtual reality are all reaching out to help patients in the ever-growing mental health crisis, which has only been made worse by the COVID-19 pandemic, she said.
A global health care problem
Dr. Wilhelm noted that half of all mental disorders begin by the mid-teens, and three-fourths of all mental disorders start by the mid-20s. Suicide is now the among the 10 most common causes of death around the world and, in the U.S., suicide rates between the ages of 15 and 24 have increased to the highest point since 2000, she said. Mental illness is also extremely costly, she noted: for example, the global cost of mental health problems was $2.5 trillion in 2010 and is predicted to reach $6 trillion by 2030. Despite the costs, 60% of people around the world are still not receiving any mental health care. And, if they do seek care, they must overcome logistical barriers, such as lack of transportation, no access to childcare, the stigma of going to a health care office, and cost of care. She added that one 18-session course of treatment for BN can easily cost $5,000 in Boston, where she lives. And, even when cost is not a barrier, finding a provider can be another very real challenge in this time of provider shortages. In some parts of the world, she added, there may be fewer than 10 health care providers. And, in one study, only 39% of those with 12-month psychiatric diagnoses received at least “minimally adequate care.” She added that if all licensed psychologists worked 50 hours per week, they could only address 12% of the need.
Technology as a solution
Dr. Wilhelm reminded the audience that internet-based CBT (I-CBT) treatments have been around for some time. With I-CBT a therapist can deliver self-help treatment online, and the patients can then work on exercises on their own time and on their own computers. She added that good global work on I-CBT has been done in the U.S. and Australia, and most of these programs do not require a licensed therapist. In fact, guided I-CBT is equivalent to in-person CBT, and an additional benefit is the need for many fewer therapist hours per intervention. One of Dr. Wilhelm’s specialties is body dysmorphic disorder (BDD), where the usual CBT treatment involves about 22 sessions; online, with I-CBT, only about 3 hours of therapist time are needed.
The arrival of the smartphone in 1992 foretold a true revolution in information-sharing, and today more than 81% of Americans have a smartphone. Dr. Wilhelm outlined the key barriers to treatment that are overcome by smartphones: long wait times, logistical barriers, shame and stigma, high cost of treatment, and variable quality of care. She noted that the smartphone apps have many advantages because they are already part of the fabric of everyday life. In addition, many apps are already available to help with healthcare needs. The smartphones provide increased access to care for those who may be ambivalent about therapy. The phones improve low motivation by providing self-monitoring and, importantly, can provide just-in-time interventions, she said.
A study by de Zwaan and colleagues in 2017 compared internet-based self-help versus individual face-to-face treatment for binge eating among a group of 178 BN patients (JAMA Psychiatry. 2017; 74:987). The results showed that face-to-face CBT led to quicker and greater reductions in eating disorder psychopathology, and that I-CBT self-help remained a viable, although slower-acting, low-threshold treatment alternative.
Dr. Wilhelm told the audience about a small joint study Massachusetts General Hospital conducted with Telephonica Alpha. The two groups developed an app for patients with binge eating disorder (BED). A chat function in the app allows asynchronous communication with coaches to help boost engagement, while weekly safety assessments trigger clinician follow-up when needed. The researchers reported a reduction in BED symptoms from the baseline through the 6-month follow-up period.
Some of the negative realities of the 6 apps reviewed include few evidence-based principles. She said that most of the apps currently available are not based on empirical principles and do not take advantage of the full range of smartphone capabilities. For example, some of the apps do not provide personalized reminders to log in; there are no ways to personalize goal-setting or tracking; there is no feedback on the patient’s progress toward goals; there is no use of passive behavioral data; and there is no way to intervene during high-risk situations. Another drawback is the lack of research on smartphone-based treatment thus far. There is also no evidence that using any of these programs will help improve access to treatment or improve treatment outcome.
Dr. Wilhelm also described her own recent work in developing mental health apps. She located a team from California that was interested in making an F5 network for patients with body dysmorphic disorder (BDD). Patients with BDD are preoccupied with a perceived flaw in their appearance and spend several hours a day obsessed about what might be a small scar, a pimple, or mole. They continuously check their appearance and engage in hiding the flaw, fixing it with plastic surgery, and avoiding other people at all costs. The more severely affected become housebound.
Dr. Wilhelm and colleagues worked to develop an app firmly based in science, with treatment components found in traditional cognitive exercises, and CBT components. Behavioral exercises were designed to encourage patients to return to situations that they might ordinarily avoid, such as group gatherings. Weekly assessments were designed to prevent relapse. An online coach was also provided. At first, the coach was a clinical psychologist, but over time this has changed to bachelor’s degree-level coaches.
Dr. Wilhelm said that smartphone use can increase access to care and address current concerns. For example, if a person is at risk for a binge-eating episode, the phone signals this.
Dr. Wilhelm described the possibilities of using smartphones as exciting, although there is still much progress to be made, for example, in improving patient engagement. She mentioned that one post-traumatic stress disorder app was uploaded more than 100,000 times, yet people did not return to the site the next day, week, or even year later. While an app may be downloaded, it may not be as engaging as hoped. What to do? To increase patient compliance, increasing the therapist’s time and patient’s engagement doesn’t have to involve the participation of a senior therapist but can just as well include a bachelor’s level therapist or coach, as long as he or she is trained in motivating patients. Chatbots are one useful addition because they use natural language processing to mimic real text conversations. (A chatbot is a software application used to conduct an online chat conversation via text or text-to-speech, in lieu of providing direct contact with a live human.)
The benefits of virtual reality
Virtual reality assessment can also be very useful for patients with eating disorders, said Dr. Wilhelm. With virtual reality, the cameras on an iPhone or computer can “read” facial expressions or clues from body positions and can then use this data to infer what the patient may be feeling. This data can provide virtual learning. Last but not least, virtual reality can provide virtual learning on the website. With 7 Cups of Tea, a site listed as “the world’s largest emotional support system,” stakeholders can get together with active listening and can provide guidance to each other. More than 40 million conversations have occurred on this website.
To make such sites more engaging for patients, it is possible to add a virtual therapist from the very beginning, in addition to healthcare professionals, said Dr. Wilhelm. She noted that one study showed that 67% of health care apps were developed without the input of healthcare professionals. “We can do much better,” she said. She suggested involving a range of stakeholders, or interested parties when a site is being developed, including clinicians, patients, third-party payors such as Blue Cross and Blue Shield, as well as engineers and designers.
Virtual reality treatment added to standard CBT can improve motivation for change, improve self-esteem, and improve body image disturbances, as well as reducing binge-eating and purging behaviors, she said. Virtual reality devices are much improved because they can be used for assessment and treatment. The technology is very powerful for exposure therapy and auditory as well as visual fun to participate in and can be therapist-led. Assessment can be improved because patients can help understand body distortions. For example, three-dimensional figures of the patient’s body can be presented in virtual reality, and patients can face and modify these figures. In addition, virtual reality (https://apps.apple.com/us/app/7-cups-anxiety-stress-chat/id921814681) allows the patient to see which foods and social situations trigger binge/purge cycles. Using virtual reality, patients can visit swimming pools and restaurants that offer high-calorie foods and can see which of these produce the highest levels of discomfort
Issues of privacy
In the midst of this, the developers of such apps also need to improve patient privacy to avoid selling medical data to third parties. This is an area that needs much improvement, she added. She noted that one analysis of 43 health apps showed a high risk of breaching privacy for 43% of users. One website works to help protect patient privacy. One Mind™ PsyberGuide (https://onemindpsyberguide.org) reviews apps in terms of their quality, providing a transparency rating, privacy policies, credibility rating, transparency guide, and professional reviews. PsyberGuide is now partnering with the Association for Depression and Anxiety (ADAA).
Dr. Wilhelm also outlined how sensors could be used in general. One drawback may be that clinicians may go for weeks without knowing exactly how a patient is doing. While some rating scales are available that indicate how a patient has been doing over the past month, they don’t indicate the patient’s condition during the past few hours. Once more, a smartphone can provide much background information, for example, about sleep. The phone is the last thing most of us use before going to bed, she noted, and the screen function on the phone can tell us about normal patterns of sleep, and perhaps hint that something else may be going on. You can engage your patient in real time or can even provide intervention right over the phone, she added. She also noted that the enthusiasm about sensor-based apps must be tempered. Different phones and different manufacturers may use the phone sensors differently, and even the ways in which a patient may carry his or her phone can have an effect.
Dr. Wilhelm said that we are currently finding ourselves in a major mental health crisis: most people are not getting good care or sometimes any care at all. Technology may help by providing or offering scalable opportunities that can maximize benefits for patients. As for assessment, sensor-based apps can be helpful, and with permission, social media can also provide information. This data can be combined with information from the patient’s electronic medical record, European Medicines Agency (EMA) data collection (https://clinicaldata.ema.europa.eu/web/cdp/home), MRI data, or genetic data. Thus, traditional information can be paired and assessed with machine-learning algorithms to provide patients with individualized and personalized treatment.
[Sabine Wilhelm, PhD, is currently a Professor at Harvard Medical School and Chief of Psychology at Massachusetts General Hospital, Boston. She is a leading researcher in obsessive-compulsive disorder (OCD) and body dysmorphic disorder, and principal investigator for NIH and privately funded studies investigating medication, cognitive behavioral therapy and digital services and other treatment of OCD and related disorders.]
To Visit the iaedp Virtual Symposium
Note: The 2020 iaedp conference is just a few keystrokes away (for conference registrants, see https://gateway.on24.com/wcc/gateway/eliteIAEDP/2266259 and for more information, visit the association website, www.iaedp.com ). This allows members and registrants to take their courses online, to hear and see the speakers and to attend the conference at their convenience.