Digitized thought records: a practitioner-focused review of cognitive restructuring apps

Development and pilot-testing of an app to complement trauma-focused cognitive behavioral therapy for adolescents

Background: Apps have the potential to support psychological treatments by providing psychoeducation, increasing homework compliance, and generalizing therapeutic skills outside of sessions. However, there are few apps developed to support specific evidence-based treatment for PTSD for adolescents.Objective: This paper shares experiences developing an app to complement Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). It also describes adolescents' and therapists' perceived usefulness and the potential effect of the app 'My everyday life' on posttraumatic stress symptoms (PTSS).Methods: We did a needs assessment with adolescents, therapists, and TF-CBT trainers, followed by programming and beta-testing. We carried out a mixed methods study of 59 adolescent patients (aged 13-18 years) and their therapists. Using a triangulation design, we combined quantitative data on app use and changes in PTSS with qualitative data from interviews with 10 adolescents and 10 therapists who described their experiences with the app.Results: The app includes psychoeducation, mental health self-monitoring, coping tools, and goal-setting functionality. The most used features were psychoeducation and breathing exercises. Few therapists actively used the monitoring progress feature. Both adolescents and therapists found the app beneficial for everyday use, though some therapists were unsure about how to integrate it with TF-CBT. Adolescents reported significant PTSS improvement during TF-CBT with the app as a complement. Adolescents with post-treatment data (n = 13) did not report significantly different PTSD improvement compared to adolescents without access to app, but the study lacked power to draw strong conclusions.Conclusions: The app 'My everyday life' can be useful for adolescents receiving TF-CBT. The therapists may benefit from clearer guidelines on how to integrate apps with evidence-based treatments. Digital tools are a promising avenue for supporting the implementation of evidence-based treatment.

Serious Games for Serious Pain: Development and Initial Testing of a Cognitive Behavioral Therapy Game for Patients With Advanced Cancer Pain

PURPOSE

Cancer-related pain is prevalent among people with advanced cancer. To improve accessibility and engagement with pain-cognitive behavioral therapy (pain-CBT), we developed and tested a serious game hosted within a mobile health intervention that delivers pain-CBT and pharmacologic support. The game focuses on teaching and practicing cognitive restructuring (CR), a central pain-CBT intervention component.

METHODS

The pain-CBT game was developed through partnerships with commercial and academic game developers, graphic designers, clinical experts, and patients. Patients with metastatic cancer and pain participated in iterative, semistructured interviews. They described their experience playing each level and reflected on relevance, clarity, usability, and potential changes. Content codes captured patients' suggestions and informed game refinements.

RESULTS

The final game includes five levels that prompt players to distinguish between adaptive and maladaptive thoughts that are pain- and cancer-specific. The levels vary in objective (eg, hiking and sledding), interaction type (eg, dragging and tapping), and mode of feedback (eg, audio and animation). Fourteen participants reviewed the game. Patients appreciated the pain- and cancer-specific thought examples, with a few noting that the thoughts made them feel less alone. Many stated that the game was fun, relatable, and an engaging distraction. Others noted that the game provided helpful CR practice and prompted reflection. For example, one 40-year-old woman said the game "brings [a thought] to the forefront so you can acknowledge it, and then maybe you could let it go or… do something about it."

CONCLUSION

Patients coping with cancer pain found the CR game helpful, enjoyable, and satisfactory. Serious games have the potential to increase engagement while facilitating learning and rehearsal of psychological skills for pain. Future testing will evaluate the efficacy of this serious game.

Is There a Place for Cognitive Restructuring in Brief, Self-Guided Interventions? Randomized Controlled Trial of a Single-Session, Digital Program for Adolescents

OBJECTIVE

Self-guided digital mental health interventions (DMHIs) teaching empirically supported skills (e.g. behavioral activation) have demonstrated efficacy for improving youth mental health, but we lack evidence for the complex skill of cognitive restructuring (CR).

METHOD

We conducted the first-ever RCT testing a CR DMHI ("Project Think") against an active control (supportive therapy; "Project Share") in collaboration with public schools. Pre-registered outcomes were DMHI acceptability and helpfulness post-intervention, as well as internalizing symptoms and CR skills use from baseline to seven-month follow-up, in the full sample and the subsample with elevated symptoms.

RESULTS

Participants (N = 597; MAge = 11.99; 48% female; 68% White) rated both programs highly on acceptability and helpfulness. Both conditions were associated with significant internalizing symptom reductions across time in both samples, with no significant condition differences. CR skills use declined significantly across time for Project Share youths but held steady across time for Project Think youths in both samples; this pattern produced a significant condition difference favoring Project Think within the elevated sample at seven-month follow-up.

CONCLUSION

Internalizing symptoms declined comparably for Think and Share participants. Consequently, future research should examine whether encouraging youths to share their feelings produces symptom improvements, and whether a single-session, self-guided CR DMHI produces beneficial effects relative to more inert control conditions. Further, the decline in CR skills use for Project Share youths versus sustained CR use by Project Think youths raises questions about the natural time course of youths' CR use and the impact of these DMHIs on that course. ClinicalTrials.gov Registration: NCT04806321.

Measuring the active elements of cognitive-behavioral therapies

Understanding how and for whom cognitive-behavioral therapies work is central to the development and improvement of mental health interventions. Suboptimal quantification of the active elements of cognitive-behavioral therapies has hampered progress in elucidating mechanisms of change. To advance process research on cognitive-behavioral therapies, we describe a theoretical measurement framework that focuses on the delivery, receipt, and application of the active elements of these interventions. We then provide recommendations for measuring the active elements of cognitive-behavioral therapies aligned with this framework. Finally, to support measurement harmonization and improve study comparability, we propose the development of a publicly available repository of assessment tools: the Active Elements of Cognitive-Behavioral Therapies Measurement Kit.

Advances in digital CBT: where are we now, and where next?

Digital CBT refers to the use of digital tools, platforms or devices to deliver or enhance cognitive behavioural therapy assessment, formulation, treatment, training and supervision. The ‘Advances in Digital CBT’ special issue aimed to document examples of innovative digital CBT practice in this rapidly developing field. In this paper, we have briefly summarised and synthesised the advances demonstrated in this group of articles. These include developments in our understanding of mental health apps, the use of digital tools as an adjunct to therapy, the effectiveness of remotely delivered CBT in routine clinical practice, our understanding of user experiences and involvement, and in digital CBT research methods. We consider the extent of current knowledge in these areas and identify where gaps in evidence lie and how the field could be taken forward to address these. Lastly, we reflect on the broader digital CBT picture and offer our suggestions of six key directions for future research: using robust study designs to evaluate and optimise digital tools; translating and culturally adapting digital tools and practices; understanding and addressing digital exclusion; exploring, reporting and addressing possible negative effects; improving user involvement in design and evaluation; and addressing the implementation gap for digital tools. We suggest that further advances in these areas would be of particular benefit to the digital CBT field.

Key learning aims

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