TAO's Founder & CSO Answers Questions about TAO

Sherry Benton, Ph.D., ABPP
Founder, Chief Science Officer, TAO Connect

First, who are the authors of this material and where are they getting their advice from?

I am the founder and chief science officer for TAO.  I am responsible for organizing content experts and creating all content in TAO.  I am a licensed psychologist with 30 years of experience and a strong identity as a psychotherapist.  I am a fellow in the American Psychological Association, I am Board Certified by the American Board of Professional Psychology, I am the past president of the Academy of Counseling Psychology of ABPP, past president of the Association of Counseling Center Training Agencies , past vice President for Practice for the society of Counseling Psychology, and a board member of the American Board of Professional Psychology Foundation.  I have a substantial list of publications in refereed journals and served as an Associate Editor for Professional Psychology: Research and Practice.  I received the “Outstanding Contributions to Psychology” award from the American Academy of Counseling Psychology and the APA annual award for Advocacy.  
I was the Director of the Counseling Center at the University of Florida and had one of the larges staff (89 direct reports) and largest budgets ($4.5 million annually) and still could not keep up with student demand.  One year I received 4 new psychologist positions that only bought me 2 more weeks without a waitlist.   It was clear to me that I was never going to hire my way out of this dilemma.  
How TAO content is developed and evaluated:
All content in TAO was developed with a group of researchers and practitioners with expertise in the problem area and theoretical model under development.  First, all published literature is reviewed, then an outline is reviewed, this is sent to the consultants, the outline is revised.  Next, content is developed and storyboarded.  These storyboards are then reviewed by the consultants.  The storyboards are revised.  We begin hiring actors, filming, creating animations, and interactive exercises.  These are reviewed again and modifications are made.  All sessions and modules are published and available for our users.   Ideally, we would have followed this with randomized control trials, but we have not had the funding for this and we try to keep our costs down as much as possible.  Instead all users of TAO complete a well-researched, reliable and valid progress measure weekly.  We evaluate TAO using these repeated measures progress instruments and effect sizes benchmarked against randomized control trials in published studies.  Results are disseminated to all users annually.  In addition, all users have an administrative dashboard that displays utilization, satisfaction, and outcomes.
Each summer we review our results and plan modifications to the product.   The product solicits feedback after every session and this feedback from students and users is essential in our product review and planning.  Most of TAO’s content development was funded by grants from The National Science Foundation.  All research in TAO is approved and reviewed by the Institutional Review Board at the College of Medicine at the University of Florida.  
I see very little to no understanding of mental illness or mental health treatment shown in this video.
Susan primarily works in client support with about 100 undergraduate programs, so she does focus on that.  However, TAO’s content is appropriate for a wide range of diagnoses, ages, and cultural backgrounds.  There is a significant body of research supporting the model, which I will include in this post.  If you review the literature, you will see that the model is used primarily for patients with diagnoses most amenable to a more structured approach.  It is not appropriate for people with complex trauma, severe attachment disorders, psychotic disorders and so forth.  
Why add TAO?
I completely agree that ideally, all students, and for that matter, all people, should have access to high quality individual psychotherapy.  There is strong evidence for its effectiveness.  I also believe that resources such as TAO should never replace individual psychotherapy and should not be used for people with severe psychopathology.  However, we have a serious access problem in the US.  Over 90,000,000 people in the US live in underserved areas, 56% of US counties have no psychiatrists, psychologists, or clinical social workers.  The access problem became very real to me in my decades working in college student mental health.  Despite having one of the largest and best funded counseling centers at UF we regularly ran with wait list.  If a student came in at the beginning of a semester, they received individual psychotherapy, psychiatric consultation, and were offered resources such as group and biofeedback.  In spite of these seemingly robust resources we would find ourselves overwhelmed by the early October and would screen for severity and put all but the most acute on a waitlist.   This is the experience of the vast majority of university mental health resources in the US.  This model was a social justice nightmare.  Students who sought treatment in early August tended to be white, affluent, and came from a culture where family members regularly received psychotherapy.  Students who came later tended to be first generation students, from low SES families and students of color.  We were essentially bestowing additional privilege on the privileged and disenfranchising the disenfranchised.  The consequences were dire.  You are all well aware that with a common problem such as depression memory and concentration are impaired.  If you make a student with depression wait 5-6 weeks to begin treatment it will affect academic performance.  For graduate and professional students like yours this can change the entire trajectory of their careers.   We have an urgent need to explore options for evidence-based resources that expand access and capacity otherwise we find ourselves primarily serving the affluent to exacerbate injustice.  Incidentally, TAO is used extensively by graduate and professional students across the US and Canada.  Our intention with TAO is to provide effective resources that can be used as an adjunct for psychotherapy or for lower intensity treatment.  Using lower intensity treatment and self-help for those who can benefit, frees hours of psychotherapy for students who absolutely must have intensive individual psychotherapy in order to heal.  
When I began my career as a psychologist the internet was non-existent, online tools had not even been considered.  Now we have resources and possibilities that we have never had before.  Given our historic failure to reach underserved populations and to democratize our knowledge and abilities, we have an obligation as a field to see what we can do to help people with these new resources.  These efforts must be led by experienced mental health professionals and not left in the hands of software engineers with little or no mental health background.  
Use of TAO across campus 
This has largely consisted of the subset of materials that are primarily wellness oriented such as the Acceptance and Commitment Therapy which has very good research support as a resilience tool, the relationship and communication materials and the evaluating alcohol and drug use materials (BASICS).  These are focused on early intervention and prevention, while materials such as CBT for anxiety and depression and substance use disorder recovery skills focus more on psychiatric disorders.  
15 minute sessions
As stated, this model is for a subset of your clients.  We have found no difference in the rating of the therapeutic relationship with the shorter sessions than with fifty-minute face-to-face sessions.  This is consistent with published research on the model as implemented in Europe and Australia.   For the subset of students who do not appear to be responding, TAO includes a weekly progress measure that can be reviewed by the therapist, which allows the therapist to move a student to a more intensive level of therapy when needed.  
Our company name “Therapy Assistance Online” TAO, the double meaning of TAO was intentional, TAO is the way or the path to enlightenment.  We believe that is our mission as a company.  Deep psychotherapy is an important path to this, but it may not be the only path.
References
Andersson, G., Rozental, A., Shafran, R., & Carlbring, P. (2017). Long-term effects of internet-supported cognitive behavior therapy. Expert Review of Neurotherapeutics, 18. doi: 10.1080/14737175.2018.1400381
Andersson, G., Hedman, E. (2013). Effectiveness of guided Internet-delivered cognitive behaviour therapy in regular clinical settings
Verhaltenstherapie, 23 pp. 140-148
Andersson, G., Cuijpers, P., Carlbring, H. Riper, E., Hedman, E. (2014).  Guided Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: a systematic review and meta-analysis
World Psychiatry, 13 (3) (2014), pp. 288-295
Andrews, G., Basu, A., Cuijpers, P., Craske, M.G., McEvoy, P., English, C.L, & Newby, J.M. (2018). Computer therapy for the anxiety and depression disorders is effective, acceptable and practical health care: An updated meta-analysis. Journal of Anxiety Disorders, 55, 70-78. doi: 10.1016/j.janxdis.2018.01.001
Austin, D., Klein, B., Shandley, K., Ciechomski, L. (2010). Training clinicians to be e-therapists: the Anxiety Online model.  In Oxford Guide to Low Intensity CBT Interventions.  Pp 459-468. Oxford University Press, Oxford, England.
Batterham, P. J., & Calear, A. L. (2017). Preferences for Internet-Based Mental Health Interventions in an Adult Online Sample: Findings From an Online Community Survey. JMIR mental health, 4(2), e26. doi:10.2196/mental.7722
Benton, S. A., Heesacker, M., Snowden, S. J., & Lee, G. (2016). Therapist-assisted, online (TAO) intervention for anxiety in college students: TAO outperformed treatment as usual. Professional Psychology: Research and Practice, 47, 363-371. doi: 10.1037/pro0000097
Carlbring, P., Andersson, G., Cuijpers, P., Riper, H., & Hedman-Lagerlöf. (2018). Internet-based vs. face-to-face cognitive behavior therapy for psychiatric and somatic disorders: an updated systematic review and meta-analysis. Cognitive Behaviour Therapy, 47, 1-18. doi: 10.1080/16506073.2017.1401115
Cavanaugh, K., Shapiro, D., van den Berg, S., Swain, S., Barkham, M. and Proudfoot, J. (2009).  The acceptability of  computer-aided cognitive behavioural therapy: a pragmatic study.  Cognitive Behavioural Therapy, 38:4, 705-712/
Coull, G & Morris, Paul. (2011). The clinical effectiveness of CBT-based guided self-help interventions for anxiety and depressive disorders: A systematic review. Psychological medicine. 41. 2239-52.
Deane, F. P., and Kavanaugh, D. J., (2010). Adapting low intensity CBT interventions for clients with severe mental illness.  In Oxford Guide to Low Intensity CBT Interventions, pgs. 357-365.  Oxford University Press, Oxford, OX2 6DP.
Dimidjian, S., Hollon, S.D., Dobson, K. S., et al (2006).  Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression.  Journal of Consulting and Clinical Psychology, 74, 658-670.
Donker, T., Blankers, M., Hedman, E., Ljótsson, B., Petrie, K., & Christensen, H. (2015). Economic evaluations of Internet interventions for mental health: A systematic review. Psychological Medicine, 45, 3357-76. doi:10.1017/S0033291715001
Donker, T., Petrie, K., Proudfoot, J., Clarke, J., Birch, M.-R., & Christensen, H. (2013). Smartphones for Smarter Delivery of Mental Health Programs: A Systematic Review. Journal of Medical Internet Research, 15(11), e247. http://doi.org/10.2196/jmir.2791
Dryman, M., McTeague, L., Olino, T., & Heimberg, R. (2017). Evaluation of an open-access CBT-based Internet program for social anxiety: Patterns of use, retention, and outcomes. Journal of Consulting and Clinical Psychology, 85, 988-999. doi: 10.1037/ccp000232
Folker, A. P., Mathiasen, S. M., Lauridsen, S. M., Stenderup, E., Folker, M. P. (2018).  Implementing internet-delivered cognitive behavioral therapy for common mental health disorders: a comparative case stdy of implementation challenges perceived by therapists and managers in five European internet services. Internet Interventions. 11 (20) pp. 60-70.
Gellatly, J., bower, P., Richards, D., Gilbody, S. and Lovell, K. (2007).  What makes self-help interventions effective in the management of depressive symptoms?  Meta-analysis and meta-regression.  Psychological Medicine, 37, 1217-1228.
Hadjistavropoulos, H. D., Nugent, M. M., Alberts, N. M., Staples, B. F., Dear, B. F., Titov, N. (2016) Transdiagnostic internet-delivered cognitive behavior therapy in Canada: an open trial comparing results of a specialized clinic and nonspecialized clinics.  Journal of Anxiety Disorders.42, pp. 19-29.
Hadjistavropoulos, H. D., Nugent, M. M., dirkse, D., Pugh, N. (2017).  Inplementaion of internet-delivered cognitive behavioral therapy within community mental health clinics: a process evaluation using the consolidation framework for implantation research. BMC Psychiatry. 17 (1), pp. 331.
Lewis, C., Pearce, J., & Bisson, J. (2012). Efficacy, cost-effectiveness and acceptability of self-help interventions for anxiety disorders: Systematic review. British Journal of Psychiatry,200(1), 15-21. doi:10.1192/bjp.bp.110.084756
Kampmen, I., Emmelkamp, P., & Morina, N. (2016). Meta-analysis of technology-assisted interventions for social anxiety disorder. Journal of Anxiety Disorders, 42, 71-84. doi: 10.1016/j.janxdis.2016.06.007
Karyotaki, E., Kemmermen, L., Riper, H., Twisk, J., Hoogendoorn, A., Kleiboer, A.… & Cuijpers, P. (2018). Is self-guided Internet-based cognitive behavioral therapy (ICBT) harmful? An individual participant data meta-analysis. Psychological Medicine, 1-11. doi: 10.1017/S0033291718000648
Kavanaugh, D. J. and Bennett-Levy, J. (2010).  Facilitating widespread adoption of low intensity CBT interventions: changing systems and routine practice.  In Oxford Guide to Low intensity CBT Interventions. Pp. 475-478.  Oxford University Press, Oxford, England.
King, R.J., Orr, J.A., Poulsen, B. et al. Adm Policy Ment Health (2017) 44: 664. https://doi.org/10.1007/s10488-016-0783-9
Lenhard, F., Andersson, E., Mataix-Cols, D., Rück, C., Vigerland, S., Högström, J…. & Serlachius, E. (2017). Therapist-guided, Internet-delivered cognitive-behavioral therapy for adolescents with Obsessive Compulsive Disorder: A randomized controlled trial. Journal of the American Academy of Child & Adolescent Psychiatry, 56, 10-19. doi:
Newby, J., Smith, J., Uppal, S., Mason, E., Mahoney, A., Andrews, G. (2018). Internet-based cognitive behavioral therapy versus psychoeducation control for Illness Anxiety Disorder and Somatic Symptom Disorder: A randomized controlled trial. Journal of Counselling and Clinical Psychology, 86, 89-98. doi: 10.1037/ccp00002-248.
Nielssen, O., Dear, B. F., Staples, L. G., Dear, R., Purtell, C., Titov, N. (2015). Procedures for risk management and a review of crisis referrals from the MindSpot Clinic, a national service for the remote assessment and treatment of anxiety and depression.  BMC Psychiatry, 15, p. 304.
Nordgren, L., Hedman, E., Etienne, J., Bodin, J., Kadowaki, A., Eriksson, S…. & Carlbring, P. (2014). Effectiveness and cost-effectiveness of individually tailored Internet-delivered cognitive behavior therapy for anxiety disorders in a primary care population: A randomised controlled trial. Behavior Research and Therapy, 59, 1-11. Doi: 10.1016/j.brat.2014.05.007
Ophius, R., Lokkerbol, J., Heemskerk, S., van Balkom, A., Hiligsmann, M., Evers, S. (2017). Cost-effectiveness of interventions for treating anxiety disorders: A systematic review. Journal of Affective Disorders, 210, 1-13. doi: 10.1016/j.jad.2016.005
Richards, D., Richardson, T., Timulak, L., & McElvaney, J. (2015). The efficacy of internet-delivered treatment for generalized anxiety disorder: A systematic review and meta-analysis. Internet Interventions, 2, 272-282.
Rosso, I., Webb, C., Gogel, H., William, K., Fukunaga, R., Buchholz, J…. & Rauch, S. (2016). Internet-based cognitive behavior therapy for major depressive disorder: A randomized controlled trial. Depress Anxiety, 34, 236-245. doi: 10.1002/da.22590
Stolz, T., Schulz, A., Krieger, T., Vincent, A., Urech, A., Moser, C…. & Berger, T. (2018). A mobile app for social anxiety disorder: A three-man randomized controlled trial comparing mobile and PC-based guided self-help interventions. Journal of Consulting and Clinical Psychology, 86, 493-504. doi: 10.1037/ccp0000301
Titov, N., Dear, B., Nielssen, O., Staples, L., Hadjistavropoulos, H., Nugent, M., Adlam, K. Nordgreen, T., Bruvik, K. et al. (2018).  ICBT in routine care: A decriptive analysis of successful clinics in five countries.  Internet Interventions, 13, 108-115.
Titov, N., Dear, B. F., Johnston, L. Lorian, C., Zou, H., Wootton, B., Spence, J., McEvoy, P.M, Rapee, R. M. (2013). Improving adherence and clinical outcomes in self-guided internet treatment for anxiety and depression: randomized controlled trial.  PLoS One, 8 (7) Article e62873.
Whiteford, H., Ferrari, A., Degenhardt, L., Feigin, V., & Vos, T. (2015). The global burden of mental, neurological and substance use disorders: An analysis from the global burden of disease study 2010. PLos ONE, 10. doi: 10.1371/journal.pone.0116820
Ye, Y., Zhang, Y., Chen, J., Liu, J., Li, X., Liu, Y…. & Jiang, X. (2015). Internet-based cognitive behavioral therapy for insomnia (ICBT-i) improves comorbid anxiety and depression – a meta-analysis of randomized controlled trials. PLos ONE, 10. doi:10.1371/journal.pone.0142258
 

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