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  • Tackling anxiety with tech-enabled therapy
  • Tackling anxiety with tech-enabled therapy
    Leo Hidalgo, Creative Commons (2015) ©
CASE STUDY

Joyable: treating social anxiety through an app

The Western world is in the grip of an anxiety epidemic, yet while rates of mental illness have surged, health services have struggled to keep up. Could effective care be delivered by an app? That’s the goal of Joyable, which offers CBT treatments to social anxiety sufferers through their smartphones.

Location North America / Northern Europe

Scope
The varied stresses of the modern world are often blamed for surging anxiety levels in the West. In the UK, 19% of people reported experiencing depression or anxiety in 2013, while 40 million Americans suffer from an anxiety disorder. [1][2]

Yet while rates of mental health problems have grown – in the UK, referrals to community mental health services increased 19% between 2010 and 2015 – the provision of health services has not matched this pace. [3] British patients can wait between a few weeks and a few years before receiving the care they need from the NHS, while cognitive behavioural therapy (CBT) treatments for anxiety disorders can cost $100 per hour in the US. [4][5] Additionally, some people live remotely from mental health services or are reluctant to reach out for fear of the associated stigma. Could an app revolutionise the way we access therapy?

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San Francisco-based Joyable launched its web service in early 2015, and its app debuted shortly afterwards. It aims to ease social anxiety by providing CBT techniques in three stages, starting with an educational period where the client learns about CBT, followed by the ‘cognitive’ stage, where they’re helped to identify negative thoughts about themselves in social interactions. Finally, during the behavioural stage, the user is set tasks that aim to challenge their previously held beliefs. These include taking actions that remove them from their comfort zone; for example, initiating a conversation with a colleague, going on a date, or pitching in during a meeting. CBT is based on the idea that the situations themselves aren’t anxiety-inducing, but how the individual interprets them. [6]

Each stage of therapy is undertaken with the support of coaches who are trained in CBT techniques, but aren’t licensed therapists. When the user signs up, they receive an optional 30-minute phone call with the coach, after which they can be contacted by text, email or scheduled phone call at least once a week. The app costs $99 per month or $239 for the full 12 week programme. [6] Considering that private therapy in the UK can cost between £40 and £100 per session, Joyable offers an affordable alternative. [7]

“I believe mental health is the single biggest waste of human potential in the developed world, and there’s quite a bit of statistics, unfortunately, to back that up,” says Peter Shalek, CEO of Joyable. “Our mission is to cure the world of anxiety and depression.” [6] Joyable reports that 90% of users experience at least a 30% decrease in symptoms – measured by taking a Social Phobia Index score at the beginning and the end of treatment – a level which they consider ‘life-changing’. [8]

Joyable offers on-the-go therapy for increasingly on-the-go lifestyles Joyable offers on-the-go therapy for increasingly on-the-go lifestyles
Yelp Inc, Creative Commons (2014) ©

Context
Does science back up Joyable’s claims? In fact, it’s been found that cognitive behavioural therapy is the most effective method for tackling social anxiety, and studies have confirmed that online provision of CBT techniques can be as effective as face-to-face time with a therapist. A 2010 study of these treatments noted: “It seems safe to conclude that guided self-help and face-to-face treatments can have comparable effects. It is time to start thinking about implementation in routine care.” [6]

And Joyable isn’t alone in the mental health app market; there are over 3,000 apps in this category across the Apple and Android stores. [9] Headspace offers guided meditation to relieve stress and anxiety, aiming to improve focus and relationships. But while it’s a hit with stressed out smartphone owners –it’s gained over three million users since launching in 2012 – it hasn’t undergone any rigorous clinical testing. [10]

Another, Mood 24/7, was developed by John Hopkins University to combat depression and mood disorders. The app tracks mood by asking users to rate their feelings daily on a scale of one to ten. These results can be used to help the user monitor and discover patterns in their emotions, thereby informing sessions with a therapist or predicting when they should reach out to others at the onset of a depressive episode. Unlike Headspace, clinical trials have testified to the app’s effectiveness as a tool to empower those suffering with depression. [9]

I believe mental health is the single biggest waste of human potential in the developed world. Our mission is to cure the world of anxiety and depression

Peter Shalek, CEO of Joyable

Other apps make use of social networks to create online support groups for those suffering from mental illness. Koko and 7 Cups of Tea generate anonymous connections between a user and a group of concerned listeners, while messaging service Talkspace puts you in touch with a therapist via a 24-hour text service. And while these digital exchanges may seem flimsy compared to hours of discussion in a psychologist’s office, evidence shows they may be sufficient to build meaningful emotional bonds. A 2015 study found that users of 7 Cups of Tea viewed their digital interactions as ‘genuine’ empathetic displays. [11]

But can an app really provide effective psychological support? "The rate at which apps come out is always going to outweigh the rate at which they can be evaluated," says Simon Leigh, a health economist at the University of Liverpool. “Evaluation takes time – you have to design a pilot study and a retrospective observational study, randomise patients – and these apps can be knocked up in a matter of days.” [12] Less than 1% of commercially available apps have been through clinical trials to assess their effectiveness. [9] And it’s possible that the success statistics reported by apps like Joyable are exaggerated due to the ‘survival bias’, which refers to the idea that the only people included in their data are the ones that liked the app enough to stick with it for the duration of the therapy. [13]

Tech-enabled support is still catching up to traditional therapy Tech-enabled support is still catching up to traditional therapy
Yelp Inc, Creative Commons (2012) ©

Insights and opportunities
Despite the lack of evidence for some apps, there’s a strong case for increasing their use. “There’s a genuine need for something that can be used to meet the unmet needs of people with depression,” says Simon Gilbody, director of the Mental Health and Addictions Group at the University of York. “There’s still overprescription of antidepressants and woefully inadequate provision of psychotherapies.” [14]

According to Nadja Reilly, clinical psychologist at William James College, there are other reasons apps may be preferred. “There’s a tremendous amount of stigma around therapy still, and I’m not sure where these misconceptions came from, but we often hear men and adolescents referring to it as lying on a couch talking about their mom,” she says, adding that using an app “feels less threatening.” [9]

But not all demographics are equally affected when it comes to mental health problems. A survey conducted by Joyable found that 18- to 29-year-olds are the most likely to experience social anxiety, with 70% exhibiting symptoms. [2] Amid uncertainty about the economy, jobs and the housing market, Gen Y has been dubbed the ‘anxious generation’, with social media and smartphones playing a role in this poor state of wellbeing. Today, young people can constantly compare their lives to peers as well as celebrities, and find themselves wanting. “Young people have to almost become a brand – Brand Me: how I look, how I feel, what I am doing every day,” says Lucie Russell, campaign director at YoungMinds. “We didn’t have that 20 years ago.” [15]

Young people have to almost become a brand – Brand Me: how I look, how I feel, what I am doing every day

Lucie Russell, campaign director at YoungMinds

Given that social anxiety disorder is rooted in the fear about what others think of us, could the constant comparison and strain to present a perfect image be stressing out Gen Y? “The relationship between narcissism and anxiety may seem paradoxical, but the extrinsic values that Generation Y value that correlate with narcissism, such as money, fame and image, also correlate with anxiety,” says Jean Twenge, author of Generation Me. [15]

Yet while smartphones and social media have been held partially responsible for this phenomenon, they may also be vital in tackling it. Of the anxious young adults Joyable surveyed, 51% said they depended on social media to get them through holiday celebrations, and 45% said their smartphone was their go-to hiding place. [2] Perhaps it’s also the perfect place for them to access some much-needed therapy.

joyable.com

Laurie Clarke is a Psychology graduate currently based in Scotland. She is obsessed with what makes people tick, especially when it comes to how people make decisions.

Related behaviours
Mindful Moments: People are trying to focus on one thing at a time

Sources
1. 'Anxiety or depression affects nearly one in five UK adults', The Guardian (June 2013)
2. 'Why most millennials find holiday gatherings stressful', Fortune (December 2015)
3. 'Mental health trust funding down 8% from 2010 despite coalition’s drive for parity of esteem', Community Care (March 2015)
4. 'Mental health patients wait 'years' for treatment', BBC News (April 2016)
5. 'Low-cost treatment', Anxiety and Depression Association of America
6. 'The startup that wants to cure social anxiety', The Atlantic (May 2015)
7. 'Cognitive behavioural therapy (CBT)', NHS
8. 'Have social anxiety? This startup is working to help you beat it', The Huffington Post (May 2015)
9. 'Mental-health apps make inroads with consumers and therapists', The Wall Street Journal (September 2015)
10. 'Meditation startup Headspace raises $30 million to help you be more mindful',TechCrunch (September 2015)
11. 'Uber, but for the mirror stage: how mental-health apps are changing therapy', New York (February 2016)
12. 'How effective are mental health apps?', Wired (October 2015)
13. 'Pseudo-therapy apps: the fad diet of mental health', TechCrunch (November 2015)
14. 'Can mental health apps replace human therapists?', New Scientist (November 2015)
15. 'Anxiety: the epidemic sweeping through Generation Y', The Telegraph (April 2015)

Author
Laurie Clarke