Cognitive Therapy Is Hard. Can a Simple App Help?

Two days ago, I sent an email to a colleague, and they still haven’t responded. My mind immediately concludes that my colleague is annoyed with my request. This makes me feel anxious, and I’m unlikely to reach out to them to follow up.

People encounter these types of ambiguous and uncertain situations countless times throughout the day. Our brains are very efficient at filling in the gaps for us, so much so that we are rarely aware that we are even jumping to a conclusion. Rather, we see these conclusions as reality.

The tendency people have to automatically resolve ambiguous situations impacts how they feel and what they do. A tendency to jump to negative conclusions (called interpretation bias) can lead to anxiety, depression, and maladaptive coping.

In my example, because I treated my interpretation as fact, I felt nervous and avoided reaching out to my colleague to follow up. If I had instead paused to consider other possibilities, such as “my colleague might be really busy right now,” I would not have felt as anxious, and I would have reached out to see if she had seen my prior email.

Interpretation bias has been linked to many types of emotional disorders (see Hirsch et al., 2016, for a great review). While the specific situation being interpreted differs in these disorders, the process is similar:

• Social anxiety: "Someone yawns while you’re talking"—are you boring, or are they tired?
• Panic disorder: “Your heart starts racing out of the blue”—is this dangerous or normal?
• Generalized anxiety: “You are driving somewhere new and get lost”—are you doomed to be lost forever, or is this no big deal?
• Obsessive-compulsive disorder: “You have the thought that something bad will happen to your mom”—are you responsible for preventing harm, or is this just a random thought?
• Depression: “You don’t get the job you applied for”—are you a failure, or is there a lot of competition in a bad economy?

The impact of interpretation is also similar, regardless of the situation. Interpretation bias causes people to feel anxious, sad, or angry and then engage in maladaptive coping—most frequently, avoidance. A tendency to jump to negative conclusions not only harms someone in the moment but also sets them up to expect the worst in future situations, maintaining a vicious cycle.

Many types of therapy address interpretation bias. Cognitive therapy helps people recognize automatic negative thoughts and reappraise them to be more balanced. Acceptance and commitment therapy and other mindfulness-based approaches help people observe their thoughts in a non-judgmental way. Mentalization-based therapy helps people recognize when they might be jumping to conclusions about others' thoughts, feelings, and behaviors.

These approaches are all effective, but they are hard! Moreover, they require a lot of time and effort and access to highly trained therapists.

In an effort to create more accessible and more efficient interventions for interpretation bias, researchers created computerized training tasks called Cognitive Bias Modification (CBM) that shift interpretation bias through tasks that allow users to practice resolving ambiguous situations more positively. The goal of CBM is to create a new, healthier mental habit. Thus, CBM training typically includes 50-100 ambiguous scenarios per session, in contrast to one or two that a client might discuss with a therapist per session.

Based on input from our Patient Advisory Board, case managers, CBM experts, and clinic program directors, my lab recently developed a smartphone app called “HabitWorks” to deliver a CBM treatment that is personalized and engaging.

The CBM exercises present ambiguous situations—“You feel dizzy when you stand up quickly”—and then a word representing either a negative conclusion—“faint”—or a neutral/positive conclusion—“normal.” The user is asked to decide if the word is related to the sentence. If a user endorses a positive conclusion or rejects a negative conclusion, they receive “correct” feedback and earn 1 point. If they endorse a negative conclusion or fail to endorse or reject a positive conclusion, they are told to “try again.”

HabitWorks included the following features:

• Instructional videos
• Personalization checklist, so the app only presents personally relevant situations out of a pool of 800 (e.g., marital status, employment status, domains of worry)
• Scheduled CBM exercises and bonus “mini-rounds”
• Weekly check-ins in the app with mood monitoring and free text prompts to identify moments in daily life where the user caught themselves jumping to conclusions
• Weekly check-ins with a coach
• Immediate performance feedback after each session and lifetime statistics
• Progression through 10 levels

We then pilot tested HabitWorks in 14 patients (64 percent women and ranged in age from 19 to 64 years) attending the Behavioral Health Partial Hospital Program at McLean Hospital. This partial hospital teaches cognitive therapy skills, but patients typically have little time to practice these or implement them into their life before discharge. Additionally, the month following discharge from hospital treatment is well-known as being extremely challenging and the period of highest risk for relapse and rehospitalization. We hoped HabitWorks might be a useful adjunct to the CBT patients received in the hospital, as well as being a way to carry the treatment with them when they left—i.e., cognitive therapy in your pocket!

Anxiety Essential Reads

Looking to Cope With Election Anxiety? Embrace It

Gen Z and Achievement Addiction

Overall, patients found HabitWorks to be moderately helpful and user-friendly. Of the patients who completed a follow-up assessment, 80 percent to 100 percent had interpretation bias scores in the healthy range, depending on the type of interpretation bias measured (see Beard et al., 2020).

Here is what patients had to say:

• "Simple at first, but crept in."
• “I can already see this re-training my mind.”
• “Wow, this is just showing me how warped my interpretations are.”
• “I am approaching certain situations in my life differently.”
• “Helped normalize my anxiety in daily life.”

Negative feedback centered around:

• Corrective feedback too rigid
• Exercises too long
• Wanting more variability in the situations presented
• A desire for more app features or customization of app features
• A desire for greater flexibility in the study protocol (i.e., daily session timing, scheduling of sessions)

We are now further testing HabitWorks in a randomized controlled trial, comparing it to a Symptom Tracking smartphone app. A future larger trial will help us determine whether HabitWorks actually improves outcomes for people discharging from the hospital.

In addition to augmenting the effects of CBT, we are also excited to test HabitWorks in different populations and settings. For example, HabitWorks could be a useful, low-intensity first-step treatment for anxiety in primary care—where most people first seek mental health treatment. Ultimately, HabitWorks may be one tool in the toolbox to help people create and maintain healthy mental habits.