mental health services

The Lancet Psychiatry Commission on intimate partner violence and mental health: advancing mental health services, research, and policy.

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Intimate partner violence (IPV) is the most common form of violence worldwide. Most victims of IPV are women—globally, an estimated 27% of women aged 15 years or older have experienced physical or sexual IPV—but high rates of IPV are also experienced by other marginalised groups. Exposure to IPV increases the likelihood of developing a range of mental health problems. The presence of mental health problems also makes individuals more vulnerable to experiencing IPV. Although IPV is endemic, it is not inevitable. Targets for intervention range from parenting or school-based programmes, to the prevention and treatment of substance misuse, and support for secondary or higher education for women. Survivors should be fundamental to the development and assessment of IPV measures and integrated support services.

In this issue, a Commission on intimate partner violence and mental health, led by Sian Oram, Helen Fisher, and Louise Howard, summarises current knowledge on this crucial topic and lays out a roadmap of recommendations to reduce incidence and aid survivors. The Commission’s approach and findings reach much further than simple clinical pathologising—it takes a broad, whole-society view of intimate partner violence and what should be done to improve the lives of survivors. A key element linking the different sections of the Commission is the concept of trauma and the need for trauma-informed care from individual providers all the way through whole mental health systems. As Oram and colleagues note, there is still much to be learned about trauma as it relates to intimate partner violence, and even more to be done to transform our systems to deal with trauma adequately. Although the focus of the Commission is on intimate partner violence, it provides important insights for dealing with individual traumas and the collective trauma whole communities are experiencing in the aftermath of COVID-19, wars and mass civilian displacement, and the increasing toll of climate change. Below, we highlight a few of the challenges raised in the Commission, and recommendations for improvement, as they relate to the broader topic of trauma.

Current measures of intimate partner violence and its mental health ramifications are inadequate. The Commission highlights how the variety of tools available to measure exposure to intimate partner violence (and the resulting heterogeneity of data), combined with mixed evidence on these tools’ validity and usefulness in different cultural and other contexts, have probably contributed to the paucity of measurement of exposure in clinical and research settings. Oram and colleagues delve into the further challenges of capturing the mental health consequences of intimate partner violence. A key point is the disconnect between what researchers actually measure, and what survivors say is important to them. These issues all have strong overlap with problems more generally with trauma, whereby researchers and clinicians often struggle to account for important nuances in exposure context and cultural settings, and to capture outcomes that matter to survivors.

Like other forms of trauma, exposure to intimate partner violence can be dynamic and cumulative, and a survivor’s response and mental health status will depend on their personal history and life stage. The authors of the Commission rightly advocate a life-course approach to understanding intimate partner violence and making recommendations for interventions. The key messages provide crucial insights for any mental health provider who is likely to encounter trauma in their patients at different life periods, from perinatal to older age.

Given these complexities, the Commission recommends a transformation of our mental health care systems into ones that are centred on, and are capable of properly dealing with, the trauma experienced by survivors of intimate partner violence. In reading the experiences of service users quoted in the Commission, as well as concrete steps proposed by the authors, it is clear that such a transformation of mental health services would probably benefit not only survivors of intimate partner violence, but also survivors of the many other forms of trauma that continue to go unnoticed and untreated in our communities and inpatient and outpatient services. Rather than a siloed mental health system that largely relies on strict categories and diagnoses, the authors recommend a more transdiagnostic approach with respect to trauma, providing specific examples, such as asking “Have I considered how experiencing trauma and violence might have contributed to the development of the presenting complaint or reason for referral?”

The Commission makes clear that there are many ways the mental health community can reduce the incidence of intimate partner violence, but also that the community needs to be better prepared to help survivors. Tackling intimate partner violence will require putting trauma front and centre—in our research, in our services, and in our policies. Doing so will be challenging, but as Oram and colleagues point out, there are principles to guide trauma-informed care and implementation. We hope our readers will see the potential these efforts have to benefit survivors of intimate partner violence and the lives of all those experiencing trauma.

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The Lancet Psychiatry

Published: May 13, 2022

Intimate partner violence (IPV) is the most common form of violence worldwide. Most victims of IPV are women—globally, an estimated 27% of women aged 15 years or older have experienced physical or sexual IPV—but high rates of IPV are also experienced by other marginalised groups. Exposure to IPV increases the likelihood of developing a range of mental health problems. The presence of mental health problems also makes individuals more vulnerable to experiencing IPV. Although IPV is endemic, it is not inevitable. Targets for intervention range from parenting or school-based programmes, to the prevention and treatment of substance misuse, and support for secondary or higher education for women. Survivors should be fundamental to the development and assessment of IPV measures and integrated support services.

Source: Lancet

Chatbot: The Therapist in Your Pocket

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AI chatbots offer a modern twist to mental health services, using texting to digitally counsel today’s smartphone generation.

Artificial intelligence (AI)-powered chatbots provide a new form of mental health support for a tech-savvy generation already comfortable using texting as its dominant form of communication.

As the demand for mental health services grows nationwide, there’s a shortage of available psychiatric professionals, according to the National Institute of Mental Health. And college campuses are seeing unprecedented rates of anxiety and depression.

Chatbots designed to spot indicators of mental health distress may provide emotional support when traditional therapy is out of reach.

While these chatbot counselors don’t replace the critical human touch essential during a personal crisis, AI and machine learning can enable the mental health community to reach more people and ensure consistent follow up, according to Michiel Rauws, co-founder and CEO of the mental health tech startup X2AI.

“There are millions of people globally who struggle with anxiety and depression, and simply not enough psychologists to take care of everyone,” Rauws said.

AI chatbots help college students

Chatbots may offer greater access to mental health services for today’s tech-savvy generation.

Based on his own experience with depression and work with immigrants affected by the war in Syria, he realized that much of cognitive behavioral therapy (CBT) is about coaching people to reframe how they think of themselves and their lives. He developed Tess, an AI chatbot that helps psychologists monitor patients, and remotely deliver personalized psychotherapy and mental health coaching.

“I had learned the psychological techniques and innovations, and realized that I might help others,” he said.

Now 27, Rauws says his generation often feels more comfortable chatting about sensitive issues via text rather than in person at a therapist’s office.

Available through text, web browsers and Facebook Messenger, Tess is offered through healthcare organizations to provide care whenever and wherever a patient needs it.

In addition to helping patients work through their issues, the AI chatbot also recognizes signals that indicate an acute crisis, such as suicidal thoughts. It alerts a human therapist when emergency intervention is essential.

The Digital Doctor is In

Several companies are developing mental health-related chatbots for direct consumer use, including the Woebot, a digital mental health coach that uses CBT to help users deal with anxiety or depression.

“Woebot is a robot you can tell anything to,” Woebot CEO Alison Darcy told Wired. “It’s not an AI that’s going to tell you stuff you don’t know about yourself by detecting some magic you’re not even aware of.”

Using Facebook Messenger, Woebot uses talk therapy prompts such as “What’s going on in your world right now?” This helps people talk about their emotional responses to life events, and identify the traps that cause stress and depression.

There’s no Freudian psychoanalysis of childhood wounds, just solutions for changing behavior. Woebot notes CBT is based on the idea that it’s not events themselves that affect people, it’s how they think about those events. What people think is often revealed in what they say.

This is just the beginning of a new era of tech-enabled mental health care. Machine learning has become so sophisticated that it can read between the lines of conversations and look for warning signs, according to researchers at IBM.

IBM used cognitive systems and machine learning to analyze written transcripts and audio recordings from psychiatric interviews to identify patterns that can indicate, and maybe even predict, mental illness.

It takes only 300 words to help clinicians predict the probability of psychosis, according to Guillermo Cecchi, a neuroscientist and researcher at IBM Research.

AI chatbots help mental health

AI technology can help in identifying patterns of thinking.

In five years, the IBM team predicts that advanced analytics, machine learning and computational biology will provide a real-time overview of a patient’s mental health.

Bringing Care to Rural Areas

These CBT technologies could meet a growing need for mental health care among the younger generation. Rates of depression and anxiety among young people are rising, according to the American College Health Association (ACHA).

Within the past year, 50 percent of college students reported feeling that things were hopeless, 58 percent felt overwhelming anxiety and 37 percent felt so depressed it was difficult to function. While universities encourage students to seek help, the social stigma still associated with mental illness can keep them from looking for a traditional therapist, according to ACHA research.

Chatbots may also help address the shortage of mental health services in rural areas where patients drive long distances to see a therapist face-to-face, said Gloria Zaionz, tech guru at the Innovation Learning Network, a think tank in Silicon Valley that studies how technology can improve healthcare.

More than 106 million people live in areas that are federally designated as having a shortage of mental health care professionals, according to the Kaiser Family Foundation.

“Mental health professionals are often limited in their capacity to provide treatment, and there are other barriers like wait times, cost and social stigma that can prevent people from getting the support they need,” Rauws said.

Companies are careful to note that AI chatbots are not intended to replace in-person treatment, but rather to expand limited access to mental health services. The tech provides more ways for patients to check in between visits and receive consistent follow-up care.

Data on the effectiveness of AI therapy is limited, but early results look encouraging, according to Rauws at X2AI. He said a trial of Tess across several U.S. universities showed a decrease in the standard depression scale and anxiety scale scores. A pilot study of Woebot also reported reduced levels of depression and anxiety.

Through a simple text conversation, AI may help in overcoming the stigma of seeking mental health care, ultimately expanding the reach of services. And a seemingly nonjudgmental chatbot may encourage people to honestly answer the question, “Are you OK?”

“There’s something about the screen that makes people feel a little bit more anonymous,” said Zaionz, “so they open up more.”

YOUR SMARTPHONE COULD BE GOOD FOR YOUR MENTAL HEALTH

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When it comes to mental health, technologies such as smartphones and social media networks are almost always discussed in terms of the dangers they pose. Alongside concerns expressed in the media, some experts believe that technology has a role in the rising rates of mental health problems. However, there is also evidence to suggest your smartphone could actually be good for your mental health.

The brain is a sensitive organ that reacts and adapts to stimulation. Researchers have looked into smartphone usage and the effects on the day-to-day plasticity of the human brain. They found that the finger movements used to control smartphones areenough to alter brain activity.

This ability of technology to change our brains has led to questions over whether screen-based activity is related to rising incidence of such conditions as attention deficit hyperactivity disorder (ADHD) or an increased risk of depression and insomnia. Technology has also been blamed for cyber-bullying, isolation, communication issues and reduced self-esteem, all of which can potentially lead to mental ill health.

Positive potential

However, focusing only on the negative experiences of some people ignores technology’s potential as both a tool for treating mental health issues and for improving the quality of people’s lives and promoting emotional well-being. For example, there are programmes for depression and phobias, designed to help lift people’s moods, get them active and help them to overcome their difficulties. The programmes use guided self help-based cognitive behavioural principles and have proven to be very effective.

Computer games have been used to provide therapy for adolescents. Because computer games are fun and can be used anonymously, they offer an alternative to traditional therapy. For example, a fantasy-themed role-playing game called SPARXhas been found to be as effective as face-to-face therapy in clinical trials.

Researcher David Haniff has created apps aimed at lifting the mood of people suffering from depression by showing them pleasing pictures, video and audio, for example of their families. He has also developed a computer game that helps a person examine the triggers of their depression. Meanwhile, smartphone apps that play subliminal relaxing music in order to distract from the noise and worries of everyday living have been proven to be beneficial in reducing stress and anxiety.

Technology can also provide greater access to mental health professionals through email, online chats or video calls. This enables individuals to work remotely and at their own pace, which can be particularly useful for those who are unable to regularly meet with a healthcare professional. Such an experience can be both empowering and enabling, encouraging the individual to take responsibility for their own mental well-being.

This kind of “telemedicine” has already found a role in child and adolescent mental health services in the form of online chats in family therapy, that can help to ensure each person has a chance to have their turn in the session. From our own practice experience, we have found young people who struggle to communicate during face-to-face sessions can be encouraged to text their therapist as an alternative way of expressing themselves, without the pressure of sitting opposite someone and making eye contact.

Conditions such as social anxiety can stop people seeking treatment in the first place. The use of telemedicine in this instance means people can begin combating their illness from the safety of their own home. It is also a good way to remind people about their appointments, thus improving attendance and reducing drop-out rates.

New routes to treatment

The internet in general can provide a gateway to asking for help, particularly for those who feel that stigma is attached to mental illness. Accessing information and watching videos about people with mental health issues, including high-profile personalities, helps to normalise conditions that are not otherwise talked about.

People can use technology to self-educate and improve access to low-intensity mental health services by providing chat rooms, blogs and information about mental health conditions. This can help to combat long waiting times by providing support earlier and improving the effectiveness of treatment.

More generally, access to the internet and use of media devices can also be a lifeline to the outside world. They allow people to connect in ways that were not previously possible, encouraging communication. With improved social networks, people may be less likely to need professional help, thus reducing the burden on over stretched services.

Research into the potential dangers of technology and its affect on the brain is important for understanding the causes of modern mental health issues. But technology also creates an opportunity for innovative ways to promote engagement and well-being for those with mental health problems. Let’s embrace that.