Ten years ago, Dame Sally Davies, then UK’s Chief Medical Officer, stated that technological innovation had the power to transform the delivery of mental health services [1].

She was right.

Yet fast forward to today, tech hasn’t quite moved the needle.

Despite industry innovations like VR tech for treating PTSD, and “mental health apps” for individuals, overall tech advancements haven't made their way to the average therapist. Other than note-taking apps, nothing much has changed. Both therapists and their clients still lack a viable tech tool to make their lives easier – and more importantly, their therapy more effective. They instead have to make do with practice management systems from general medicine rather than something designed for therapy.

The unfortunate reality is this: Therapeutic outcomes are shackled by a lack of technology with the power to aid therapeutic alliances. 

Proven time and time again, effective therapy relies on a strong therapeutic alliance.

Defined as a relationship that relies on empathy, respect, collaboration, motivation, fostering of hope, the provision of feedback, trust, and reflection within a therapeutic setting [2], over 200 research reports show a consistent positive relationship between therapeutic alliance and treatment outcomes [3].

Amazingly, but perhaps unsurprisingly, therapeutic alliance has a bigger impact on therapeutic outcomes than therapy type [4] and even medication use.  

So if therapeutic alliance is the strongest predictor of success [5], then why does a chasm remain between therapist and client when it comes to collaboration outside of sessions?

More importantly, how do we bridge it?

The answer to that started with hundreds of hours talking to therapists about their experiences, and really, really listening.

Understanding what therapists need, and what their clients want

From all the conversations we had, the one thing we kept hearing was: Therapists are overwhelmed by time pressures [6].

We’re guessing this isn’t news.

Silly amounts of paperwork and manually scoring psychometrics make it tough for therapists to find time to fully prepare for sessions. Don’t even get us started on an exhaustingly high patient count!

It’s not just timesinks. We learned about the issues that hinder the alliance and collaboration between therapists and their clients:

• Overworked and underutilised: Therapists obviously strive to make therapy bespoke and individualised. Research shows that individuals can disengage from therapy if they don’t feel it is sufficiently personalised to their needs [7]. But despite knowing this, therapists are limited by having too little time, too much information, and precious minutes wasted during sessions playing catch-up, all the while lacking enough information or insights on their clients.

• Incomplete assignments: Psychoeducation is critically important [8]. But worksheets are often left uncompleted or hastily completed just before sessions, meaning that learning doesn’t happen outside of sessions.

• Flawed self-reporting: When looking to track progress, clients’ responses are often flawed by recency bias or one big event during the week, so therapists are lacking the finer details.

• Out of sight, out of mind: There is low self-reflection and low motivation for clients to spend time on themselves once the session is over. This makes progress significantly slower.

Meanwhile, clients are frustrated by the rate of their progress. 

Therapy is powerful.

But the average therapy-goer spends less than 1% of their week working on their mental health.

And while good therapy is fantastic value for money, it’s still expensive for many. There’s nothing more demotivating than feeling like you aren’t getting the progress you want for what you’re spending because you’re repeating yourself unnecessarily, struggling to choose the most important event from the week to talk about, or having to remember arbitrary timeframes.

This translates into therapists getting a ‘snapshot’ of their client’s lives and mental health. So while there might be an improvement during and immediately after a therapy session, this progress can only plateau or degrade in the following days.

Outside of therapy sessions, your clients’ attempts to better their own mental health is often lost in a haze of google searches. Even worse, social media sites like TikTok [9]. More often than not, clients are surprised to learn of the many things that impact their poor headspace — much less understand how to remedy it.

The 5 essential elements for tech-enhanced therapeutic alliances — and how we built that into Bravely

Therapy in the 21st century is no longer confined to the four walls of a room. With digital tools at our fingertips, it’s time to redefine and reinforce the therapeutic alliance, ensuring it remains strong, even beyond sessions. Here are five pivotal ways technology can facilitate this:

1. Maximise your session time by shifting non-essential work to outside of the session

Fostering even better collaboration can only happen outside of sessions. As it is, sessions barely have enough time to fit in everything that’s needed. The time between sessions should be just as important as the sessions themselves.

Yet as it stands, when the session is over, there’s little to no contact until the next one.

We’re not advocating for the client to have more access to their therapists’ already limited time. Instead, tech should facilitate engagement outside of sessions — without added burden on therapists.

In creating Bravely, we’ve kept this in mind. With Bravely Connect, therapists don’t waste precious session time repeating instructions and assignment details. Instead, you can easily allocate measures, assignments and tracking logs to clients. As they complete this work on their Bravely Home mobile app, you’ll receive data and progress updates, available for you to review anytime you want to.

2. Leverage data insights to augment your sessions

At present, therapists spend a lot of session time trying to understand how their clients have been since the last session. This means that sessions are often improvised attempts to identify where relationships might lie between behaviours and emotions.

We cannot expect clients and therapists to collaborate effectively if a large portion of a session is spent with the therapist playing catch-up amidst unfocused information sharing.

It simply isn’t time-efficient.

Instead, therapists need consistent, quality data to complement what their clients tell them in-session.

When building Bravely Connect, it was critical to create a way for therapists to access useful, visualised data so they can find specific talking points around moods and behaviours on specific days.

Be it observing nightmares as a common issue, or finding a relationship between variables like sleep and anxiety, we built Bravely Connect to allow you to identify relationships between habits and behaviours in your clients that you might never have noticed – without additional work or reminders on your part.

This is super personalised feedback. It’s feedback that isn’t the same rote advice given to every client struggling with anxiety.

3. Collaboratively tracking progress improves clinical success

An analysis of multiple studies showed that measuring, monitoring, and feeding back information can nearly double clinically significant change rates in clients who are predicted to have a poor outcome [10]. 

Getting tracking right is so important. Tech and great design can take this even further by making tracking feel rewarding and enjoyable, battling user disengagement.

In the fitness industry, effective tracking through technology has become a vital cog in motivating people. For instance, we all know people who previously weren’t passionate about exercise but transformed into consistent runners or cyclists by persistently tracking their progress and performance. And the stats back it up. Activity trackers improve physical activity levels by up to 81%, with 89% of users saying they value real-time feedback [11].

Yet, tracking mental health progress today is one-dimensional.

With a primary reliance on outcome measures, current tracking offers a limited view — especially from the client’s perspective. They complete an outcome measure, which the therapist has to score before their next session. These scores then may or may not get discussed, leaving the client in the dark when it comes to where they started and how far they’ve progressed.

While these measures are undeniably, critically valuable, they’re only a piece of the puzzle. So, we have looked beyond traditional outcome measures.

Together with tracking psychometric scores, therapists and clients can also benefit from Bravely’s Home mobile app’s Track feature. Track helps clients see where they’re struggling and what they’re doing well on a day-to-day basis. Complemented by actionable advice, they can grasp the effects of their habits and discover ways to initiate positive changes.

For therapists, our Track feature offers a goldmine of helpful data. It provides a holistic view of your client's habits, allowing you to identify behavioural patterns, discern mood triggers, and tailor your guidance accordingly.

4. A leap beyond unwieldy email attachments – facilitating better learning and engagement

For therapists and clients alike, sifting through unwieldy email inboxes in search of that one crucial attachment has become an all-too-familiar and annoying task. These decades-old methods are not just inefficient, but they can also detract from the core therapeutic process.

At Bravely, we’ve made that obsolete. 

No more hunting down the resources used across multiple clients. With Bravely Connect’s centralised document library and assigning features, it's just two clicks to assign work, and a single click to notify your client — saying goodbye to lost or overlooked PDFs in tangled email threads.

For clients, psychoeducation should be an enjoyable process, not a chore. With the Bravely Home mobile app, they can access their assignments and instructions easily through a digital experience they've come to expect in their everyday lives.

5. Gain more time and focus with organisation and automation

The last thing therapists need is more wasted time on repetitive, unnecessary tasks.

Easier said than done, we know!

Technology is fantastic for its ability to automate tasks like these. We feel pretty confident in saying that most therapists would be happy to leave manual measures scoring and tedious tasks behind. With Bravely Connect, you can:

• Say goodbye to manually scoring outcome measures; let automation handle it.

• Stop your reliance on easily lost paper handouts, reminiscent of dreaded school assignments.

• Bid adieu to cluttered email threads filled with PDF attachments.

• Eliminate the need for long explanations about complex cut-offs and labels.

Therapists now save time while acquiring more valuable data in an easy-to-digest format: automated charts over time for all allocated outcome measures (coupled with key stats like comparing to baseline) and tracking data visualised in an easy-to-digest format.

On top of that, all important client information now sits in one easy-to-access place, so you don’t have to worry about rummaging through mountains of paper to find your intake notes. And vitally, you also won’t be scrambling for their emergency contact when they’re really struggling.

The reason why 74% of tech-based interventions fail – and how Bravely fixes that

Research shows that one primary reason for client dropout in technology-based interventions is limited monitoring [12]. Moreover, other studies reveal that tech-based interventions are considerably more effective with support, demonstrating a drop-out rate of just 28%, in stark contrast to the 74% observed for unsupported interventions13.

What does this mean for therapists? 

Despite good intentions, referring to a mental health app that hasn’t been built with therapists in mind, like Headspace, will have limited impact on the mental health outcomes of your client.

Currently with most recommended mental health tools, a client’s app engagement is also entirely separate from their therapy sessions. When their personal app use is completely disconnected from their therapy, both therapist and client miss out on the opportunity for a coordinated strategy.

Bravely was built to foster deeper collaboration between therapist and client

Recognising the fundamental importance of the therapeutic alliance in optimising treatment outcomes, we crafted Bravely with a singular vision: to enhance collaboration between therapists and clients. Our aim is to reduce the operational burden on practitioners, while simultaneously making the process more seamless and accessible for their clients.

With Bravely Connect, therapists can effortlessly assign measures, handouts, and exercises straight to the Bravely Home app on a client's phone. This facilitates real-time monitoring of client engagement, discussions about results, and addressing any barriers faced in the critical process of “doing the work”.

In essence, Bravely bridges the digital divide, fostering an environment of constant interaction, accountability, and support, mirroring the dynamics of real-life therapeutic interactions.

The future of therapy is integrated, and with Bravely, it’s here.

References

1. Hollis, C., Morriss, R., Martin, J., Amani, S., Cotton, R., Denis, M., & Lewis, S. (2015). Technological innovations in mental healthcare: harnessing the digital revolution. The British Journal of Psychiatry, 206(4), 263-265.    

2. Cahill, J., Barkham, M., Hardy, G., Gilbody, S., Richards, D., Bower, P., ... & Connell, J. (2008). A review and critical appraisal of measures of therapist-patient interactions in mental health settings. HEALTH TECHNOLOGY ASSESSMENT, 12(24).

3. Horvath, A., Del Re, A. C., Flückiger, C., & Symonds, D. (2011). The alliance in adult psychotherapy. APA Psychotherapy, 48, 9-16.

4. Sharpley, C. F., Jeffrey, A. M., & Mcmah, T. (2006). Counsellor facial expression and client-perceived rapport. Counselling Psychology Quarterly, 19(4), 343-356.

5. Fuentes, J., Armijo-Olivo, S., Funabashi, M., Miciak, M., Dick, B., Warren, S., ... & Gross, D. P. (2014). Enhanced therapeutic alliance modulates pain intensity and muscle pain sensitivity in patients with chronic low back pain: an experimental controlled study. Physical Therapy, 94(4), 477-489.

6. Lee, M. K., Kim, E., Paik, I. S., Chung, J., & Lee, S. M. (2020). Relationship between environmental factors and burnout of psychotherapists: Meta‐analytic approach. Counselling and Psychotherapy Research, 20(1), 164-172.

7. Lambert, M. J., Whipple, J. L., & Kleinstäuber, M. (2018). Collecting and delivering progress feedback: A meta-analysis of routine outcome monitoring. Psychotherapy, 55(4), 520.

8. Motlova, L.B., Balon, R., Beresin, E.V. et al. (2017). Psychoeducation as an opportunity for patients, psychiatrists, and psychiatric educators: Why do we ignore it?. Acad Psychiatry, 41, 447–451.

9. Caron, C. (2022). Teens Turn to TikTok in Search of a Mental Health Diagnosis. The New York Times.

10. Lambert, M. J., Whipple, J. L., & Kleinstäuber, M. (2018). Collecting and delivering progress feedback: A meta-analysis of routine outcome monitoring. Psychotherapy, 55(4), 520.

11. Maher, C., Ryan, J., Ambrosi, C., & Edney, S. (2017). Users’ experiences of wearable activity trackers: a cross-sectional study. BMC Public Health, 17(1), 1-8.

12. Johansson, O., Michel, T., Andersson, G., & Paxling, B. (2015). Experiences of non-adherence to Internet-delivered cognitive behavior therapy: A qualitative study. Internet Interventions, 2(2), 137-142.