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Can A Sleep App Really Deliver Cognitive Behavioral Therapy?

Researchers who study the effectiveness of different therapeutic approaches and treatments for insomnia have long held that the most effective way to approach the problem is through cognitive behavior therapy. Though there is a tendency to try to treat the problem with medication, when compared to sleeping medications cognitive behavior therapy has proven time and time again to be far more effective, and without any of the negative side effects or dependencies that can come with medication. 

Cognitive behavioral therapy is a psychological approach that helps those suffering with insomnia to identify what it is in their environment, and more importantly in the way that they think about sleep, that is causing them to have problems with falling asleep. It identifies the underlying issues and systematically addresses and eliminates them until the patient has effectively been restored to a normal, healthy sleep pattern. Cognitive behavioral therapy usually takes a period of several weeks, during which the patient is asked to keep a detailed sleep diary so that the therapist is able to see exactly what their attitudes and behaviors are. Some of the treatments that a therapist might offer include improving sleep hygiene issues such as setting a regular bedtime and wake time or eliminating electronics, noise and light from the bedroom. Other approaches may include restricting sleep and then gradually reintroducing it, or teaching the patient how to relax more effectively. Often the therapist will utilize more than one of these approaches in order to achieve success. Cognitive behavioral therapy is particularly helpful for those who are dealing with long-term, chronic insomnia, but it does involve a commitment of time and requires making appointments that may interfere with a work schedule. There is a notable shortage of qualified cognitive behavioral therapists available to help patients, and the costs may be prohibitive for many.

One approach that is getting a great deal of attention recently has been the growing popularity of the use of sleep apps – programs that can be accessed via a smart phone and that claim to provide the benefits of a therapist virtually. Big Health is a San Francisco start-up that recently launched the app Sleepio, which features an animated character called The Prof. The Prof provides feedback to its users based upon the inputs that the app receives both through a sleep diary that the user keeps and via biofeedback that it gathers through fitness monitors and other sensors.

Though many sleep apps are available at no cost, the Sleepio app is available as a 12-week subscription for a cost of a hundred and forty-nine dollars, and that hefty price tag has made many people wonder whether a virtual therapist can actually provide enough benefit to be worth the expense.

The app company’s CEO, Peter Hames, obviously believes that it is. He indicates that the animated character with a Scottish brogue “combines authority with approachability, but yet with a sort of no-nonsense streak that can nudge you towards doing a bit better.” He claims that men and women have found the insomnia treatment equally effective, but that men tend to get the message without paying as much attention to the character, while women actually feel a connection with it. People seem to be engaged and continue using the program, though some of that may have to do with the amount of money that they have invested.

Still, there is scientific research that has been done into the impact of a digital therapist. Hames himself has written about it in the medical journal Sleep, saying that a placebo group exposed to a “Prof” who provided nothing but useless, nonsense information engaged with the animated character to the same degree as a group that was provided actual therapeutic advice. And Timothy Bickmore, a professor of computer science at Northeastern University has studied the use of these characters in health care for years and has found that they are particularly effective when used by those who are not as sophisticated in their use of technology, specifically older people and people who are more economically challenged. In fact, his research showed that many patients preferred to go through administrative procedures in a hospital setting, such as a discharge from a hospital, with an animated character to doing so with a live administrator. In the case of seniors, other research has found that by utilizing a virtual coach, they experience a diminishment of feelings of loneliness.

Though the idea of a virtual therapist certainly holds out the possibility of a number of important benefits, it is essential that those who choose to utilize this technology are aware that there are shortcomings that come with using a technology rather than a person. No matter how much information a program has been built with or how realistic the artwork, there is a lag between actual intelligence and artificial intelligence. The inputs that a virtual therapist receives are controlled by the user, and in the case of the Sleepio app are provided through a series of multiple-choice questions, as well as through sleep trackers. Innovators are attempting to build in additional sensitivity, but that may involve needing additional equipment and may end up raising the costs to the point where the savings offered over seeing a live cognitive behavioral therapist may be eliminated.

Still, the Sleepio app has been designed to come as close to the real thing as possible, including establishing a baseline regarding amount and quality of sleep and the current impact on health and mood, determining the user’s goals and even establishing a therapy contract that spells out homework and a schedule of weekly appointments. There is group work provided for support as well as behavior modification instruction provided, and when users do not adhere to the schedule they not only receive reminders, they get a bit of grief about it as well, just as they would if they were seeing a live therapist. One user indicated that she had appreciated the encouragement that she received from the animated character, while another indicated a sense of guilt that he got when the Prof chided him for not filling in his diaries. Perhaps the program really does replace the real thing?

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