The Impact of Digital Mental Health on Counseling

Emily St. Amant:

Hello, and welcome to The Voice of Counseling from the American Counseling Association. I'm Emily St. Amant, and joining me today is Chris Gamble, who is here to talk about the impact of digital mental health on counseling.

Emily St. Amant:

For our listeners who are interested in learning more about providing counseling via telehealth, we recommend checking out the ACA book, Distance Counseling and Supervision: A Guide for Mental Health Clinicians edited by Jennifer Nivin Williamson, and Daniel G. Williamson. You can find it on our website, counseling.org in the ACA store located in the publication section.

Emily St. Amant:

Our guest today, Chris Gamble, is a licensed professional counselor, nationally certified counselor and certified clinical mental health counselor based in Washington, DC. He has worked with children, teens, and families in a number of community-based mental health settings, and now at a children's advocacy center. He is dedicated to showcasing the power within marginalized communities and improving their experiences within the mental healthcare system.

Emily St. Amant:

Thank you so much for joining us today, Chris. How are you?

Chris Gamble:

I'm great. Thanks for having me on, I'm excited to be here.

Emily St. Amant:

Yeah, we're so excited to have you. To get us started, do you want to tell us a little bit about the work that you do, your background in the counseling field, and the type of populations that you primarily serve?

Chris Gamble:

Sure. So, I am a LPC in Washington, DC. Well, I've been in DC for about eight years, I've graduated, got my master's in 2016 from GW, and I've primarily worked in community-based settings, so a lot of community-based agencies. I'm currently not in a direct clinical role providing therapy, but I work at a child advocacy center as a client advocate. So supporting families whose children have experienced different forms of abuse and trauma, but mainly the populations I've worked with have been low income Black youth and families in DC, so that has been the majority of my experience so far.

Emily St. Amant:

Okay, great. Yeah, thank you for all that you do for the communities that you serve. You have some experience with how the community-based treatment settings and how the people that interact with those systems of care, you have experience with that, but then also recently in the past few years, technology has started to play a role in the treatment field like it has not before, right? So, I think a lot of people may not even understand what the different types of mental health or digital mental health technology stuff is. So-

Chris Gamble:

Yeah.

Emily St. Amant:

If you want to kind of talk to us a little bit about the different types of digital mental health offerings, platforms, what the differences between those are?

Chris Gamble:

Sure. So I mean, it seems like there's new things coming up every day. So first I would say, when I think about digital mental health, I guess for me, digital is anything basically that uses either computer technology or is internet connected, so kind of a wide range there. But what may be most familiar to people, there's online platforms that connect people with therapy. Just to side note, I'll try not to specifically name any companies, because I don't want to sound like I'm endorsing or going against certain companies and don't want any lawsuits or anything.

Chris Gamble:

So yeah, those online therapy platforms, there's more apps that have self-guided mental health exercises, might be a mood journal or something like that. There's chatbots, there's things more on the diagnostic side where using people's voices, different characteristics, trying to predict diagnoses sounds a little sketchy to me.

Chris Gamble:

Then what else? There already are some in virtual reality space, but as the metaverse becomes more of a thing, I'm sure there's going to be some more in there, but I think it's really important for people to understand with all these different technologies that are popping up is that, well, one, a lot of the companies did exist before the pandemic, but also a lot of these technologies have been around for a long time, but are just proliferating now because of the wider availability of our smartphones and things like that. So, yeah.

Emily St. Amant:

Okay, so maybe these things aren't necessarily brand new, it just might be brand new to some people, right?

Chris Gamble:

Right, right.

Emily St. Amant:

I think because that was one of the impacts of the pandemic was that a lot of people that maybe didn't even think of telehealth or technology, it wasn't on their radar at all, because they were doing primarily in-person work. Then people had to shift very quickly to be able to actually meet with their clients, they had to figure it out during the pandemic. So I think it makes sense that maybe now we're seeing these things more so even if they may have been around a while, because we were all at home for so long.

Emily St. Amant:

So, I think it's important for people to ... you spoke to different types of services. It's not just telehealth, there's a ton more under the umbrella of digital mental health, and I think it's important to understand the differences between those things.

Emily St. Amant:

These are often marketed as solutions to the behavioral health treatment field, the problems that exist as far as access to care, affordability, et cetera in the general health and wellness space, there's a lot going on, right? But I think everybody, probably with different people in different areas and different specialties, we've probably all seen this play out differently. But what about in your experience in the community that you serve, the impact of technology, how has that impacted the clients y'all serve?

Chris Gamble:

Yeah, it's really interesting, because I feel like ... so when the pandemic started, I was still at a community-based mental health agency, but like I said, with some of these companies existing even pre-pandemic, with the population I serve, I really haven't seen a big impact, so it's a bit strange how there's this broader narrative of this revolution of digital mental health. Everything's changing, there's all this new stuff, but then what I'm seeing, I'm not seeing that impact really.

Chris Gamble:

I think part of that ... of course working at a mental health agency, so my clients, they're already receiving therapy, but in terms of recommending any types of other apps, it's hard to tell what's really dependable, it's hard to know just everything that's out there, so actually putting it into practice.

Chris Gamble:

So where I was when the pandemic hit, one of the first things that we saw was just the lack of access to technology that people had.

Emily St. Amant:

Okay, okay.

Chris Gamble:

I was working with youth, so as they're trying to transition to virtual school, it's like, oh, there's only maybe one laptop in the house if that, it might just be mom's smartphone that's the only internet connected device. So even that fact of that digital divide, yeah, it makes hard to really see the impact of these technologies for low income population.

Emily St. Amant:

So, I heard you say digital divide. I think that that's a really good way to summarize the situation then, because like you said, you're seeing so much in the media, on social media being marketed, advertised, talked about, but the impact hasn't gotten where it maybe really needs to actually be yet, right?

Chris Gamble:

Yeah.

Emily St. Amant:

Okay, wow.

Chris Gamble:

Yeah, I would add onto that, just in terms of the digital divide, in terms of that being whether there's internet access in a community. I think that was maybe a surprise for a lot of people with the pandemic, that there's a lot of places that just don't have the internet. It's such a necessity for us now, but it isn't everywhere.

Emily St. Amant:

Right.

Chris Gamble:

Then also just digital literacy of just how to understand how to use the technology, which is not only just with maybe a older population, but just across the board there can be a learning curve with a lot of technologies. So, I think that's something that needs to be considered when we talk about technology as the solution to the problems with our mental health system.

Emily St. Amant:

Okay, absolutely. Yeah, 'cause it does seem like we hear about people that are in rural areas that are in resource sparse areas that technology can help fix that problem, but you raised a lot of the challenges. People don't know how to actually use the technology, because they haven't had that opportunity before, or internet access or bad internet access, that can be very, very frustrating, especially if you're trying to talk to your therapist and open up about something very personal and to have technology issues, that's definitely a challenge.

Emily St. Amant:

Then like you said, even privacy even in homes is also another barrier sometimes, so I think it's important to think about those things, that just providing the technical digital offering, it's maybe not enough for a lot of folks.

Emily St. Amant:

When it comes to these technologies, how does this impact the users who come from different, especially minoritized cultural backgrounds? Who makes them matter? So the people that are actually creating these technologies, how does that impact the user who actually ends up engaging with them?

Chris Gamble:

Yeah, that's a great question. I kind of mentioned this a little earlier of just how it seems like every day there's a new company popping up, a new platform, so it's definitely hard to keep track of, of course, every company who's starting it, but I think the main thing for people to be aware of is, one, whether the people starting the companies have a clinical background or a background in the mental health field, or whether they are just serial entrepreneurs that start companies here and there.

Chris Gamble:

There's definitely of course a lot of use of having that business background to know how to build a company. That's a hurdle that a lot of counselors who are just trying to start a private practice, discovering all the business side of it, that makes it so much more difficult. But with these companies, I think it's really important to know whether there is that clinical background, because it can change the way they are seeing the problems that exist in our systems.

Chris Gamble:

So there's a few companies where the founder, maybe their parents were therapists or they've had experience in therapy and maybe experienced some issues, and then were like, "Oh, let me start a company." Even if you find a co-founder that does have a clinical background, there is the question of what framing you have. My dad is a dentist, but I would never think of starting a dental-focused company, because it's like, okay, I go every six months, but what could I really offer to the field?

Chris Gamble:

Then in terms of the race of the people that start these companies, I think that's important in terms of, again, the perspective, but I do also think that there can be some limits to the idea of just representation as the answer, as, okay, if we have more of these companies that are founded by Black people or other people of color, that will make them better. But I think some of the practices of these companies could still happen regardless of the race of the person who's starting it.

Chris Gamble:

Then you're asking about on the user's end, once it gets to the user. From the beginning, the founders are maybe not seeing the scope of the problem in a way that includes the concerns of marginalized communities, then the tool or the product that's developed isn't going to be very relevant for them.

Emily St. Amant:

Okay, I think that that makes a lot of sense, because it matters what you know and what you've experienced. If you've not done the research to know what are the problems actually present, but then you start offering solutions, maybe this is a problem that maybe doesn't exist or there are a lot of problems that aren't getting those solutions.

Chris Gamble:

Yeah. Yeah, I think to me at least, I do think that just the general conversation around mental healthcare access is limited by only seeing access as how quickly or conveniently someone can get in front of a therapist. I think that's what we've ... with the context that the pandemic provided, that became the most obvious thing. People are at home, so what's the convenient way that they can just open their laptop, get on their phone and see a therapist?

Chris Gamble:

To me, that really keeps us within the medical model where mental health is only just seen as, okay, this is a set of symptoms, it's a brain disorder. Is it chemical imbalance? Is it not? Is it all these things? But it's ultimately just about getting this person in front of a professional, but we lose so much of the other things that impact our mental health.

Emily St. Amant:

Okay, I think that's an incredibly important point, because we've seen a lot of funding go to digital mental health offerings that are working to solve the access to care problem. However, having access to care isn't enough to have wellness and a quality of life. I think that's an incredible call-out, is that it's not enough to just offer access. Can you speak to the needs that marginalized communities are experiencing that is impacting their mental health and their potential for wellness?

Chris Gamble:

Yeah, so to me, access is really about ... I think something that we neglect a lot in the mental health field is those social determinants of health or of mental health. So for me, it's not just access to treatment, but access to the conditions that promote mental health, or to the context where you can experience mental health, you can be in a state of mental health because of what's around you.

Chris Gamble:

So things like food insecurity, transportation, climate change, these are all upstream things that have these downstream effects on mental health, and I think that by ignoring that, we end up ignoring the impacts on marginalized communities, because so many of these social factors are so much stronger for us I would think.

Chris Gamble:

For example, native or indigenous communities, thinking about mental health for that community without thinking about land access or land stewardship, it's like what sense does it make to provide more access to therapy if there's just no consideration of these core events that have put communities in this marginalized position?

Chris Gamble:

For Black communities, our separation from our original cultures, the design of poverty, I always think of poverty as policy, so providing therapy. It's something that I've run into a lot in my experiences of where I'm providing therapy to clients, but it feels like I'm hitting a wall, because just the context that they're living in seems so much more and more powerful to still have to figure out a budget of less than $1,000, because they're only living off of TANF is the program, Temporary Assistance for Needy Families is what I'm thinking of.

Chris Gamble:

But things like that, just other stressors in your life that are built into society and therapy alone can't really upend those. So, I do think there is a lack of focus on that and more of a need of focusing on those upstream interventions so that downstream there may be less need of that direct intervention with a clinical treatment.

Emily St. Amant:

Yeah, absolutely. Because if we can prevent things from happening in the first place, I think you're right, that that is an overlooked area of effort and advocacy. I think that that's why we are ethically mandated to advocate for our clients and to promote changes that are not just in their direct control, right?

Emily St. Amant:

Because if someone lacks interpretation, I think if ... Having worked in community mental health myself as a therapist, it definitely can be very frustrating, because you see the impact that their community and the resources they have available is having on them. You do feel like, "Well, I'm trying as hard as I can to help this person, but we're encountering so many barriers," right? Yeah, I think that that's all important to keep in mind when we're talking about addressing the mental health of various communities.

Emily St. Amant:

So, when it comes to various apps or if you are trying to find some resources for your clients that are digital-related, I think a lot of educational self-directed activities can be helpful, but we have to make sure that what we're recommending our clients, that we know what that's about. So, what are some things that counselors need to keep in mind if you are recommending services or other things that are under that umbrella of digital offerings for clients?

Chris Gamble:

Yeah, and what can be so difficult about it is that even the idea of us recommending them, a lot of times we're not even getting the opportunity, because these apps are directly marketed to the consumer. So you might just encounter it as a ad in your Facebook feed, or you might just be searching for it for yourself in the App Store and be trying things out. It's different from a commercial for a medication that says, talk to your doctor if you think this is good for you. It's just like you're coming across these apps and not really knowing.

Chris Gamble:

But for counselors, I think there are ... so there are some websites out there that actually kind of look into each of these apps and give reviews, give the pros and cons of them. There's some research for some of these apps that you can look into, but I do think it's important for us as counselors to, at least at this moment, see a lot of, especially the self-guided apps with mental health exercises, as supportive components of treatment.

Chris Gamble:

Some may market themselves as being a treatment in itself that you can improve your depression or anxiety just with this app, but I feel like there's just so many different options and so many possible shortcomings of the research that's out there, that it's probably best to see it as something that's supportive at best in this moment before we really have more solid evidence of being able to recommend them.

Emily St. Amant:

So, I think that I see this as a part informed consent with our clients and that there's a need to provide psychoeducation about this.

Chris Gamble:

Yeah.

Emily St. Amant:

Because you're right, they may encounter these things and like, "Oh, I tried this." Or they might say, "Oh, I've tried this app," and you as a counselor have never heard of it before.

Chris Gamble:

Yeah, yeah.

Emily St. Amant:

So I think it's a challenge to keep up, but also it's important to try to stay abreast of these issues, because there could be the various things that our clients may not think about, as far as from a privacy or efficacy standpoint, that we want to be able to offer them information so they can make an informed decision about using those technologies.

Chris Gamble:

Yeah, I agree. I agree.

Emily St. Amant:

So a lot of extra things for us to learn about, and it's not like we have enough to research and to learn about, right? So as far as the impact technology's had on our field, counselors, mental health providers, how have you seen that play out in the workforce, if you have?

Chris Gamble:

So I would say in my personal circles, I only know maybe one or two people that actually work for a digital mental health company, so I haven't seen it a lot in my personal sphere. But I guess just in thinking about the ways that it can impact the workforce or that it has already, to me there's ... For me, it's not really a conversation of whether in-person or virtual therapy is better than one or the other, I think they work for who it works for in certain contexts. We can't say it's for everybody, but I don't think that teletherapy is bad at all.

Chris Gamble:

But in thinking about our workforce, to me, I feel like we have some examples in other fields that can be analogies for us to pay attention to. So for example, what Uber did to the taxi industry and basically taking it over in a way, and in some instances, ruining people's lives in some ways from how they were operating before in the taxi system.

Chris Gamble:

I don't necessarily think something like that could happen for the mental health field. I don't think it could really impact us in a way where a private practice couldn't get off the ground because there's a company operating, or that the community-based agencies that I've worked for would go out of business.

Chris Gamble:

I don't think there's a direct competition in that kind of way, but I do think there are similar concerns with Uber of how the drivers are paid or not considered employees, even though they're doing the work of employees. So, there are a lot of these online therapy companies that only do contract work. So you're providing healthcare, but you don't get healthcare benefits, because you're not considered an employee.

Chris Gamble:

I think in a way it contributes to the further fragmentation of our field. It's confusing enough for the general public to know what all the letters after our names mean, to know how to locate a therapist that takes their insurance, and now there's just dozens of online companies to choose from, it can make it more difficult. So, I think there's probably more to see in the years to come.

Chris Gamble:

That was probably a lot of negatives I just listed there, but I do think it gives us ... one, it can give counselors the ability to get into independent practice a little easier. So a lot of these companies will handle the business side of things, getting you paneled with insurances, handling some of the billing infrastructure, and so that can be very convenient. For people who want to be licensed and practice in multiple states, it can be a little ... I know some companies might cover the cost of doing that as we're still working on the counseling compact being in full effect, so it does have those positive impacts as well.

Emily St. Amant:

Yeah, I think that those are important call-outs to think about as far as the potential drawbacks to these things and the way it impacts us in our field, but also there are some people getting it right out there and there are some things that are actually helpful. So, I think that that's also important things for people to seek out is what are the options that are taking us as human beings and providers into account?

Emily St. Amant:

As far as technology offering solutions, what are some ideas that maybe you have to make technology more inclusive and help it work for people that do want to access care that way, or access resources that way?

Chris Gamble:

I do think there's a need for more inclusion of the populations that you want to serve. So having the general public, having potential users a part of the development process really from the beginning, so that you can understand what the needs really are and help to better develop the technology to make something that is relevant to the people that are going to use it.

Chris Gamble:

Yeah, I think there's also just the question of whether some of these tech solutions are really meant for everybody. Not in that it should remain exclusionary, but just is a certain tech solution necessarily the thing that somebody needs? What we were talking about before, if after their therapy session there's still no food in the fridge, is developing a new technology going to solve that problem that is a stressor impacting their mental health?

Chris Gamble:

So as we're developing ways to make more culturally relevant technologies, we also have to look at for certain marginalized communities, what can the tech help with and what is just another concern that needs a different type of solution.

Emily St. Amant:

Yeah, I think that's incredibly important to remember that, I think it's maybe the disabled community says this a lot, nothing about us without us.

Chris Gamble:

Yeah, yeah.

Emily St. Amant:

I've heard that with a lot of different marginalized communities, that if you really want to help us, you have to actually involve us and listen to what we actually need.

Chris Gamble:

Yeah.

Emily St. Amant:

Sometimes that involves technology, but then sometimes that involves other things that we need to make sure that we're prioritizing as well.

Chris Gamble:

Right.

Emily St. Amant:

Well, thank you so much, Chris. This has been a great conversation. We are so thankful for you to share your perspectives and experiences with us. If people want to learn more, do you want to tell our listeners how to find you?

Chris Gamble:

Sure. So, I'm on LinkedIn. Chris Gamble, probably ... yeah, I think you'd have to find with the letters after the name. LPC, NCC, CCMHC. So, I'm on there. You could also follow me on Instagram @chris_thecounselor. Yeah, so that's how people can reach me.

Emily St. Amant:

Awesome. Thank you so much for being our guest today, Chris, and thank you to our listeners for listening in.

Chris Gamble:

Thanks. Thanks for having me.

Emily St. Amant:

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Emily St. Amant:

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Speaker 3:

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