Bridging the gap between the therapists’ office and daily life

Ordering that delicious dessert in your favorite restaurant even though you’ve already eaten more than enough, watching a movie with a bag of crisps in front of you and suddenly realizing that the bag is empty; or the situation in which you plan to only take a small piece of chocolate but end up finishing half of the bar. Sounds familiar, right? Completely normal! We all eat more than our body needs from time to time. However, when this happens regularly, in large amounts, and over a longer period of time, it can have consequences for your physical health or daily functioning, and it might become problematic.  

Take my patient Josephine , (not her real name), for example. Josephine is a 42-year-old woman diagnosed with Binge Eating Disorder (BED). Approximately three times a week, when she is alone, Josephine loses control, and eats very large amounts of food within a short timeframe. She does everything in her power to prevent these episodes, with various degrees of success. After an episode of binge eating, she feels awfully guilty and because it happens so often, she has gained a lot of weight. Josephine is not the only one. Binges are a common phenomenon, not only in the context of eating disorders, but also in the (non-clinical) overweight and obese population. Studies show that as many as 50% of this latter population has recurrent binge eating episodes.

I treated Josephine with Cognitive Behavioral Therapy (CBT), currently the psychological treatment of choice for BED. The theoretical model that underlies CBT assumes that dysfunctional beliefs about (the function of) eating, weight and body shape play a decisive causal role in the complex network of environmental, psychological, physiological, and behavioural factors that drive binge eating. The CBT-based treatment therefore focuses on the identification and modification of distorted thinking patterns. The idea is that by changing the way you think, you can change the way you act. Within the CBT framework, it is important that the insights and skills that are learned in the therapy sessions are tested and put into practice repeatedly and in various relevant context in daily life. Therefore, patients are strongly encouraged to complete homework assignments between sessions.

Josephine was very motivated and made good progress. She worked hard during our sessions and did her homework. However, in spite of this, Josephine found it difficult to get her binges under control. During one of our sessions, she had already lost control on her way home from our last meeting. She had gotten off the bus a stop early to go to the store and had a binge right after she got home. When she left my consulting room an hour earlier, everything seemed fine. Josephine had no idea how this could have happened as well. She told me: ‘I know what to do, but it happened anyway… it was almost as if everything I’d learned during treatment was suddenly gone…’

And, again, Josephine is not the only one who finds this difficult. Although CBT has been shown to be effective for a large group of patients, not everyone benefits (sufficiently) from the intervention, and even those who initially do, often fall back in old patterns over time.

Stories like Josephine’s and statistics about CBT treatment outcome made me wonder why it is so difficult to put therapy skills into practice in daily life. One explanation for this might be that the step from the therapist’ office to daily life is too big. We might need intermediate steps in the treatment process. Recent technological developments might be beneficial in this regard. I therefore started a research line in which I examine whether and how technology can serve as a bridge between the therapist’s office and daily life.

More specifically, I am developing and testing a personalized self-learning e-coach provided via a smartphone app that can predict binges and that can offer additional in-the-moment support when people are at risk of losing control.

Similarly, virtual Reality (VR) is highly promising in this regard. With VR it is possible to create environments that are highly similar to everyday experiences. Because of this ecological validity, it feels as if people are present at the scene, without actually being physically there. Furthermore, VR allows assessment of cognitions, emotions and behaviour, and enables manipulation and control of the environment, including presenting (personalised) triggers that elicit distress in people with mental health problems to test coping skills. In addition, it is possible to include a digital coach or instructor to the VR environment to provide guidance throughout pre-defined exercises (hereby serving as a proxy for the therapist). As such VR can serve as ideal bridge between the clinic and real life. Until recently, VR was highly expensive and bound to hardware limitations. However, nowadays immersive VR systems can run on smartphones at a fraction of the costs, resulting in a new impulse in VR research and VR applications (apps) as a tool in mental health care. The Socrates project is a great example of this, and I’m very excited to be part of a project like this.

With this, we can develop more focused, personalized and in-the-moment treatment strategies, which will lead to better treatment outcomes. Not only is this relevant to researchers and therapists, but most of all it’s a first step in improving treatments for patients like Josephine. And that is the ultimate goal!

About the author

Dr. Lotte Lemmens (PhD) is an assistant professor of Clinical Psychology at Maastricht University (NL). She combines research and teaching with clinical work (scientist-practitioner). Her research is aimed at optimizing psychotherapy treatment outcomes. In various studies conducted in clinical practice she examines how, how well, how long, and for whom psychotherapy works. Furthermore, she examines whether and how technology (such as self-learning smartphone apps) can serve as a bridge between what happens in the therapist’s office and daily life.