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Expert Q&A: Dr. Khush Amaria on CBT

Cognitive Behavioural Therapy (CBT), with or without medication, seems to be the go-to treatment for teenagers with moderate to severe depression.

The catch is that one-on-one CBT with a psychologist or licensed clinical social worker in Toronto can cost anywhere from $150 to $225 an hour in Toronto, and appointments outside of work and school hours are hard to get.

Which is why I’m pretty excited about Beacon.

Beacon is a digital application for therapist-administered CBT. It was developed by Sam Duboc in partnership with CBT Associates.

Through the app, clients (ages 16 plus — it’s not yet available for younger teens or children) can be assessed, diagnosed and treated using the the same protocols as in-person therapy.

While not covered by OHIP in Ontario, it is covered by some insurance companies and is said to reduce the cost of treatment by up to 75 per cent.

Too good to be true? I’m not sure. I’ve not tried Beacon and wasn’t aware of it when my daughter was treated for depression, but after talking to Dr. Khush Amaria, I can tell you it will my first step if either I or my daughter need to manage negative thinking in the future.

Dr. Khush Amaria, PhD, CPsych Senior Clinical Director, CBT Associates

Khush is the Senior Clinical Director at Beacon, responsible for oversight of the clinical therapists at CBT Associates, the trained professionals who administer therapy both in person and digitally via the Beacon app.

Prior she was a Clinical Psychologist in the division of Adolescent Medicine at Sick Kids and Team Lead of Sick Kids’ Good 2 Go Transition Program.

I sat down with her in March to find out how and why she became an expert in CBT and why as a practising clinical psychologist she’s helping to lead Beacon digital therapy.

What is your background and training?

I am trained as clinical psychologist. In Ontario, essentially what that means is I’ve completed a PhD based program.

PhD programs, again for clinical psychology specifically in Ontario, are almost exclusively clinician scientist based, and what that really means is you’re trained to be a researcher. To be able to scientifically evaluate things, do a dissertation, thesis, all of that kind of stuff.

Why did you choose to focus on CBT?

And all of my training came out of a strong clinical science program and we were exclusively taught CBT. I mean we had historical information about other therapeutic approaches, but the idea was you’re being trained as a scientist, so if you’re going to be providing service to someone who has an identified mental health issue, let’s give them the best chance of being successful. Just like we expect the same rigour with our medication or even a physical therapist.

Why is CBT so appealing to you?

The attraction for me to CBT is not simply just the testing of the therapy, but it’s the underlying understanding of the theory.

I also want to think about things at a brain level. How did that individual get to where they are in terms of having that reaction when they were anxious or depressed or angry. What’s the behavioural mechanism? What would be happening in their brain at the neuronal level? CBT comes from this research and exploration at a basic science level.

The other piece that is attracting to me, and this is where my love of adolescents and teens comes in, is that it’s adaptable. It’s something you can make kind of fun.

CBT is always described as being ‘evidence based’ – what exactly does that mean?

We always talk about CBT as having a long history of evidence. The evidence comes in a lot of different ways and it comes from very sterile circumstances.

So, let’s take people who have depression at this severity, based on this scale, with nothing else going on, or between this age and this age, and we’ll put them through this protocol. We’ll look at their scores on a depression symptom scale before and after and if they get better, and by an amount that we think is meaningful clinically, as well as in real life, than that is a sign this treatment works.

What is the benchmark for “better”? That it works better than medication?  

There are different metrics. Certainly there’s the medication one. You can do nothing. There’s time. There’s placebo. You can do a treatment that’s not therapy. You can say we’re going to talk. Then there are other true therapies like Interpersonal Psychotherapy (IPT) or Dialectical Behavioural Psychotherapy (DBT).

The key is the sterile piece. To do the good science you have to control all those other factors to be able to show effectiveness. Then we also have to decide what’s a reasonable level of improvement.

How does CBT differ from other types of therapy?

It differs from a process point of view. It’s a short term treatment. Short term doesn’t mean come in for five sessions. Short term means we have an end in sight. It’s goal directed. It’s is focused on the here and now.

That is actually really important to me. It’s this recognition that people have some really bad things happen to them, and they have sucky life experiences, and sometime they don’t even — everything seems ok – and yet they end up where they are right now.

Understanding and respecting what happened is one part of it, and yes we may need to talk about the past and go through experiences, but I’ve yet to find a person who can change any of that. We can’t.

So CBT acknowledges the past, it’s brought into how we conceptualize where the individual is, but the intention is not to change their memory of it, their experience of it, reframe it even. You can’t do any of that stuff.

Is there an ideal time in an illness to administer CBT?

We have some parameters to when CBT is appropriate.

You do need a certain level of cognitive capacity. If you access it at the right time, then you are developing the tools for where that person is at in that stage. There are tangible things we want to get rid of. For example, we want to decrease how many days a week you skip school. You want to say yes to the next guy that asks you out. Whatever it is. It doesn’t matter what teens wants, but the goals should be tangible and then we decide is CBT going to work for those things.

What outcomes can we expect from CBT?

Empowerment. There’s a sense of responsibility with CBT. In the best case scenario, we get somebody to a better functioning level and then we plan ahead.

We say, ‘here you are, we got you through grade 12, we’re going to make the transition in the fall. You know, through this insight you developed through CBT, that those transitions are hard for you. You don’t reach out for help. Or you do this or do that. You don’t want to get to where you were in December where you didn’t leave your house for three weeks, so what are you going to do?’

I love seeing the skill development and improved hope, and then a sense of decreased victimization, blame and misunderstanding. That happens very early in the first part of treatment.

I often use the example of when medication and CBT work equally, the key difference is, when the course of say your 12 weeks of CBT ends, and you stop the medication, they look the same, but when you check in with them 6 months later, the group with the CBT improves.

Their post-treatment results get even better. What that tells me is you take the skills and you continue to use them. They get to solidify and that’s the idea of building new pathways and replacing these previously worn pathways in your brain.

How can parents get ahead of potential mental health issues?

As a parent, the first part is that you need to be willing to talk about emotional health. Period. Even if you’re the greatest observer, if you don’t have that dialogue, you wouldn’t know.

The other thing a parent should know is what is the general risk? So there’s the prevalence rates that we’re all susceptible to. Then there are familial genes so if you have any mental health issues or your siblings or your parents, that risk is higher for your own child. If we know that we have risk periods, we should talk much more about early planning.

Then there are some other factors that contribute to risk. They’re called adverse childhood events so you can have one adverse childhood event and the risk goes up a little bit for both physical and mental health issues as an adult, but it’s really the accumulative effect. So, if you had like, divorce can be an adverse childhood event, but most people with divorce don’t grow up to have cardiac issues or depression, but if you had to divorce and move across the country, and financial instability developed, then that has an accumulative effect. As a parent we should all be thinking about which kids are more vulnerable.

The other thing is modelling stress management. Not everything needs to dive into therapy. As a parent, you can tell them, I have stresses at work and this is how I manage them and you must have stresses at school with friends. You model this is how we handle things as a family.

You’re now delivering CBT via Beacon, a digital application. Can you tell me more about why you’re all in on Beacon?

The public health system is saying we need to do better in psychotherapy access. There’s a whole population out there who will never access psychotherapy as I’m providing it. They can’t get to a psychotherapist between 9 to 5 so Beacon is going to be an opportunity for them. For the workfoce, there’s a commitment to Beacon, but it’s different from having to take an hour off work.

It’s also cost effective. You can’t match it. I mean, what you can pay for Beacon, you might see me twice and I can’t do therapy twice. Two sessions isn’t going to do anything.

It’s customizable still in the way that I would provide treatment in a therapy setting. So I have a protocol and a direction, yet when that client comes in, there are modules you can pick and choose from based on what’s going on or what they’re presenting with in that moment.

And we’re still looking at evidence. Just as you would have done in the standard trials, we want to know when you start and when you end. What’s better? Beacon allows us to monitor this data much more regularly. When I have Beacon in the clinic, I’ll just say before you come in, enter your five scales and then show up and I’ll look at the data in front of me.

Will Beacon replace face-to-face therapy?

The other part I really like about it, especially running a clinic where I have clinicians, is that it’s not a replacement. You can imagine there are psychologists out there would say you can’t replace what I do with technology, but the idea is that it’s not to be about replacement. It’s about access. It may be a stepped approach at time.

It’s also about preference. The average age of people who use the app is 38. So you think about the 38 year old woman who gets her kids to bed at eight o’clock and thinks, I actually have some me time, but I can’t go to the therapist, but I can sit down and I can read what I said I was going to read.

And you’ll still have a real person at the other end. The e-therapist is a registered mental health person and there’s still relationship building that happens.

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