“evolved strategy”: Online CBT provider Joyable lays off 20, shifts focus from direct-to-consumer to employers, providers

From MobiHealthNews:

“We let a number of talented people and friends go this week,” CEO Peter Shalek said in an emailed statement. “We did this in order to refocus our efforts on partnering with employers, insurers, and providers to increase access to evidence-based mental health care and to reduce costs. We are positioned financially to pursue this new strategy over the next several years. We’ve built a product known for having the best engagement and outcomes of any mental health-focused digital therapeutic, and we believe that our evolved strategy will allow us to reach and help the most people.”

In an interview, Shalek clarified that Joyable’s direct-to-consumer offering, an online cognitive behavioral therapy (CBT) and coaching program for social anxiety, isn’t going away completely: people currently using it will still be able to use it and new sign-ups will still be supported. But the company won’t put any more resources into developing or marketing the direct-to-consumer offering, and most of the staff involved in marketing and support for that product specifically were let go.

Shalek said that the company had always planned to go in this direction anyway and that, while they reached a lot of people, they recognized that the best way to move the needle meaningfully on social anxiety would be to help more people, which the company could accomplish by targeting populations that don’t need to pay for the service directly (the company charges individuals $23 per week for a 12-week course after a seven-day free trial).

With Joyable’s platform, first users are paired with a coach who has been trained in CBT techniques. Before starting the program, users are invited to speak to the coach for 30 minutes on a phone call about how social anxiety affects them and what they want to get out of the program. After that, the program helps consumers identify and understand their social anxiety triggers. Users must complete activities such as challenging anxious thoughts with evidence and developing alternative thoughts that are more helpful. Each activity takes around 10 minutes to complete.

From there, Joyable teaches users techniques to reduce their anxiety by putting themselves in anxious situations and working on applying the skills they learned. The coach supports the user throughout the program through text and email, and the user can also reach out for help whenever they want. The program is available online, and can also be accessed from smartphones and tablets.

One does wonder how much of Shalek’s statement on “evolved strategy” and the assurance “we always intended to go this direction anyway” masks a certain realisation that many online mental health providers are coming to: that, for all the hype and optimistic rhetoric about empowering “consumers”, ultimately engaging providers is a necessity for these technologies to actually reach the potential users who could benefit most.

Asking about dreams

A while back I blogged a brief note about sleep and dreams, essentially discussing my own interest in sleep and noting that at the current historical moment, for the first time “sophisticated” people don’t take dreams in any way seriously. As I wrote then:

The contemporary medical/scientific conception of dreams is that they are either meaningless or at most reflect the emotional state of the dreamer. This is one of the most dramatic breaks with most of human history, during which dreams were seen as messages from the Divine, or or prophetic. Freudian dream interpretation – with its idea that dreams are the Royal Road to the Unconscious – was perhaps, despite Freud’s atheism, the apotheosis  of the significance of dreams in culture.

A vivid, detailed, and somewhat disconcerting dream last night (no, I won’t bore you with the details – unless supremely well executed, the i-had-this-dream story sits with I-was-so-drunk or I-was-so-high or I-was-backpacking-being-such-a-traveler-not-a-tourist storiy in a pantheon of the ultimate stories inflicted by bores) made me think of this again.

It is not strictly true that contemporary psychiatrist don’t ask about dreams – quite often it is a manifestation of PTSD. In that context, however, in my experience it is very much a “checklisty” phenomenon. There are some interesting papers on dreams in PTSD, especially the paradox that dreaming is often posulated to help process traumatic and other events, yet nightmares are a feature of PTSD. Papers on drug dreaming also appear in the recent literature, as does this this paper on dreams in people with a diagnosis of personality disorder.

I want to avoid being too dogmatic about my sense that this contemporary literature is very much functional in its approach to dreaming – not ascribing any particular meaning to it. The literature is no doubt richer than the above links alone would suggest. This is an area in which a thorough literature search would have to be especially well designed – think of how many synonyms and variations of “dreams”, “dreaming”, “nightmare” in so many languages one would have to do to do it properly, and is therefore beyond the scope of a blog written in fugitive time of the early morning. However, I do feel confident enough to comment that the content of dreams are rarely explored in contemporary psychological or psychiatric practice. The increasing influence of CBT both within mental health practice and in the wider culture leaves little room for issues of the meaning of dreams.