Clinicians have long known that a client’s failure to practice skills learned in therapy can be associated with higher relapse rates. As a result of this, many techniques and models have been created in order to assist patients in maintaining the clinical progress that they have achieved in their typical once a week session. Many providers have often wondered, “What are better ways to keep patients engaged between sessions or the ‘off time?” Often times, many mental health practitioners are working with very demanding and severely mentally ill patients who may require more engagement other than the typical once or twice a week therapeutic intervention. In addition, many mental health patients are challenged with access to consistent and quality mental health treatment due to the deinstitutionalization of our mental health systems across the country as well as the revolutionary changes in the health care laws. These challenges add to the struggles of practitioners and patients to consistently maintain clinical engagement, due to these and many other factors that can thwart clinical outcomes.
To bridge the gap in services or the challenges patients face related to accessibility of quality mental health services, “Can the use of mobile phone application technology or ‘Apps’ provide a “mental health” woven blanket that wraps around the patient during the ‘in between’ times?” “Can the use of ‘apps’ aid in the delivery of mental health services for patients who are unable to access mental health services? “What can practitioners do to address the lack of motivation or the lack of therapeutic connection if the patient has poor attendance, access barriers or the inability to simply pay their health insurance co-pays if they do have health insurance?” For example, there are many patients who struggle with treatment resistant depression or TRD who were unable to motivate themselves enough to simply get out of the house and make it to therapy. One potential answer arises here, that being, “Can app technology motivation a client to the point of them actually making it to the therapeutic session?
Emerging technological trend
The research of Proudfoot, Parker, & Hadzi-Pavlovic, (2010) suggested a changing attitude related to the use of technology in mental health. There was a time not too long ago in which we did not have electronic medical records, sophisticated software programs and the Internet. Fast-forward to the present time, the emerging technological trend data reports that 91% of all people on the earth have a mobile phone with 60% of the homeless population having access to or owning a cell phone. In addition to that, 50% percent of the phones on the market are smart phones with 50% of these mobile phone users state that they use their smart phones as their access point to the Internet. In a study of 100 psychiatric outpatients at the Boston Beth Israel Deaconess medical Center, found that 97% of patients reported owning a mobile phone and 72% owned a smart phone with 67% of patients willing to try mobile apps designed to monitor their mental health conditions. In addition, the general public wants to receive more mental health information by phone with 75% reporting they would definitely like to use mobile phone apps to monitor and manage their moods. Nearly 80% according to these researchers reported that they would find it helpful to receive SMS (text) reminders to help track their moods, attendance or any assignments or messages that the therapist could relay to the patient. Lastly and maybe most importantly, 80% of the time a person spends on their mobile phone is spent inside an “app” (Rizvi, Dimeff, Skutch, Carroll, & Linehan, 2011).
In the current marketplace it is estimated that there are more than 300,000 apps with 40,000 health related downloads occurring each day. A recent search by the writer revealed 200+ apps specially designed for behavioral health. These apps include alcohol and drug assessment, suicide risk assessment, interventions for smoking sensation as well as mood trackers and apps for stress management.
There have been many research articles that have probed the use of app technology in terms of integrating this dynamic into the daily practice of mental health counselors related to improving mood, decreasing stress, increasing client motivation and client engagement as these elements are positively correlated to positive client outcome.
A recent study by Slabodkim (2013), concluded from a study of five evidence-based mental health apps that are being used that significant reductions in stress and substance abuse but did not yield any significant effect on depression. However, in the research conducted by Donker (2013) found mental health apps to be effective and significantly improved feelings of depression as well as confirming the research of Slabodkin (2013) on stress and substance abuse. In an investigation conducted by Rizvi, Dimeff, Skutch, Carrol, & Linehan, (2011) found that adult participants enjoyed using these programs as it helped them to decrease their feelings of depression, general distress; helped to reduce their relapse potential and/or engagement in maladaptive behaviors.
In two studies conducted by Kim & Jeong, (2007) and Kubota, Fujita & Hatano, (2004) on adolescents, found that texting was an effective way to disseminate behavioral information to adolescents as 50% of these adolescents sent 50 or more texts per day. In a double-blind study on adolescent engagement, Whitaker et al. (2012) found a significantly large number of adolescent participants reporting enjoying interventions that were delivered through cell phone technology that included the combination of text, video, celebrity cameos and cartoons. In addition the research found that using an interactive website where they could down load ring tones, wallpaper and music can reinforce the delivery of important mental health information directly to the participants.
A meta-analysis studied the use mobile phones to enhance smoking cessation programs and found that those assigned to experimental conditions were significantly more likely to attain abstinence than individuals in control groups (Ehrenreich, Righter, Rocke, Dixon, & Himelhoch, 2011, as cited in Donker, 2013). Similarly, another study examined the effectiveness of face-to-face versus telephone support in increasing physical activity in mental health, and found individuals randomly assigned to either group had improved outcomes in terms of minutes spent exercising and ratings of self-efficacy (Opdenacker & Boen, 2008 as cited in Donker, 2013).
Integrating Apps Into Clinical Practice
Now that we see the research supporting app technology in managing mood disorders, stress and other medical issues, the question becomes how do we integrate these technologies into clinical practice? For example, eMoods, which is an application for bipolar mood tracking that can assess and monitor symptoms with that data are being shared with the clinician. Several apps can be programmed to respond to critical items in self-assessment inventories to auto detect significant changes which may trigger a “one touch hotline” or a direct phone call to the therapist. Adding a journaling feature to track subjective moods, sleep patterns, anxiety levels and medication compliance can also generate reports that can be transmitted to the clinician which can be used in the next clinical session.
eCBT Mood is another application that helps patients decreased depressed feelings by using principles of cognitive behavioral therapy. A practitioner can integrate this technology into clinical practice by assigning to the patient the task of capturing photos during different mood states or behavioral states which can be then used as subject matter for the upcoming session. Photos can be linked to various websites or technologies like Pinterest or Facebook in which the patient canjournalize their moods by capturing this on their cell phone.
Applications for PTSD can track changes in moods, behavior as well as sending the clinician an alert if a patient is decompensating. The clinician can provide feedback through the application, as well as make recommendations if the patient needs to be hospitalized. Another way to integrate therapy into this technology world would be the use of recorded audio from therapy sessions and being able to upload these recordings into the patient’s cell phone in which they can listen to these discussions in between sessions. In addition , the use of breathing or relaxation apps or GPS tracking apps to monitor the patient’s movement through a mall, for example, if they are doing exposure therapy for anxiety or panic reduction. These apps can be used at any time to deal with depressed feelings, anxiety and stress. Patients can be taught in the counseling session how to use breathing apps so that they are familiar with using these types of applications in the event of a panic attack or a situation of high anxiety or depression.
As it relates to integrating smart phone technology into clinical practice, aside from app technology, practitioners and patients can use real-time video teleconferencing to compensate for the lack of face-to-face communication. In addition, companies like Thepsycfiles.com have produced an estimated 3.8 million podcasts in which patients can use in terms of psycho-education and didactical learning.
So in applying this technology to a real-life case, let’s take a look at a female patient who was diagnosed with bipolar disorder with the extreme rapid cycling moods. She reports sleep irregularities, chronic migraine headaches and has had several hospitalizations but does not want to take any medications. She struggles with drug addiction, self-mutilating behavior and low self-esteem. Her goals are to reduce mood swings, decrease cigarette smoking and reduce or eliminate her migraine headaches. Therefore with this type of patient you can see there are several apps that may be useful. For example, the application that focuses on bipolar mood swings would be helpful as well as some of the applications that focus on breathing and relaxation for migraine headaches. In addition there are several applications in the area of guided meditations that can address her low self-esteem, lack of confidence and poor self-worth. Another strategy to use with this patient would be to connect her to the mental health focused websites under Facebook, Twitter and LinkedIn, as empirical studies found that social networking activity was beneficial to mental health patients because it decreases their feelings of isolation and helps patients feel more engaged and connecting (Ellison, Steingield & Lampe, 2007). Lastly, she can join AA/NA online or through their apps.
So in summary, while the research shows a positive trend related to the integration of app technology into clinical practice, more research needs to be conducted on all mental health apps to determine their effectiveness. This interface, may not work for all therapists or for all clients. Due to the nature of some patient’s mental health impairments, they simply may not be cognitively or mentally able to interface using this technology. It is also very wise to assess recommending this type of technology to your patient as one size does not fit all. Even though the practitioner may feel there is a great benefit in using this technology, it should be discussed and recommended on a case-by-case basis as some patients may view this type of interface as intrusive in their life while others may see it as a wonderful wraparound feature. Lastly is important to make sure that all safeguards are taken to ensure confidential communication using these application as some apps may share some personal information to outside sources; IE telemarketing.
Donker T; (2013) Smartphones for smarter delivery of mental health programs: a systematic review. Journal of Medical Internet Research, 15, 247.
Ellison, N. B., Steinfield, C., & Lampe, C. (2007). The benefits of facebook “friends”: Social capital and college students’ use of online social network sites. Journal of Computer-Mediated Communication, 12, 1143-1168.
Gartnerberg et al. 2013. Collecting health related on the smart phone: mental models, cost of collection, and perceived benefit of feedback. Pers Ubiquit Comput, 17, 561-570
Kim, H. S., & Jeong, H. S. (2007). A nurse short message service by cellular phone in type-2 diabetic patient for months. . Journal of Clinical Nursing, 16, 1082-1087.
Kubota, A., & Hatano, Y. (2004). Development and effects of a health promotion program utilizing the mail function of mobile phones. Nippon Koshu Eisei Zasshi, 51, 862-873.
Proudfoot, J., Parker, G., & Hadzi-Pavlovic, D. (2010). Community attitudes to the approapriation of mobile phones for monitoring and managing depression, anxiety and stress. Journal of Medical Internet Research, 12, 64.
Rizvi, S. L., Dimeff, L. A., Skutch, J., Carroll, D., & Linehan, M. M. (2011). A pilot study of the DBT coach: An interactive mobile phone application for individuals with borderline personality disorder and substance use disorders. Behavior Therapy, 42, 589-600.
Slabodkin, G. (2013). Mental health apps lack scientific evidence of efficacy. Pierce Mobile Healthcare Newton: Questex Media Group LLC.
Whittaker, R., & Stasiak, K. (2012). MEMO-A mobile phone depression prevention for adolescent. Journal of Medical Internet Research, 14, 13.