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Joe Ruzek is an Adjunct Professor at in the Department of Psychiatry and Behavioral Sciences at Stanford University and Co-Director of the Center for m2 Health at Palo Alto University. He is a former Director of the VA National Center for PTSD Dissemination and Training Division. His current interests include development and evaluation of technology-based interventions for those exposed to disasters and trauma, especially in low income countries.

To me, the most exciting thing about many behavioral health apps and web interventions is that they go beyond simple delivery of information to assist clients in learning and practicing skills.  Using apps, our clients can practice muscle relaxation or slow breathing, be helped to lift their mood by increasing participation in positive activities, or record their alcohol consumption to help cut down on drinking.  But use of an app is itself a new behavior for many clients, and research shows that we as clinicians play a critical role in helping clients persist in using the apps and thus reaping the benefits of behavior change.

 

To help our clients get a “therapeutic” dose of what an app offers, we need to bring the app into the therapeutic process and make it a key part of the treatment experience.  A good starting place is to inquire about current use of technologies, especially for personal change.  Many clients will already have tried using an app to increase their walking or running, monitor their sleep, or count calories in the food they eat.  As you discuss possible use of an app that fits the needs of your client, it is first and foremost important to present a clear rationale for use of the app, and then to actively discuss and explore client perceptions and receptiveness.  The rationale should, of course, be specific to the individual person, but possible elements to emphasize and discuss include the personal goals of the client and potentials advantages of use for the client (for example convenience, pervasiveness, or automated reminders).  Helpful talking points include outlining some central benefits of the app: helping the client learn and practice new skills, moving treatment out of the office into the real world where the problems occur, and offering a resource that is easy to use and available 24/7. Based on your clinical judgment that an app is appropriate for the individual, and if the client is receptive to the idea, it will be especially important to demonstrate the tool in session, which means of course that the clinician will need to have become familiar with the content and structure of an app, downloaded it ahead of time, and have it available in session; if a web-based program is being used, it will be important to have a computer screen available to demonstrate the Internet program.

 

Perhaps most critical to the process is collaboration with the client to decide upon between-session use of the tool.  Here, as with any therapeutic between-session (“homework”) assignment, it is important to be specific: how often will the client use the app, how much time will they spend, how much of program and/or what sections of the app will they explore?  Check to ensure clear understanding of expectations for use and the nature of the commitment (e.g., how long it will take to go through the whole intervention?).  Try framing app use as an experiment, something to try out and then discuss together, to collaboratively determine whether the app seems useful and should be continued.

 

To fully integrate apps into the process of therapy, the clinician should regularly review client experiences with the app, to find out about perceived challenges and benefits.  A great way to do this is to discuss app experiences and app-related task completion at the beginning of each session to help underline the importance of use.   Here the therapist plays a critical role in reinforcing use and where appropriate, drawing attention to any positive consequences it may bring.   Discussion of app use offers a chance for the clinician to strengthen client perceptions of self-efficacy and confidence in ability to cope.

 

If the client did not follow-through with agreed use of the app, it will be important to discuss this.  Often the client may have made some effort but done less than anticipated. This is common to any therapeutic task assignment and it is very helpful to note their effort and encourage it, even if initially it was not perfect or complete.  If they didn’t use the app at all, ask what got in the way and make it a topic of in-session discussion.  It may be necessary to revisit the rationale for using the app, and ask about continuing commitment to use:  Does the client still wish to use the tool? Is there a persuasive reason for a renewal of effort that makes sense to the client?  Clinician and client can identify potential obstacles to use, and brainstorm or problem-solve ways of dealing with anticipated obstacles.  As the client uses the app more regularly, sessions can include discussion of experiences in coping and the therapist can expand upon the messages and skills embodied in the technology tool.

 

        By including the app in the treatment process in this way, you can help your client benefit from “guided self-management.”  Such guidance takes into account that it is often difficult for clients to sustain technology use in the absence of any external support.  If it is successful, it can help the client sufficiently engage with and persist in using the app long enough to derive its benefits.

 

Mobile mental health is a continuously evolving field with a rapid growth of technology products, capabilities, and research.  Increasingly, apps will generate large amounts of data that can be used in real time to inform and guide more effective treatment.  Now might be a good time to begin to experiment with incorporating technologies into your treatment processes and participate in the future of mental health treatment.

 

Are you interested in learning more about integrating apps into your practice? Here are some resources to help:

  • The U.S. Department of Defense (DoD) Mobile Health Practice Guide offers an overview of mobile health which is primarily tailored for military health providers, but can be used by clinicians across the health care spectrum who diagnose and treat behavioral health conditions.
  • In October, we’re offering a workshop on Identifying and Using Mobile Apps in Clinical Practice. The workshop takes place at the Annual ABCT Convention in Washington, D. C. on Friday, November 16. The workshop is designed to help clinicians identify and evaluate consumer available mobile apps, and learn how to introduce them into practice appropriately. More information and registration details can be found here.
  • At PsyberGuide, we want to provide resources and information that clinicians need to effectively use mobile apps with patients. Over the coming months, we will be exploring what topics clinicians are most interested in and how we can best serve their needs, and we would love to hear from you. Sign up to our Clinicians Mailing list here and we will reach out to you soon to get your valuable input.