Mobile Devices and Clinical Practice: Unlikely Partners?
Every therapist has probably had the experience of a client’s cell phone ringing in the middle of a session, usually at the most inopportune moments. So it might come as a surprise for some therapists to hear that these devices might actually help with therapy. I think that smartphones and other mobile devices have the potential to enhance therapy in many ways and that we’re only starting to explore these possibilities.
One straightforward example is measuring mood and symptoms with mobile apps. I realize that many therapists don’t use ongoing measures in their therapy practice. However, I have found that using brief, repeated measures provides significant value in my practice. It provides a way to track progress with enough sensitivity to pick up small changes over time–or the lack of changes. It allows the client and I both to quickly assess how the week has gone. And it illuminates patterns in symptoms or growth–when we track these on a graph over time and then note the timing of significant life/therapeutic events, we can learn things together about what might be happening for a client. For example, we might learn than a person’s anxiety symptoms got significantly worse after a schedule disruption or a change in diet. Measurement scales can be standardized, where the scores have meaning in relationship to some clinical and normative data. Or scales can simply be a self-monitoring tool, a scale that helps an individual rate levels of symptoms, but where the scores don’t have any specific meaning related to clinical standards.
So I was particularly excited when I learned of this new application for Android phones developed by the National Center for Telehealth and Technology (T2), T2 Mood Tracker. It has several categories of symptoms to rate: anxiety, depression, general well-being, head injury, post-traumatic stress, stress, and a custom category that will allow users to create their own scales. It also will graph the ratings, allow you to enter a note for a particular date, and allow the notes to be password protected. It even will allow the user to set reminders to enter a mood rating.
T2 Mood Tracker General Well-Being Scale (Droid X)
While T2 Mood Tracker is not yet available for the iPhone, there are plans for an iPhone app in the first half of 2011. And while I haven’t had a chance to look at it closely, I did notice that there is a different app in the iPhone app store called MoodReporter that also seemed to track symptom levels and allows you to add a brief note.
T2 has also developed an app for the iPhone and Android called Tactical Breather, designed to be “used to gain control over physiological and psychological responses to stress.” This highlights another fruitful area for mobile phone application development: apps to teach specific coping skills, for example, use of soothing imagery and anxiety reduction breath training. I haven’t yet seen any good apps with this type of content–would love to hear of any you have found.
What roles can you see, if any, for mobile devices in psychotherapy?
Jan 09, 2011 @ 21:55:39
Nancy, thanks for calling our attention to the Apps you mentioned, and the possiblity of using them for stress reduction and mood tracking!
I often shock the adolescents I work with when I encourage them to bring in their laptop or iPhone to sessions. But what better way to get access to their taste in music, and assess their social life (facebook or texting.) I often get a better sense of their realtime relationships because their texts alert me to how they are feeling about who.
I do have one rule about texting and IMing in our sessions: Anything they decide they want to answer or respond to is clinical material, and they need to tell me who they’re talking to. If they don’t want to do that, that’s fine, but then they are choosing to wait until after our appointment to read and text on their phone. I have yet to have an adolescent have a problem adhering to that limit, and they find the ability to choose empowering.
Again, thanks for a great intro to a very important topic.
Jan 10, 2011 @ 20:45:39
Mike, I love how you use technology with the adolescents that you work with (and I can hear your love of working with that population!).
I’m reminded of an adolescent residential drug treatment program that I know of–in the last few months of treatment they have the kids work on their Facebook pages in the sessions, so the therapist and the client can work together on Facebook, helping the kid reconstruct a Facebook presence that is consistent with being drug free. Remembering this and hearing about your work makes me even more bewildered about therapists who work with young people and don’t bother to really learn about the technology the kids are using (see a prior post: When is Cultural Incompetence Okay?).
Jan 12, 2011 @ 00:29:24
You are so very innovative and clever, Mike.
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Jan 09, 2011 @ 22:33:39
Jan 09, 2011 @ 23:05:20
These mobile apps sound like great applications, Nancy. Thanks for providing information about them.
I would think that clients are more likely to fill out an online version of how they are feeling than a photocopied worksheet out of a book (I know – I’ve tried – somehow, the worksheets get lost, forgotten etc.).
A mobile version is probably more likely to make the whole process feel more like a game as opposed to a chore – leading to greater compliance.
Jan 10, 2011 @ 09:38:36
Good point, Dorlee. Since compliance is a major issue in therapy, especially for homework, that could be a real plus. Thanks for weighing in!
Jan 11, 2011 @ 00:18:08
This is exactly what I was thinking. Might actually get my young clients excited about “homework!” Thanks for the tip.
Jan 11, 2011 @ 08:42:19
I’ll be interested to hear how it works when/if you’re able to give it a try.
Jan 10, 2011 @ 06:41:00
While I love that mental health is being included in the app world, and agree that clients would be more likely to remember to rate their mood, anxiety, etc with an electronic reminder, I have a couple of concerns. First, I wonder if this daily rating might increase self obsession about mood or anxiety and detract from more positive interpersonal experiences. Second, I have concern that it might produce a false rating for some individuals; when people have the history of how they felt in their hand, they may not want to repeat the same rating.
I do, however, love the idea of a breathing/meditation/visuilization tool. I wonder if the android phones, with their touch sensitivity could one day serve as a mini biofeedback device…?
Since I am a psychodramatist, another app that I can envision is one that asks a client to choose a new role when they find themselves in trouble or in need of increased spontaneity. It would be fun to develop this!
Thanks for starting the conversation, Nancy!
Jan 10, 2011 @ 20:32:01
Thanks for raising such interesting points Pamela! I love your ideas for apps and I suspect they would have a wide appeal. Now we just have to get someone to create them!
Your concern about clients obsessing over ratings is an interesting one. I would say that this is definitely possible. As with all the tools we use, I think each one has to be fit with the client andbe discontinued if it’s not working or creating problems.
However, practically, in the 25 years I have used brief assessment scales with clients (most of whom had significant anxiety problems) I have never had problems with any client obsessing over the ratings and almost all clients have found the ratings to be very valuable. Maybe the reason I haven’t had problems is that I work hard (especially with people who obsess a lot) to make sure I minimize expectations about what the scales are supposed to do or show. I make it clear that there is no right or wrong answer and that I’m not expecting them to go up or down. We’re just doing them to learn about patterns (a discovery process). I describe our work together also as a discovery/testing process: a series of trying things and deciding if they are working or not. Then I present that the value of the ratings are that they tell us the answers to how things are working, but I make it clear that if there is no change that it’s a positive thing that the scales are letting us know that. I really try to model the “let’s try it and see what happens approach. And so if there is some positive change I don’t jump right on it enthusiastically: I’m careful to solicit their reactions first and, together, we decide if we think things look promising or not. And finally, if things do look promising, I point out that change rarely happens in a consistently positive direction and that we will keep using the scales to help us learn more over time.
I don’t know if I have described the above clearly enough, but I hope you can hear that the rationale for using ratings needs to be presented carefully with an emphasis on the need for honest assessments, not choosing a number that a client would like to see or that a client thinks I would like to see.
Thanks so much for fleshing out this issue–like so many things that we do in clinical practice, there are many layers to it.
Jan 11, 2011 @ 09:55:08
Those who know me only slightly might think that I would avoid technology in practise because I concentrate on helping clients develop mindfulness skills, using the breath, meditation, visualisation and biofeedback interventions among other things. Nope; tech geek in bare feet and peasant skirts here.
My experience in using rating scales is much like yours, Nancy; I have never had a client perseverate on the outcomes and I agree that it is possible that how this tool is presented likely makes that work. I was introduced to this type of use about 20 years ago in my own personal work, and have found it really valuable with clients.
I see such scales as important introductions to mindfulness in our culture. The changes in results can be meaningful lessons in the inevitability of change in life. One of the issues so many people bring to their work is hopelessness – maybe not to the extent of considering suicide – but certainly to the extent of tolerating (clinging to, if you will) their suffering. Using scales illuminates change in real time, and having an app for it allows people to live into their work, in the present moment, in the life they actually live. Seeing the ups and downs in a culturally relevant way only make sense. When the “DayTimer” thing was big, I used little forms folks could insert in their planners – now it’s the Blackberry/iPhone/Droid. It sets the stage for affect tolerance in everyday life. (With children I use crayons, their fingers, play smartphones that have different tones in their keypads, whatever…)
Then there is the part where we know that simply noting a behaviour has some tendency to reduce its intensity, allowing the rating itself to serve as intervention. My experience with adolescents is that they’ll go along with almost any intervention that is essentially invisible to their peers – accessing an app is about as invisible as it comes right now. I think the invisibility factor is one of the reasons I have such good luck with breathing interventions and adolescent boys – we all have to breathe and I help them figure out ways to make getting the body and mind on board through the breath virtually undetectable to peers and the ever dreaded adults…
I like interventions that are internally motivated and directed, and natural to life. While I know that technology has come with some serious downsides, it is as natural to our current lifestyle as were stone tablets (or those huge day planners – I swear mine weighed five lbs !). I suspect that using apps for “good” (I have mindfulness chimes on my computer and smartphone) can mitigate some of the potential of tech to become an omnipresent sabretoothed tiger, constantly chasing us, keeping us in a state of alarm, and reframe some of that anxiety into support, challenge into opportunity.
All that said, I also have a 100% success rate getting people of all ages and stages to blow bubbles: an app that allowed one to blow into the device in question and get the appropriate bubble result on the screen would make my day…especially if it shared the bubbles with select others and made them smile, too, the way physical bubbles do…maybe I can get my brother the software analyst to put that together in his retirement…:)
Jan 12, 2011 @ 07:44:03
What a rich perspective to bring to this process, Elaine. I don’t think I’ve consciously put the use of rating scales in the category of cultivating mindfulness, but as soon as I read what you wrote it made perfect sense to me. Thanks for extending the conversation into this domain. And you’ve raised another topic close to my heart: technology and mindfulness. Might make for an interesting blog post at some point.
Jan 22, 2011 @ 01:37:32
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Jan 22, 2011 @ 01:48:19