INTRODUCTION

the anxiety and depression association of america [ADAA] reports that anxiety disorders are the most common mental illness in the united states, affecting 40 million adults every year. from preparing for a class presentation to relying on public transportation to get around; anxiety can overpower the mind and ultimately control life if allowed. 

 

WHAT IS EMA?

 

ecological momentary assessment [EMA] is a method for collecting data in real time to avoid biases and to study behavior over time. in the past, EMA mobile apps are used to gather data on topics like substance abuse and emotional well-being, but the visual design system is less than appealing. a mobile app is the next natural progression to increase homework compliance in therapy. designers are equipped with the knowledge to build visual guidelines needed to move forward with a mobile app, which is engaging to the user.

 
 

VCU GRADUATE RESEARCH SYMPOSIUM SUBMISSION

 

Experts Collide: Designers and Doctors Team Up to Make Self-Guided Therapy Device

By: Missy Thieman, Experience Designer

 

The purpose of this paper is to discuss a different approach to therapy. A new trend has

allowed patients to seek help via text, video chat, and voice or audio messages. In-office therapy

is being challenged by this trend mostly due to the fact that people cannot afford it. I will

discuss how a mobile solution is the next natural step in progressing digital therapy, and the

guidelines a mobile app needs to follow for successful homework compliance. Some

opportunities for a user-focused product in the current marketplace are the affordance of a

one-time payment product and little to no competitive products currently available.

 

Introduction

 

The Anxiety and Depression Association of America [ADAA] reports that Anxiety disorders are

the most common mental illness in the U.S., affecting 40 million adults every year. Anxiety

affects the entire body and can make daily activities extremely difficult or overwhelming. From

preparing for a class presentation to relying on public transportation to get around; anxiety can

overpower the mind and ultimately control life if allowed.

 

1 in 5 Americans does not have health insurance, making the affordance of in-office therapy

limited to 50 million adults ( 77% of the population was over the age of 18 in 2017 [1] ). A little

perspective: there are 30 million adults in California [1] alone, and not all 50 million adults will

seek out therapy in their lifetime. Those are just facts about the United States. Even with

insurance, in-office visits are expensive, and it is not uncommon to “test” out a few different

therapists to find the right match for you.

 

Typically therapy visits are week-to-week, an hour long, lasting in an agreed-upon length for

treatment. However, therapy culture is changing, and that is because homework behaviors are

also changing. Homework non-compliance is one of the top cited reasons for therapy failure in

Therapy [2] . An article written in 2017 states "The popularization of the mobile phone with app

capabilities (smartphone) presents a unique opportunity to enhance CBT homework compliance;

however, there are no guidelines and no existing research that directly address the design of

mobile phone apps for this purpose [3] ". With the availability of smart devices, and the probability

any person has one on them at all times of the day, can a smart accessory mobile app help

when therapy does not?

 

Ecological Momentary Assessment [EMA] is a method for collecting data in real time to avoid

biases and to study behavior over time. In the past, EMA mobile apps are used to gather data on

topics like substance abuse and emotional well-being, but the visual design system is less than

appealing [reference image 1]. A mobile app is the next natural progression to increase

Homework Compliance in therapy. Designers are equipped with the knowledge to build visual

guidelines needed to move forward with a mobile app, which is engaging to the user.

 

The Hypothesis

 

A mobile app will improve access to material, comprehension of lessons, and overall compliance
when combined with specific content, and the correct set of design systems. There are three
homework requirements the app has to address: psychoeducational, self-assessment, modality-
specific. The app must also include essential features like therapy congruency, fostering learning,
guiding therapy, connection building, emphasis on completion, and population specificity for
self-guided digital therapy to be successful [5].

 

Test ideas

 

A physical prototype combined with a mobile app will be the best tool for patients to use and

will generate the most results. A hotspot is an area on a screen that can be clicked to activate a

function, but in this case, a hotspot is a physical button. EMA gathers real-time data, historically

through an app, but a phone case with hotspot buttons that trigger music, or emergency

services can also gather real-time data. Knowing when the mobile app is in use, and the length

of time spent active will produce peek trigger data points. The data can help the patient pinpoint

their emotional journey, but also consciously start to be aware of the time(s) in life causing

stress or anxiety. The benefit to this data is that it helps show patterns in real-time for future

understanding of what patients need from therapy and their therapist. Users will need to feel

familiar using the app. Designers will need to utilize behavior patterns of other apps that are

second nature when using technology. Not all users are created equal; therefore the app will

need to be accessible to people with vision impairments, as well as hearing if an audible sound

plays. Directions should be clear, easy to understand, and not stressful, like being forced to

complete a task by a particular deadline. Examples of stressful design include the date vs.

number of days, bright flashy graphics, and excessive notifications. Not forcing the user to

complete tasks will empower them to become more motivated and take an active role in their

treatment. When ready, they will ultimately self-guide themselves through their treatment plan.

 

Test Goals + Learning Objectives

 

To determine the best execution for digital therapy to be delivered for maximum success, the

study should include four variables. Refer to these variables as “concepts.” The first concept is

a two-part prototype: a phone case equipped with software in the case, and hotspot buttons on

the outside of the case. It tests the combination of a durable phone case and app that work

together in harmony. Concept two is a pre-loaded app available as mobile software (i.e., the

health folder on iOS devices). The test should include all phone providers if possible. The third

concept is a phone case without the software to test the utility of only the hotspot buttons. The

fourth, final concept is a phone accessory plug-in with only the software. This concept explores

the possibility of a less-expensive accessory, and if the user is partial to their current phone

case, they will not have to switch.

 

Introduce clinical trials in two phases. Phase one should observe a hundred users per concept -

four hundred people overall - of various age, education, income, and family size. This test will

help understand who benefits most from a product like EMMA. The top-performing half of each

concept - fifty people who use their concept the most - should stop the trial after one month

because they have validated the product by this time. The remaining fifty users should

participate for a total of three months. These are the people who are not engaging with their

concept. Varying the trial will show areas for improvement, and allow professionals to have a

better understanding of users’ phone habits.

 

Other methods to test in the trial can include users who have been to therapy for their anxiety,

versus users who are seeking help without ever having been to therapy. This differentiation will

narrow to users who are most likely to use the product; those familiar with in-office therapy, and

those who are not. Defining a specific user is important because not all methods of treatment

are equal. For example, if this product only works for a specific age group, then the development

of the product should reflect that group of people. As soon as a user profile exists, Phase Two

should observe two hundred people who fit the user profile.

 

Methods to Test

 

The strategy needs testing. Will people use a one-of-a-kind digital product regularly to manage

their anxiety? There is not anything like EMMA on the market, and there is most certainly a need

for one. Anxiety is not something that goes away, and it takes continuous effort throughout life

to manage. A benefit of this product is the affordable one-time cost, unlike in-office therapy

where patients pay per visit. In order to confidently bring this product to market, it should

become clear that the positioning in the marketplace will be one for growth.

 

Before using a concept, each user needs to meet with a Subject Matter Expert [SME] to answer

questions. The SME needs to understand the user’s current homework habits and typical phone

activity like app usage. Ask them if they know any products like EMMA in the industry that

currently exist or have they ever been to therapy before. Their answers become very useful in

setting a standard measurement before the study begins. Setting a baseline measurement for

each user will show the viability of the product, and help when interpreting success after the

clinical trials end.

 

Collect Qualitative data in focus groups after the clinical trial from the participants. Ask them to

rate their satisfaction with the functionality of the app. Questions like: how often the software

was active, when and where it was used can help further develop the app. Ask what sections of

the app were least popular with users’, and even what they wish they could do next time.

Questions about the visual design as well as the physical design should also be documented.

Lastly, SME’s should test the concepts and give their feedback. It is essential to know if they

would recommend this product to patients and rate their effectiveness.

 

Test Plan

 

There are three phases to execute to find the best product for development. Phase One starts

with the testing of four variables. Phase Two involves the two most successful variables from

Phase One, with slight changes to the qualitative research, if necessary. Those two variables

should be turned into working prototypes and tested. Once Phase Two testing is complete,

Phase Three will introduce the best possible prototype, and move into the development stages

of a fully functioning product.

 

Projected Results

 

The test plan will prove the necessity for an alternate solution to therapy and the best way to

deliver content to users in need. The data collected from this new digital system will be integral

in proving further research in understanding OCD and anxiety is required.

 

The aims can be achieved by maintaining relationships with expert professionals such as Dr.

Michael Southam-Gerow, the Associate Editor to the Journal of Consulting & Clinical

Psychology, to ensure the content meets the requirements of CBT homework. To ensure

protection over the privacy of the user a specialized team is to assist with the app development.

The software needs developing; therefore a team is needed to develop a synchronized system.

 

Risks

 

The most considerable risk is the possibility of a digital delivery system for homework does not

show any differentiation from previous homework compliance. Another concern is that a

product is introduced into the market before EMMA is developed, therefore eliminating this test.

Even if another app emerges after EMMA, there is a risk in competition and performance with a

similar product. Because there are physical prototypes, account for care and replacement of

materials in the test plan. The cost to produce this product is relatively low, but if materials or

factories cannot keep the projected cost down, that is a risk during production. The software

carries a risk of compatibility with phones, and any updates released to the public. Clinical trial

participants carry risks as well. Forgotten phone, phone dying without access to a charger, or

just not using the product to generate any data are all risks. Discuss all risks during Phase Three

of the test plan and workarounds should be discussed to eliminate as much risk as possible.

 

Closing

 

Even with a long list of potential risks, EMMA still is a new approach to therapy; and with data

collection, will have an impact on understanding how to help more people. Anxiety is necessary

for survival because it motivates behavior [4] . The brain is hardwired with instinctual urges that

have not evolved with society or technology. Humans occasionally receive false signals about

non-threatening situations, although they perceive them to be the opposite. Anxiety cannot be

eliminated, but helping a person build a better relationship with anxiety is a better approach [4]. It is

essential to be able to self-identify with problems or situations holding someone from their

potential. If traditional therapy is not helping, there should be another way.

 

 

Citations

 

1 Data collected from Annie E. Casey Foundation Kids Count Data Center,

https://datacenter.kidscount.org/

 

2 Helbig S, Fehm L. Problems with homework in CBT: rare exception or rather frequent?

Behav Cognit Psychother 1999;32(3):291-301

( https://www.cambridge.org/core/journals/behavioural-and-cognitive-psychotherapy/

article/problems-with-homework-in-cbt-rare-exception-or-rather-frequent/0C47B89190

ED53495A5223D38216B45A )

 

3 Wei Tang, David Kreindler, Supporting Homework Compliance in Cognitive Behavioural

Therapy: Essential Features of Mobile Apps, published on 08.06.17 in Vol 4, No 2

(2017): Apr-Jun ) https://mental.jmir.org/2017/2/e20/ )

 

4 Dr. Michael Southam-Gerow, in-office meeting on 11.02.18

 

5 Tompkins M. Guidelines for enhancing homework compliance . J Clin Psychol 2002

May;58(5):565-576. ( https://onlinelibrary.wiley.com/doi/abs/10.1002/jclp.10033 )

( https://www.ncbi.nlm.nih.gov/pubmed/11967881?dopt=Abstract )

 

IMAGE 1

Screens that look and feel like a test. These tests, although called a “test” shouldn’t feel like a burden and that is where design can help gamify the experience.