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.
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  ). A little
perspective: there are 30 million adults in California  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  . 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  ". 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.
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 .
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.
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.
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.
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.
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  . 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 . 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.
1 Data collected from Annie E. Casey Foundation Kids Count Data Center,
2 Helbig S, Fehm L. Problems with homework in CBT: rare exception or rather frequent?
Behav Cognit Psychother 1999;32(3):291-301
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 ) )
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. ( )
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.