PERSPECTIVES

Mental Health Apps: Homework for the Digital Age

 

Jane, a 16-year-old female and high school sophomore, presented to therapy following a recent incident of cutting. Jane’s mom discovered fresh cut marks on Jane’s arm, and several bloody tissues in the trash can and bloody residue in the bathtub. Concerned, Jane’s mom scheduled an appointment with Kim, a 40-year-old licensed marriage and family therapist who specializes in attachment-based family therapy. Jane lives with both her parents, Sally and Robert, and her 13-year-old brother, Cabel. PHQ-9 scores indicate that Jane has moderate depression symptomology with suicidal ideation (parents report minimal depressive symptoms; Berryhill, Cohn, Hertlein & Long, 2019).

As we consider the possible systemic therapy applications that could be used to support Jane and her family, this article proposes an investigation of a less understood and under researched area: online apps.

Four types of systemic applications

Mental health apps tend to fall into one of four categories. Some apps combine two or more types to provide more resources to meet client needs. There are psychoeducation apps that provide information about the signs, symptoms and treatment options of concern to a person interested in learning more about the topic. There are tracking apps that give the user feedback about their activity, e.g. step counters, calorie counters, heart rate, etc. These apps are sometimes combined with a goal setting function that will give the person feedback in relation to a goal they set for themselves. There are skill-building apps that reinforce a set of skills, based on a particular model or approach to treatment. Finally, there are coaching apps that are developed to build on information provided, a target goal, a skill set and motivational counsel for sustaining goal achievement.

Table A shows examples of each category of apps.

ND20-perspectives-tabel-1

Karen Wall (personal communication, March 11, 2020) calls for the need for online reviews of apps. As apps become more prevalent, a ‘Consumer Report-style,’ review of apps could describe an app’s usability, validity, effectiveness, interoperability, and relevant security issues. Beacon 2.0 (https://beacon.anu.edu.au) provides a good example of how one such website was developed in Australia. A site like this would be helpful to MFTs interested in supporting treatment with digital homework.

Beyond the question of functionality is the question of whether an app is systemic in content. Knowing which apps can be used to sustain relationships and therapy depends on the achievement of therapeutic objectives as well as the client’s report of the utility of the app (Hertlein & Cohn, 2018). What is assumed is a degree of reflections about the impact of an app on the social ecosystem.

To recognize that apps are not value neutral, here are some examples of what might be asked of a client about app use. What would you consider saying to family and friends about your app use? What would you avoid saying to family and friends about your app use? How might family and friends view your app use?

Table B shows  examples of apps that align with the goals of clients in their pursuit of individual, couple and/or family therapy.

ND20-perspectives-tabel-2-new

Evidence in support of technology-assisted devices

One way to think about effectiveness is to consider what we know about the evidence in support of technology-assisted services. We know that there is a gap between supply and demand when it comes to providing mental health services to reach more people (Lui, Marcus, & Barry, 2017). As stated in Derring-Palumbo and Zeine’s Online Therapy (2005), skills used in in-person therapy can be generalized to online therapy. Given that the number of people who own smart phones in this country is expanding (Luxton, June, & Chalker, 2015), it makes sense that the skill of supporting talk therapy with digital homework can be transferred from in-person to online therapy, thereby bridging the supply and demand gap in providing technology-assisted services. The bridge from effectiveness of telemental health treatment to use of mental health apps is a work in progress.

As previously reported (Lui, Marcus, & Barry, 2017), when MHealth, that is the use of mobile devices such as a smart phone, is used as an adjunct to traditional therapy, it has the potential to increase homework compliance and generalizations of therapeutic skills outside of sessions.

How is the app being used

Another way to think about effectiveness is to consider how the app is being used. Again, the previous study concludes that MHealth may also promote early identification and early intervention of mental health services. In other words, psychosocial apps promote a better understanding of symptoms and their treatment. The same may be true for skill building and coaching apps.

The fact that all of the dots are not connected provides an incentive for researchers to connect the dots and for practitioners to work with clients to find out what apps help them in their own pursuit of personal growth and development.

Pitfalls of app use: Ethics

As we consider the potential use and application of digital apps in mental health, we need to be proactive in developing procedures and processes for implementing these tools. “What I propose is very simple: it is nothing more than to think what we are doing (Arendt, 1958, p. ix).” For the facilitators of app use, the issues of confidentiality, limited research, social justice and unexamined systemic implications are paramount. Simply because data breaches have become the norm does not mean we can ignore the harm a leak could do to our clients. In an early draft of the Minimum Standards Report, Aaron Cohn (Berryhill, Cohn, Hertlein, & Long, 2019) calls on professionals to scrutinize applications for data security policies and ensure that clients are informed of risk to their data. In Section 6.1 of the AAMFT Code of Ethics (2015) the following appears:

Prior to commencing therapy or supervision services through electronic means (including but not limited to phone and Internet), marriage and family therapists ensure that they are compliant with all relevant laws for the delivery of services. Additionally, marriage and family therapists must: a) determine that technologically-assisted services or supervision are appropriate for clients or supervisees, considering professional, intellectual, emotional, and physical needs; b) inform clients or supervisees of the potential risks and benefits associated with technologically-assisted services; c) ensure the security of their communication medium; and d) only commence electronic therapy or supervision after appropriate education, training, or supervised experience using the relevant technology.

Future rules makers will want to add principles to prevent a play-for-pay situation in which practitioners could be invited to “test” an app for selected populations and in return receive some sort of “honorarium” for testing the app. Currently Standard III, Professional Competence and Integrity implies a conflict, but is not explicit with regard to a play-for-pay app developer/MFT partnership scenario.

Aaron Cohn relates in the Minimum Standards Report (Berryhill, Cohn, Hertlein, & Long, 2019) that being systemically minded mental health providers embodies a number of paradoxes. Practitioners must see to their own interests and to the interests of all MFTs while aspiring to transcend self-interest ways of thinking and being. This means MFTs must plot a course with limited information toward ethical technology practices (yet to be written) that are themselves just being recognized as missing in the current code.

Minimum standards

Minimum standards were developed by the CEO workgroup, using a Delphi method, which allows for collecting views between geographically separated experts. An initial list of 49 standards, based on a search of the telemental health literature was reduced to seventeen. The list is arranged into four categories: standards for MFTs, standards for clients, standards for developers, and standards for regulatory boards. Here are examples of standards found in each category:

For marriage and family therapists
MFT will self-test all of the features of an identified and selected systemic family therapy app prior to recommending its use.

For clients

  • Clients can expect their MFT to respond to questions asked about the client’s experience using the app

For developers

  • Application developers will draw from models and/or principles that are among those taught in COAMFTE-accredited training programs.

For regulatory boards

  • Boards will include application use as part of continuing education requirements.

A complete list of standards is available in the AAMFT Store at www.aamft.org/store. In the search field enter “2015 Code of Ethics: Emerging Issues in MFT Practice.”

Application competency

Based on the Coalition for Technology in Behavioral Science (CTiBS) Competency Task Force (2019), the use of apps falls into domain 6 Mobile Health Technologies. “These include demonstrating alignment with therapeutic goals (e.g., “good” app selection); assess positive/negative effects on the therapeutic relationship; and adhere to professional standards and state/provincial and/or federal law; help patients select options based on evidence” (Maheu, Drude, Hertlein, & Hilty, 2018). Maheu et al. (2018) reference three levels of competency: novice, proficient and authority. What is missing is an example of how a competency approach to app use might be developed for practitioner use. Practitioners and programs interested in the practice of competency development will want to add application use to their ongoing process. In their discussion of the development of core competencies for the practice of marriage and family therapy (Nelson et al., 2007) they relate that faculty in particular appreciate having a tool for assessing trainees’ skills as they progress in a program of study.

Whatever happened to Jane and her family?

Returning to the case study, we learn that Jane had been bullied at school. Her parents dismissed her concerns saying peer disagreements were normal. As a result, Jane felt she could not turn to her parents for support at times of distress, and when she has the urge to harm herself. Kim, the MFT, punctuated the seriousness of the self-injury, empathized with Jane and contracted for relational repair through ABFT. While being dismissive of the bullying complaint, Jane’s parents took the cutting seriously. They stated their desire for Jane to inform them when she was experiencing strong urges to cut, and her location throughout the day so they could get to her if she needed their help. Kim suggested using notOK, a free app to inform others of self-injury with the push of a button. Once Jane presses a button on the app, it alerts selected others and provides her location. Jane and her parents agreed to give the app a try. Kim worked with the family to avoid Jane’s “crying wolf,” the parents failing to respond to a serious “push,” and steps to take when the button was pushed. She talked with Jane’s parents about active listening strategies, calming strategies, and ways to help Jane manage an urge to cut. Kim also used Life360, an app that features private location sharing and in-app text chat. The family agreed that notOK is a good way for Jane to communicate when she is having negative thoughts and urges to harm herself. They determined that Life360 improved communication by adding text in addition to talk between family members.

The digital world presents professionals with multiple, perplexing options. While seeing the potential uses of digital tools for increasing communication, intervening in serious and life-endangering activities, and much more, it is critical to develop guidelines for the ethical use of these tools. I urge professionals to begin using systemic apps and share with colleagues successful outcomes of their use as an adjunct to good therapy.

Richard P. Long

Richard P. Long, PhD, is chair of AAMFT’s Telehealth and Technology Interest Network. Long is an AAMFT Clinical Fellow and Approved Supervisor.


REFERENCES

AAMFT. (2015). User’s guide to the 2015 AAMFT code of ethics. Alexandria, VA: Author.

Arendt, H. (1958). The human condition (2nd ed.). Chicago: University of Chicago Press.

Berryhill, B., Cohn, A., Hertlein, K. M. & Long, R. P. (2019). Minimum standards for systemic therapy applications. Alexandria, VA: AAMFT.

Coalition for Technology in Behavioral Science. (2019). Initiatives. Retrieved from https://ctibs.org/our-initiatives

Derrig-Palumbo, K., & Zeine, F. (2005). Online therapy: A therapist’s guide to expanding your practice. New York: Norton.

Hertlein, K., & Cohn A. (2018, November). Technology in MFT service delivery: Should therapists swipe right on disruptive tech? Retrieved from https://digitalscholarship.unlv.edu/mft_fac_articles/95

Lui, J. H. L., Marcus, D. K., & Barry C. T. (2017). Evidence-based apps? A review of mental health mobile applications in a psychotherapy context. Professional Psychology: Research and Practice, 48(3),199-211. doi.org/10.1037/pro0000122

Luxton, D. D., June. J. D., & Chalker, S. A. (2015). Mobile health technologies for suicide prevention: Future review and recommendations for use in clinical care. Current Treatment Options in Psychiatry, 2(4), 3490362. Retrieved from http://dx.doi.org/10.1007/s40501-015-0057-2

Maheu, M. M., Drude, K. P., Hertlein, K. M., & Hilty, D. M. (2018). A framework of interprofessional telebehavioral health competencies: Implementation and challenges moving forward. Academic Psychiatry, 42(6), 825-833. doi:10.1007/s40596-018-0988-1

Nelson, T. S., Chenail, R. J., Alexander, J. F., Crane, D. R., Johnson, S. M., & Schwallie, L. (2007). The development of core competencies for the practice of marriage and family therapy. Journal of Marital and Family Therapy, 33(4), 417-438. doi:10.1111/j.1752-0606.2007.00042.x

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