SummaryAs an adjunct to weekly face-to-face sessions, individuals in cognitive behavioral therapy receive as-needed support by accessing mobile phone applications that mirror cognitive behavioral therapy techniques. These applications prompt individuals to assess their mood and allow them to select from a variety of self-directed therapeutic interventions that encourage cognitive reappraisal and physical relaxation, such as modulated breathing, relaxation of specific body areas, and reassessment of negative thoughts. In a small pilot study, participants reported greater self-awareness and mood awareness; improvements in coping skills and mood patterns; and reductions in negative emotions such as anger, sadness, and anxiety. Individuals not in therapy may benefit from these applications as well.Suggestive: The evidence consists of interview and experience sampling data from a 1-month field study with 8 participants.
Developing OrganizationsIntel Corporation
Intel Corporation is headquartered in Santa Clara, CA.
Problem AddressedEmotional reactions to stressful events can affect both physical and mental health. Cognitive behavioral therapy helps individuals to develop emotional awareness and self-regulate their reactions to stressful situations, but may not be available or easily accessible when needed.1
- Physical and mental health implications of stress: Stress has been linked to health problems such as heart disease, blood pressure, and depression. Signs of stress include a myriad of physical and mental manifestations, including sleep disturbance, noncardiac chest pains, digestive difficulties, hyperventilation, dizziness, fatigue, confusion, difficulty concentrating, and negative social relationships.2
- Potential of cognitive behavioral therapy to help: Cognitive behavioral therapy is a systematic, evidence-based psychotherapeutic approach that helps individuals manage dysfunctional emotions. Individuals in this type of therapy monitor and log their thoughts to identify negative thinking patterns and develop more productive alternatives.3
- Limited access to cognitive behavioral therapy: Individuals in cognitive behavioral therapy visit a therapist periodically (usually weekly), and thus have no immediate support between sessions when negative thoughts arise. Other individuals who may benefit may not receive cognitive behavioral therapy at all, due to lack of adequate mental health insurance coverage, inconvenience, or reluctance to seek mental health care.
- Unrealized potential of mobile applications: Mobile applications have the potential to increase access to behavioral therapy, to offer support between therapy sessions, and to help patients in electronically logging their emotional experiences (rather than using a cumbersome paper-based log1), but few patients have access to such applications.
Description of the Innovative ActivityAs an adjunct to weekly face-to-face sessions, individuals in cognitive behavioral therapy receive as-needed, real-time support by accessing mobile phone applications that mirror cognitive behavioral therapy techniques. These applications prompt individuals to assess their mood and select from a variety of self-directed therapeutic interventions that encourage cognitive reappraisal and physical relaxation, such as modulated breathing, relaxation of specific body areas, and reassessment of negative thoughts. Key elements of the program include the following:
- Access to mobile therapies as needed between sessions: As an adjunct to standard weekly sessions, clients use mobile phones loaded with specialized applications (called mobile therapies) related to mood assessment and cognitive behavioral techniques, along with a manual that describes the applications and their use. Between sessions, the mobile phone periodically prompts an individual to assess his or her mood; the client can then access various self-directed cognitive behavioral therapies as needed. Additional details on the mobile applications are provided below:
- Periodic self-assessment of mood: The mobile phone prompts clients to assess mood on a periodic basis (approximately every 30 minutes or as scheduled according to the user). The mood reporting scales include the Mood Map and four single-dimension mood scales:
- Recognition of overall mood: The Mood Map consists of a touch-screen translation of a model of emotion depicted by a four-quadrant graphic formed by a horizontal “negative–positive” axis and a vertical “high–low energy” axis; each axis has scores that range from –7 to +7. The client describes his or her mood by placing a fingertip on the graphic, causing a red dot to appear on the graphic in the position describing the client's mood. This approach allows the client to easily summarize his or her emotional state at a given point in time.
- Assessment of specific emotions: Clients can also indicate their mood using single-dimension scales for happiness, sadness, anxiety, and anger. Each is depicted as an 11-point vertical scale labeled with the mood (i.e., happy, sad, anxious, angry); the client places his or her fingertip on the scale, which ranges from “not at all” at the bottom to “extremely” at the top.
- Self-directed cognitive behavioral therapy: Once clients recognize their moods, they can access mobile therapies as needed throughout the day by touching icons on the phone. The three principal therapies include the following:
- Reappraisal of negative thoughts: The Mind Scan consists of a series of cognitive reappraisal questions that address distortions in thinking associated with depression, anxiety, or anger. Sample questions include, “Might I be globalizing?”, “Might I be making rules out of my pet peeves?”, and “Might I be exaggerating the urgency of this situation?” Other prompts addressed constructive confrontation and goal-oriented problem-solving.
- Breathing modulation: The breathing exercise consists of a blue circle that slowly expands and contracts. The user inhales and exhales in concert with the circle’s contractions, thereby deliberately slowing his or her breathing.
- Relaxation of body areas: The Body Scan prompts the viewer to achieve physical relaxation by successively highlighting different parts of an outline of a human figure. As each part of the figure is highlighted, the user reads a question about whether tension exists in that part of the body. For example, the animation highlights the forehead and then prints the question, “Are you furrowing your brow?” As the user clicks through the questions, each section of the body outline changes from red to blue.
- Proactive therapeutic intervention: Each morning, as the phone queries about sleep and mood, it also asks users if they expect to face a stressful event that day (such as a business meeting or a family event). If the user inputs a time for such an event, the phone prompts an appropriate cognitive behavioral therapy application before the event.
- Incorporation of mobile applications into weekly sessions: In addition to engaging in standard therapy during weekly face-to-face sessions (which focus on identifying negative emotions and triggers for these emotions, physical or behavioral consequences, and positive thinking alternatives), the cognitive behavioral therapist spends a portion of each session asking clients about the mobile therapies, including which applications have been used, under what circumstances, and how helpful they have been. The therapist can also review data on mood patterns (stored in the phone) with the client, and offer suggestions for how mobile therapies can be used going forward to address the client’s needs.
References/Related ArticlesMorris ME, Kathawala Q, Leen TK, et al. Mobile therapy: case study evaluations of a cell phone application for emotional self-awareness. J Med Internet Res. 2010;12(2):e10. [PubMed] Available at: http://www.jmir.org/2010/2/e10/
Contact the InnovatorMargaret E. Morris, PhD
Digital Health Group
333 NW 9th Ave #811
Portland OR 97209
Phone: (971) 285-6815
E-mail: email@example.com; firstname.lastname@example.org
Innovator DisclosuresDr. Morris has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile.
ResultsThe mobile therapies were tested in a small pilot study of employees at a large technology company who had indicated during a routine annual health risk assessment that they wanted to address stress as an issue in their lives. Users of the mobile therapies reported greater self-awareness and mood awareness, along with improvements in coping skills and mood patterns and reductions in negative emotions such as anger, sadness, and anxiety; users ascribed these changes to use of such therapies.1 The study used an ethnographic case study approach. Excerpts from several of these case studies can be found below. All names used in these cases have been changed to protect confidentiality.
Suggestive: The evidence consists of interview and experience sampling data from a 1-month field study with 8 participants.
- Tobias reported significant feelings of stress and irritation due to conflicts with his wife over household responsibilities and childcare. After work, Tobias would return home and immediately assume responsibility for his children, including preparing dinner, while his wife departed the house for a break. Throughout the evening, his irritation generally grew. Tobias used the mobile therapies to predict and cope with the negative emotions associated with arriving home from work. For example, after reading the following question from the Mind Scan, “Might I be stabilizing?” he told himself to “just get through the first 15 to 30 minutes and then I’ll be fine.” He also developed other coping skills, and worked with his wife to develop a more satisfactory plan for sharing responsibilities. Tracking data revealed that Tobias’s average (mean) anger, anxiety, and sadness ratings fell from the first to the second half of the study, with his anger rating falling from 0.49 to 0, his anxiety rating falling from 0.37 to 0.04, and his sadness rating falling from 0.61 to 0. Over the same time period, his energy rating increased from 3.28 to 6.58.
- Forest, who recently immigrated to the United States, often became angry and frustrated with his struggle to establish professional and financial stability. For example, he reported extreme frustration during two different interactions: one with an insurance company representative when trying to identify an in-network physician for his wife, and another with a U.S. consulate official when trying to obtain a U.S. passport for his daughter. Before followup interactions with these representatives, Forest accessed the mobile therapies and engaged in positive self-talk about goal orientation and constructive confrontation. Forest’s anger rating fell during the second interactions, and he reported feeling positive about the way he handled himself.
- Octavia faced ongoing struggles with anxiety, unhappiness, and mental focus (particularly in the mornings), manifesting in her inability to be productive at work. Octavia accessed the mobile therapy that offered prompts about prioritizing and, after 4 weeks, reported that she had improved her focus and productivity, attributing these improvements to the mobile therapy. These positive benefits also yielded improvements in mood, with her mean anxiety rating falling from 2.88 to 2.16 and her mean unhappiness rating falling from 4.39 to 3.41.
Context of the InnovationIntel Corporation is a large technology company headquartered in the Silicon Valley, CA. Aware of the psychosocial factors that can increase the risk and impact of chronic diseases, Margaret Morris, a clinical psychologist in Intel’s Digital Health Group, began investigating the potential to use personal technologies such as smart cell phones to broaden the reach of cognitive behavioral therapy as a way to mitigate these psychosocial risk factors. This approach was tested in a small pilot test with employees of a large technology company who had indicated during a routine annual health risk assessment that they wanted to address stress as an issue in their lives.
Planning and Development ProcessKey elements of the planning and development process included the following:
- Iterative design of mobile therapies: Dr. Morris selected cognitive behavioral therapy interventions and tools that could be adapted to mobile phone software. She then worked with designers to translate these techniques into brief mobile interactions, to map those into storyboards, and to create process flows to guide the sequence of mobile therapies that would follow specific user responses. This iterative design process included ethnographic interviews with individuals prone to stress and conflict, expert interviews with clinicians and researchers, and collaboration with designers and software engineers.
- Product testing: Intel informally "pretested" the applications over a 12-month period with roughly 50 individuals (including Intel employees, college students, experts, and community volunteers) to determine how well the system worked and to gauge user reactions to the applications.
- Pilot study: The clinical psychologist conducted a pilot study with a small group of individuals who indicated in an employee health risk assessment that they wanted to address stress as an issue in their lives. Health coaches who work with employees gave interested individuals flyers about the program and invited those interested in participating to call the clinical psychologist.
Resources Used and Skills Needed
- Staffing: The program required no new staff.
- Costs: Data on program costs are unavailable.
Funding SourcesIntel Corporation
Tools and Other ResourcesA free app for smartphones called "My Mood Map" is available in Apple and Android App Stores. This is an application based on mood experience sampling and visualization of mood trends as described in the profile and can easily be used by individuals, clinicians, or researchers to understand emotional patterns.
Getting Started with This Innovation
- Build on existing programs: Health-related applications for personal technologies (such as mobile phones) already exist, including personalized, real-time coaching related to diet, exercise, mental health, and other areas. Reviewing and adopting/adapting these applications can expedite the development of this type of program.
- Start simple: Many different opportunities and techniques exist for implementing mobile applications to encourage behavior change. Program developers should start small, with one technique or focus, and then expand to others.
- Have users test the device in real life: This type of testing as part of the development process provides valuable feedback about product design that cannot be obtained through laboratory testing.
Sustaining This Innovation
- Integrate strategies that people use in daily life with strategies recommended by clinicians: This helps ensure both the acceptability of the tool to patients and its effectiveness as a therapeutic device. For example, the use of images to operationalize cognitive behavioral prompts.
- Be cognizant of how people interact with personal technologies: Ensure that application design mirrors how individuals use technology and other tools, otherwise patients will not use it.
- Use the mood data trends as prompts during weekly feedback sessions: Viewing mood patterns as a function of time, social context, and other variables helps patients develop insights about their emotional patterns and develop coping strategies based on these insights. This trend analysis reinforces self-monitoring and can motivate behavior change.
Additional Considerations and LessonsThe applications used in this pilot are experimental and not available for general use; however, the concepts underlying these applications can be applied using other software applications. Dr. Morris and other researchers at Intel may pursue several directions with this program going forward; potential options include integrating the technology more closely into clinical practice, and/or developing a stand-alone application that can be used by individuals not working with a clinician.
Service Delivery Innovation Profile
Original publication: November 24, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: December 19, 2012.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: September 27, 2012.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.