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Smartphones, Trauma and the Mental Health Revolution

A new smartphone application for trauma counseling may be the future of therapy

Can a mobile phone application help veterans deal with trauma?  A new phone application, PE Coach, is already being used by thousands of veterans attending treatment and rebuilding their lives.

Developed by the Department of Defense’s (DOD) National Center for Telehealth and Technology, Center for Deployment and the Veterans’ Adminstration’s  (VA) National Center for PTSD,   PE Coach is a key component in the treatment program used with traumatized veterans.   Available for free download from iTunes and Google Play, PE Coach supplements the formal treatment manual followed by treatment professionals working at VA and DOD clinics across the United States.

Though treating posttraumatic stress disorder in returning veterans has posed major challenges for mental health professionals, the surge in new cases threatens to overwhelm available health services.  With an estimated 19 percent of the 1.6 million members of the U.S. Armed Services deployed to Iraq and Afghanistan in the past five years reporting mental health symptoms, finding better treatment options has become more crucial than ever.   

As an alternative to medication-only approaches to treatment (which are often the only treatment many veterans receive),  the Department of Veterans Affairs and the National Center for PTSD have sponsored research investigating better treatment options for veterans dealing with trauma symptoms.   Among the most promising approaches is the prolonged exposure therapy (PE) model first developed by Edna B. Foa.   Based on the behaviour therapy principles developed by Joseph Wolpe,  PE was specifically developed to  treat PTSD by having patients re-experience traumatic events to help them learn to handle the anxiety associated with those events.   Using methods such as imaginal and in-vivo exposure (where patients experience realistic simulations of the traumatic setting or event), patients can learn to defuse their learned anxiety and control their panic symptoms.   Research has demonstrated the effectiveness of PE in treating veterans with PTSD as well as survivors of physical and sexual abuse.

But the key to successful treatment is convincing patients to attend the treatment sessions and doing the homework assignments.  Yes, PE has homework to help patients practice what they learned at home.   Using homework can improve the outcome of the treatment program but encouraging patients to follow through is not easy.   Many therapists can use reminder phone calls and recruit the help of family members to encourage patients to follow through with attending treatment and doing homework assignments.   Still, as much as thirty percent of trauma patients drop out (and this can be even higher for veterans).  

Part of the problem is the homework itself.   Assignments can take as much as two hours a day and often require patients completing paper logs describing daily activities or listening to in-vivo descriptions of stressful events recorded on compact discs.    Hi-tech solutions are becoming more common during PE therapy though.  This can include telehealth-based cognitive assessments, recording sessions with digital cameras, and even virtual reality simulations of stressful situations.

Since most patients own smartphones, PE Coach was specially developed for use during treatment sessions and between sessions to help with homework.   Structured for use with the PE manual, the different tools available for PE Coach only become functional after the treatment session in which they are covered.  After the first session, for example, the First Session screen lists different options and then the Second Session screen becomes active after the second session, and so on.  

Though not meant to take the place of formal treatment, PE Coach helps patients keep track of what has been covered and even allows for audio recording during sessions and while doing homework.    With imaginal exposure in which patients listen to descriptions of stressful situations that might trigger flashhbacks, their responses are automatically recorded for the homework assigned for each session.    PE Coach also helps measure treatment progress by administering the PTSD Checklist during odd-numbered sessions with total scores and item responses being saved for later review.   All of this information is available for therapists and their patients to discuss the progress made during treatment. 

Among the other features available on PE Coach are:

  • appointment scheduling using the phone’s calendar and alarm functions to prevent no-shows
  • providing itemized information on each treatment session and homework session to keep track of progress
  • Patient recording and playback of sessions for use as needed and for homework
  • Portable reference guide to review material covered in the treatment sessions

Though the information covered during sessions is also available in the PE Workbook, PE Coach also provides this information on the go, especially descriptions of common reactions to traumatic stress.   PE Coach also allows patients to create an in-vivo hierarchy of situational triggers ranging from most to least anxiety-provoking and to keep it for a handy reference as well as contact information for the therapist in case of emergencies.

So how useful is PE Coach?  To date, there have been more than 5,000 downloads although research is still ongoing to see its effectiveness in encouraging trauma patients to stay in treatment.   The National Center for PTSD also offers a PE Coach Clinician’s Guide to help new clinicians learn more about how to use it to treat patients.   According to a recent review in  Psychological Services,  PE Coach is just one example of how new technology is changing the traditional therapist-patient relationship and allowing therapists to expand the kind of services they can provide.    

Considering the thousands of traumatized veterans needing help and the difficulty that the VA and the DOD is having meeting this demand,  tools such as PE Coach have become increasingly important in providing treatment.  Still, it’s also important to point out that applications such as PE Coach are NOT intended for self-help and should only be used while receiving treatment from a trained professional.    While anyone can download Android and iPhone versions of PE Coach for free, people dealing with trauma need far more than what a phone application can offer.  

With that caveat in mind, phone apps such as PE Coach represent an important step in making treatment more available.    While prolonged exposure is just one of many different evidence-based treatments that have been developed,  PE Coach can be a useful model for developing new phone apps that can help with other forms of treatment as well.  

As smartphones become more sophisticated, we will be seeing a rise in mobile computing tools to make psychological assessment and treatment more accessible by people needing help.   How these new tools will improve their lives is a challenge that researchers and mental health professionals will have to meet.

Romeo Vitelli, Ph.D. is a psychologist in private practice in Toronto, Canada.

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