Introduction
With technology informing and influencing each and every part of our lives, it was only a matter of
time before there was an app for everything, from your favourite books to carrying a counsellor in
your pocket, no arena is free from potential impact. So why should I care? My work as a counsellor
relies upon person to person connection and will remain so despite the proliferation of mobile phone
apps claiming to do my job for me? This paper provided me with the opportunity to explore the world
of mHealth, specifically the PTSD Coach Australia product, and fully appreciate just how much of an
impact there could be from such tools on my work in the future. What follows is a reflective
commentary of my exposure to mobile phone apps in the mental health and wellbeing space,
exploring and evaluating the validity of what was encountered, and questioning the ethical
implications for including or ignoring their presence.
First response
Not Appy Jan – not familiar with apps – new to smartphone use – unconscious bias that time on small
screen other than communicating is playing games – not really helpful – just a distraction – you cannot
replace a therapist with technology – thin end of the wedge – what a waste of time – where is the
rigour in this task – surely there is a better topic for research for emerging counsellors – what do you
mean we have to work in pairs – like that is going to work – What you don’t know and understand is
daunting – I will have to enter a zone outside of my comfort – Perhaps this is exactly what my clients
feel when I begin to work with them and ask them to trust me – Deep breath – nothing to lose – here
we go…
Exploring the App
Including PTSD Coach Australia, I have downloaded 4 apps on my smartphone, the other 3 are
entertainment and news apps. Clearly this particular app has some relevance to working with
veterans with PTSD, but what support is there for me as the counsellor to assist me in using this tool
effectively? Is there any evidence to suggest that this tool has been developed with evidence based
practice informing the methodology and user features? Time to do some background work – just as I
would if using a different treatment approach with any other client and presentation. I went to the
DVA website and explored PTSD support information therein. I was surprised at the amount of
information and support for families and therapists found on the website, including a clinician’s guide
to inform use of the app with clients. Beginning to feel a lot more comfortable and reassured that this
tool has been developed by experts in PTSD, and has the backing of both US and Australian
Government agencies charged with Duty of Care for defence personnel. Bravely, and with only slight
hesitation, PTSD Coach Australia joins the elite status of app on my phone, no 12-gun salute was
evident.
Surprised at how easy it was to navigate, and the thoughtful inclusion of features such as images and
sounds identified by the client as having the capacity to calm them, I particularly liked the features
which allow the client to feel that they are managing their schedule and actively participating in the
collection and analysis of data about themselves and their experience with PTSD. As identified by
Morland, Greene, Rosen, Kuhn, Hoffman, & Sloan (2017), use of technology has the potential to
overcome several significant barriers to accessing mental health support for PTSD sufferers, in this
way some support is preferred to no support at all. One of the barriers identified by the authors is
stigma, self or other, which may prevent help seeking by individuals and it is in this space that the
mHealth technology has potential reach. Just as Headspace and Beyond Blue websites in Australia
have enabled self-help seeking behaviour for those isolated, geographically and socially, the use of
portable, accessible mental health support may be the first step towards identification of a need to
seek treatment. Rather than instead of therapy, PTSD is a tool for use with therapy, and to enhance
therapy. I discovered that the strongest evidence for using smartphones to treat anxiety disorders
currently appears to be in the context of integrating these devices to enhance and support the delivery
of existing face-to-face or internet-based therapy programs. (Firth, Torous, Nicholas, Carneya,
Rosenbaum & Sarris, 2017).
Unexpected support for use of this app was beginning to register. What right do I have as a therapist,
charged with a duty of care to help my clients, to withhold information or access to a tool which may
assist my client? It is not all about me you know? The least I can do is find those tools which have
evidence of efficacy and explore them with my clients in a solution seeking and open manner.
So what do the experts have to say about PTSD Coach Australia?
One of the most widely downloaded trauma-related mobile apps, PTSD Coach, provides both
psychoeducation about PTSD and suggestions or coaching in evidence-based strategies that can be
used in the moment to address various symptoms (i.e., worried/anxious, unable to sleep) as they occur.
As of November 1, 2016, the freely available PTSD Coach has been downloaded nearly 275 000 times
across 96 countries. Preliminary research suggests that users highly value the portability and
accessibility of mobile tools like PTSD Coach. Two preliminary studies found that about four out of ten
people who used PTSD Coach independently (without clinician support) showed clinically significant
improvements in PTSD symptoms, but these studies were not adequately powered to test these
effects relative to waitlist controls or PTSD Coach plus clinician support. (Morland, Greene, Rosen,
Kuhn, Hoffman, & Sloan 2017)
According to Sloan et al., 2011, the PTSD Coach mobile application was developed to reach those
service members and veterans who may be reluctant to engage in therapy. User metadata on PTSD
Coach from more than 150,000 downloads indicates that users generally endorse clinical levels of
symptomatology, utilize the application an average of six times, and show significant reductions in
PTSD symptoms over the course of use. (Armstrong, Hoyt, Kinn, Ciulla, & Bush, 2017)
A study of patient perceptions of PTSD Coach showed good rates of perceived helpfulness and
acceptability, with overall results suggesting that this mobile application is appropriate for selfmanagement of PTSD symptoms (Kuhn, Greene, et al., 2014). Indeed, preliminary analyses indicate
that PTSD Coach can be used as an effective intervention for reducing PTSD symptoms in primary care
settings even if the patient receives only a ten-minute introduction to the mobile application
(Possemato et al., 2016).
Another set of case studies evaluated the inclusion of PTSD Coach as one component in a three-hour,
single-session intervention for emotion regulation, showing promising results for patients
remembering to engage in the skills taught by the program (Miles, Thompson, Stanley, & Kent, 2016).
In the evaluation of the evidence base, PTSD Coach was built on a foundation of empirically supported
techniques for education and treatment engagement (Possemato et al.,2016). However, the current
level of the evidence base comparing the use of this mobile application with the provision of the same
information using traditional methods is currently at the level of non-experimental or correlational
studies (level IV). (Armstrong et al, 2017)
In the 2018 study conducted by the Centre for Research in Evidence-Based Practice (CREBP) at Bond
University, the Simblett 2017 systematic review, assessed e-therapies aimed at treating posttraumatic
stress disorder (PTSD) It included 39 RCTs. Only one of the RCTs tested PTSD Coach against waitlist
control for 1 month; however, there were no significant between group differences in the PTSD
Checklist–Civilian questionnaire result. (Byambasuren, Sanders, Beller & and Glasziou 2018). In
an effort to discover more about this study and the implications for my own work, I contacted
the lead researcher and we discussed the findings related to PTSD Coach and the broader
implications of mHealth. Byambasuren indicated that; the overall low quality of the evidence
of effectiveness, greatly limits the prescribability of health apps. Further that mHealth apps
need to be evaluated by more robust RCTs that report between-group differences before
becoming Prescribable. The implications of this information for emerging counsellors is clear.
We can become active participants in the development and evaluation of mHealth and other
innovations in practice, or we can allow developers of this technology to dictate the choice
of tools we have to use with our clients. Beyond PTSD Coach Australia, there is much to be
explored in terms of the revolution occurring on our mobile telephones. Yes, mine is now
part of this mHealth exposure and exploration – Downloaded about 5 apps after seeing
Michael Carr-Gregg – see reference in broader literature section ahead, and following the
endorsement of one Gill Hannah, Mood Tracker is also in my stable – Have I been seduced?
Review of the broader literature – mHealth in research
So how big a deal is this? According to Kao & Liebovitz, Mobile devices, especially smartphones,
have revolutionized people’s lives, including the way they seek medical information. “According to a
global survey in 2015, 72% of all U.S. adults owned a smartphone, up from 63% in 2012, and 62% had
used their smartphones to look up information for a health condition, up from 53% in 2012. The
penetration rate of smartphone continues to increase. It is estimated by 2020, there will be 6.1 billion
smartphone users globally, comprising approximately 80% of the world’s population.” (2017: S106)
Using the data from this global survey in 2015, the authors report that there are currently more than
165,000 mHealth apps (including free and paid) publicly available in major app stores, and some
academic medical centres also are developing apps on their own. The mHealth market now embraces
about 45,000 app developers, and more than 3 billion mHealth apps were downloaded in 2015. By
2017, it is projected that 50% of the mobile phone users will have downloaded at least one mHealth
app. (Kao & Leibovitz 2017). I just joined this group, as did my classmates, and surely
from now on all pre-service mental health practitioners will also need an awareness
of this technology and its potential uses.
Common to much of the literature explored was the potential benefit verses risk commentary,
particularly addressing issues of informed consent, security and privacy and how these might be
effectively managed, Kramer, Kinn, & Mishkind (2015). The mHealth apps have the potential to
provide low- cost, around-the-clock access to high-quality, evidence- based health information to end
users on a global scale, overcoming barriers as previously mentioned, and improving compliance with
treatment protocols via Behavior change models. However, the accuracy of the health information
contained in most of these apps is not scrutinized by regulatory bodies, which could compromise
users’ health and safety. (Kao & Leibovitz 2017 )
Ahh-ha! So in order to use these tools as a compliment to therapeutic practice, the ethical counsellor must have done
some due diligence in terms of what they will and will not use and recommend. Makes sense. This sentiment was echoed
during a seminar attended at which Dr Michael Carr- Gregg was speaking about treating anxiety in children. I was
gobsmacked to discover that there are a multitude of mHealth apps to help youth with their breathing. Dr Carr- Gregg
shared that he had been approached to endorse certain apps and had engaged with a process not dissimilar to this, in
which we are participating. Only when convinced that an app had been developed with evidence based technical
consultation and RCT efficacy demonstrated, would he promote and endorse a product. (Resilient Kids Seminar
26/05/2018) He recommended; Smiling Mind, The Reach Out products of Breathe and Worry time and Mood Gym, each
was demonstrated and discussed – and you guessed it, downloaded, I think we are reaching addiction status.
So if we have to be in the arena, at least we can choose our weapons. My perception of the responsibility held by
counsellors and other mental health professionals is beginning to resonate with an understanding of our potential for
influence and endorsement of tools. According to Firth et al 2017, given the accessibility and availability of
mental health apps, ensuring that consumers have access to evidence-based interventions is vital,
and may necessitate methodological changes in mHealth research. Some authors even proposed the
notion of prescription mHealth apps to ensure tailoring and effectiveness of treatment as part of an
integration of Mobile Health Information into the Health Care System, with data stored in a
cloud for informed treatment access. (Kao & Leibovitz, 2017; Byambasuren et al, 2018)
At the beginning of this review of literature, 2015 data was used to demonstrate how widespread
mHealth exposure had become. In a 2018 publication, Bond University Centre for Research in
Evidence Based Practice revealed the following; The number of smartphones worldwide is predicted
to reach 5.8 billion by 2020 and there are 6 million multimedia applications (apps) available for
download in the app stores. According to the latest report from IQVIA Institute for Human Data
Sciences (formerly IMS Institute for Healthcare Informatics) 318,000 of these are mHealth apps. As
one of the prominent digital behaviour change interventions of our time, mHealth apps promise to
improve health outcomes in a myriad of ways including helping patients actively measure, monitor,
and manage their health conditions. (Byambasuren et al 2018)
In 3 short years, the number of mHealth apps have doubled. If any further evidence were required to
examine this phenomena, here it is. Most authors in this space agree that future apps need to tailor
their content and user-interaction to the needs of the user, their situation and environment
in order to be successful. Clear guidelines on privacy and user safety need to be established
in order to overcome trust issues developers are facing due to the large number of apps
available. (Helf & Hlavacs, 2016) How on earth will practitioners maintain currency with what
is available, suitable and without identifiable risk? No wonder the notion of identifying a few
trusted apps and issuing prescriptions for their use is gaining momentum. (Byambasuren et
al 2018)
What lays ahead?
The acceptance that blended delivery of therapy is possible – as a teacher this certainly has
happening in the distance learning space, affording greater flexibility, and apparently this
need not impair quality of experience – this prospect is explored by Fairburn and Patel
(2016). They paint a picture of the future in which, over the next decade or two, much is
likely to change. Digital interventions will gradually find their place within mental healthcare
systems, and online clinics will become more commonplace. Digital assessment and
treatment are likely to merge. Blended treatment may displace some conventional face- toface treatment, and the limitations and negative effects of these innovations are likely to
become evident.
Surely we still need some face to face connection for therapy to be
effective? The integration and optimization human support are examined in a 2016 paper
published in the American Journal of Preventive Medicine. Whilst acknowledging the value
which human support can add, the authors question if the potential reach of systems which
offer intervention without human contact is worthy of exploration. ( Yardley, Spring, Riper,
Morrison, Crane, Curtis, Merchant, Naughton & Blandford 2016) They do, fortunately,
acknowledge that this will only apply in certain presentations and treatments, but this was
exactly where I feared that this thin edge of the wedge might take me.
A comprehensive analysis of the use of technology based self-help in the treatment of
anxiety and mood disorders is undertaken by Newman, Szkodny, Llera & Przeworski (2010),
in which they ask the question; Is human contact necessary for therapeutic efficacy? I think I
just heard Norcross and Wampold have simultaneous heart attacks, just audible above my own
gasping and sobbing. The authors claim that, overall, efficacy of computerized interventions has
been demonstrated in the treatment of anxiety and depression. In particular, studies of mixed
anxiety disorders, panic disorder, and social phobia are promising. However, they acknowledge,
almost begrudgingly I feel, that there continues to be a pattern of lower compliance when
technologies are used at home in conjunction with little or no human contact. (Newman et al,
2010) HA! One for the therapists.
I am reliably informed that John Torous is regarded as a leading researcher in this field. He writes
in his 2015 paper that mobile mental health is an evolving and dynamic area of research.
Interestingly he explains that through understanding the basic principles of smartphone data
collection and the diagnostic versus interventional aims of apps, it is possible to contextualize this
research and discern trends. He encourages the active engagement of practice based research so
that as interest in smartphones for psychiatry and mental health continues to expand, the
research base expands to fill evidence gaps and provide clinically useful results. (Torous and
Powell, 2015) With this in mind, the understanding of how I might conduct simple but
meaningful evaluations began to evolve. In reading the MoodPrism study by Bakker and
Rickard (2018), it became possible to see how engagement and self-monitoring techniques
might be used to determine app impact on mental health. There is much scope for active
participation in this research space, as evidenced by my discovery of The IntelliCare Team.
According to their website, listed in references, the IntelliCare Team showcases the work of a team
of academic researchers, psychologists, and software developers dedicated to developing eHealth
behavioural interventions that can help people make positive behaviour changes that can improve
their health and well-being. We collaborate with teams all over the world to study ways technology
can benefit those living with depression and anxiety. The aforementioned John Torous is a key
contributor, as is Dr. David Mohr of the Centre for Behavioral Intervention Technologies at
North western University. I had found a virtual Aladdin’s Cave of research, discussion and even more
apps to download – novelty wearing off a bit now. Of particular interest was a newsfeed of published
and online articles related to mHealth, though I noticed that since 2015 little has been added. It does
give some inspiration however, to how one might set up a modest version of the same for a network
of counsellors interested in the topic and willing to participate in practice-based research. Food for
thought.
Where am I now? What have I learned? – Implications for Practice
I remain unconvinced that any technology can completely replace a therapist. However, any therapist
who chooses to disregard the ever growing presence of technology in all aspects of our lives, risks
rendering themselves redundant. Our clients have every right to negotiate and explore all options
available to them as they seek assistance to achieve connection, balance and meaning in their lives.
By demonstrating our willingness to be open to new technology and the role that it might play in
meeting client needs, we are acknowledging a potential opportunity, not surrendering to a perceived
threat. Our clients will be the beneficiaries and they can determine for themselves which tools form
part of their work on self. Our capacity as skilled helpers, to embrace these emerging technologies
and critically review their capacity to be utilised effectively, is more likely to ensure that we remain a
key component of that work with our clients.
Without this opportunity to delve into the mHealth world, I would have remained on the sidelines
watching the game play out with me only a spectator. As a result of this task, I have sought
opportunities to explore and evaluate, with an informed knowledge base, the potential for mHealth
technology to enhance my work and provide clients with opportunities for engagement and selfdetermination. My antennae have been attuned to learning opportunities dealing with PTSD,
Veterans, mHealth, technology assisted therapy and how to install apps on your phone. I have come
a long way from my not Appy Jan tantrum. This bodes well for how I might respond to other
technology developments in our field as they arise. Change is change, it is as much part of life as any
other truth about our existence. This exercise has served as a timely reminder to remain open to
possibilities and that the unknown need not be a source of fear, rather of wonder.
What would I do differently?
I have thought long and hard about this question. I don’t know that my end point would have been
as meaningful for me had I taken a different route to get there. I value the learning experience which
was provided by this exploration and I can certainly understand the thinking behind the task design.
Encouraging students to share and interact over the project was well intended but I saw little of this
happening, even on the Facebook page established for this very purpose. The nature of students as
competitors rather than collaborators is a challenge I have sought to overcome in my own teaching,
with little success also. I would have liked the notion of multiple apps being reviewed by the cohort
and then these being used to compile a database that would be useful in supporting practice. I can
only dream. Or perhaps, as I proposed after the Intellicare inspiration, a digital resource that we can
contribute to and continue to draw from as a practice tool beyond graduation. Setting us up as a
community of practice, research and peer based learning.
Conclusion
What began with a simple allocation of a mobile phone application for exploration and analysis has
evolved into so much more for this learner. From a position of relative naivety in relation to apps in
general, the appreciation of the emerging influence of mHealth, which is here and now, has been
gained. With the plethora of offerings and slick graphics inviting consumers to heal themselves with
the download of an app, the therapist has an additional sphere of knowledge over which some
guidance may be sought. We do have choices about how we engage with this phenomenon. We can
remain counselling purists with a denial of the potential value which the mHealth revolution may offer
to our clients and to our treatment. Or we can be open to the inclusion of tools which we have found
to enhance the face to face work we do with our clients. As previously indicated, this is a choice
between being actively engaged in the use, development and evaluation of such tools, or the blinkered
denial of their relevance. I intend to be in the game.
Word Count 4335 Including references
References
Armstrong, C.M., Hoyt, T., Kinn, J.T., Ciulla, R.P., & Bush, N.E. (2017) Mobile Behavioral Health
Applications for the Military Community: Evaluating the Emerging Evidence Base. Best
Practices in Mental Health, Vol. 13, No. 1, Spring 2017 pp105-118, The Follmer Group.
Bakker, D. & Rickard, N. (2018) Engagement in mobile phone app for self-monitoring of emotional
wellbeing predicts changes in mental health: MoodPrism. Journal of Affective Disorders, 227,
432-442. doi:10.1016/j.jad.2017.11.016
Byambasuren, O., Sanders, S., Beller, E. & and Glasziou, P. (2018) Prescribable mHealth apps
identified from an overview of systematic reviews. npj Digital Medicine, 1:12;
doi:10.1038/s41746-018-0021-9
Carr-Gregg, M. (2018) Tackling Anxiety & Mental Health Issues in Young People, Resilient Kids
Conference – Gold Coast 2018 – www.resilientkidsconference.com.au
Department of Veterans Affairs http://at-ease.dva.gov.au/veterans/resources/mobile-apps/ptsdcoach/
Fairburn, C.G. & Patel, V.
(2017) The impact of digital technology on psychological
treatments and their dissemination. Behaviour Research and Therapy, 88,
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doi.org/10.1016/j.brat.2016.08.012
Firth, J., Torous, J., Nicholas, J., Carneya, R., Rosenbaum, S. & Sarris, J. (2017) Can smartphone mental
health interventions reduce symptoms of anxiety? A meta-analysis of randomized controlled
trials. Journal of Affective Disorders, Volume 218, 15 – 22, DOI: 10.1016/j.jad.2017.04.046
Helf, C. & Hlavacs, H. (2016) Apps for life change: Critical review and solution directions.
Entertainment Computing, 14, 17–22, doi:10.1016/j.entcom.2015.07.001
Intellicare https://intellicare.cbits.northwestern.edu/
Kao, C-K MD, & Liebovitz, D.M. MD (2017) Consumer Mobile Health Apps: Current State, Barriers,
and Future Directions. PM&R American Academy of Physical Medicine and Rehabilitation
(AAPM&R). 9, S106-S115, doi:10.1016/j.pmrj.2017.02.018
Kramer, G.M., Kinn, J.T. & Mishkind, M.C. (2015) Legal, Regulatory, and Risk Management Issues
in the Use of Technology to Deliver Mental Health Care. Cognitive and Behavioral
Practice, 22, 258-268, Elsevier Ltd
Kuhn, E., Greene, C., Hoffman, J., Nguyen, T., Wald, L., Schmidt, J., Ramsey, K.M., & Ruzek, J. (2014)
Preliminary Evaluation of PTSD Coach, a Smartphone App for Post-Traumatic Stress Symptoms
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Morland, L.A., Greene, C.J., Rosen, C.G., Kuhn, E., Hoffman, J. & Sloan, D.M. (2017) Telehealth and
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108, This review comes from a themed issue on Traumatic stress, edited by Anka A. Vujanovic
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Newman, M.G., Szkodny, L.E., Llera, S.J. & Przeworski, A. (2011) A review of technologyassisted self-help and minimal contact therapies for anxiety and depression: Is human
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Assessment 2: Reflective Essay
Fail
Pass
Credit
Distinction
High
Distinction
Demonstrates an understanding of researching and
evaluating key concepts and theories relating to the
topic covered.
Reflections which are supported by the research
literature and include an understanding of the
impact of personal and cultural characteristics on the
quality of technology reviews.
Reflections which are supported by the research
literature and include an understanding of ethical
issues raised by using technology with clients.
Presentation of a scholarly piece of reflective writing
that conveys an understanding of evaluation and
critical analysis.
Demonstrates insights through synthesis, evaluation
and critical examination of the literature.
Textual accuracy including spelling and grammar as
well as appropriate use of formal academic writing
style.
Presentation – correct APA style of citation and
references.
COMMENTS:
referencing.
GRADE: