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Development and Evaluation of a Virtual Hope Box for Reducing Suicidal IdeationPI: Nigel Bush, PhDT2: Julie Kinn PhD, Matt Higgins, Wes Turney-LoosVA National Ctr. for PTSD :Julia Hoffman PhDVAMC Portland: Steven Dobscha MD, Lauren Denneson PhD
"The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or reflecting the views of the Department of Defense.“This work was in part supported by the Military Suicide Research Consortium (MSRC), Department of Defense, and VISN 19 Mental Illness Research, Education, and Clinical Center (MIRECC), but does not necessarily represent the views of the Department of Defense, Department of Veterans Affairs, or the United States Government. Support from the MSRC does not necessarily constitute or imply endorsement, sponsorship, or favoring of the study design, analysis, or recommendations.”
Since 2001, >1.5 million US military service members deployed in support of Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF).Traumatic Brain InjuryMental/Behavioral Health ProblemsPTSDDepressionAnxietyStressFamily/Social DysfunctionSuicide2010 DoD Suicide Event Report281 suicide completions confirmed863 attempts by 837 individuals
Suicide Prevention
Cognitive Therapy (CT) & Dialectical Behavior Therapy (DBT):Suicidal patients are able to citereasons for wanting to die,but they often find it challenging to think of and believe in reasons for livingCT/DBT teaches patients to identify desired outcomes and modify thoughts and behaviors to increase the likelihood of such outcomesAimed at redirecting the distressed individual’s attention towardsreasons for livingCombined withstress-reductiontechniques - relaxation and distractionCT/DBT effective in managing suicidal patientsHope Box or Hope KitCommon component of CT and DBTPhysical representation of the patient’sreasons for livingthat the patient creates and customizesStores items that a patient can refer to during feelings of hopelessnessE.g. favorite CD, family photographs, reminders of accomplishmentsand future aspirations, supportive messages from loved ones.
Personal Smartphone Revolution
CDS’s Behavioral Risk Factor Surveillance System (BRFSS) 2009:Personal Cell Phone Use74% non military83% active duty service members77% recent veteransT2’s PTEC 2010:Personal Cell Phone Use85% to 93% active duty service members60% had downloaded free “apps”Smartphone Apps 2012>300,0008,000 health-related
Smartphone Apps for Psychological HealthApprox 5,000 – 10,000Anxiety, depression, smoking, alcohol use, psychosis, diet, exercise, weight loss, nutrition, parenting, cognitive performance, relationships, relaxation, sleep, spirituality, and general wellbeing.Army exploring plans to equip all service members with smartphones
DCoE’sNational Center for Telehealth & Technology (T2)
New and innovative technologies,including virtualreality and virtual worlds
Technologies for remote clinical care. Addresses health care access barriers (geography, mobility, and stigma).
Website development, surveillance tools, mobile applications
Technology for Military Psychological Health & TBI
8 ongoing suicide research projects
National Center for Telehealth & Technology (DCoE)
At least 27 military psychological health and TBI apps planned, in development, or already publicly availableT2MoodTracker- Enables users to create a personal graphical record of their post-deployment mood changes.Breathe 2 Relax- Demonstrates and guides deep breathing techniques to reduce stress.Tactical Breathing Trainer- used to gain control over physiological and psychological responses to stress.Mobile PE- Allows PTSD patients undergoing prolonged exposure therapy to track the progress of daily homework exercises.PTSD Coach- an app to provide self-assessment, education, symptom management, and support information, to Veterans and Active Duty personnel (and civilians) who are experiencing symptoms of PTSD.T2 Mobile Screener- A portable self-assessment screening tool for measuring brief psychological “vital signs” symptoms in the field.Provider Resilience- An app to track and address provider burnout, compassion fatigue, and secondary traumatic stress
Smartphone Apps
Virtual Hope Box: Create a smartphone app containing essential elements of a hope box and associated components of CT/DBT for military service members and veterans in distress
Virtual Hope Box (VHB) App for Smartphones: Rationale
Severe psychological problems leading to hopelessness and even suicide are impacting recently deployed service members and their familiesCT & DBT have shown promise in treating suicidalityTherapeutic coping strategies often include use of hope boxHope box is key therapeutic component but physically unwieldy and inconvenient- often not available when patient needs it most during crisesRates of personal cellphone use among active and recently retired military personnel are extremely high- ubiquitousBecause mobile devices such as smartphones are carried all the time, they can expand the reach of traditional therapeutic interventionsA “Virtual Hope Box” (VHB) takes the common hope box practice and uses smartphonevehicle and features to enhance the access and experience.Rich multimedia options on smartphone allow more varied options. Furthermore,smartphones are already common repository for user-generated and user-preferredmedia.Service members are highly mobile. Suicidal crises most likely to emerge inabsence of healthcare providers.Smartphone-based app allows for easily personalized VHB that is highly portableand always available to a user in distress wherever they are.
VHB Study
Objective: To conduct a proof of concept development and evaluation of a virtual hope-box (VHB) smartphone app to supplement in-person clinical therapy for service members with suicide ideation or behavior.We will develop and test the VHB app in two phases:Phase 1: an initial prototype development followed by usability testing of the prototype to inform refinement of the app interface, functioning and content.At T2/JBLMPhase 2: a proof of concept pilot comparing acceptability and utility of the VHB with a conventional “physical” Hope Box (PHB) in clinical practice.Dialectical Behavior Therapy (DBT) Program at the VAMC Portland Mental Health ClinicHigh-risk-of-self-harm veterans entering DBT for Bipolar Disorder or PTSD“Self-soothing box" currently used in distress tolerance module
VHB Proof of Concept Study
Research Questions:Can a smartphone app be developed that contains the essential elements of a hope box and associated components of CT/DBT in a package acceptable to and usable by military service members and veterans?Is the prototype VHB app as usable, acceptable, convenient, and ostensibly useful as a conventional hope box to a clinical sample of service veterans at high risk of self-harm and suicide, and their providers.Hypotheses:The VHB will demonstrate high usability (e.g., easy to learn, efficient and convenient to use) with clinical outpatients in treatment for suicidal ideationPatients will use the VHB more than a traditional “physical” hope box (PHB)The VHB will demonstrate high patient acceptability and satisfaction.Patients and their providers will prefer the convenience, easy utility, content richness, and hip-pocket portability of the VHB to the more static and cumbersome PHB
VHB Study: Phase 1- T2
VHB Design Specs & Functional Requirements
“Agile” Development of Prototype
Iterative Usability Testing in T2 TEC Lab20 active duty soldiers
Review and Input from Portland VA DBT Clinic Study Staff
Final Modifications
Move to Phase 2
Developers and T2 Content Specialists
External Review
VHB Study: Phase 2- Portland VA DBT Clinic
Screening & Enrollment10+ DBT Patients
1st Field Testing:PHB or VHB6-8 Weeks:Phone Interviewsevery 2 weeks
2nd Field Testing:VHB or PHB6-8 Weeks:Phone Interviews every 2 weeks
Evaluation of 2ndField Test & Final Assessments
In Clinic
Away from Clinic
Baseline Assessments
Construction of 2nd Hope Box (PHB or VHB)
Evaluation of 1st Field Test.
Clinician Focus Group
Construction of 1st Hope Box (PHB or VHB)
VHB Study: Patient & Clinician Outcomes
Baseline:During Hope Box Use:Follow-Up:
Common Data Elements (CDE).Compilation of selected items from well-established and standardized subclinical self-assessments questionnaires. The CDE will be used as a comparative baseline measure across a number and variety of future studies.
Background Questionnaire:Standard demographical information + experience and proficiency with personal technologyThoughts, Feelings & Behaviors Questionnaire (TFB):PHQ9Interpersonal Needs Questionnaire (INQ-12)Revised Suicide Ideation Scale (RSIS)
Usage Semi-structured interviews(every 2 weeks by phone). Frequency of PHB or VHB use, purpose of use, how it was actually used, whether goal was achieved.
Electronic usage logs.Encryptedand storedon phone to be downloaded.
Thoughts, Feelings & Behaviors Questionnaire (TFB)PHB Usability questionnaire & VHB Usability Questionnaire.a) frequency of use; (b) ease of use; (c) functionality; (d) understandability; (e) overall impression; (f) recommendations for future modifications; (g) likelihood to use again; and (h) error and technical difficulties (VHB only).
Clinical in-person debrief:compare experiences using the PHB with the VHB, including preference of use and barriers or facilitators to use.Clinician Focus Group:Clinician, RC and other staff perceptions of the VHB v PHB conducted by T2 staff.
T2 Virtual Hope Box
Focuses the user on cherished memories, reminders in digital media: Photos, videos, recorded messages, music.
Distraction pieces for the user: Activity Planner, and puzzles/word search games taken from user content.
Preloaded inspirational quotes can be supplemented or replaced by personal quotes, family aphorisms, biblical phrases, etc.
Relaxation pieces, such as a deep breathing tool, progressive muscle relaxation, etc.
User customized support contacts, hotline info.
Coping Cards highlight adaptive thoughts and behaviors when in crisis or managing problematic core beliefs.
VHB: Construct & Customize
Add supportive contacts from phone’s contact list or create new ones.
VHB: Construct & Customize (cont.)
Add supportive, comforting, distracting, or relaxing audio, video, pictures, messages, inspirational quotes, or other media.
VHB: Support Contacts
VHB: Remind Me
Select from collection of media in multiple formats. Set Remind Me to shuffle display.
VHB: Relax Me
Selectable timing and duration for inhale, hold, and exhale
VHB: Distract Me- Games & Puzzles
Puzzle photos and words extracted from user content
Selectable levels of difficulty
VHB: Distract Me- Activity Planner
Positive Events Scheduling
VHB: Coping Cards
VHB: Inspire Me
Nigel Bush, [email protected]





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