Assessment and intervention in the wild: possibilities for redeeming the smartphone.

Daugherty, Douglas A. ; Fratzke, Betty Jane ; Steenbergh, Timothy A. 等

An Introduction to Smartphone Possibilities

Among other things, human change depends on self-awareness and self-reflection. But the pace and distractions of modern life often crowd out self-reflection. Technology--especially mobile technology--has made it easy to fill our downtime with various distractions, limiting our capacity for awareness and even empathy (Konrath, O'Brien & Hsing, 2011). Remarkable tools for modern life, smartphones seem to be adding to the noise and frenetic pace of our lives. But can smartphones also be part of the solution to the challenges of modern life? Can the smartphone contribute to human flourishing and the common good? Can the smartphone be redeemed? These are important questions because smartphones seem here to stay.

Nearly two-thirds of Americans now own smartphones and 90% of the time their devices are in the same room with them (Dey et al., 2011). Smartphones are increasingly being viewed as an extension of the self. It's no wonder that our students, like many of us, feel uneasy when separated from their phones. MIT professor Sherry Turkle (2015) recently noted, "Our phones are not accessories, but psychologically potent devices that change not just what we do but who we are." Social scientists and technologists alike have suggested that smartphones will continue to expand our senses and capacities in an integrated, social and self-evolving manner. In one sense, smartphones are making superheroes of us all. We can simultaneously take a walk in the park, track our steps, connect with our spouse across town and business associates across the world--a feat that would have seemed superhuman less than 25 years ago. This idea of being mobile and in multiple places, at the same time, was reserved for Superman less than 25 years ago. On the other hand, as noted above, there are valid concerns about the way smartphones may be shaping us. Given the role technology and smartphones play and will play in shaping us and our interactions, how might smartphones be used well? What are the implications for understanding and caring for our students, clients and underserved community members?

Possibilities for Psychological Research and Practice

Psychological research and clinical assessment have often relied heavily on surveys and retrospective self-reports, despite our limited ability to recall the past. Recall tends to be unduly influenced by recent and emotionally salient events, as well as current mood and setting. We recognize that our clients, like all of us, do their best to reconstruct their thoughts, experiences and behaviors. But this is less than ideal. There are other ways to understand the challenges our clients are facing, as well as their potential blind spots and biases, as we seek to collaboratively navigate a way forward.

One way forward involves the use of experience sampling, which is increasingly used in an effort to address limitations of recall. Experience sampling refers to a set of strategies for recording individuals' experiences in the context of daily life. For example, we might invite clients to journal their thoughts and feelings each evening and to bring these journals to subsequent therapy sessions. Or we might ask them to record the strength, context and specific triggers associated with their desire to drink.

"Experience sampling" is often used interchangeably with "ecological momentary assessment" (EMA). EMA refers to systematic efforts to capture people's experiences in real-time and realplace--to understand their behavior and experience in and across the moments of daily life. As practitioners, we notice that the border separating EMA from what is called "ecological momentary intervention," or EMI, can be blurry. The experience of observing and measuring something about oneself, or one's life, often becomes a form of intervention (e.g. self-monitoring) as well as a means of understanding. For example, one of us recently noted how EMA questions about his prayer life led to a meaningful change in his prayers--"I started praying less about me and my family and more about God and others."

Early EMA methods used journals. Later on, wristwatch alarms and 3x5 cards were used in an effort to capture what was happening in people's daily lives. With the advent of Palm Pilots and other handheld computing devices, EMA became more efficient, though the devices were still cumbersome. Today, smartphones offer new possibilities for EMA/EMI in both clinical practice and population-level interventions.

Clinical psychologists are interested in both nomothetic and idiographic truths--what is true about people in general, and what is true in particular cases and contexts. Our capacity to serve others effectively is enhanced when we learn generalities about various groups (e.g. clinically depressed adults). On the other hand, in our daily work, we are especially interested in what is true about a person, at a time, in a particular situation and cultural context--what is this person's story and experience? As clinical scientists, we are continually asking questions, forming hypotheses, and collecting data in regard to our clients and their treatment progress. Smartphones appear especially well-suited to this kind of single-subject, real-world, research and practice.

Imagine having clients respond to several therapy-pertinent questions, on their smartphones, throughout the week and in the context of their daily lives. Imagine having their responses readily available and graphed, or otherwise highlighted, in a web-based "dashboard." This dashboard could be made available to the therapist and client, informing and facilitating the plans and processes of psychotherapy. Of course, this will present some challenges in terms of therapist training, efficiency and flexibility as well as empirical evidence, client interest and client engagement. But these challenges can be addressed.

Many of us, therapists by nature and training, are understandably skeptical of technology and impersonal therapeutic interventions. As Hans Strupp has noted, psychotherapy takes advantage of our attachment to a benevolent caregiver and the human capacity to change in the context of a meaningful relationship. In fact, our contribution to the common factor in successful psychotherapy is most fundamentally an effective working relationship between client and therapist. So we see smartphones as offering a potentially useful auxiliary to existing psychotherapeutic interventions--a supplement intended to inform, enhance and extend person-to-person interaction, not replace it.

We see a growing role for individualized and person-centered smartphone interventions. At their best, these auxiliary interventions are a response to the question: "How might mobile interventions enhance the efficacy of psychotherapy for this person, at this time, with these challenges, strengths and opportunities?" By tailoring questions around a person's life and schedule, therapists and clients can use information collected in the context of daily life to monitor symptoms, goals treatment progress. This information can further inform collaborative development of applications ("apps") that are motivating, engaging, culturally-sensitive and progressive, and evolving in tandem with client needs and growth. Imagine app experiences between sessions and/or as an extended aftercare component of successful treatment, reducing the risk of relapse.

Smartphone interventions have the advantage of being in-time, on-time, and over-time. By in-time, we mean that smartphone interventions can allow us to intervene sooner and increase the likelihood that people engage with help in some form. These interventions are also flexible, scheduled and available as needed, according to the preferences of our clients--in other words, on-time. The feasibility and cost-effectiveness of smartphone interventions suggest that they may be useful for providing extended support over-time.

Psychological and other health interventions delivered by means of mobile technology fall under the umbrella of "mHealth." Evidence for the efficacy of psychologically-focused EMI is limited, but growing. EMI has been used successfully to facilitate smoking cessation and sobriety, improve emotional regulation and mood, increase self-awareness, and invite prevention behaviors (Gustafson et al., 2014; Runyan & Steinke 2015). There is also evidence suggesting that smartphone interventions can enhance one's motivation for change, and several researchers have cited evidence that app-based interventions have high feasibility and acceptability (see Clough & Casey, 2015 for a review).

In-time smartphone interventions include population-level efforts, extending our reach to those who would otherwise not receive psychological services. It is widely recognized that most people with mental health issues are not receiving services of any kind, and there are significant barriers (e.g., geographical and financial) to timely services. Furthermore, it is well known that ethnic/racial minorities are even less likely to receive mental health services. Fortunately, it appears that minority individuals, who are traditionally understudied and underserved, may have higher rates of smartphone ownership than majority individuals (Pew Research Center, 2015). Smartphone-based interventions may be a first-line approach in a stepped care model, allowing us to provide population interventions to large numbers of people. Economies of scale allow for wide distribution and minimal cost. We envision culturally-sensitive prevention and early intervention EMI app tools with motivational, psychoeducational, experiential and practical-resource components. These could be brief behavioral health or more sustained, graduated experiential interventions. The biggest challenge here would likely be how to increase awareness and incentivize engagement with these resources.

Possibilities for Positive Psychology and Spiritual Formation

Smartphones can become important tools in the promotion of well-being and human flourishing. Various positive psychology interventions have been researched and recommended in recent years, including gratitude, strengths-based interventions, optimism and perspective-taking. Smartphone apps may prove to be a highly accessible and cost-effective means of expanding the reach, dose, and ecological nature of these kinds of positive psychology interventions. For example, we conducted a smartphone EMA/EMI study involving gratitude and found that a gratitude intervention improved mood and reduced mood variability in the moment.

Of particular interest to our research group is how smartphone-based EMA/EMI can be used to study and promote virtue and spiritual formation. In fact, our interest in experience sampling started with a study of Christian exemplars. Our shared interest in spiritual formation and positive psychology led us to examine the perceptions, practices, and experiences of everyday Christian exemplars. At first blush, it seems that "everyday" and "exemplars" don't belong in the same sentence. But what we had in mind were everyday saints who stood out because of their obvious love for God, their daily demonstration of the fruit of the Spirit, and their daily experience of an abundant life. We found that pastors had no problem identifying a few people in their congregation who met that description. So we asked, how had they grown in their faith through the years? How did they manage to vibrantly live out their faith in the context of contemporary culture? We found several recurring themes, most notably the importance of community and mentoring, as well as respondents having new, kingdom of God perspectives (e.g., new identity as God's child, shifts in thinking, and healing/peace/gratitude/joy). These exemplars also emphasized a process of growing intimacy with Christ and the practice of spiritual disciplines. They humbly shared a pattern of surrender and service, which we call the "not-about-me" life. We're presently reviewing these findings and considering publication options.

In the process of interviewing our exemplars, it occurred to us that we might not think to ask, and they might not think to tell, of various longstanding practices, habits or social realities so naturally embedded in their walk with God. This led us to think about other methods, including naturalistic observation, as impractical as that seemed, self-monitoring and, ultimately, EMA. Fortuitously, Apple's 2010 iPhone operating system allowed apps remain active even when not in use, paving the way for app-based EMA. This led us to develop the first EMA app, called iHabit (Runyan et al., 2013).

We continue to conduct EMA/EMI research involving spiritual practices and human flourishing, believing that smartphone apps hold promise not only for understanding spiritual formation, but also for fostering formative development. Perhaps app-facilitated interventions can be created that will help people practice the presence of God, express and experience gratitude, pray without ceasing, and walk with humility, while, simultaneously, monitoring their progress in actively cooperating with God's gracious work in their lives. Of course, spiritual development occurs in the context of meaningful community, and motivated followers of Christ will need to continue to share life with others in their faith communities. Ideally, in the near future, people will be able to share their formative experiences, spiritual practices and progress, or setbacks, with others in their community by means of mobile devices and web-based tools in addition to face-to-face interactions. Imagine, for example, being able to share meaningful events, experiences, or struggles, throughout the week with one's accountability group by means of app-responding (EMA) and a web-based dashboard.

We find these interests lining up very well with a commitment at our university, and in our division, to be proactive in cultivating and measuring virtue and spiritual formation among our students. Furthermore, this may, in time, become another effective tool to use within our church communities to stimulate spiritual growth in line with Paul's advice to Timothy to "...rekindle the gift of God that is within you" (2 Tim. 1:6), and his advice to the Hebrews to "consider how to stimulate one another to love and good deeds" (Heb. 10:24). Whether we desire to help our clients, our students, or church communities, smartphone technology offers exciting possibilities for intervention and growth.

Before leaving the topic of spiritual formation, we should mention smartphone possibilities for the study of virtue. It seems to us that EMA smartphone research is uniquely positioned to help us examine questions about the nature of human virtue. Virtues have traditionally been understood as dispositions that promote flourishing, and that some people express over time and across situations; that is, they are relatively stable and robust. Therefore, the kind of repeated, cross-situational assessment allowed by smartphone-based EMA provides a way to better assess virtue, its formation, and its influence on various aspects of daily life (Runyan & Steinke, 2015). We have begun to apply this approach to better understanding dispositional gratitude, empathy and compassion as they are expressed in daily life.

Practical Considerations: Technology Options, Costs and Challenges

There are more than 10,000 mental health apps available for consumers, including PTSD Coach, T2 Mood Tracker and MyCompass (Ben-Zeev et al., 2013; Clough & Casey, 2015). Most of these are static apps that push specialized content-to-end users, although some of these also allow users to monitor their behavior and progress. A discussion of these apps is beyond the scope of this article. However, the difference between these apps and the EMA/EMI future we envision involves the flexibility afforded to researchers and clinicians. We believe the future of EMA/EMI depends primarily on approaches and platforms that will enable researchers and clinicians to create, employ and test their own app experiences. These researchers and clinicians will also need secure access to participant/client responses in manageable formats.

Three methods of smartphone-based EMA/EMI are currently available. One method is Short Message Service (SMS) text messaging. With this approach, clinicians and researchers create schedules to send text messages and, in some cases, to capture users' responses. For several years, this technology has been available and many use it because it is economical and does not require a smartphone. Text messaging services are widely available (e.g., http://www.messagemedia.com). This approach is ideal for delivering simple messages to individuals throughout their day. For example, one might imagine periodically delivering messages of encouragement and Scripture relevant to those dealing with a specific issue (e.g., anxiety, relational problems, and addiction). Other options should be considered if providing a more varied and interactive experience is important or if data will be gathered and analyzed. SMS text messaging systems are limited in terms of the kind and length of questions that can be presented to users, and the data that these systems gather often require considerable manipulation before analysis is possible. Further, for research applications, SMS text messaging can be problematic due to disruptions in cellular service.

For those interested in gathering data, two other options are available, especially if repeated assessment is desired. One option is to send a text message with an embedded online survey link to users who have a smartphone. When users receive a text, they can click on the embedded link and the survey will open in the smartphone's browser. This requires the clinician or researcher to create online surveys using existing web-based systems (e.g., www.surveymonkey.com, www.qualtrics.com) and link the surveys to a separate text messaging system (e.g., www.surveysignal.com). There are two main advantages to this approach. First, users interact with text messaging and an internet browser--two applications available on all smartphones and with which users are already familiar. Second, the data gathered by most online survey systems tend to be more easily configured than data gathered by text messaging systems. The primary drawbacks of this approach include the cost and challenge of integrating text messaging and online software systems, the requirement that all users have a smartphone with continual internet service or an adequate data plan, and the limited kinds of interaction one can have with users (i.e., only schedule-based interactions are possible, so users cannot initiate an assessment or intervention on their own).

The third option for mobile interaction involves the use of smartphone apps. This represents the fastest developing area in mobile assessment and intervention, allowing researchers and clinicians to interact with users in multiple ways. These systems (e.g., www.lifedatacorp.com; www.metricwire.com; www.movisens.com/en) have a web-based application where clinicians and researchers can log in and create schedules and questions, or other prompts (e.g., pictures and text), to be delivered to users who have downloaded a smartphone app. These app-based systems allow for more than just experience sampling. For example, the LifeData system we use, and some of us helped develop, allows us to create sessions that users can initiate on their own using a mobile app. This provides users with an opportunity to interact with prompts, or answer specific questions, which are relevant to what they are experiencing in a given moment.

We have used this feature to provide users with a chance to practice the Daily Examen (see: www.ignatianspirituality.com/ignatian-prayer/theexamen), or report blessings as they experience them through the day. These kinds of interactions open up new possibilities for providing mobile-users with helpful content when it is useful to them, or to gather information on specific experiences when they occur (e.g., panic attacks, cravings, and relationship interactions). Other features of app-based systems that make them especially attractive to clinicians are the ability to use system tools to create a dashboard of client functioning and their ability to run "offline." For researchers, other features, such as gathering GPS coordinates or integration with physiological sensors open up new avenues for discovery.

While we think smartphone app platforms represent the direction the field is moving and open up new possibilities, the cost of app-based systems may be a barrier for some. For example, the price of annual subscriptions may reach $1,000-$5,000 or more depending on the number of researchers or clinicians accessing the system. But use of the app by end users is typically free, so this is not a barrier. Finally, the reach of these systems for population health may be limited by the fact that approximately one-third of the U.S. population does not have smartphones.

Future Directions

We are all interested in developing the empirical base for using smartphones to promote change. Research regarding smartphone possibilities considered here is limited, with few randomized clinical trials, the gold standard of outcome research. Riley and colleagues (Riley, Glasgow, Etheredge & Abernethy, 2013) have suggested that research needs to be rapid, responsive and relevant. We agree, with the technology and person-centered applications leading us to underscore the value of single-subject, multiple baseline designs, which are well-suited to the challenges of timely smartphone efficacy research. Single-subject research also fits well with the realities of clinical practice and the goal of individualized treatment. This seems to be a fruitful direction for smartphone research to go, with emphasis on auxiliary, individualized smartphone interventions, and on-going data collection, analysis and related improvements. Clough and Casey (2015) have specifically recommended this approach as a best fit for psychological/mHealth interventions. And, over time, we imagine that these efforts will inform more traditional clinical trial research, as well as uncover new ideas for mobile intervention.

Mobile technology is shaping us for better and worse. We are hopeful about the many possibilities for harnessing the power of smartphones to enhance research and psychotherapy while also expanding the reach of psychology. We also envision these tools being used to help foster human flourishing and Christian formation. We believe that together we can imagine and test new ways of using smartphones for realtime/real-place assessment and intervention--for the common good and the kingdom.

Douglas A. Daugherty, Betty Jane Fratzke, Indiana Wesleyan University, Timothy A. Steenbergh, Jason D. Runyan, Indiana Wesleyan University & Excelsia College, Brian N. Fry, Indiana Wesleyan University

References

Ben-Zeev, D., Kaiser, S. M., Brenner, C. J., Begale, M., Duffecy, J., & Mohr, D. C. (2013). Development and usability testing of FOCUS: A smartphone system for self-management of schizophrenia. Psychiatric Rehabilitation Journal, 36, 289-296. http://dx.doi.org/10.1037/prj0000019

Clough, B. A. & Casey, L. M. (2015). The smart therapist: A look to the future of smartphones and mHealth technologies in psychotherapy. Professional Psychology: Research and Practice. Advance on-line publication: http://dx.doi.org/10.107/pro0000011

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Gustafson, D. H., McTavish, F. M., Chih, M-Y., Atwood, A. K., Johnson, R. A., Boyle, M. G. & Shah, D. (2014). A smartphone application to support recovery from alcoholism: A randomized clinical trial. Journal of the American Medical Association Psychiatry, 71, 566-572. http://dx.doi.org/10.1001/jamapsychiatry.2013.4642

Konrath, S. H., O'Brien, E. H. & Hsing, C. (2011). Changes in dispositional empathy in American college students over time: A meta-analysis. Personality and Social Psychology Review, 2, 180-198.

Pew Research Center (April, 2015) U. S. smartphone use in 2015.

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Runyan, J. D., Steenbergh, T. A., Bainbridge, C., Daugherty, D. A., Oke, L., & Fry, B. (2013). A smartphone ecological momentary assessment /intervention "app" for collecting real-time data and promoting self-awareness. PLoS ONE 8(8): e71325. doi:10.1371/journal.pone.0071325

Runyan, JD & Steinke, E (2015). Virtues, ecological momentary assessment/intervention and smartphone technology. Frontiers in Psychology, http://dx.doi.org/10.3389/fpsyg.2015.00481

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Correspondence regarding this article should be addressed to Douglas A. Daugherty, PsyD., Indiana Wesleyan University, 4201 S. Washington St., Marion, IN 46953; doug.daugherty@indwes.edu

Douglas A. Daugherty, Psy.D., HSPP is a Professor at Indiana Wesleyan University and co-founder of LifeData.

He teaches abnormal psychology, positive psychology, and evidence-based practices in addictions counseling, among other courses. His research interests include positive psychology, spiritual formation, addiction and the use of mobile technology for understanding and change. He can be reached at doug.daugherty@indwes.edu

Dr. Betty Jane Fratzke is Professor of Psychology at Indiana Wesleyan University where she Chairs the Behavioral Sciences Division and teaches personality, learning and motivation, and human development. Her research interests are in forgiveness, hope, attachment and spiritual formation. She can be reached at bj.fratzke@indwes.edu

Timothy A. Steenbergh, Ph.D., HSPP is Professor of Psychology at Indiana Wesleyan University, a Research Fellow at Lumen Research Institute (Excelsia College), and co-founder of LifeData. He teaches abnormal psychology, statistics and research design. His primary research interests include addictive behaviors, spiritual formation, and real-time assessment and intervention.

Jason D. Runyan, D.Phil., is Associate Professor at Indiana Wesleyan University, a Research Fellow at the Lumen Research Institute (Excelsia College), and cofounder of LifeData. At IWU, he teaches in the Psychology Department and Honors College. His research interests span psychology, neuroscience and philosophy.

Brian N. Fry, Ph.D., is Professor of Sociology at Indiana Wesleyan University. He is interested in how empathy and nonviolent communication can help improve intergroup relations.