Technology Applications in Delivering Mental Health Services
Service members returning from military deployments are at increased risk of mental health disorders to include depression, posttraumatic stress disorder (PTSD), and a range of behavioral or substance abuse problems. With increasing numbers of military personnel returning from deployment with behavioral health needs there have been calls to increase access to psychological resources and specialty mental health treatment. Increased access is necessitated by the remote geographic location of many service members, particularly National Guard and reservists, who may live far from military medical centers and VA mental health treatment facilities. Many military personnel also have concerns with treatment stigma and peer or leader perceptions of help seeking, resulting in calls for access to anonymous and less stigmatizing forms of help. Improvements in treatment outcomes are also of concern. Although effective psychotherapies and medications exist to treat many of the postdeployment concerns of some service members, the efficacy of most treatments with military populations is unknown, and some research has found decreased efficacy with military veterans. Technology developments provide a range of opportunities to improve access to resources and to potentially improve the quality of care delivered.
Technologies to Support Military Personnel
Technologies have continued to evolve simultaneously with the military operations in Iraq (p. 289) and Afghanistan. These technologies provide novel opportunities to support the psychological health of service members. This section will briefly review several key technology capabilities currently available to military psychologists.
Internet and Web Resources
With nearly ubiquitous service member access to the Internet, websites provide a readily accessible source of information, self-assessment, and support. Web resources can be accessed anonymously, which may mitigate the stigma of presenting at a brick and mortar military mental health clinic for information and initial screening. A wide range of websites exist, a number of which offer high quality, evidence-based information and resources. Although a comprehensive review of psychological health websites is beyond the scope of this chapter, a review of representative quality examples will elucidate the type of capabilities these technologies can make available. Afterdeployment.org is a Congressionally mandated Department of Defense (DoD) website that provides a self-care solution for service members with preclinical problems. The site includes self-assessments and multisession self-guided workshops for 18 content areas such as anger, depression, alcohol and drugs, and life stress. These workshops provide evidence-supported skills and information that can be learned independent of face-to-face care. Although websites such as these do not serve as a replacement for mental health treatment when indicated, they can provide significant support to military personnel seeking to understand their difficulties or provide key self-management strategies to those whose problems do not rise to a clinical level of intensity. Some providers are also beginning to leverage website capabilities like these to support relevant patient homework between psychotherapy sessions. Others are using web content live during group therapy sessions.
Social networking is a special case of Internet capability that has a primary opportunity for users to offer and obtain social support. Many mental-health-related organizations also use these capabilities to disseminate strategic information to stakeholders. A range of complex issues must be considered by any clinician considering the use of social networking for professional purposes. A recent paper, which focused on the topic of suicide and social networking, provides a thorough overview of some relevant issues (Luxton, June, & Fairall, 2012).
Smartphones and Mobile Computing Platforms
Smartphones are increasingly in the pockets of our military personnel. These mobile computing platforms offer a range of capabilities including impressive computer processing speeds, local device storage of data, access to cloud-based data storage and resources, GPS, 2-way camera/video viewing, accelerometers, phone, and compass functionality. The size of these devices makes them highly portable and accessible to users throughout their day. Specialized computer software applications, or apps, are routinely used by smartphone owners for a wide range of purposes.
Many are beginning to think about how to leverage these capabilities to support the psychological health of Warriors. Smartphones provide ongoing, instant access to web content and apps in a surreptitious and potentially nonstigmatizing format. Collaborations between the DoD and the Department of Veterans Affairs (VA) have resulted in apps to support: (1) self-assessment and population surveillance of warriors and veterans, (2) self-care and symptom management, and (3) the delivery of evidence-based treatments. Regarding self-assessment and surveillance, the T2 Mood Tracker provides one example. This app is designed to support the ecological momentary assessment of service members. Users can track their moods daily (or multiple times a day) on a range of visual analog scales. Service members or veterans can log events and circumstances related to mood changes to help understand their difficulties and support behavior change efforts.
Tracking mood, in and of itself, can be helpful to many people. Others are using mood tracking apps as an adjunct to therapy. Logs from (p. 290) mood tracking apps can be reviewed in therapy sessions to discuss the successes and barriers to success for implemented interventions. An app currently in development is designed to support the ongoing assessment of symptoms or to support population surveillance. This app would allow a patient to complete any validated self-report measure inserted into the platform, provide their responses, and securely transmit their data to a provider or a secure data base. Apps such as these could provide future support to the assessment and ongoing symptom management associated with the delivery of psychotherapy. Alternatively, apps of this type could efficiently support large-scale assessments or surveillance efforts, such as that conducted by entire military units following operational deployments. At risk populations could provide ongoing secure self-assessments to providers to assist in the identification of increased risk between psychotherapy sessions.
A number of apps have also been developed to support the psychoeducation and self-care of service members and veterans. VA and DoD collaborated on PTSD Coach, a smartphone app that provides information about PTSD, self-assessment, and symptom management strategies for military personnel and veterans. If veterans self-rate their distress at a high level, the app leverages the phone capabilities of the device and the user is provided one-touch access to a crisis-line, should they choose to do so.
Apps have also been developed to support the tasks of evidence-based psychotherapy. These apps are not designed to be used as self-help, but rather to support the work of a patient and provider engaged in a manualized treatment. For example, prolonged exposure (PE) is an evidence-based treatment for PTSD. PE Coach was designed by the National Center for Telehealth and Technology (T2), the VA National Center for PTSD, and the Center for Deployment Psychology to improve the implementation, treatment fidelity, and adherence of patients and providers engaged in PE. The app provides a range of capabilities necessary to the treatment protocol to make participation in treatment more convenient. The app supports audio recording of PE therapy sessions directly onto the patient’s phone, logging of imaginal and in vivo exposure homework in the app (instead of paper worksheets), tracking and graphical display of trauma-related distress and PTSD symptoms over time, and device calendar reminders of PE sessions and homework. At each session, the therapist can review the patient’s homework adherence based on actual app usage supporting the identification of barriers and problems with homework adherence. Obviously, these descriptions of a few apps do not begin to summarize the broad range of apps available for clinical use. Although apps like PE Coach have the ability to transform our delivery of evidence-based treatments in helpful ways, clinicians must carefully judge the quality of the content of apps and research is needed to evaluate the effectiveness of apps like these to determine their value and any contributions to treatment outcomes.
Virtual Reality and Virtual Worlds
Virtual reality (VR) is a more innovative technology available to some military mental health providers. VR leverages computers and a range of peripherals to give the user the psychological experience of participating in a computer-generated environment although they are physically located elsewhere. Head-mounted display systems or immersive visual display systems, vibro-tactile platforms, 3D audio and visuals, haptic devices, and delivery of relevant manufactured olfactory stimuli are common components of VR.
The ability to psychologically transport a user to an alternate location may be relevant to certain military behavioral health goals. Distraction is an effective form of nonpharmacological pain management and there is evidence that VR may be useful for some patients undergoing painful medical procedures. VR-based assessment is another area of interest. Ecologically valid assessment of attention processes and other cognitive functions may be very helpful in the future to providers wanting to answer real-world questions about fitness for duty.
However, the most broadly researched area of VR relevant to military clinicians is probably the potential to use VR to help activate the fear structures of patients engaged in an exposure (p. 291) therapy for PTSD. During VR exposure, multisensory VR stimuli are modified in real time during imaginal exposure to help patients activate their memory and modulate therapeutic levels of emotional engagement. The VR system is not a replacement for formal training in exposure therapy and it does not replace the role of the clinician. However, it may prove to be a useful tool for a skilled clinician to use with military personnel who have developed strong emotional detachment and have difficulty achieving adequate levels of engagement during imaginal exposure. Research has supported the effectiveness of VR exposure, but quality randomized controlled trials are needed to determine the efficacy of this form of exposure therapy.
Shared computer-generated environments, referred to from here forward as virtual worlds (VW), are also being explored for supporting the psychological health of military personnel. VWs typically involve use of a digital representation of oneself, called an avatar, to navigate through and interact with other users and the 3D computer generated environment. In many cases, access is available to anyone with a broadband Internet connection. Users can typically communicate with one another through text-based chat or can use a digital microphone to speak directly through Voice Over Internet Protocol (VOIP). Software capabilities are often incorporated into these spaces to enhance user experience. For example, some VWs allow incorporation of Microsoft Office products to support collaborative work and meetings. In an era of increased calls for efficiency, one can imagine the potential utility of a VW that is approved for use on the military network to increase collaborative DoD meetings while reducing costs associated with travel. Some are considering whether VWs could effectively replace inefficient classroom gatherings of mental health providers for training on evidence-based treatments.
Of all the VW uses considered, experiential learning is one clear use case. The Virtual PTSD Experience is one example. This space is located in the VW called Second Life and takes the user through an asynchronous, stand-alone, interactive educational experience. It teaches the user about the causes, common symptoms, and help available for deployment-related PTSD. Users proceed through a series of “exhibits” that attempt to leverage gaming motivation to help users learn by doing. Like an interactive museum, the Virtual PTSD Experience is an example of using a VW space to deliver psychoeducation in a manner unlike typical didactic methods. This space is available at no cost, and users can name their avatar anonymously, potentially mitigating the stigma related to seeking information about mental health issues.
Considerations in the Clinical Decision to Use Technology
The decision to use a technology to support clinical practice requires deliberate thought to ensure the solution being considered is a good fit. A framework that was previously described for considering the design of virtual environments to support patients with central nervous system dysfunction (Rizzo, Buckwalter, & van der Zaag, 2002) can be adapted for considering questions relevant to a range of technologies. First, can the same benefits be achieved without the technology approach? Gadgets for gadgets’ sake do not support military personnel. An honest appraisal of how the technology capabilities are helpful is needed to ensure good clinical decision making. Second, how well do the capabilities of the technology fit the clinical goals? The mere insertion of technology into the treatment plan of a clinical issue does not make treatment better. However, technologies that provide capabilities that help the clinician address a logistic or clinical problem can provide dramatic improvements. Third, consideration must be given to how well a technology solution fits the characteristics of the patient population. Young, technologically experienced “digital natives” make up a sizable proportion of today’s Active Duty military. The integration of appropriate technologies into clinical practice can be a successful fit for many. However, service members are not a homogeneous group. Users must have access to the relevant technologies to take advantage (e.g., the Internet or smartphone devices). In addition, certain clinical populations may not be appropriate for certain technology solutions. For (p. 292) example, patients with a lower threshold for seizure activity may not be appropriate to use certain low frequency visual displays. Patients with vestibular problems may need to avoid technologies with the potential for balance or dizziness side effects (e.g., immersive virtual environments). Clinicians must give careful consideration to the specific clinical population and their fit with the targeted technology.
Several sections of the Ethical Principles of Psychologists and Code of Conduct (American Psychological Association [APA], 2010) are relevant to the discussion of the clinical use of technology. First, psychologists are expected to practice within the limits of their competence. “Psychologists planning to provide services, teach, or conduct research involving populations, areas, techniques, or technologies new to them undertake relevant education, training, supervised experience, consultation, or study” (APA, 2010, p. 5). Similarly, in emerging areas where agreed upon standards and training do not yet exist, psychologists are expected to take reasonable steps to ensure their competence. Continuing education is increasingly available to support skill development in the use of certain technologies, and some professional societies are beginning to give significant thought to the appropriate use of a range of technologies in clinical practice (e.g., American Telemedicine Association, accessed August 20, 2012). Information should be obtained from guidelines such as these and professionals with relevant experience should be consulted.
Mental health providers seeking to apply technologies in practice should ensure they are current on the available scientific literature supporting the use of the selected technology approaches, as well as the limits of what can currently be concluded from that literature. Doing so supports compliance with the APA ethical requirement to obtain informed consent. If a selected technology treatment is judged to be one for which recognized techniques and procedures have not been established, providers must inform Service Members “of the developing nature of the treatment, the potential risks involved, alternative treatments that may be available, and the voluntary nature of their participation” (APA, 2010, p. 13).
Some technologies increase the risk of challenges to professional boundaries. Communication technologies that include e-mailing or texting provide instant delivery of messages and the expectations and management of such communications during nonbusiness hours can be complicated. It is possible that the APA Ethics Code’s Standard 3.05 on Multiple Relationships could be relevant to the use of some technologies in clinical practice. Finally, some technology solutions support the face-to-face delivery of care. If a technology solution obtains or stores confidential information, psychologists have an ethical obligation to take reasonable steps to protect that information (Standard 4.01).
A range of technologies are emerging with interesting and potentially useful capabilities to support some of the goals of the military psychologist. With these capabilities comes the obligation to think carefully about when and where such technology applications are appropriate. A thoughtful and ethical clinical implementation of technologies has the potential to dramatically impact and improve our future care of Warriors.
American Psychological Association. (2010). Ethical principles of psychologists and code of conduct. Retrieved from http://www.apa.org/ethics
American Telemedicine Association. (2012, August). Telemedicine standards and guidelines. Retrieved from http://www.americantelemed.org/i4a/pages/index.cfm?pageid=3311
Luxton, D. D., June, J. D., & Fairall, J. M. (2012). Social media and suicide: A public health perspective. American Journal of Public Health, 102 (Suppl. 2), s195–s200.Find this resource:
Rizzo, A. A., Buckwalter, J. G., & van der Zaag, C. (2002). Virtual environment applications in clinical neuropsychology. In K. M. Stanney (Ed.), Handbook of virtual environments: Design, implementation, and applications (pp. 1027–1064). Mahwah, NJ: Erlbaum.Find this resource: