Using mobile apps with patients who have experienced trauma

Several peer reviewed research studies of PTSD Coach demonstrate efficacy of the app for mild to moderate PTSD symptoms. Clinician support appears to increase the effectiveness of the app compared to self-management.

The content is appropriate as a complement to therapy or for those who are considering getting additional support for their symptoms or wanting to learn more about PTSD. PTSD Coach mostly follows empirically based cognitive behavioral therapy (CBT) approaches and mindfulness practices. A recent update also included use of inspirational quotes, engagement ideas, and taking a different perspective, but it is unclear whether those are based on CBT.

PTSD Coach is available in Spanish and can be adapted for those who are hearing and visually impaired. The multiple ways the app can be customized with each user’s uploaded content make it more of a culturally congruent and personal experience; however, the content remains fairly sparse on issues of diversity and cultural factors.

The app is straightforward and very easy to use. Interventions can be saved as “favorites” making them much easier to find if an individual is accessing the app while in distress. Users can also link helpful contacts from their phone or any national number within the support section.

The app functioned well and no glitches or issues were observed. Once downloaded, PTSD Coach does not need internet to function. Assessment data can be exported.

It is clear that mental health and psychology experts were involved in the development of the material. It is exceptionally appropriate when used within a therapy context, or for individuals who are not interested in or ready for individual treatment. It is also ideal for rural populations who may not have access to individual care.

The program was developed by the U. S. Veterans Administration, and thus it is focused on American populations. It seems to be appropriate for both male and female individuals, though content is not gender specific, nor does it address nonbinary populations. Specific cultural references in terms of racial and ethnic groups are not addressed. It can be set for use in English and Spanish, and several members of the project development team were Spanish-speaking individuals.

The program is laid out very clearly and it is easy to navigate. The software works effectively. It is customizable to the extent that there are many choices, tools, and educational modules.

Functionality is strong, and the internet is required only for the initial download. The program tracks symptoms over time, when requested, and offers to send reminders to complete tracking and interventions at specified periods of time.

Numerous studies have found CPT to be effective in reducing symptoms of PTSD following a variety of traumatic events including child abuse, combat, rape and natural disasters, though no specific research on the app itself could be found. The app was developed by two of the authors of the CPT patient manual for military use.

The app is very true to the structure that CPT recommends. The reading materials are quite good, and graphics are provided to clearly describe symptoms such as emotional avoidance, vivid images, and negative thoughts. A comprehensive list of strategies that people use to escape and avoid emotions is also included.

The app appears to only be available in English, and no specific references are made to gender, sexual preference, racial or ethnic differences in the experience of the patient. This is consistent with the Cognitive Processing protocol, and one would hope that these issues would be discussed with the therapist using the app with the patient.

The design of the app is a bit outdated and navigation can be confusing. However, if using it with a therapist who is experienced with both cognitive processing protocols and the app itself, it should be easy to track and navigate.

Functionality is strong, though the internet is required to access it. The program includes homework assignments and provides reading material to be read between sessions. It does not appear that you can download your data.

The use of CPT’s main features (e.g. re-examining the traumatic event narrative, identifying stuck points, modifying extreme thinking and underlying beliefs) are all represented in the forms and readings. It is a CPT consistent app, however, it uses more directive language--such as “Practice assignments are the path to CPT success – if you don’t use them you won’t get better”--that is inconsistent with activation of the patient’s beliefs and making their own decisions to move forward.

The content is largely appropriate only for military personnel, and much of the content is aligned with combat-related traumas.

The app does not appear to address cultural issues in any systematic manner. The memes used in its graphics are genderless and are white/gray. The readings do not appear to employ culturally sensitive content (e.g. gender-based stereotyped pronouns, aggression conceptualized differently across cultures). Different language versions of CPT Coach were not apparent.

CPT Coach is remarkably easy to navigate in the iOS environment. The navigation buttons are intuitive and move from one section of the app to another without hesitation. The app is not customizable in any obvious way except for the difference between the Military Sexual Trauma (MST) versions of some components vs. the “Combat” versions. The MST versions rely less on military service as the setting or contexts for the traumas. The app also allows the user to tailor the name and phone number of their therapist.

CPT Coach performs well and does not rely on the internet for most of its functionality. To use the “Call” function in the Next Appointment section, the app does require access to cell phone service. If personal downloading of data in the app is possible, the app fails to provide an easily identifiable way to do so.

Research has shown PE to be one of the most effective treatments for PTSD. While no randomized control trials were found using PE Coach, small feasibility studies demonstrated support for users in primary care settings or receiving therapy, including higher levels of satisfaction during PE with PE Coach as compared with PE alone. The app was developed in collaboration with clinical psychologists and adheres to the protocol of PE developed by Foa, E., Hembree, E. & Rothbaum, B.

The app clearly outlines the PE treatment model and includes background readings that explain trauma, avoidance behaviors, arousal, and feelings associated with trauma; the SUDS hierarchy, and a breathing tool. The content is appropriate and consistent with PE. The project team and subject matter experts include psychologists, experts in PTSD treatment, and one of the authors of the PE Treatment Manual.

PE Coach is only available in English. It is text-heavy and has very few graphics. However, the app was not designed for the general public and its simplicity will be appealing to those who are not digital natives or those who prefer low tech apps. On the other hand, I imagine that adolescents and young adults may not find it as engaging.

It is easy to use. The main menu has graphics that highlight each section and navigation steps are clearly labeled. Patients can take the PCL-5 and the PHQ-9 right on the app. PE Coach also has a great tool for patients to practice their breathing technique between sessions.

Overall, PE Coach seems to perform well. Most functions are available offline, but you will need an internet connection to export the data to your email. I had trouble exporting my data as the app would crash. However, it is a valuable resource for patients to document SUDS rating between sessions and to listen to recorded sessions.

The content on the app is focused on the target population (i.e. those who are undergoing treatment by a trained PE provider for PTSD) and adheres to the protocol of PE. It was developed as a collaborative effort between the VA’s National Center for PTSD, the Department of Defense’s DHA Connected Health and Center for Deployment Psychology. Clinical psychologists who provide treatment of trauma using PE were a part of the team in the development of the app.

The app and general protocol of PE does not explicitly address matters of cultural considerations within use of PE Coach and this information was not available online at the time of the review; however, clinicians will need to tailor the content and interventions of treatment to the patient and potential impacts of cultural factors in the expression and experience of PTSD symptoms.

The app is straightforward and will be especially familiar to psychologists who are trained in PE. The VA provides a Clinicians Guide on how to use the application for both Android and iPhone that also provides an outline of each session within the mobile application through the final scheduled session.

The app is also easy for patients to navigate but has very limited customization options.

PE Coach performs well, and I have not experienced any issues with it. The app works without internet and when in airplane mode. Data can be exported to a secure personal email and can also be erased within the app. This app does not replicate the recordings to other apps (e.g. Amazon music) or when downloading information off of a phone that other phone app recorders may automatically do.