This webinar is designed to inform providers as to how mobile applications like Virtual Hope Box can empower and engage patients in their own care. Clinicians will learn how to integrate the Virtual Hope Box app into their clinical practice supporting the mental health of military service members and their families. The "Hope Box" is a tool used to support patients who feel hopeless and may be considering suicide or self-harm. Therapists suggest that their patients fill a shoe box (or other container) with items that remind them of why their life is worth living, such as supportive letters from loved ones, their favorite music CDs, photos, reminders of their accomplishments, or a list of things they want to do. However, since such a box is awkward to carry, it may not always be handy when a patient needs it most. Using the principles of the original hope box, a smartphone app was created called the “Virtual Hope Box” (VHB). As with its namesake, patients choose items, but the “container” is more portable and more private—and it’s always with them. Patients can also add more-accessible types of content like music files and video files.

1. Integration of Virtual Hope Box
Mobile Application in Clinical Care
Nigel E Bush Ph.D. & Amanda Stewart, Ph.D.
16 OCT 2014

2. 2
Integration of Virtual Hope Box
Mobile Application in Clinical Care
October 16, 2014, 1-2:30pm (EST)
Presenters:
Nigel Bush, Ph.D.
Deputy Chief of Research
National Center for Telehealth & Technology (T2)
Joint Base Lewis McChord, WA
Amanda Edwards-Stewart, Ph.D.
Clinical Psychologist, Deputy Director of Emerging Technologies Program
National Center for Telehealth & Technology (T2)
Joint Base Lewis McChord, WA
Moderator:
Robert Ciulla, Ph.D.
Psychologist, Division Chief for Mobile Health Program
National Center for Telehealth & Technology (T2)
Joint Base Lewis McChord, WA

3. Learning Objectives
3
At the conclusion of this webinar, participants will be able to…”
• Describe the social paradigm shift to mobile health among younger
service members.
• Articulate the potential benefits of mobile personal technologies as
accessories to behavioral health treatment.
• Examine the value of clinical involvement in patient use of health related
smartphone apps.
• Incorporate key principles behind hope box use in clinical therapy.
3

4. Presenters
4
Nigel Bush, Ph.D.
U.S. Department of Defense
National Center for Telehealth & Technology (T2)
Deputy Chief of Research
University of Washington
Affiliate Associate Professor, Dept of Psychiatry &
Behavioral Sciences
nigel.e.bush.civ@mail.mil

5. Presenters
Amanda Edwards-Stewart, Ph.D.
U.S. Department of Defense
National Center for Telehealth & Technology (T2)
Clinical Psychologist, Subject Matter Expert
Deputy Director of Emerging Technologies
Program
Northwest University
Adjunct Professor
amanda.e.stewart7.civ@mail.mil
5

6. Disclosures
• The views expressed in this presentation are those of the
presenters and do not reflect the official policy of the U.S.
Department of Defense.
• We have no relevant financial relationships to disclose.
• We will be discussing web and mobile applications that have
been developed by the Defense Department, including those
developed by the National Center for Telehealth and
Technology (T2). Some of these applications may fall under
FDA device regulations, and in those cases we will consult
with the USAMRMC Division of Regulated Activities and
Compliance for guidance.
6

7. Making Self-Help Apps
7
Source: National Center for Telehealth & Technology (T2)

8. Augment Standard Care
8
Source: VA/DoD

9. VHB Overview
9
Source: National Center for Telehealth & Technology (T2)

10. Physical vs. Virtual
10
Source: National Center for Telehealth & Technology (T2)

11. Advantages of Virtual Hope Box
Conventional Hope Box: physically unwieldy and inconvenient- often not
available when patient needs it most during crises.
A “Virtual Hope Box” (VHB) takes common hope box practice and
uses smartphone vehicle and features to enhance access and
experience.
• Personal cellphone use extremely high among active and recently retired
military personnel
• Service members highly mobile. Need for psychological support most
likely to emerge in absence of healthcare providers.
• Smartphone apps can expand the reach of traditional therapeutic
interventions beyond the clinic and benefit from rich multimedia.
• Smartphone-based app allows for easily personalized VHB that is highly
portable and always available to a user in distress wherever they are.
11

12. US Service Members are Heavy Users of Smartphones
and Personal Technologies
97.4%
96.6%
96.6%
2013: % Using Mobile Phones at Home.
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Active SMs (n=151)
Guard/Reserve (N=29)
Military Veterans (N=57)
Bush NE, Wheeler WM. Personal Technology Use by US Military Service
Members and Veterans: An Update. Telemedicine and eHealth. 2014; In Press.
12

13. US Service Members are Heavy Users of Smartphones
and Personal Technologies
68.9%
78.8%
65.6%
97.4%
91.4%
87.4%
92.7%
31.1%
28.5%
24.9%
64.1%
26.3%
42.1%
87.6%
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Mobile Phone
Browsing Net
Email
Texting
Photos/Videos
Music
Games
2010/11 vs. 2013
% of Active Duty SMs Using Mobile Phones at Home.
Years 2010-2011 (N=273) Year 2013 (N=151)
Bush NE, Wheeler WM. Personal Technology Use by US Military Service
Members and Veterans: An Update. Telemedicine and eHealth. 2014; In Press.
13

14. Providers and Smartphones
14

15. T2 Virtual Hope Box
VHB designed as tool for use by MH
providers with patients as accessory to tx
Patient and MH Provider work together in
the clinic to populate VHB on patient’s own
smartphone with appropriate personalized
content
Patient uses VHB away from clinic and
continues to add/change content as
needed, with guidance from provider
15

16. Reminders:
Focuses the user on
cherished memories,
reminders in digital media:
Photos, videos, recorded
messages, music.
Distraction tools:
Puzzles/word search
games taken from user
content.
16
Preloaded inspirational
quotes can be
supplemented or replaced
by personal quotes, family
aphorisms, biblical
phrases, etc.
Relaxation tools:
controlled breathing tool,
progressive muscle
relaxation, guided
meditations.
User customized
support contacts,
hotline info.
Coping Tools:
(a) Coping Cards highlight
adaptive thoughts and
behaviors when in crisis or
managing problematic core
beliefs.
(b) Activity Planner used to
improve mood by engaging
in activities that are
meaningful.
T2 Virtual Hope Box

17. Example: Remind Me
Take photos
with phone,
select existing
photos from
phone, or
download
17

18. Example: Remind Me
Record
personal audio
or video with
phone, select
existing from
phone, or
download
18

19. Example: Remind Me
Select existing
music from
phone, or
download
19

20. Example: Remind Me
Select from collection of media in
multiple formats. Set Remind Me to
shuffle display.
20

21. Example: Relax Me
Selectable timing and
duration for inhale, hold,
and exhale
21

22. Example: Distract Me
Puzzle photos
and words
extracted from
existing user
content
Selectable
levels of
difficulty
22

23. Example: Coping Tools
23

24. Example: Coping Tools
24
John Doe

25. Example: Inspire Me
Dr. Bush’s Mother:
“Better to be kind
than clever”
25

26. Example: Contacts
26
John Doe

27. Pilot study: Cross-Over Design
Screening &
Enrollment
DBT Patients
1st Field
Testing:
PHB or VHB
6-8 Weeks:
Phone
Interviews
every 2 weeks
2nd Field
Testing:
VHB or PHB
6-8 Weeks:
Phone
Interviews
Baseline
Assessments
Construction of
2nd Hope Box
(PHB or VHB)
every 2 weeks Evaluation of
2nd Field Test
& Final
Assessments
Construction of
1st Hope Box
(PHB or VHB)
Evaluation of
1st Field Test.
Clinician
Focus Group
In Clinic Away from Clinic
27

28. Results: Baseline Demographics
Sex Male
Female
10
8
Age Mean
SD
Range
41.4
8.6
28-56
Race Hispanic
Asian/Pacific Islander
African American
White
Other/More than one
1
1
1
14
1
Education GED/HS
Some College
AA/Tech Degree
Bachelor’s Degree
2
8
4
4
Former
Military
Branch
Air Force
Army
Marine Corp
Navy
Coast Guard
3
8
1
5
1
Former Rank E1–E4
E5-E9
O1-O5
11
6
1
Deployment
Hx
None
Desert Storm
OIF
OEF
Vietnam
Other
9
2
5
4
1
3
• 18 US Service Veterans at high-risk-of-self-harm
• Entering the VAMC Portland Mental Health Clinic
DBT program for BPD or PTSD
• Identified as clinically suitable by their clinicians for
hope box utilization as part of treatment
• Own and regularly use/carry their own iPhones or
Android phones
PTSD/ Depression 3
PTSD/Bipolar II 1
Borderline Personality Disorder/ Anxiety Disorder 1
Borderline Personality Disorder/ PTSD 2
PTSD 2
PTSD/Opioid Dependence 1
Depression/ Alcohol Dependence 2
PTSD/ Bipolar 1
Mood Disorder NOS 1
Bipolar II/ Alcohol abuse 1
Borderline Personality Disorder/ Bipolar I 1
Borderline Personality Disorder/ Bipolar II 1
Borderline Personality Disorder/ Depression 1
Total 18
28

29. Results: Experience with Technology
Self-Rating of Computer Skills
Novice 1
Advanced beginner 3
Competent 6
Proficient 8
Total 18
Personal cellphone usage hours per week
Less than 1 1
2-5 3
6-10 5
More than 10 9
Total 18
Smartphone Use <1 Year 1-2 Years >2 Years
iPhone 4 4 2
Android 3 3 5
Blackberry 1 4 1
Windows 1 0 0
Smartphone Used
iPhone 9
Android 9
• Participants were relatively experienced
smartphone users, with nearly 80%
using a smartphone for 6 or more hours
a week
• Type of personal phone used for the
VHB were evenly divided between
iPhone and Android
29

30. Selected Pilot Study Results:
Downloaded VHB Usage Logs
Typical new App use in market place: 1-2 times, < 5 minutes, then uninstall
22% of apps used only once (Marketing Pilgrim. 2013. )
Only one in four apps engages user (Gahran A. CNNTech. 2011.)
VHB Usage
Detailed usage logs recorded for each patient (17/18) by VHB
VHB # of Days: VHB used on average one or more times on more than 13 separate
days (mean=13.58, range 4 - 43 days) away from the clinic
30

31. Downloaded VHB Usage Logs
Overall period of VHB use
14 Typical Users
3 High Users
Almost all patients used the VHB either intermittently or
regularly across several weeks away from the clinic.
• 15 of the 17 patients used the VHB for more than 2 weeks
• 13 used the VHB for more than 4 weeks
• 10 of 17 for more than 6 -8 weeks.
31

32. Downloaded VHB Usage Logs
Total Duration of VHB Use over All Days
The remaining three show exceptional commitment to
daily use of VHB, averaging 26 total hours of VHB
use.
Participants with total duration of use < 2.7 hours
Duration of VHB use amounted to an average of
more than one hour of total individual use for the
more typical 14 of 17 patients
Three outliers with total duration of use > 15 hours
32

33. Selected Pilot Study Results:
Downloaded VHB Usage Logs
Added by Patients Away from Clinic
After initial VHB setup, patients added a variety of personalized
media to their VHBs to fit their needs over time, as was intended.
• 483 new Photos
• 328 new Inspirational Quotes
• 184 new Music files
• 74 new Contacts
• 40 new Coping Cards
33

34. Self-Report Comparing VHB with Physical
Selected Results: Self-Report Comparing VHB with PHB
18
16
14
12
10
8
6
4
2
34
Compared to the Physical
Hope Box
More patients
a) used the VHB regularly;
b) found the VHB beneficial
and helpful;
c) found the VHB easy to set
up;
d) said they were likely to use
the VHB in the future and;
e) would recommend the VHB
to peers.
0
Found Setup
Easy
Used at least
1-4/wk
Hope Box (PHB)
Found Helpful &
Beneficial
Would consider
using in future
Would
recommend to
fellow vet or SM
# Patients
VHB/PHB Patient Feedback N=18
VHB
PHB

35. Self-Report Comparing VHB with Physical
Hope Box (PHB)
Compared to the Self-Soothing Box or
Physical Hope Box,
a) Twice as many patients preferred the
VHB for future use than the PHB.
b) Some recommended using both VHB
and PHB as a complementary
combination
c) None (0) of the patients would
recommend the PHB alone to fellow
veterans or SMs
d) 38.8% (7) would recommend the VHB
alone
e) 61.1% (11) would recommend the VHB
and PHB in combination.
4 Prefer VHB alone
9
4
for future use
Prefer PHB alone
for future use
Prefer Combination
of VHB & PHB for
future use
7
11
Would recommend
VHB alone to
fellow SM or Vet
Would recommend
PHB alone to
fellow SM or Vet
(none)
Prefer
Combination of
VHB & PHB for
future use
Reported Preferences between VHB and PHB
35

36. PHB Items Collected
Items collected and used by patients in Self-Soothing (PHB).
• blanket/soothing feeling
• rock
• I play with broken lighters to take mind
away from negative
• Pocket bible from uncle
• Stuffed animal
• Rock from Israel
• Bath salts
• relaxation cd
• coffee
• Sit by fireplace feeling warmth or failing
to determine how to keep fire lit :)
• Vanilla candle
• Jars of tears earrings (gift from sister
from Israel)
• Oils/scents - amber & sandalwood
• candy cane
• tea
• Quote cards
• A smooth stone from my therapist with a
positive message printed on it
• Deck of cards (to shuffle)
• vanilla/coconut oil
• Stone
• blanket
• coffee/tea
• articles (car related)
• Veterans crisis line reminder card.
• calming techniques cd
• rock, most useful
• Rocks
• Bath salts
• candy
• Children's hair
• Dried flowers from my father he gave
me flowers when I graduated DBT and I
dried them to keep them.
• Candy mints
• Scented bath crystals
• My un-plated dime
• Candles, incense, scented oil
• Shells
• movies
• Rock gold (iron pyrite)
• Stones
• My shells
• Lighting that can be adjusted/moved
• Pictures
• Marbles
• Small pillow of hair from my children
• My knife
• Notebook/journal for thoughts/ideas
• Loop (for jewelry)
• Loop (for jewelry)
• Magnetic balls
• Plastic baby doll
• My Monkey card
• Assorted colored rocks
• My collage
• cats
• baby doll
• stones
• canes
• sunflower seeds
• vanilla/coconut oil
• Candle with scented oils
• kids arts and crafts
• Sparkly rock
36

37. Comments Comparing Two Versions
Self-Soothing Box (PHB) “Tangible”, “Personalized”, “Want to be able to
physically touch”; “Having the smell, taste, and touch is
important sometimes”
VHB “Can take it everywhere with you”, “More convenient”,
“More private”, “More portable”, “With me all the time
and it's more effective”, “The other one I have to keep
at home”, “More accessible and easier to put together”,
“More options”, “Easier to remember to use”;
VHB and PHB Together “There is a benefit to both. PHB has tactile advantage,
VHB is more accessible”, “PHB can be more
comforting at times, but less convenient.” “The
convenience of the VHB and the tools it has, has been
beneficial”.
37

38. VHB Patient Feedback
38
Patient Feedback for VHB
Participants confirmed that they used the VHB application when they felt distressed or emotionally
overwhelmed, and spoke to the importance of the application being something private they could
access, whether at home, or in a crowded area
• “Helped numb away from distress. Quotes helped turn a negative self-image into a positive self-talk “
• “Keeps me grounded, there are options at what to look at, made it very personal”
• “Helped manage distress at work when having memory issues”
• “Controlled breathing helps me to relax. Pictures remind me that I have a reason to stay on the earth”
• “Quotes keep me thinking about who I am and gave me positive messages. Coping cards reminded
me that it is ok to not be perfect”
• “Helped to soothe when thought about cutting. Was distracting until felt better”
• “Helped manage PTSD symptoms like hyper-vigilance”
• “wouldn’t want to get rid of it”
• “It is soothing and prevent me from doing things like yelling at people in line, used
box instead to distract self”

39. VHB Patient Feedback
39
Patient Feedback for VHB
“Helped numb away from distress. Quotes helped
turn a negative self-image into a positive self-talk”
Participants confirmed that they used the VHB application when they felt distressed or emotionally
overwhelmed, and spoke to the importance of the application being something private they could
access, whether at home, or in a crowded area
“Controlled breathing helps me to relax. Pictures
remi“nQdu motee sth kaet eI ph amvee tah irnekainsgo na btoo ustt awyh oon I tahme eaanrdth g” ave
• “Helped numb away from distress. Quotes helped turn a negative self-image into a positive self-talk “
• “Keeps me grounded, there are options at what to look at, made it very personal”
me positive messages. Coping cards reminded me
that it is ok to not be perfect”
“Helped to soothe when thought about cutting. Was
distracting until felt better”
• “Helped manage distress at work when having memory issues”
• “Controlled breathing helps me to relax. Pictures remind me that I have a reason to stay on the earth”
• “Quotes keep me thinking about who I am and gave me positive messages. Coping cards reminded
“Helped manage PTSD symptoms like hyper-vigilance”
me that it is ok to not be perfect”
• “Helped to soothe when thought about cutting. Was distracting until felt better”
“It is soothing and prevent me from doing things like
yelling at people in line, used box instead to distract self”
• “Helped manage PTSD symptoms like hyper-vigilance”
• “wouldn’t want to get rid of it”
• “It is soothing and prevent me from doing things like yelling at people in line, used
box instead to distract self”

40. VHB Clinician Feedback
Clinician Feedback
• “I find the VHB to be a great tool for completing, working, collaborating with a client,
40
actively, in session. When I find that the focus of a session turns to themes of “I can’t do
anything”; “Nothing will work”; “I won’t do that”, this tool enables collaboration to
happen...”.
• “I think it’s great, super easy to use. I show it to all the clients I work with, even the non
DBT clients, to show them the range of other apps they can use. … there’s nothing I
didn’t like. I found it to be really, really easy to use, remarkably so…”
• “I think VHB could be used both therapeutically or more generalized to other vets. I found
it seemed beneficial to those who used it and were engaged with it, not just those with
suicidal ideation – good for distress tolerance in general.”
• “Lots of disorders could benefit, like PTSD, depression, anxiety – it could be generalizable
therapeutically. It’s not so specific that it only works for certain disorders.”
• “The biggest thing I did was coping cards. It was very powerful to observe and describe
their negative statements which were hard to identify as beliefs because they seemed so
true. That was a powerful intervention to have those discussions about beliefs vs. truths.

41. VHB Clinician Feedback
“I find the VHB to be a great tool for completing, working,
collaborating with a client, actively, in session. When I find
that the focus of a session turns to themes of “I can’t do
anything”; “Nothing will work”; “I won’t do that”, this tool
enables collaboration to happen...”.
“I think VHB could be used both therapeutically or more
generalized to other vets. I found it seemed beneficial to
those who used it and were engaged with it, not just those
with suicidal ideation – good for distress tolerance in general.”
“Lots of disorders could benefit, like PTSD, depression,
anxiety – it could be generalizable therapeutically. It’s not so
specific that it only works for certain disorders.”
Clinician Feedback
• “I find the VHB to be a great tool for completing, working, collaborating with a client,
41
actively, in session. When I find that the focus of a session turns to themes of “I can’t do
anything”; “Nothing will work”; “I won’t do that”, this tool enables collaboration to
happen...”.
• “I think it’s great, super easy to use. I show it to all the clients I work with, even the non
DBT clients, to show them the range of other apps they can use. … there’s nothing I
didn’t like. I found it to be really, really easy to use, remarkably so…”
• “I think VHB could be used both therapeutically or more generalized to other vets. I found
it seemed beneficial to those who used it and were engaged with it, not just those with
suicidal ideation – good for distress tolerance in general.”
• “Lots of disorders could benefit, like PTSD, depression, anxiety – it could be generalizable
“The biggest thing I did was coping cards. It was very
powerful to observe and describe their negative statements
which were hard to identify as beliefs because they seemed
so true. That was a powerful intervention to have those
discussions about beliefs vs. truths.
therapeutically. It’s not so specific that it only works for certain disorders.”
• “The biggest thing I did was coping cards. It was very powerful to observe and describe
their negative statements which were hard to identify as beliefs because they seemed so
true. That was a powerful intervention to have those discussions about beliefs vs. truths.

42. Market Place Feedback
42
Love it! Great app!
Love this app. Thanks you put it for free use It can save lives. I can carry VHB anywhere whether im deplyed or at home. Could be improved with more sharp sceneries and
sounds. It will be good idea if one has the option of playing a favourite game by storing it in the box apart from the few fixed ones in box.
Won't install on HTC Incredible 4G Looks great, but on installation it keeps giving an "unknown installation error: 919"
Finally! This is a great app for when you need a lift and some hope no matter where you are. Bravo!!!
WONDERFUL APP Incredible incredible app. Very helpful.
MA MFT Great app. I recommend it to my clients.
Inspiring As someone who suffers from depression and anxiety it can be hard for me to relax or focus on positive things. I have never found an app more perfect. I never
write reviews or rate but this app deserves it!!
Fantastic app My therapist recommended this app to me and I downloaded it immediately. I have suffered from anxiety and depression most of my life and I find this app
helps me tremendously. Can't recommend it highly enough.
Good app Very nice, helpful... I like it
Thank you I use the app everyday. And I have used plenty of apps but this one seems to be the best.
Highly recommend This is just what I was looking for as assistance following some intense therapy sessions. Highly recommend to anyone needing a variety of distractions
or grounding to use in different situations.
Joyful, relaxing and positive This app is so well balanced and is a positive and meaningful part of my recovery
Wonderful app! I use this app for myself and for my clients struggling with anxiety and depression. I love it and my clients love this app. I hope you all continue to update the
app often. Keep up the good work!
Like I just installed it and will recommend it to my patients, but I haven't added any content as yet. When I or my patients find it helpful, I can give a better rating.
Virtual hope box This app really helps me
Like the app for variety dont like that you can't play bg music when doing puzzles or playing games
More apps like this needed! Excellent app! This is the type of thing needed for today's youth and creating healthy ways to interact and use technology! Bravo! We will be
recommending this for our inpatient psychiatric adolescent patients!
A beautiful app I just love this APP. Kudo's to whoever designed this one!
Helpful It's a great start. The tools could be very useful and potentially save lives. I will be recommending this to my Soldiers.
Great Awesome app, has a few glitches on the music portion and the hold on the relax part, helps me when trying to sleep after a long day
amazing Amazing app!! I use this myself and recommend it to my clients! Love it!!!
Wow This is really really great. never found anything like this - for someone with ptsd & bipolar disorder, this is like a dream-App come true! thank you!
Excellent, take home tools for your clients in a teen friendly format
As a person who suffers from SAD and Bipolar this app is great for my down days and helps me get through those days where I feel like I'm stuck with no escape
Hallelujah! An app that I can use myself and recommend to my Soldiers. Well done, easy to use and simple. I will be using this app with all of my Soldiers in conjunction with
our HeartMath biofeedback sessions.
Amazing As a therapist this is the best app I've ever seen. Takes complete advantage of every capability of a smart phone. Just what the Dr. Ordered.

43. Market Place Feedback
“Wow This is really really great. never found anything like this
- for someone with ptsd & bipolar disorder, this is like a
dream-App come true! thank you”
43
“Inspiring Love it! Great app!
As someone who suffers from depression and
Love this app. Thanks you put it for free use It can save lives. I can carry VHB anywhere whether im deplyed or at home. Could be improved with more sharp sceneries and
anxiety sounds. It will be it good can idea if one has be the option hard of playing a for favourite me game by storing to it relax in the box apart or from the focus few fixed ones in on box.
positive
things. I have never found an app more perfect. I never write
reviews or rate but this app deserves it!!”
“Fantastic app My therapist recommended this app to me and
I Won't downloaded install on HTC Incredible 4G Looks it great, immediately. but on installation it keeps giving an I "unknown have installation suffered error: 919"
from anxiety and
Finally! This is a great app for when you need a lift and some hope no matter where you are. Bravo!!!
depression WONDERFUL APP Incredible incredible most app. Very of helpful.
my life and I find this app helps me
MA MFT Great app. I recommend it to my clients.
Inspiring As someone who suffers from depression and anxiety it can be hard for me to relax or focus on positive things. I have never found an app more perfect. I never
t“rJeomyfeunl,write reviews or rate d but roeulasxlyi.this app deserves n Cg it!!
aann'dt rpeocsoimtivmee Tnhdi sit ahpigph ilsy seon owuegllh b.”alanced and
Fantastic app My therapist recommended this app to me and I downloaded it immediately. I have suffered from anxiety and depression most of my life and I find this app
helps me tremendously. Can't recommend it highly enough.
is“Good Thank W a app opnodseitrivfuel Very nice, helpful... I like aanpdp it
!m I euasen inthgisfu al pppa rfto or fm myys erelfc aonvde rfyo”you I use the app everyday. And I have used plenty of apps but this one seems to be the best.
r my clients
Highly recommend This is just what I was looking for as assistance following some intense therapy sessions. Highly recommend to anyone needing a variety of distractions
struggling or grounding to use in different with situations.
anxiety and depression. I love it and my
Joyful, relaxing and positive This app is so well balanced and is a positive and meaningful part of my recovery
clients Wonderful app! I use love this app for myself and for my clients struggling with anxiety and depression. I love it and my clients love this app. I hope you all continue to update the
app often. Keep up the good work!
this app. I hope you all continue to update the app
often. Keep up the good work!”
“More apps like this needed! Excellent app! This is the type of
thing needed for today's youth and creating healthy ways to
interact and use technology! Bravo! We will be
Like I just installed it and will recommend it to my patients, but I haven't added any content as yet. When I or my patients find it helpful, I can give a better rating.
recommending this for our inpatient psychiatric adolescent
patients!”
“As a person who suffers from SAD and Bipolar this app is
great for my down days and helps me get through those days
where I feel like I'm stuck with no escape ”
Virtual hope box This app really helps me
Like the app for variety dont like that you can't play bg music when doing puzzles or playing games
More apps like this needed! Excellent app! This is the type of thing needed for today's youth and creating healthy ways to interact and use technology! Bravo! We will be
recommending this for our inpatient psychiatric adolescent patients!
A beautiful app I just love this APP. Kudo's to whoever designed this one!
Helpful It's a great start. The tools could be very useful and potentially save lives. I will be recommending this to my Soldiers.
Great Awesome app, has a few glitches on the music portion and the hold on the relax part, helps me when trying to sleep after a long day
amazing Amazing app!! I use this myself and recommend it to my clients! Love it!!!
Wow This is really really great. never found anything like this - for someone with ptsd & bipolar disorder, this is like a dream-App come true! thank you!
Excellent, take home tools for your clients in a teen friendly format
As a person who suffers from SAD and Bipolar this app is great for my down days and helps me get through those days where I feel like I'm stuck with no escape
Hallelujah! An app that I can use myself and recommend to my Soldiers. Well done, easy to use and simple. I will be using this app with all of my Soldiers in conjunction with
our HeartMath biofeedback sessions.
Amazing As a therapist this is the best app I've ever seen. Takes complete advantage of every capability of a smart phone. Just what the Dr. Ordered.
“Hallelujah! An app that I can use myself and recommend to
my Soldiers. Well done, easy to use and simple. I will be
using this app with all of my Soldiers”
“Amazing As a therapist this is the best app I've ever seen.
Takes complete advantage of every capability of a smart
phone. Just what the Dr. Ordered.”

44. Need for More Awareness
44

45. Current Status
1. Release: Revised production VHB released as free app to
45
Android and IOS marketplaces March/April 2014.
• 500-600 downloads/week, 10,000 total by September 8.
2. RCT: New 2 year MSRC RCT: 100 VA patients at elevated risk
for suicidal self-harm behaviors:
• VHB vs. TAU for 12 weeks with measures at baseline, 3
weeks, 6 weeks and 12 weeks.
• Effectiveness of VHB smartphone app to a) reduce
severity of suicidal ideation; b) increase ability to cope with
stressors and; c) increase perceived reasons for living,
both pre-post and compared to TAU

46. Individual vs. Group Therapy
• Research above is largely based on
Individual therapy but skills building is
often done in a group setting
• Using VHB in IOP
46

47. In Session
(1). Emergency Contact
(2). Remind me
47

48. In Session Work
(1). Coping Cards
(2). Activities
48

49. Clinician Buy-in
• Train-the-trainer model used in IOP
• Do they have a smartphone?
• Do they know how to use it?
• Do they have the time to learn the app?
• Privacy/Security concerns
– Understanding a EULA
49

50. Call to Action
• Military provider’s technology use, in the
support of treatment, is limited and less than
medical providers use.
• Several mobile applications exist to support
gold standard treatments such as PE, ACT,
CPT, DBT, CBTi.
– As well as applications that support therapy
efforts (PES, mindfulness training)
• Education and training efforts should be
made to increase use of such technologies
among DoD and VA providers.
50

51. Translation into Practice:
Downloads & User Guides
51
o Android
https://play.google.com/store/apps/details?id=co
m.t2.vhb
o IOS
https://itunes.apple.com/us/app/virtual-hope-box/
id825099621?mt=8
o Downloadable Clinician and Patients Use Guides
http://www.t2health.org/apps/virtual-hope-box
http://www.t2health.dcoe.mil/apps/virtual-hope-box
Paper of results : Bush NE, Dobscha SK, Crumpton R, et al. A Virtual
Hope Box Smartphone App as an Accessory to Therapy: Proof-of-Concept
in a Clinical Sample of Veterans. Suicide & Life-Threatening Behavior.
2014. DOI: 10.1111/sltb.12103
Android
IOS

52. Does it Work? Recent Email
-- "I wasn't sure who to contact about this. I was going to leave a comment on the
Facebook post about this, and maybe still will, just feeling a little sensitive and not
sure how much to share on such a public forum. Anyway, I just wanted to say a
huge thank you for putting the VHB out and for whomever posted it on fb when they
did. The last few weeks have been especially hard. I suffer from PTSD and have
been going through a lot of trauma therapy. The past 3-4 days I have come to the
point of suicide. Made all the plans, wrote the notes, etc. Then I came across the
VHB post. Now I know I am not a clinician, but I looked [at] the guide and
downloaded the app anyway. I use the PE Coach regularly and thought why not see
what the VHB is about. As I started adding pictures and videos and songs I found
myself smiling and feeling better. I started thinking, okay maybe life isn't so bad that
I need to end it. I knew I needed to just get through this hard time and that the sun
will shine again. I am rambling, but I sincerely wanted to thank you. You and your
company and what you guys are putting out here for those that suffer from mental
illnesses is saving lives. You saved mine today."
(T2 followed up with this individual and ensured they put a good safety plan in place.
In addition they facilitated a visit to the person’s therapist).
52

53. References
• Bush NE, Dobscha SK, Crumpton R, et al. A Virtual Hope Box Smartphone App as an Accessory
to Therapy: Proof-of-Concept in a Clinical Sample of Veterans. Suicide & Life-Threatening
Behavior. 2014. DOI: 10.1111/sltb.12103
• Bush NE, Wheeler WM. Personal Technology Use by US Military Service Members and Veterans:
An Update. Telemedicine and eHealth. 2014; In Press
53

54. Amanda Stewart, Ph.D.
amanda.e.stewart7.civ@mail.mil
54
Nigel Bush, Ph.D.
nigel.e.bush.civ@mail.mil
http://t2health.dcoe.mil/

55. Product Brief
55

56. Questions?
 Submit questions via the
Q&A box located on the
screen.
 The Q&A box is monitored
and questions will be
forwarded to our
presenters for response.
 We will respond to as many
questions as time permits.
56

57. DCoE Contact Info
DCoE Outreach Center
866-966-1020 (toll-free)
dcoe.mil
resources@dcoeoutreach.org
57

58. Save the Date
Next DCoE TBI Webinar:
Thursday, November 13th, 2014, 1-2:30pm EST
Technology Interventions for TBI
Presenter: David Cooper, PsyD
Next DCoE Psychological Health Webinar:
Thursday, November 20th, 2014 1-2:30pm EST
Technology Interventions for Psychological Health
Presenters: Robert Ciulla, Ph.D. & Don Workman, Ph.D.
Next DCoE Behavioral Health Technology Webinar:
Wednesday December 17th, 2014, 1-2:30pm EST
Evidence base for using Technology Solutions in Behavioral Health Care
Presenters: Nancy Skopp, Ph.D. & Jae Osenbach, Ph.D.