by Bradley C. Riemann, PhD and Rachel C. Leonard, PhD
This article was initially published in the Winter 2013 edition of the OCD Newsletter.
New technologies have paved the way for a wide variety of mobile treatment options for OCD, including smartphone-based applications (aka “apps”), and internet and computer-based software programs. These apps and programs have the advantage of being widely accessible, and in some cases can provide lower cost alternatives to traditional therapy. In this article we attempt to provide a basic overview of some of these programs. None of our comments should be viewed as a critique or an endorsement of any of these products.
OCD Challenge is an internet-based program developed by the Peace of Mind Foundation. OCD Challenge is an on-line behavioral “self-help website” that is based on the principles of exposure and response prevention (ERP), one of the most effective treatment options for OCD. The OCD Challenge program was developed with input and commentary from leaders in the field of ERP. According to the website, this program takes approximately eight to twelve weeks to complete, and moves the user through three modules.
The first module, Assessment, requires users to complete various questionnaires to assess their own OCD symptoms. In the second module, Gaining Awareness, users learn the results of these assessments including identification of their specific obsessions and compulsions. This module also explains the basics of ERP and how it works. During this module an “exposure hierarchy” is created ranking each obsession or compulsion by order of severity based on the user’s assessment results. This hierarchy lists various exposure activities for the user to try without engaging in rituals, with the most anxiety-producing activities ordered towards the end of the hierarchy, so that the user begins with simpler exposure activities and gradually progresses towards the more difficult challenges. The final module, Intervention, involves the user working through the exposure hierarchy. As the user completes more and more of their hierarchy they move up the “OCD Mountain” shown on the screen. When all items on the hierarchy are completed, the user reaches the top of the mountain and the program concludes. A research study of the effectiveness of the OCD Challenge program is currently being conducted with early results expected later in 2013. OCD Challenge is available free of charge at www.ocdchallenge.com.
Another internet-based program is BT Steps. Like OCD Challenge, BT Steps incorporates the principles of ERP. BT Steps was developed by OCD researchers John H. Greist, MD, Isaac M. Marks MD, and Lee Baer, PhD roughly 20 years ago as a telephone-based treatment program. Today, it is available as a internet-based program, but the concept remains the same. In BT Steps, users progress through six different steps, starting with learning more about OCD and how it affects them. In the second step, users are provided with information on cognitive behavioral therapy (CBT) and ERP so that they can determine if exposure treatment is right for them. Following this, users are guided through the process of identifying triggers across different OCD symptom dimensions. Then detailed information on how to complete an exposure trial is provided and users are prompted to complete their first exposure session. In the fifth step, users work to refine their exposure technique. The final step focuses on maintenance of gains that users have made throughout the program. Research studies of the original phone-based BT Steps found the program to be effective in lowering OCD symptoms when compared with relaxation techniques, though BT Steps was not as effective as traditional clinician-supervised ERP. The new online version of BT Steps is currently being evaluated through a clinical trial funded by the National Institute of Mental Health. For more information about the program and to find out when it will be available to the general public, please contact Revere Greist at firstname.lastname@example.org or by telephone at (608) 556-0766.
Cognitive Retraining Technologies has developed several software programs for treating anxiety, including a program aimed specifically at fear of germs and contamination using a method known as Attention Retraining. This technique is based on the premise that individuals with OCD have been found to focus their attention on threat cues (i.e. triggers) related to their fears of contamination. Attention Retraining teaches users to retrain their attention away from these types of cues (for example, germs and contamination) to cues that they don’t fear called “neutral cues.” This method has been supported by research conducted by Dr. Nader Amir. The Fear of Contamination and Germs Relief Program, as well as other anxiety relief programs, is available for download for $139.99 from www.managingyouranxiety.com.
In addition to these computer-based self-help programs there are also several other smartphone apps available
Decontamination OCD Retrainer is a free smartphone app launched by Neurosail, which also uses Attention Retraining in a similar fashion to the software program described above. This app is available for free on the iTunes store for Apple mobile devices.
Live OCD Free by Pocket Therapist, LLC is an ERP-based smartphone app developed by Kristen Mulcahy, PhD. Within this app users develop their own exposure hierarchy and set reminders to complete exposure trials. Following each exposure trial, users record their anxiety. Users can also record the number of times per day they resist or give in to urges to ritualize. The app also asks users to rate their anxiety on a weekly basis. Users receive progress reports regarding their exposures, engagement in rituals, and weekly anxiety ratings, and these progress reports can then be emailed to a treatment provider if applicable. This app includes separate versions for adults and children. In the child version, users fight the “Worry Wizard” and are taught that giving in to the requests of the Worry Wizard will make the Wizard and their worry or anxiety stronger. The wording within this version is also more child-friendly; however, the basic concepts remain the same across both versions. There is also an online forum provided for additional support (www.liveOCDfree.com). The LiveOCDFree app is currently available for $79.99 through the iTunes store for Apple mobile devices.
The Anxiety Coach app by the Mayo Clinic was developed by Stephen Whiteside, PhD and Jonathan Abramowitz, PhD. Within this app users start by completing a short test to assess the severity of their symptoms. They then create a personal treatment plan that targets their specific fears or worries. To assist with the development of the treatment plan, the app allows users to browse over 500 activities designed to assist with symptoms of OCD, panic attacks, social anxiety, specific fears, separation anxiety, general worries, and anxiety related to trauma. Users can also add in their own hierarchy items. The Anxiety Coach prompts users to track their anxiety before each exposure trial, and then in two-minute intervals throughout the exposure trial, until they reach a 50% reduction in anxiety. When this happens they can then choose whether to check the item off of their list or keep it for continued practice. Anxiety Coach allows users to record and view their progress over time. If the user’s anxiety is more severe the app provides tools to help users learn when and how to seek professional assistance. Anxiety Coach costs $4.99 and is available for Apple mobile devices through the iTunes store.
iCounselor OCD is an app designed to teach users skills to help them with OCD symptoms. Users are asked to rate the frequency and strength of OCD-related thoughts. They are then presented with various skills sets. The first involves calming activities for the user to perform, such as progressive muscle relaxation, breathing techniques, imagery, and focusing on the present moment. The second skills set involves working to change OCD-related thoughts, and the third skills set works to help users resist engaging in rituals through either completely resisting the ritual, or through other techniques, such as delaying or changing the ritual. After using the different skills, users are prompted to rate their OCD symptom severity again to determine whether the skills were helpful. If the user has not experienced a significant decrease in anxiety, they are given the opportunity to practice the skills again. iCounselor OCD is available for Apple mobile devices through the iTunes store for $0.99.
Finally, OCD Manager, launched by Gareth Jones with content developed by Cheryll Meikle, MSc, is an app based on CBT and rational emotive behavior therapy. This app includes information on OCD as well as audio recordings, such as mindfulness of breathing and a “body scan” mindfulness exercise. OCD Manager also includes a “challenges” section in which users can choose from pre-programmed exposure activities, or add in their own. It also includes a section on “rational thinking” that guides users through the process of challenging some of their irrational beliefs. OCD Manager is available through the iTunes store for $19.99.
Computer-assisted and smartphone-based self-help programs such as these are likely to become much more common with time. Most current programs utilize CBT principles that have been found to be effective in treating OCD. Others, however, are using newer treatment methods, such as Attention Retraining. Users of any of these programs may find them effective — indeed some have research support backing their use. However, for some it may be more appropriate to use these programs in conjunction with ongoing treatment with a CBT provider.
Dr. Bradley Riemann is the Clinical Director of the OCD Center and CBT Services at Rogers Memorial Hospital. He is also Chair of the Clinical Advisory Committee and a member of the Scientific Advisory Board of the IOCDF. Dr. Rachel C Leonard is a full-time psychologist at Rogers Memorial Hospital in Oconomowoc, Wisconsin. She specializes in cognitive-behavioral therapy approaches for the treatment of anxiety disorders and depression.