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Background “People always judge me negatively, they watch and gossip about me everywhere I go. I don’t even feel safe at home. I’m so anxious and overwhelmed. I wish I could feel safer and do more with my life.” (Robert) Paranoid thoughts, like those experienced by Robert, affect approximately 1 in 5 of the general population (Bebbington et al, 2013). They are one of the most common symptoms of schizophrenia-spectrum disorders, which are estimated to cost the UK economy 11.8 billion pounds a year (Schizophrenia Commission, 2012). Promisingly, talking therapies have been shown to be effective in targeting the psychological mechanisms that play a causal role in paranoia, such as thinking habits, thereby reducing distressing thoughts (Garety & Freeman, 2013; Waller et al, 2015). However, treatment effects are in the small to medium range, and there are significant barriers to implementation (Schizophrenia Commission, 2012). Obstacles include training and delivery costs, and problems with access, uptake and adherence. People may not be motivated to engage in therapy or struggle to use strategies learnt outside of sessions (Garety et al, 2014). Psychological interventions for paranoia need to be improved so they have a meaningful, sustained impact on people’s everyday lives. Digital technology presents unique opportunities for empowering clinicians and service users to make use of talking therapies, thereby enhancing outcomes and reducing costs (Hollis et al, 2015). However, despite the rapid growth in digital health, a multidisciplinary, user-centred design method is rarely used (Alvarez-Jimenez et al, 2014; Donker et al, 2013). Digital solutions are often not tailored to specific clinical populations and service contexts, and are therefore unlikely to facilitate significant change in health-related behaviours (Patel et al, 2015). Interventions should be sensitively designed to address well-established challenges to access, engagement and adherence in complex clinical populations. Aim This study aimed to improve therapy outcomes in psychosis by developing a user-centred digital solution as an adjunct to an existing, evidence-based intervention targeting thinking habits associated with paranoia (Waller et al, 2015). Method We initiated the first UK collaboration of healthcare design researchers, digital health experts and clinician academics to develop a digital design solution to improve therapy outcomes in psychosis. Our user-centred inclusive design approach was informed by the Design Council’s (2005) double diamond method consisting of discover, define, develop and deliver phases (see Figure One). As an inclusive design project, stakeholders (service users, clinicians and researchers) were involved from the outset, with interviews iteratively conducted to generate and validate hypotheses regarding possible design solutions. In the 'discover' phase our research included literature review, observing therapy sessions, system mapping of the contexts in which therapy was delivered, together with research into behaviour change models and new technologies. Workshops were held at the 'define' phase to synthesise the research insights, from which the area for achieving maximum impact on outcomes and the aim of the eventual design brief were defined. The insights highlighted the need to improve the efficiency of the in-session process, for service users to feel more supported outside of sessions, and to improve the enjoyment of the therapy experience, whilst reducing information processing demands. We therefore aimed to explore the potential for mobile technologies to support the delivery of the therapy. In the 'develop' phase, during collaborative ideation workshops, we generated over 60 concepts. Working closely with service users and clinicians, we gradually distilled them and developed three concepts: bubbles, where thoughts are visualised as bubbles that can be influenced by our actions; journey, where therapy is a journey with incremental progress, challenges and achievements; and interaction, which focuses on providing simple, habitual tools for coping with upsetting thoughts. We then conducted three phases of user testing, one focusing on narrative and the others on optimal ways of monitoring and coping with thoughts through interaction with the app. The 'deliver' phase consisted of iterative development of the Thinkthru app including rapid prototyping, storyboarding and eventual coding, with an emphasis on user testing and feedback at every stage. Results Based on our inclusive design method, we produced the Thinkthru app (see Figure Two). The app supports users by providing a means of monitoring their thoughts and applying tips learnt during therapy, to assist them in developing alternative, less distressing explanations for their experiences. Users visualise their thoughts as bubbles and adjust their size according to how much distress they cause (see Figure Three). Thinking habits are represented through bubbles spinning faster or slower. Faster spinning reflects less helpful thinking, and users are prompted to slow down their thought bubbles and offered tips to support them in developing alternative ideas (see Figure Four). Users audio or text record information they notice in response to the tips and store their alternative explanations, which can then be easily retrieved if the distressing thought occurs again in the future. Importantly, the app's intuitive interface is more appealing to users than traditional talking therapy tools and it reduces information processing demands. Preliminary feedback indicates users feel more supported outside of sessions and able to cope with paranoia in their daily lives. Conclusion A mobile app appears to be a feasible means of addressing barriers to access, uptake and adherence in talking therapies for psychosis, and may reduce costs and improve outcomes. Wellcome Trust funding has recently been obtained to investigate integrating wearable technology into the app, with the aim of increasing its sensitivity to user needs and further reducing processing demands. A Thinkthru digital platform is also being designed for use during therapy sessions and will be synchronised with the app. Further investigation of the platform and app’s potential to facilitate meaningful behaviour change is warranted, and a feasibility study and randomised controlled trial are planned.
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