Life with FOCUS: A qualitative evaluation of the impact of a smartphone intervention on people with serious mental illness

Abstract

Objective:

A growing body of literature indicates that mobile health (mHealth) interventions that utilize smartphones for illness management are feasible, acceptable and clinically promising. In this study, we examine how individuals with serious mental illness use a mHealth intervention, FOCUS, to self-manage their illnesses. Additionally, we explored participant perceptions of the intervention’s impact on their subjective illness experience.

Methods:

We analyzed qualitative data from 30 individuals with serious mental illness who participated in one of two community-based, 3-month trials of FOCUS. In Study 1, weekly calls were conducted by a mhealth specialist to facilitate and enhance intervention use. In Study 2, researchers conducted qualitative interviews to gather detailed perspectives of intervention use. Data were sampled from the weekly call notes and qualitative interviews and analyzed using a thematic and collaborative approach.

Results:

Thematic analyses revealed six recurring themes. Three themes emerged in regard to participants’ ongoing daily use of FOCUS: “Back Up” Support, Symptom Management, and Self-Awareness. Another three themes emerged related to the intervention’s impact on participants’ recovery processes: Acceptance of Symptoms, Motivation and Supporting Positive Outlook.

Conclusions and Implications for Practice:

This qualitative study offers insight into how individuals with serious mental illness made use of a mHealth intervention designed to support illness self-management. Our findings suggest that individuals may benefit differently from mHealth interventions depending on where they are in the recovery process. As mHealth interventions become increasingly popular in clinical settings, it is important to understand consumers’ short-term and long-term benefits from these interventions.

Serious mental illnesses, such as schizophrenia, bipolar disorder, and major depression affect approximately 6% of the U.S. population (Kessler et al., 2008). Despite recent advances in psychological interventions, many individuals with serious mental illnesses are unable to access and engage in treatments due to a range of barriers, including perceived stigma (Berry & Haddock, 2008; Clement et al., 2015), treatment costs, (Berry & Haddock, 2008), and limited availability of trained mental health care professionals (World Health Organization, 2016).

Over the last decade, researchers and technology developers have sought to mitigate these barriers in care by developing smartphone and web-based mobile health (mHealth) programs focused on psychoeducation (Barnes et al., 2011; Depp et al., 2015; Rotondi et al., 2005; Wenze et al., 2013), self-management (Ben-Zeev et al., 2013a; Todd et al., 2013; Todd et al., 2014) and symptom monitoring (Ainsworth et al., 2013). Evidence shows that individuals with serious mental illness typically own mobile phones, including smartphones that can host mHealth software (i.e., “apps”), and that they are interested in using them to receive mental health services (Ben-Zeev et al., 2013b; Firth et al., 2015). There is also growing evidence that mHealth interventions are feasible, acceptable, and clinically promising among individuals with serious mental illness (Ben-Zeev et al., 2014; Ben-Zeev et al., 2016; Ben-Zeev et al., 2018; Granholm et al., 2011). However, missing from the literature is insight into how individuals apply the skills and knowledge learned from these interventions into their everyday lives. Qualitative research can enhance our understanding of the impact mHealth has on the daily lives of people with serious mental illness (Berry et al., 2016).

In the current paper we explore how individuals with serious mental illness integrate a mHealth intervention into their daily lives. Our team used a qualitative approach to evaluate individuals’ use of FOCUS, a smartphone-based mHealth intervention, to self-manage their mental illness and explore perceptions of the intervention’s impact on their subjective experience and recovery. Through analyses of weekly call notes, we aimed to better understand how individuals integrate lessons and coping skills from the intervention to manage their day-to-day symptoms. Additionally, we analyzed semi-structured qualitative interviews, to deepen our understanding of satisfaction and engagement as well as participants’ retrospective perspectives on how their illness management changed over the course of a 12-week deployment of the FOCUS intervention. Our overall goal was to inform future development of the FOCUS intervention and similar mHealth interventions.

Methods

Description of the mHealth intervention

FOCUS is a smartphone-based mobile intervention that was developed to provide individuals with serious mental illness a real-time illness management support tool that targets auditory hallucinations (i.e., voices), social functioning, medication use, mood problems, and sleep disturbances (Ben-Zeev et al., 2014). The intervention prompts users to engage daily via auditory signals and visual notifications that appear on the screen. When prompted, users are asked questions about their symptoms using multiple-choice options. Based on their self-ratings, FOCUS delivers an intervention containing illness management suggestions and support statements in written text with images, audio clips, or videos. Participants’ use data (e. g., responses to self-assessments) are transmitted to a secure server when the smartphone is connected to the Internet via mobile data plan or Wi-Fi. Once data are transmitted, clinicians or researchers can view summaries of the participants’ responses in real time via a secure online dashboard.

Each participant works with a mHealth specialist (i.e., a human support personnel designed to help facilitate intervention use) (Jonathan et al., 2017), to get set up with a smartphone with an active data plan and participate in a tutorial on how to use the device (e.g., making calls, sending messages, changing volume). After the introductory meeting, the mHealth specialist reviews participant responses on the secure dashboard and calls participants once a week to check-in. During this call, participants are encouraged to share their experiences integrating the intervention into their daily routine and ask any technical questions about the intervention or the phone. After completing 12-weeks of the FOCUS intervention, participants met with the mHealth specialist for a final debrief meeting where they returned the smartphone and discussed the impact of the intervention and the skills they learned.

Qualitative Data Sources

This paper leverages qualitative data from two community-based trials of FOCUS in order to construct a more complete understanding of how participants apply illness self-management skills from a mHealth intervention in their daily lives. Study 1 was a pilot randomized controlled trial completed in Manchester, New Hampshire. Study 2 was a comparative effectiveness study completed in Chicago, Illinois. Study 1’s qualitative data consisted of detailed notes taken during weekly calls with participants. Semi-structured interviews were conducted for Study 2 after participants completed the 12-week FOCUS intervention. These two differing sources of data allow insight into two complementary levels of analysis. Weekly call notes (Study 1) taken each week offer a prospective view of participants’ ongoing use of FOCUS. Semi-structured interviews administered approximately 2-months post-trial (Study 2) provide insight into what aspects of FOCUS continue to inform participants’ illness self-management and a broader view of how FOCUS has impacted participants’ recovery processes. Weekly calls and interviews were conducted by members of the research team between October 2015 and March 2017.

In Study 1, calls were conducted weekly by a mHealth specialist (GJ) and lasted between five and fifteen minutes. During these calls, participants were asked questions about their experiences integrating the FOCUS intervention into their everyday routine (e.g., “Did you try out the sleep tips you received today? How did it go?”). They were also encouraged to share what they liked about the intervention and to describe the challenges they faced in using the intervention.

In Study 2, qualitative interviews were conducted by three researchers (GJ, ECS, RW) trained in qualitative interviewing and experienced in working with people with serious mental illness. The interview guide used participant satisfaction, engagement, and clinical outcomes as points of departure for analyses and was refined and expanded upon according to nuances that emerged from the interviews, in accordance with the principles of grounded theory (Charmaz, 2006; Corbin & Strauss, 1990). The interviews inquired into the following domains: (1) overall perspectives on FOCUS; (2) level of engagement with FOCUS; (3) FOCUS in relation to illness experience; and (4) FOCUS in the context of other mental health services. Interviews were 45–60 minutes long and were audio-recorded and back-up notes were taken, including researchers’ reflections and observations.

Data Collection and Analysis

Study 1 was approved by the Institutional Review Boards of the New Hampshire Department of Health and Human Services and Dartmouth College. Study 2 was approved by the Institutional Review Boards of the University of Washington and Dartmouth College and monitored by an independent safety monitoring board at Dartmouth’s Department of Psychiatry. Participants in both studies completed informed consent.

Individuals were eligible to participate in the studies if they; (1) had a chart diagnosis of schizophrenia, schizoaffective disorder, bipolar disorder, or major depressive disorder; (2) were 18 years or older, (3) had a rating of “3” or lower on one of three items which comprise the Domination by Symptoms factor from the Recovery Assessment Scale (RAS) (Corrigan et al., 2004), indicating a need for services. Individuals were excluded if they had: (1) hearing, vision, or motor impairment that made it challenging to operate a smartphone, (2) English reading level below 4^th grade, or (3) in Study 2, received FOCUS intervention in the past three years.

In Study 1, thirteen FOCUS participants completed 10 or more weekly check-in calls with the mHealth specialist and their weekly notes were used for data analysis. In Study 2, sixteen FOCUS participants engaged in interviews approximately 2 months after they completed the 12-week intervention. For the qualitative interviews, our team used purposive sampling to select individuals who ranged in engagement with FOCUS to capture positive and negative sentiments about the intervention. Participants were offered $30 compensation for their participation in interviews.

The first author (GJ) led the analysis in consultation with a medical anthropologist and qualitative mental health services researcher (ECS). Weekly calls for Study 1 were typed verbatim by the mHealth specialist (GJ). Interviews from Study 2 were audio recorded, then transcribed by a professional transcription service. Interview transcripts were uploaded to Dedoose (Dedoose, 2015), a web-based qualitative analysis platform and independently coded by the first author (GJ). We used a team approach to develop a codebook based on domains and categories in the interview guide, as well as inductive review of transcripts. The codebook was refined as transcripts were coded. Three members of the research team reviewed all text excerpts from the weekly calls and interview transcript excerpts aggregated by code using a thematic analysis approach (Braun & Clarke, 2006). Themes were constructed through continued immersion in the dataset and dialogue amongst team members to reach consensus on the main themes and illustrative quotes reported herein (GJ, ECS, RB).

Results

Participants

The total sample from both studies consisted of thirty individuals; sixteen of which took part in qualitative interviews (Study 2). Table 1 summarizes the combined participants’ demographic characteristics. Collectively, the mean age of the sample was 48 (SD=12) years. The majority were male (60%), Caucasian (47%) and had a diagnosis of schizophrenia or schizoaffective disorder (70%). Most reported unemployment (87%), had a high school diploma or higher (77%) and lived independently (63%). About half of the participants had six or more hospitalizations in their lifetime (47%). Although the majority had some form of prior smartphone experience (73%), less than half (46%) actually owned a smartphone.

Table 1.

Sample Demographics(n=30)

Age, mean (SD)	48 (12)
Qualitative Interviews	16
Weekly Call Notes	14
Gender
Male	18
Female	12
Diagnosis
Schizophrenia	13
Schizoaffective disorder	7
Major depression	6
Bipolar	2
Psychosis NOS	1
Race
Caucasian	14
Black/African American	12
American Indian	1
More than one race	3
Education
≤ Some high school	7
≥ High school diploma	23
Living Situation
Independent	19
Assisted/Support Living	6
Living with family	5
Past hospitalizations
0	1
1 – 5	15
6 – 10	6
11 – 15	5
20 +	2
Past smartphone experience?
Yes	22
No	8

Overview

Three themes emerged in regard to participants’ ongoing daily use of FOCUS: ‘Back Up’ Support, Symptom Management, and Self-Awareness. Another three themes emerged related to the intervention’s impact on participants’ recovery processes: Acceptance of Symptoms, Motivation, and Supporting Positive Outlook. These six themes are described and expanded upon with exemplary quotations below.

24/7 ‘Back Up’ Support

Most striking was participants’ use of FOCUS as an alternative support resource when their clinician or care team was unavailable. Rather than calling the clinic after business hours, many turned to FOCUS for immediate feedback about their symptoms:

“[FOCUS] helps when I cannot reach my case manager or when there isn’t an opportune moment to call somebody. It’s always there to help.” – Study 1, ID 10

FOCUS also was noted to be helpful in reducing the need for calls and visits with their clinical teams, since the skills provided helped resolve minor disputes or concerns (e.g., conflicts with friends, brief questions about symptoms).

“Before FOCUS, I was always bugging my therapist and waiting to see her. With FOCUS, I have the tools available I [can] hit into any time… Like if I heard voices, I would use FOCUS to calm down. The next time I saw my therapist, I would tell her what happened.” – Study 1, ID15

FOCUS offered some individuals an opportunity to seek guidance for symptoms that they were apprehensive to discuss with their care team because of concerns about having their medication increased. The intervention served as an outlet for participants to vent and receive advice:

“I used [FOCUS] for like my mood. If I’m having a bad day usually I [tell] my case manager but not all the time. I feel pressured to tell [her] that I’m in a good mood, otherwise they might up my medicine.” – Study 1, ID42

A few participants cited the intervention’s flexibility and availability as a reason that they would prefer the intervention to replace face-to-face care all together:

“I would prefer [FOCUS] to take the place of doctors; it makes things easier for people with problems instead of having to go to appointments all the time. I could just check right in when I was upset.” – Study 1, ID 15

By contrast, several participants felt that although FOCUS was accessible, it should only be used in conjunction with face-to-face care because in-person treatment provides more options:

“You can go into [FOCUS] and it is convenient whenever you need to use it. The downside is that I have more options when I discuss things with my case manager.” – Study 1, ID 39

Symptom Management

Participants used FOCUS to log, monitor, and track their symptoms. Participants felt in control of their symptoms when using FOCUS, since the program offered strategies and reminders in the moment when needed:

“FOCUS reminded me of things a couple of times, things that were right in front of me but I couldn’t register them. I need to be reminded regularly to hang in there and that I matter and to find a quiet place. FOCUS helped me learn to take my medication on time in the morning but also kept reminding me to keep busy. It’s a really positive way to spend my time.” – Study 1, ID08

Some participants were excited about using a program to manage their symptoms on a day-to-day basis. A few participants said that it was the first time they had ever tried to monitor or keep track of their mental health:

“All areas [of FOCUS] worked for me… Especially keeping track of my moods because I didn’t have much experience keeping track of my mood beforehand.” – Study 1, ID25

FOCUS also provided participants with “on the go” resources they could use when placed in stressful situations and experiencing distressful symptoms such as auditory hallucinations, anxiety or paranoia:

“I used relax this week and listened to music because I went to my first DBT class. I was stressed out from the group setting and absorbing all the information, so I played it outside when I got out of class to help me relax.” – Study 1, ID27

Some participants used FOCUS to reframe destructive thoughts or maladaptive coping mechanisms:

“When I want a cigarette I go to FOCUS, especially when I am crawling out of my skin. Last week, I wanted a cigarette real bad. I was able to take the suggestions that [FOCUS] told me and switch gears.” – Study 1, ID 17

Participants who spent most of their day at home often had a hard time trying out the tips and skills FOCUS offered. A few felt that they did not maximize their use of the intervention because they had limited opportunities to try out the tips in real-life scenarios:

“I didn’t really use the tips [for social anxiety] because I didn’t have opportunities to use the [them] in real life… I don’t leave the house much.” – Study 1, ID 37

Self-Awareness

For some, FOCUS was an opportunity to reflect after challenging experiences and develop self-awareness. One participant shared that she used FOCUS to better understand herself in relation to other people – especially during conflict with others:

“Sometimes I am just looking to get through stressful moments, like I can’t tell when I’m being a b**** or not. I like the social part because I always thought I was good at being social but the reality is that I don’t pay attention to people’s feelings as much as I think that I do.” – Study 1, ID 15

Others used the mood and social modules to challenge preconceived notions and learn about how symptoms might affect their behavior and ability to connect with others:

“[FOCUS] is informative, it makes me think about things. It makes me compare and think about the way tips tell me to do things and the way I do things and think about how I might improve the way I do things. I used social this week because I can’t live in a bubble by myself. The more I try to be social, the more I can get out of the bubble.” – Study 1, ID13

Several participants used FOCUS as a daily reminder to recognize self-achievement and acknowledge that there is more to who they are than just their symptoms:

“I like the tip about voices, [it] told me that what the voices tell me are wrong and that I’m more than just voices. I am a good wife…a good mother… a good grandmother too. There are many aspects to me other than voices and [FOCUS] reminds me of that… You can’t always call your therapist so I think this is a good way to solve that.” – Study 1, ID 10

Acceptance of Symptoms

Upon reflection, many participants expressed that FOCUS provided a private means for them to learn more about their symptoms and come to terms with aspects of their illness that they felt uncomfortable discussing with others. For some, the intervention provided a sense of normalcy and reassurance that others were also dealing with similar difficulties:

“ I started hearing voices…it really scared me, but to see that [FOCUS] had a thing for voices, I was able to more deal with it, ‘cause it was very new for me. I had never dealt with voices before, so that was something that was a good thing for me, ‘cause I was scared. I didn’t know what to do. One thing they [FOCUS] said was, it’s okay. People can live with voices, and how to maintain them, but to me, it was like, oh my God. It was good for me to be able to go through voices, and see what they said to do or that people live with it and its okay, I’m not crazy, that this is real.” – Study 2, ID 134

Several participants mentioned using FOCUS made them realize it was okay to accept help and guidance from other people and they did not have to battle their symptoms on their own:

“It [taught] me how to deal better with [my symptoms] than I used to, and know how to take suggestions now instead of trying to do it my way. That feedback made me realize that some people are sicker than others and we’re all dealing with it. I had a hard time accepting [my] illness. FOCUS made me realize that you can help yourself if you want to, or you can take suggestions to make the situation you’re in better than what it is.” – Study 2, ID 17

Although the intervention promoted self-awareness, there were instances where some felt it prompted undesired self-reflection. Some participants cited these negative moments as a reason they stopped using the intervention when they were feeling symptomatic:

“Sometimes you don’t tap in [to FOCUS] because you don’t wanna hear the right answer. You know they’re gonna tell you that it’s wrong… So you try to justify it by ‘I don’t need that today.’’’ – Study 2, ID 17

Motivation

The short-term goals FOCUS established motivated some participants’ to pursue their aspirations – ranging from volunteer work to general self-care activities (e.g., reading, housekeeping, organization, exercising). Others felt that FOCUS was an inspirational way to start their day:

“FOCUS [was] a way you [could] wake up and just start your day off with something positive like, ‘how well did you sleep’. It was something to listen to, to make you feel motivated to get up and do whatever you need to do for that day. For me, I can say the mood [module] was definitely a plus in the morning… It would help me realize that I needed to do this or that to make myself feel better.” – Study 2, ID17

Some mentioned that using the intervention to access alternative coping methods when they were feeling down motivated them to abstain from self-harming behavior:

“When I’m out in suicidal mode, I go into mood… [The voices] can be so vicious. I use FOCUS to come back to myself… It helps me get out of a bad mood. I like to do strategies on the spot… I like what it tells me about myself.” – Study 2 ID 21

One individual said that because of his regular use of FOCUS, he stopped using substances to cope with his symptoms:

“The way I would cope with things would be through drinking and drug use, you know? And [there was] a decrease in that for the last couple of months, I ain’t had it.” – Study 2, ID 10

Some participants felt FOCUS could be more motivational by tailoring to different stages of recovery:

“I am in sort of the, you know, advanced stage of recovery. The composite of choices was a bit dumbed down… So [FOCUS] might have to target specific graduations of the program… I would say at least three different levels… Level one would be persons at the beginning of their recovery. Let’s say they’ve just been discharged from a facility or just was diagnosed… starting to learn about the illness. Level two is in the middle. They’ve reached a point where they’re getting more self-awareness or understanding of the illness and how to cope with certain symptomatic episodes. And then you have the advanced level where that would be the one that would be the deepest.”- Study 2, ID 60

Additionally, several participants mentioned they struggled to motivate themselves to check-in with FOCUS because content on the intervention was too repetitive:

“To quote the bible, the vain repetition. Which I’m sure, you know, for some people, it helps right… for me, though, it kind ended up being redundant… superfluous or whatever.” – Study 2, ID 101

Similarly, one participant felt the intervention was not motivational because it touched on content he had already covered individually with his clinician:

“Yes, I did already know those things [FOCUS intervention content]. And it didn’t really help, you know. So I had changed the med one to sleep. And there was this um… it was feeling like it’s a waste.” – Study 2, ID 10

Supporting Positive Outlook

When asked to reflect on the intervention’s general impact, participants expressed optimism about the future. For some the optimism was a result of learning new strategies to cope with their symptoms:

“[FOCUS] upgraded me, mentally, physically, psychologically and spiritually. It uplifted me to another level, a better understanding of my diagnosis.” – Study 2, ID 67

The intervention allowed many of its users to rid themselves of self-defeating thoughts. Participants attributed this to learning more in depth about themselves and their illness:

“Before I started FOCUS I was a train wreck, a bad one. I’ve learned, I’ve gotten strong, I still have my weak points, but I believe if it could help me, it could help pretty much anybody.” – Study 2, ID 108

Participants most frequently cited their use of the intervention’s social module as the most beneficial. Some felt more open-minded toward their friends, family and peers, as well as more comfortable with taking a step back during difficult social situations to collect their thoughts. Several participants expressed that even though their use of the intervention had discontinued, many of the lessons and strategies they learned were still relevant:

“It reminded me that people are people, that they’re not inherently out to get me. Sometimes stuff happens and you’ve got to understand they’re individuals and you can’t predict their behavior, you can’t control [it] either.” – Study 2, ID 10

For some, the positivity simply came from FOCUS’s reminders to take time throughout the day to appreciate oneself:

“FOCUS gave me a chance to say, it’s okay to take time to yourself. And it really helps me. You know calm down if I’m upset I just relax, read a little book or whatever I want to do just for myself. So I do that a lot now.” Study 2, ID 134

Others felt that being able to acknowledge and record a lack of symptoms raised their spirits:

“[FOCUS] is like somebody talking to you and waking you up and giving a positive thought… You feel confidence because you know that whoever you’re talking to in FOCUS is trying to help you and you don’t feel suspicious… It’s just reinforcing. It gave me a little uplift about not having symptoms. It made me more confident in myself.” – Study 2, ID 140

Discussion

The present study contributes to the evidence base around experiences of adults with serious mental illness and their willingness to accept, use and integrate a smartphone-based intervention designed to support illness self-management. This paper builds on previous findings demonstrating high acceptability of FOCUS among individuals with serious mental illness (Ben-Zeev et al., 2014; Ben-Zeev et al., 2018) by providing insight into how, specifically, participants use this mHealth intervention in everyday contexts of their lives.

Participants readily turned to FOCUS to manage challenging situations and symptoms in the moment. The “24/7” availability of resources supported participants to address emerging concerns on their own, without involving clinicians. These findings align with research suggesting that mHealth interventions may facilitate the transfer of skills to real-world settings (Depp et al., 2010). The ability to gain control of one’s life and symptoms can lead to a greater sense of hope (Kirkpatrick et al., 2001). FOCUS’ coping strategies and brief reminders encouraged self-awareness in many participants. This self-awareness, we believe in part, was rooted in participants’ use of FOCUS as a learning tool. Many participants described how the intervention helped them achieve a greater understanding of their symptoms and identity. Evidence shows that individuals with chronic illnesses who can acknowledge and interpret symptoms linked to their illness often experience enhanced self-awareness and self-empowerment (Aujoulat et al., 2008).

At a broader level, participants described shifts in perspective toward greater acceptance of their illnesses, attributing these changes to things learned in the intervention. FOCUS also motivated positive coping strategies and supported participants in cultivating a more positive outlook. Acceptance of a diagnosis and developing a positive attitude toward treatment is, for many, a critical step towards recovery and willingness to adhere to treatment (Hatfield & Lefley, 1993). Several participants shared that the intervention helped them recognize that they are not alone and feel more positive about their symptoms.

Most participants spoke positively about using FOCUS. While it is possible that the positive tone reflects a social desirability bias, the research was designed to minimize such bias. Participants had opportunities to express ongoing challenges and frustrations in their conversations with the mHealth specialist (Study 1). Similarly, during interviews for Study 2, participants were encouraged to elaborate on a full range of positive and negative feedback. In addition, interview participants were sampled purposively for a range of engagement (i.e., “high engagers” and “low engagers”) with the goal of eliciting both positive and negative experiences with the intervention. The few criticisms expressed by participants raise important issues regarding the desire for a mHealth intervention tailored to stages of recovery and for fresh content. These findings align with mHealth studies that show that individuals using smartphone interventions want tailored and personalized feedback (Huerta-Ramos et al., 2016; Palmier-Claus et al., 2013; Povey et al., 2016; Ranney et al., 2014).

To our knowledge, it is the first qualitative study to leverage prospective and retrospective qualitative data to provide a greater understanding of how participants apply illness self-management skills from a mHealth intervention in their daily lives. Study 1 provided detailed experiences of participants’ day-to-day experiences of using the intervention on the go; while Study 2, emphasized participants’ retrospective thoughts on how the intervention impacted their overall ability to manage their illness. The combination of these resources allowed us to examine the shift from how participants used FOCUS to what they learned from the intervention.

The study had several limitations. Participants in the study were current service-users in community mental health centers. It is possible that because these individuals were already familiar with psychosocial interventions and recovery they were more accepting of, and positive toward, clinical perspectives embedded within the mHealth intervention. Despite informing participants that they had an equal chance at being randomized to the smartphone arm or a group intervention (Study 2)/treatment-as-usual (Study1), our studies may have involved individuals who were open to/interested in trying mental health technologies. As a result, these findings may not be generalizable to the entire population of individuals with serious mental illness (Mohr et al., 2017). Future research should examine this intervention among populations not well connected to mental health services. As noted previously, the positive tone of the interviews may reflect socially desirable responses despite best efforts to minimize such bias. Conducting multiple interviews or observations in naturalistic settings would be useful techniques in future research to build stronger rapport with participants to further limit such bias.

This qualitative inquiry offers insight into the specific ways in which individuals with serious mental illness made use of a mHealth intervention designed to support illness self-management. Previous research has demonstrated the feasibility, acceptability, efficacy, and comparative effectiveness of FOCUS (Ben-Zeev et al., 2014; 2014; 2018). The qualitative findings reported herein augment previous findings by illuminating how participants apply new skills and insights gained through their use of FOCUS and the perceived longer-term impacts of FOCUS to support recovery processes.

Conclusions and Implications for Practice

The participant feedback presented in this paper shows that mHealth interventions can provide personal benefits for individuals with serious mental illness and that they can be positively integrated into day-to-day life. Our findings suggest that individuals may interact and benefit differently from these interventions depending on where they are in the recovery process (e.g., recovering from a recent hospitalization versus several years without significant symptoms). Further research should examine the relationship between clinical outcomes and participants’ self-perceived benefits to explore whether the two align.

The qualitative findings of these studies also add an additional layer to the growing body of work supporting the feasibility, utility, and potency of the FOCUS mHealth intervention in supporting the recovery of people with serious mental illness. The themes raised by participants go beyond successful mastery of skills or simple in-the-moment coping strategies; the experience of engaging in the mHealth intervention supported individuals’ insight, sense of connectedness/feeling supported by others, and general outlook. These findings deepen our understanding of the impact a mHealth intervention may have on one’s life, and can inform the development of additional FOCUS content and functionality that are specifically designed to support these forms of personal growth. As FOCUS and other mHealth interventions continue to show promise in enhancing mental health and recovery, it will be important to examine how best to implement and integrate these novel approaches in real-world practice.

Impact Statement:

The qualitative feedback presented in this paper illustrates that smartphone interventions can be successfully integrated into the everyday lives of individuals with serious mental illness. Additionally, it suggests that these interventions may need to be tailored to meet the needs of individuals at different stages in their recovery. These smartphone interventions have the potential to increase access and availability of mental health care services and may offer individuals seeking more autonomous care additional resources for illness self-management.