Breathing Fresh Air into OCD Therapy
The Problem
Obsessive Compulsive Disorder (OCD) is ranked as one of the top 10 most common forms of disability worldwide by the World Health Organization. It is depicted as an obsession with cleanliness and order, but it comes in various shapes and sizes, and is often misunderstood due to its stereotyping and simplification in the media. Treatment for OCD has improved in recent years, but the most effective treatments aren’t well-known and not all therapists are trained to provide it. In addition, it is natural for OCD patients to avoid therapy or talking to someone because of how disturbing the intrusive thoughts can get. The more intense and disturbing an intrusive thought gets, the more an OCD patient will want to isolate themselves out of fear of it becoming reality.
How might we increase awareness of OCD services that are accessible to users’ specific situations?
How might we help users identify effective forms of treating and managing their OCD?
How might we prepare users to effectively communicate about their OCD and build a supportive network of empathizers?
How might we equip users with tools to optimize the effectiveness of their OCD treatment and manage their intrusive thoughts post-treatment?
The Solution
I approached this problem with a focus on designing the tools to assist with ERP (Exposure and Response Prevention) Therapy, as this was the form of therapy that inspired me to tackle this problem. ERP involves intentionally exposing oneself to their triggers and leaning into them rather than acting on the compulsions that their body wants to react with. I added a journal log into the mix as well since self-reflection and monitoring are helpful for finding habits with one’s triggers and recording these things in between therapy appointments can provide a clearer picture for the therapist.
My Role
I performed all aspects of the design for this app, including UX Research, Ideating, Information Architecture, Wireframing, UI Design, and Usability Testing.
Understanding OCD
Despite my personal experiences with OCD and going through therapy for it, I still believed it was necessary to do research on it. OCD has been identified as a neurobiological disorder, which means it can always resurface after it’s been treated. OCD patients have intrusive thoughts that they obsess over, which keeps them from completing simple, everyday activities. I learned that OCD patients may hide having it to avoid being hospitalized, arrested, or looked at negatively, which will make them avoid getting therapy or treatment. Studies have also shown that patients can improve their symptoms by watching videos of themselves or other people being exposed to their triggers. Regarding therapy, studies have noticed that OCD patients are far more likely to show improvements after about 6 therapy sessions, even if they drop out before completing their treatment.
The Competitors
To my surprise, I managed to find one direct competitor that had already made an ERP Exercise component of their app (NOCD). I prioritized this app in my heuristics analysis and ended up examining two other apps (OCD.app and CBT Thought Diary). I examined the visibility of system status since OCD patients don’t do well with uncertainty, user control and freedom to compensate for perfectionist OCD, and flexibility and efficiency of use because OCD therapy needs to be tailored to work for each specific case. All of these apps managed to ask the user how they felt upon performing check-ins via combinations of mood and emotions, so I made note of that. I also took note of where the apps didn’t inform the user when actions were completed and didn’t give warnings or ask for confirmation when undoing or removing progress that took time to replace. I was disappointed to see all the places that didn’t ask for confirmation for OCD apps.
Understanding the Users
I approached user screening and interviews with the assumption that it was going to be difficult to find users. I started with a narrow scope, asking people to fill out a survey if they had OCD and had at least been recommended to see a therapist. I wanted to interview users that were at least aware of ERP as a form of therapy and get more information on potential users that denied therapy. I extended the survey out on social media for friends and family to share with very little results to show for it. I also asked my local OCD clinic for permission to ask people on site to fill out the survey and participate in interviews with no confirmation. Due to the nature of the problem, I also discovered that almost all Facebook groups, OCD Subreddits, and OCD forums disallowed the advertising of surveys.
After receiving very few survey responses, I opened my scope to interview anyone that had been diagnosed with OCD. I changed my strategy to personal requests to fill out my survey by sifting through #OCD results on Twitter, determining if the author talked about having a real case of OCD and then asking them in a private message. I managed to complete a couple of interviews, but due to the amount of time I lost here, I had to develop insights from my own personal bouts with OCD and insightful comments from screenings to round out my research.
“OCD is about disrupting the loop [of intrusive thoughts].”
Through user interviews, I met OCD patients that had treated their OCD and learned ways to manage it. Users noticed stronger symptoms of their OCD in moments of hunger, dehydration, forgetting to take their medication, and/or fatigue. I spoke to people that refused to leave their house with the fear that they were a danger to others from their intrusive thoughts. I heard accounts of therapists giving bad, outdated advice on managing OCD because they didn’t understand OCD well enough. Surveys that led to no-show interviews provided insightful information as well, as I learned that someone avoided seeing a therapist because they were terrified of phone calls. Even if someone was ready to see a therapist, some users cited being unable to see one because they were too expensive or their parents told them they didn’t need to. OCD patients are also afraid to confide in others with the fear that their intrusive thoughts may be interpreted as interests or desires. Despite this, the people I spoke with mentioned how much a support group helps them manage their OCD.
With all of my observations and insights noted, I struggled to arrange them to identify the main categories of focus, but I settled on Self-Monitoring, Treatment & Resources, Internalizing, Therapy Accessibility, and Misconceptions.
Donning the Persona
With a refined vision of the user base, I created CBT Steve, my sole persona for this project (for now). The Steves that I was designing this app for will be able to use the app to:
Assist them in their ERP therapy
Record their thoughts and feelings
Build their OCD support networks
Monitor their daily routines.
Bringing Order to the OCD
Before I started sketching the app, I needed to define the app’s structure and make the most efficient red routes for users. In order for users to stay committed to their treatment and therapy in the app until they start seeing improvements in their symptoms, prioritizing user retention through an intuitive interface is key. I decided on 3 primary tabs based on the affinity mapping from earlier using the Self-Monitoring and Treatment & Resources groups:
Self-Therapy
Community
Therapy
I wanted to use the Therapy and Community tabs not only as communicating with a therapist and building a supportive network of people, but to also tackle the issues identified in the Therapy Accessibility group.
When identifying the MVP of the app and its red routes, I designated completing a journal log and completing an ERP exercise as the 2 primary uses of the app. While there are various other reasons to enter the app like finding a Therapist or Support Group, or checking on when your next therapist appointment is, I felt that these were the most recurring uses of the app for both users in therapy and post-therapy.
Sketches and Testing
With the journal being the easier and faster of the two red routes, I decided it was best to give it the most weight on the Home screen and the Self-Therapy screen with banners that included direct links to the Journal Log screen. At first, I used various ribbons and scrollable menus in the app to experiment with how I wanted to present the menus, but I reduced the scrolling to only a few places and removed any ribbon functionality to avoid conflicting with iOS’s native swiping gestures.
In testing, my focus was on the presentation and efficiency of the journal log. The simplest red route needs to be comforting and efficient. I worded the log to be second-person with question prompts, but I asked the users about if one-worded questions made them feel more comfortable to confide in the journal. I also left the emotions screen blank with squares to ask users what number of emotions would be too much before they would start ignoring them, and also to see if I could get them to list any off to get a feel for the depth and breadth of emotions to display. While I was unsuccessful with getting the users to list off emotions as they completed the log, I was given a confident range of 12 to 16 emotions and the second-person prompts were more appropriate because the users felt like they were talking to someone.
The second half of the test involved the ERP Exercises, and since I couldn’t identify any OCD patients to test for this phase, I had to rely on the prompts on screen and question prompts to guide the users. I tasked the users to create an exercise and add a video resource to it here to observe the visibility of the tabs, then later start and complete that same exercise. Due to constraints of the app I used to wire the sketches together, I had to instruct the users to force end the exercise since the app was incapable of performing time-based transitions. I experienced some visibility issues with the tabs on resource creation as I suspected, but the main takeaway with this half of the exercise was that it made more sense to supply users with pre-built, generalized exercises and resources so that they aren’t overwhelmed with this section.
Wiring with the right Frame of Mind
With the insight on creating exercises vs running them in the guerilla usability testing, I simplified the ERP red route by removing the “create exercise” portions from the route itself and supplied placeholders of pre-built exercises and resources. I also began to refine the button placements based on Gestalt principles. I started realizing that I was adding too much weight to all of my buttons on each screen, so I learned to apply less weight to the buttons of lower priority so the user’s attention is in the right place.
Setting the Mood
I discovered the app’s personality on a whim when I explored the average user’s mindset when opening the app. The user needs a space where they feel safe enough to be vulnerable and feel free enough to explore their thoughts. I focused on fresh air and deep breathing to build my mood board. The colors reflect a calm evening sky to depict a tranquil and reflecting period of the day.
Tailoring the Style Guide
I switched the font of the style guide from the Montserrat Alternates I placed in the mood board because while the font was airy, it felt playful to be in a mental health app that needs to be designed to feel trustworthy. I switched to a Narin font to keep the roundness but have something appropriate for the context. I stuck with a grayscale over any brown accents to retain simplicity and went with the apricot accent over the sycamore because it provided more contrast for the accent on this particular palette.
Putting it all Together
With the initial high-fidelity mockups, I focused on making screens that worked with colorblindness, but I was unaware of the requirements for color compliance until reviews occurred. I needed to darken both the apricot and the breaker bay by significant amounts and alter the whites and grays I paired them with in order to reach AA compliance. While the primary blue looked like it worked better on the white in my style guide, it was far less compliant than when it was paired with the dark gray. My secondary buttons thus became white with the new dark-pink text instead of the blue text to satisfy compliance. I also center-aligned the text to be consistent with the buttons and labels, which was fitting for an app to help a user center themself. I thought the banners were enough for the journal call to action buttons, but I was unaware of the implications of banners when going into usability testing.
Testing the Prototype
The usability tests consisted of two waves, the first one featuring 4 people in remote moderated tests. I made the transparency and understanding of the ERP exercises the priority for these tests since I was still worried about the users’ inexperience with them. Before that, I tasked the users with completing a journal log to see how they acknowledged or even used the Skip button to see how its minimal weight operated. While the initial prompt and the alert window informed users about ERP Exercises, the terminology used for the parts of the exercise were not well-documented in the app. Users also expressed concern about the lack of an emergency number in a mental health app, as well as the concern of where the journal log information was being stored and who it could be shared with. One user, despite finding the journal log buttons in a sufficient amount of time, expressed concern for the lack of redundancy of a journal log button on the self-therapy tab.
Although I didn’t identify the need for an additional journal log button as a critical issue, I created a “More Information” screen for the ERP Exercise page that explained them more in-depth along with defining its components. I also added an Emergency number on the Home Screen and an alert window on the Journal Log menu that briefly explains what it entails and reassures the user that they have full control over if they want to share their entries.
I started the second phase of usability testing with another 5 users after making these changes. The need for an additional Journal Log button jumped to the forefront of this wave of tests, as 3 of the 5 users had difficulty locating the Journal Log with relative ease. In addition, despite the tasks and red routes not including it, one user was unable to see how to schedule an ERP exercise after noticing the scheduled label at the top of the page. I realized that my initial placement for it on the “New Exercise” page didn’t make as much sense as placing it on the Saved Exercise screen. The prototype, in its current state, also lacked any form of confirmation or user feedback that a completed journal log had been sent to their therapist, nor is there anything in place to confirm that for past logs. After identifying and resolving critical issues from the first usability tests, more critical issues appeared.
Final Thoughts and Next Steps
Overall, the app was designed with ERP therapy in mind to treat and manage OCD, and it does that for users that understand how ERP works. The users saw its merit and approved of the flow of the design. Journal logs were fast and efficient for users, and the only part they felt inclined to skip were the prompts that required long text inputs during the Anxiety portion. I failed to identify scheduling an exercise as a primary red route alongside performing one for this build. The user would want to schedule an exercise before they would plan to start it, and push notifications at the scheduled time would give the user the opportunity to jumpstart it.
Next steps would focus on additional therapy exercises and building out the therapist’s information. CBT is another common form of OCD therapy that could have features built out, and one user said they would like to see a meditation/deep-breathing function as well. The therapist screen would allow users to manage their appointments and notes with their therapist, while giving the therapist the option to send notes and appointment invites to the user through the app. While I intend on starting this functionality to communicate from the therapist’s email to the app in the same way as the journal logs get sent, I would like to consider the possibility of building out a whole therapist side of this app.
This isn’t a regret, but I believe the broad problem of helping all OCD patients treat and manage their disorders has a stronger solution out there: prioritizing the education of OCD and building a supportive network of fellow OCD patients and empathizers. Educating the users with an app that gamifies how OCD manifests and identifying healthy and effective forms of treatment could empower the user with effective self-therapy, or encourage them to seek therapy. If I could attempt the user research again, I would prioritize the therapist’s role just as much as the patient’s. The goal is to treat the patient’s OCD, and it’s a team effort most times to see it through.