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Digital diaries help struggling youths

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In cooperation with CheckWare, The University Hospital of North Norway (UNN) has developed a digital version of DBT Diary cards for youths that struggle with handling their feelings. Ease of use, security, and clinical usefulness have been major keys in the development of the digital solution, and UNN has already registered more frequent use and updates of the cards from their patients.

The digital cards are an important part of Dialectical Behaviour Therapy (DBT) to assist the clinicians with assessing problematic behaviour and finding context in the youths’ actions. DBT is a treatment form to help young people and adults finding the balance between accepting difficult emotions and being able to change behaviour. The treatment form focuses on behavioural change, and includes practicing relational skills and interpersonal skills, naming feelings, regulating feelings, and handling stress.

The therapy aims at patients being able to think clearly in situations where they normally feel overwhelmed. Suicidal youths are one of the main target groups

DBT - Dialectical Behavioural Therapy

DBT is a treatment form focusing on replacing behaviour making life difficult, with behaviour assisting towards the set goals.

A digital version of the diary card is developed in a cooperation between The University Hospital of North Norway and CheckWare.

Registering diary cards is a central part of DBT. The patients’ reporting is used to identify behavioural patterns, map problematic behaviour, and assist the patients in reflecting on how their days have been. In the therapy session, the diary card is used as a starting point for creating hypotheses on what triggers and influences patients’ problematic behaviour, and to help patients finding good, alternative ways of action.


In good cooperation with CheckWare, the University Hospital of North Norway has developed a digital version of the diary card for youths. Digitalization of the diary card gives new possibilities for evaluating important processes through summary reports based on the patient’s reporting. Priorities in developing a digital solution has been ease of use, security, and clinical usefulness.
 

Developing digital versions of a diary card instead of paper versions, is in line with feedback from patients who have undergone the treatment. This gives the clinicians a unique possibility for continuously familiarizing themselves with the patients’ state of mind and connect this to actions and subsequent treatment.

Must make room for the young voices

Kamilla Sørensen has herself been treated with Dialectical Behaviour Therapy and today represents the user group of youths aged 12-25. She sits in the Youth Council, which is an advisory board to UNN, as well as a consultation body for the clinic’s work in developing and maintaining good health services for youths.


Recently, she has been active in the development of the digital diary card.


- It is essential that the voices of the youth are given a place in matters like this. I participate to ensure that the younger perspective is included and taken seriously, she says.


- It has been very important that Kamilla has participated from the Youth Council. She has participated as an advisor regarding the youths, which is our target group, but she has also had input on design of the assessment and digitalization in general.
This is stated by Vegard Slettli. He is a specialized psychologist at the Youth Psychiatric Section (UPS) at UNN, Tromsø. Slettli is the team leader for the DBT Team for youths, and also on the board of the Norwegian Association for Dialectical Behaviour Therapy (N-DBT).

A good thing with the diary cards, is that you dare more, and can write down what you feel is difficult and very private in a normal conversation

Kamilla Sørensen

Representative in the Youth Council at the University Hospital of North Norway

Digital assessments lower the threshold for use

When Kamilla underwent the treatment eight years ago, she questioned why the process was not digitalized. For her this resulted in many cards piling up, some cards were not filled in, while others were forgotten when attending the appointments. It was hard to keep track.


- There was no real continuity. Digital cards make a real difference. One issue I am really concerned with, is to find a language the youth are familiar with. Then one cannot use too many difficult terms. Another aspect is asking the correct questions that actually capture the individual’s problems. The questions cannot be too open or abstract. They should be very direct, she says, and thinks that generally young people appreciate that clinicians address difficult issues.


- It can be a bit difficult at first unless you are used to receiving such questions. A good thing with the diary cards, is that you dare more, and can write down what you feel is difficult and very private in a normal conversation, she says.


- We experience that the treatment has gotten a positive reception. As we get more and more teams using it, we expect that the feedback from the youths increase. Then we will have a bigger volume, allowing us to say more about experienced use of the diary cards, says Vegard Slettli, and explains that they originally considered making an app.


- That became too challenging, not least with regards to privacy. The most important in this solution is ease of use and security for each youth. We must make it as easy as possible to answer, but in a secure way, so that information is not illegally disclosed. This could easily happen if sensitive personal information was stored on each mobile phone. In addition, we must clearly define who should have access to the submitted assessments, say Slettli.


Even a simple matter as order of questions matter. They both say that they have received a lot of feedback and point of views, but the most important thing is still that the diary card is submitted.


- It is really incredible that digital cards have not been made before. Many young people have asked for it, says Slettli.

The most important in this solution is ease of use and security for each youth. We must make it as easy as possible to answer, but in a secure way, so that information is not illegally disclosed. This could easily happen if sensitive personal information was stored on each mobile phone. In addition, we must clearly define who should have access to the submitted assessments

Vegard Slettli

Specialized psychologist at the Youth Psychiatric Section (UPS) at UNN, Tromsø and on the board for the Norwegian Association for Dialectical Behaviour Therapy (N-DBT)

The treatment works

Through research, it has been found that young people having attended DBT treatment do better when it comes to self-destructive behaviour. Those who have been treated have been followed up after three years – now they will follow up the same people also after ten years.


- It seems that the change has a lasting effect. We work a lot with commitment, motivation, and personal effort. It is very hard to work with someone who does not really want to change. Inappropriate coping strategies are in focus. They can give a feeling of relief or short-term comfort, but they do not help over time. For many this is a scary process, regardless, because often they need to change ingrained habits. DBT works, because they are not only offered the possibility to persevere, but to get new strategies, says Slettli, and believes that most patients will find something in the treatment to help them.

DBT skills

In DBT for young people, they work with five different skills:

  • Mindfulness

  • Regulation of emotions

  • Interpersonal skills

  • To endure

  • To find the middle ground

- We believe that young people can gain relief with their sense and use their senses in different ways. They must be able to give themselves a break. It is all about relaxing the muscles, mindfulness, not doing anything, and at the same time they must choose not to run away from their feelings, he says, and explains that the clinician team is available for the young people well beyond normal working hours for coaching and guidance. In addition to supporting the youth, parents/guardians get the opportunity to learn the same skills.


Kamilla adds that motivation is important. When the youth experience that skills actually work, this gives motivation and a desire to learn more, and then participate more actively in the treatment.


They are also working with spreading the concept. Today they have youth teams in the cities of Tromsø and Narvik, while they have an adult team in Finnmark.


- We have received feedback from participants at the different conferences we have presented the treatment, that people are happy that the project has started, and that it integrates well with the EPR system. This makes it easier for both clinicians and patients to use this actively in the treatment. One of the things I do, is getting clinicians in other parts of the country to contact the right persons in CheckWare. There are many questions that I cannot answer, Slettli says with a smile.

People are happy that the project has started, and that it integrates well with the EPR system. This makes it easier for both clinicians and patients to use this actively in the treatment. 

Vegard Slettli

Specialized psychologist at the Youth Psychiatric Section (UPS) at UNN, Tromsø and on the board for the Norwegian Association for Dialectical Behaviour Therapy (N-DBT)

Dreaming of a CheckWare operated DBT portal

The specialized psychologist at the Youth Psychiatric Section at UNN Tromsø says that the collaboration with CheckWare has been very good. 


-  here is a lot we do not know about development diary cards, and it has been an educational process. We do not have much insight into the technical aspects, but we have been given the opportunity to go through the entire user journey and how we envision it. It is very nice to experience how the vision has become a reality through a useful and functional diary card that we are very proud to have helped develop, he says, and confirms that he thinks this in ground-breaking in practice:


- This is the first digital diary card that is actively in use. CheckWare is involved in most health care organizations in Norway. A prerequisite for getting this in motion, is that you have people assisting the clinicians elsewhere to get started. It will be very exciting to follow new teams, and also to see if this digital solution of diary cards is suitable for adult patients, says Slettli, who dreams of more than submitting assessments in DBT.


- I dream of a portal where you get access to videos translated from English as a supplement to the treatment. Much of the treatment is about learning new skills. Today the information is located in different places, but could successfully be available in one single portal, he believes, and sends the ball back to CheckWare: A future development of a treatment program with videos and texts, that supplement standard assessments in a common, national DBT Portal.

The University Hospital of North Norway's use of CheckWare

Respondent tools:

  • Measures

  • Plans

Clinician tools:

  • Clinical reports

  • Clinician insight

  • Treatment roles

  • Raw data exports

  • Flags

System management tools:

  • System settings

  • Access control

  • System log

  • System reports

  • Respondent management

  • Clinician management

  • Authentication:  level 3