Self-Help for Anxiety Management (SAM) is a free app that provides people with instructions and activities for managing anxiety. Users can log in and trend their present level of anxiety, list things that make them anxious, read about activities for improving anxiety management, use tools (e.g. thought recorder, breathing timer) for anxiety management, bookmark useful tools and approaches, and discuss anxiety management issues with other users.
SAM offers a number of different highly innovative activities and tools for users to utilize while managing their anxiety. Some of the activities involve reflection, while others involve action. Features are organized into six categories: information about anxiety, thinking and anxiety, mental relaxation, physical relaxation, health and anxiety, and taking small steps. Several of the activities are highly unusual. For instance, the mental relaxation activities include one in which touching the touchscreen gradually reveals a pleasant image (e.g. a flower, a butterfly) which had previously been concealed. Another mental relaxation activity involves typing a worry and then watching a balloon containing the worry explode. The health and anxiety section includes a colorful animation with suggestions on how to make anxiety worse, such as “drink lots of coffee” and “smoke lots of cannabis”. The scientific basis of these features is not documented, and it is unclear if they are effective, as they do not all rely upon techniques common to cognitive behavioral therapy.
Ease of Use and User Experience
SAM is intuitive to use and highly interactive. It is best suited for users who are familiar with smartphone interfaces. This diversity of interfaces is likely to make SAM more entertaining for some users. The user experience is entirely self-paced, as users are free to explore the content and tools in a non-linear fashion. Users are invited to save particularly helpful passages and tools to their personal “toolkit” for easy future retrieval. An integrated “social cloud” discussion board is available for discussing anxiety with other users. While the user interface makes use of a fair amount of text, it has a greater number of interactive features than many competing offerings, and feels as though it was designed specifically for use on smartphones.
The app was tested on an iPhone 6S running iOS 9.3 and on a BLU R1 HD running Android 6.0. The app performed identically on both, and scaled its interface appropriately for the resolutions of the two smartphones. The user interface feels a bit like a control panel, in that users are presented a series of hierarchical options, and may access them in any order, at any time. Favorite features may be saved to a toolkit for easy future access. The philosophy behind the user interface is to provide users with access to a series of activity prompts and interactive features, and then to let users focus on the ones that are most suited to their needs. Literacy is required in order to use the app, as many of the prompts contain substantial amounts of text. However, many of the activities could be used by a person unable to read if provided assistance from a caregiver.
Appropriateness of Content
The app is likely to be appropriate for people with self-identified mild to moderate anxiety seeking tools and suggestions on how to improve their anxiety. It may be unsuitable for people in a formal treatment program, as it does not contain any features for interacting with healthcare professionals, and not all of the content may be evidence-based. Although the app was developed in the United Kingdom, the developers were thoughtful to include references to resources for help in both the United Kingdom and the United States.
Appropriateness of Feedback
The app does not provide users with feedback. Instead, it delivers content and activities. Users can engage with each other on the “social cloud” discussion board, which is integrated within the app. The discussion board is quite active, but appears to be a peer support group rather than an avenue for seeking professional advice. As is the case with any un-moderated peer support group, the quality of the advice may vary. Many of the users on the discussion board describe severe anxiety, which may be beyond the scope of a self-help app.
The app provides less cognitive challenge than many competing tools, as it tends to focus on having people recall thoughts without exploring their implications. For instance, users are asked to list positive and negative thoughts, but are not provided comprehensive instructions on exploring the linkage between their thoughts, behaviors, and actions. The focus of the tools is largely on physiological approaches to anxiety management, such as breathing and muscle relaxation exercises.
Cognitive behavioral therapy is vaguely introduced in one activity, which states in its entirety: “How we think influences how we feel and behave. We learn to think in particular ways; some ways are more likely to make us anxious. Try and distinguish between your thoughts and your feelings.” Although this activity may be sufficient for someone who already understands the principles of cognitive behavioral therapy, it may be insufficient for someone unfamiliar with the principles.
Ease of Account Management
No account is necessary to use the app, and the content within the app is not password protected. An account may be optionally created to engage in the “social cloud” discussion board with other users. Accounts are password-protected, and users are asked to provide an optional password recovery email address. Users remain signed-in after closing the app, which may be a security issue for people whose phones are not password-protected.
SAM was developed by the University of West England for both internal and external use. The considerations made during the development process have been documented in a white paper released by the university.[i] The white paper states that development was overseen by an advisory board, which included a counseling psychologist, a cognitive behavioral therapist, and a research psychologist. While the white paper suggests that the University of West England intended to research the therapeutic impact of SAM, it is unclear whether they have done so. The scientific basis of the various activities within SAM are not cited in the app or elsewhere. Some of them have a scientific basis (such as the cognitive behavioral therapy activity mentioned previously), while others may not. The four-question anxiety assessment available within the app is not congruent with the more common Generalized Anxiety Disorder 7-item Scale (GAD-7)[ii], and thus it is unclear whether it accurately measures anxiety.
Qualitative Review of Program Efficacy
It is unknown whether SAM is efficacious. Many of the activities that it contains may help people facing temporary moments of anxiety. For instance, the breathing exercise timers may be useful for people anxious about waiting for the takeoff of a plane or waiting to give a presentation. The efficacy of other activities, such as simply listing things that cause anxiety, is a bit more ambiguous. It is also possible that some of the activities may be harmful, such as viewing an animation of ways to increase anxiety. However, the active “social cloud” discussion board and over 2,500 reviews in the Google Play store suggest that a substantial number of people are receiving value from the app.
Estimate of Efficacy Relative to Similar Products
SAM offers a broader and more unique set of therapeutic activities than many alternative tools. The efficacy of SAM is untested, and it is unclear whether there is a scientific basis to many of its components. While it is possible that it is more efficacious than alternatives, the efficacy of many alternatives has been better characterized. Furthermore, alternative tools have more explicitly taken an evidence-based approach. Users may wish to supplement their use of SAM with more traditional cognitive behavioral therapy apps, such as iCBT, as well as web-based educational tools, such as FearFighter.
Review date: August 2016
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[i] Topham, P., Caleb-Solly, P. and Matthews, P. (2015) Project SAM: Developing an app to provide self-help for anxiety. Project Report. University of the West of England, Bristol. Available from: http://eprints.uwe.ac.uk/27231
[ii] Spitzer RL, Kroenke K, Williams JBW, Lowe B. A brief measure for assessing generalized anxiety disorder. Arch Inern Med. 2006;166:1092-1097.