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Publication Briefs

"Virtual" Hope Box Smartphone App Delivers Patient-Tailored Coping Tools to Help Veterans at Risk for Suicide

Cognitive-behavioral-based therapies have demonstrated efficacy in helping individuals manage suicidal thoughts or behaviors. In particular, improving emotional regulation and distress tolerance during episodes of significant distress is an important component of therapy for suicidal patients. During stressful episodes, the identification and affirmation of reasons for living (e.g., children, pets, loved ones) may become difficult. Tools that assist patients in accessing and affirming their reasons for living enable patients to mitigate suicidal thoughts. One such tool, which a patient creates and customizes with clinician guidance, has been labeled a "hope box": a physical representation of the patient's reasons for living, reminders of individual accomplishments and future aspirations, or things the individual finds soothing, e.g., a worry stone, family photographs, or letters. However, a conventional hope box can by physically unwieldy and inconvenient; thus, the investigators in this study developed a "Virtual" Hope Box (VHB) for service members and Veterans that expands the reach of the hope box modality to a smartphone app. This study compared the VHB with a Conventional Hope Box (CHB) integrated into VA behavioral health treatment. Participants in this feasibility study included 18 Veterans enrolled in a Dialectical Behavior Therapy program, who were identified as being at high risk of self-harm. Participants had been diagnosed previously with borderline personality disorder, bipolar disorder, treatment refractory depression, or PTSD. Participating clinicians included six clinical social workers and one clinical psychologist. Half of the Veterans used the CHB for eight weeks, followed by the VHB for eight weeks; the remaining half used the VHB followed by the CHB. Veterans were interviewed and completed questionnaires during pre-testing, testing, and post-testing.


  • Compared with a Conventional Hope Box, more Veterans used the Virtual Hope Box regularly and found it to be beneficial, helpful, and easy to set up. Veterans stated that they would recommend the VHB to their peers, and twice as many preferred the VHB over the CHB for future use.
  • Written comments from Veterans cited the helpfulness of the VHB with managing distress, negativity, hopelessness, anger, and various other symptoms. Moreover, mental health clinicians were unanimous in their praise for the VHB as an eminently usable therapeutic tool.
  • Veterans did note the inability of the electronic medium to offer a complete sensory experience, i.e., they could not experience the texture or smell of objects in their CHBs.


  • This study had a small sample size.


  • The Virtual Hope Box smartphone app offers clinicians and their patients a valuable tool to supplement face-to-face treatment for stress and negative thinking.

Drs. Dobscha and Denneson are part of HSR&D's Center to Improve Veteran Involvement in Care.

PubMed Logo Bush N, Dobscha S, Denneson L, et al. A Virtual Hope Box Smartphone App as an Accessory to Therapy: Proof of Concept in a Clinical Sample of Veterans. Suicide and Life-Threatening Behavior. May 15, 2014;e-pub ahead of print.

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HSR requires notification by HSR-funded investigators about all articles accepted for publication. These journal articles are reviewed by HSR and publication briefs or summaries are written for a select number of articles that are then forwarded to VHA Central Office leadership to keep them informed about important findings or information. Articles to be summarized are selected by HSR based on timeliness of the findings, interest of leadership, or potential impact on the organization. Publication briefs are written for only a small number of HSR published articles. Visit the HSR citations database for a complete listing of HSR articles and presentations.

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