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Publication Briefs

"Virtual Hope Box" Smartphone App Helps Veterans Regulate Emotion and Cope with Distress that Can Lead to Suicide

To augment cognitive behavior therapy for Veterans with mental health conditions, clinicians sometimes encourage patients to use a "Hope Box" when experiencing periods of acute or significant distress, or suicidal ideation. A hope box is a physical container (e.g., shoebox) holding items that serve as reminders of positive life experiences or reasons for living, or that serve as coping or distracting resources. Investigators in this study developed a smartphone app, Virtual Hope Box (VHB), to provide a portable and easily accessed suite of tools to enhance coping self-efficacy. This randomized controlled trial assessed the impact of VHB on stress coping skills, suicidal ideation, and perceived reasons for living in patients at elevated risk of suicide and self-harm. Veterans identified as having current or recent suicidal ideation, per clinician assessment, were assigned to use the VHB (intervention, N=58) versus printed materials about coping with suicidality (control, N=60) to supplement treatment-as-usual. Measurements were obtained at baseline, 3, 6, and 12 weeks. Self-reported primary outcomes included coping, suicidal ideation, and reasons for living.


  • VHB users reported significantly greater ability to cope with unpleasant emotions and thoughts (i.e., coping, self-efficacy) at 3 and 12 weeks compared with Veterans in the control group. There was no significant advantage of treatment augmented by the VHB for other outcome measures.
  • The most frequently cited reasons for using VHB by Veterans were for distress (69% of respondents), when emotions were overwhelming (57%), when they felt like hurting themselves (31%), and for relaxation, distraction, and/or inspiration (51%).
  • Data from structured interviews suggested that clinicians appreciated the VHB's capacity to serve as an additional therapeutic tool – and valued the fact that the VHB served to reinforce patients' existing coping skills and gave them an outlet to practice these skills.


  • Because the Virtual Hope Box smartphone app is easily disseminated across a large population of users, investigators believe it has broad, positive utility in behavioral healthcare.


  • Results are based on a relatively small study sample that may have limited power to detect small differences.
  • On average, Veterans in this study did not score very high on the Beck Scale for Suicidal Ideation at baseline. Thus, while investigators were able to detect a small reduction in suicidal ideation over time in the total study population, a floor effect may have contributed to an inability to discern any differences between the treatment groups on this outcome.

Drs. Denneson and Dobscha are part of HSR&D's Center to Improve Veteran Involvement in Care (CIVIC) in Portland, OR.

PubMed Logo Bush N, Smolenski D, Denneson L, Williams H, Thomas E, and Dobscha S. A Virtual Hope Box Smartphone App for Emotional Regulation and Coping with Distress: A Randomized Clinical Trial. Psychiatric Services. November 15, 2016;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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