Helping those with Obsessional Compulsive Disorder (OCD)
Final year project at university.
September 2021 - June 2022
Human-Centred Design, UX Design, Product Design
This project was a self-allocated brief on helping those with Obsessive Compulsive Disorder cope with their disability. Its duration allowed for the application of an end to end, best practice design approach to the problem.
A rigorous research process revealed that these individuals had a more positive relationship with their compulsions than often externally observed, as they had complete faith in their successfulness. However, as they are often lengthy rituals, their necessity consumes far too much time daily, significantly impacting quality of life.
The final solution, Compulse, uses a centralised app alongside two physical products. Together they allow users to automate their mental and checking compulsions to make them over 90% more efficient, freeing up valuable time daily. The app acts as a hub to set up compulsions, build motivation and a portal to receive professional help through therapy.
Secondary research
• literature review
• Insights
Primary research
• Diary study
• Love letters
• Professional Interviews
Assessing Research
• Affinity diagrams
• System thinking methods
Framing user needs
• Insights
• Personas
• How Might We Statements
Generation Methods
• Doodling
• Group Lotus Bloom
• Mash-ups
• Challenge
• Essence
• Brain Writing 3-6-5
Evaluation Methods
• Concept Mapping
• Negative Selection
• NUF Method
• Concept Screening
• Waited Matrix
Developing against a justified Human-Centred PDS.
Useful points
• Concept and user testing
• Professional consultations
Usable Points
• Wireframing and Wireframe testing (low fidelity)
• Usability testing for errors, efficiency (medium and high fidelity)
• Application of design theories and literature
Meaningful Points
•Journey Mapping
• Empathy Mapping
• Application of literature
Desirable Points
• Design Persona
• Group brainstorming
• Desirability testing
• Application of design theories and literature
During the secondary research stage of the design process, a phase of exploratory research was used to identify an actionable problem to help or solve, clearly identify the users who experiences the problem and to synthesise detailed insights that would act as a foundation for primary research. To achieve these goals a literature review was conducted, where a vast variety of sources were consulted.
Large areas of the illness were looked at, from psychologically based research such as causes, the condition, treatment, to more circumambient factors such relationship functioning, quality of life and its connection with suicide.
Books such as Break Free From OCD (Challacombe, Oldfield & Salkovskis, 2011) were consulted to gain a more narrative based look at the illness and to understand the treatment methods available such as Cognitive Behavioural Therapy (CBT).
Trusted resources such as OCDUK, the NHS and NICE were used to understand accessing treatment, what was available in the UK to these individuals and how the illness was assessed by medical professionals.
Large areas of the illness were looked at, from psychologically based research such as causes, the condition, treatment, to more circumambient factors such relationship functioning, quality of life and its connection with suicide.
Books such as Break Free From OCD (Challacombe, Oldfield & Salkovskis, 2011) were consulted to gain a more narrative based look at the illness and to understand the treatment methods available such as Cognitive Behavioural Therapy (CBT).
Trusted resources such as OCDUK, the NHS and NICE were used to understand accessing treatment, what was available in the UK to these individuals and how the illness was assessed by medical professionals.
User Group
They are individuals with high severity OCD, who spend large portions of their day locked in a fearful mental state (8+ hours).
Insight
OCD is a disabling condition that goes on for an average of 17 years before help is sought. It causes such a poor quality of life, worse than schizophrenia one study shows (Wenkze et al, 2006), that it has a strong relationship with suicide and suicidal attempts. (Fernandez et al, 2016)
This average length is surprising, considering NHS treatment of CBT is readily available, which takes a relatively short time to complete (5-12 months) and has a high success rate of making a considerable improvement in mental state. (OCDUK, 2022)
What makes this even more strange that it is allowed to go on this long is that those with OCD lead a quasi-normal life and are self-aware of their problem. They realise what they are doing is strange and the senselessness of the cycle. It has even been described by patients as ‘uncontrollable, incomprehensible, and bizarre’ or ‘being crazy on a conscious mind.’ (Angermeyer & Killian, 2005)
So with all this considered, why do these individuals let it go on for so long? Secondary research had revealed some answers such as concealing obsessions because of fear of rejection, but in order to gain a deeper understanding, this became the focus of the primary research to come.
To develop a deep and empathetic understanding of why it is so hard for these individuals to exit the OCD cycle, 3 different primary research methodologies were used in triangulation. It was important to adopt a multi-method strategy as the limitations of one method can be balanced out by the others and would help gather rich latent needs.
10 participants with high severity OCD took part in a 3-day diary study. Each day they were given multiple tasks to finish, amounting to 5 in total over the course.
Here, the same participants completed this exercise following the diary study. In order to understand their ambitions, motivations and feelings, the method was altered into two break up letters instead, which was successful.
After the first two methods were analysed, a professional interview was conducted with a therapist who specialised in anxiety disorders. This session was used to clear up uncertainties and dig deeper into the behaviour.
10 participants with high severity OCD took part in a 3-day diary study. Each day they were given multiple tasks to finish, amounting to 5 in total over the course.
Here, the same participants completed this exercise following the diary study. In order to understand their ambitions, motivations and feelings, the method was altered into two break up letters instead, which was successful.
After the first two methods were analysed, a professional interview was conducted with a therapist who specialised in anxiety disorders. This session was used to clear up uncertainties and dig deeper into the behaviour.
Although all three methods were successful at diving into the latent needs of the participants, this method stood out the most. The normal format for this method is to present the user with both a love and break up letter, but in order to fit the relationship between someone and their own OCD, it was changed. Instead, the first letter would be from the participant to their OCD, explaining why they would like it to leave. The second was written from the perspective of their OCD, fighting the side of the argument on why it should stay. Below is a set of letters from one participant, who has given permission for them to be shown here.
Compulsions to these individuals ‘are a safety net without which would be detrimental.’ (Therapist, 2021) They are the only feasible way to let go of their obsessions, and they find comfort in the faith that they work. To them they are a part of them and are the only thing stopping them descending into worse coping methods such as self-harm. Their necessity is essential, but the energy and time they take to perform daily is enormous, often distracting them from the world around them.
OCD is a battle between the emotions of desire and fear. But it's not the desire for more, it is the desire to keep what they have. If they didn't perform their compulsion and their obsession became a reality, they would blame them self, and believe it was this act of avoidance that caused it. ‘If harm came to my family I would never forgive myself, it’s all my fault for not doing it.' (Participant, 2021)
Not using a compulsion after an obsession would lead to a deep state of over-evaluation on whether the obsession is coming true. The fear of this possibility causes immense focus on empirical evidence, distracting the individual from reality. If the obsession became true coincidentally, they would blame themself fully. ‘If harm came to my family I would never forgive myself, it’s all my fault for not doing it.' (Participant, 2021)
How might we stop those with OCD from constantly evaluating whether their obsessions are coming true and thinking they are responsible on the off chance they do.
How might we make the use of compulsions on a daily basis less wearisome, time consuming and easier to cope with whilst encouraging professional help.
How might we show those with OCD that being fearful of losing what you have isn’t the only option and to encourage living in the moment instead.
During ideation, a triple diamond methodology was used in order to generate a unique, suitable idea. Over 100 ideas were initially dreamt up, but at the end of the process only the best candidate was taken forward into the development stage. Below is the process of emerging and converging that was carried out.
To make sure ideation was effective, a mixture of approaches were used including individual, group, internal stimuli and external stimuli. This gave the best chance for valuable ideas to be produced, and made sure the process was exhaustive.
Individual
• Doodling
•Brainstorming
Group
• Group Brainstorming
• Challenge
• Essence
Internal Stimuli
• Brain Writing 3-6-5
• Lotus Bloom
The multiple diamond approach allowed for 6 consecutive phases of idea creation followed by idea evaluation. After the final phase of evaluation a single idea was left, which was the most suited to the 3 How Might We Statements, and therefore directly inline with the design challenge.
User
Those with OCD that specifically use mental and checking compulsions in their rituals, which is over half. (NICE, 2022)
Elements
The original idea included a centralised app, a portable remote and a pad speaker that resides in the user's home.
How it works
Users input their obsessions and compulsions into the app where they allocate them a button on the remote. When they obsess during the day, they press the button which automates the compulsion either on the phone or on the pad at home (depending on compulsion type). Simultaneously, they receive professional therapy through the app.
Benefits
This idea helps the user by automating their compulsions which allows them the same relief as performing them would. But by automating them it will save tremendous amounts of time and energy, giving them the ability to live in the moment more. At the same time, they will be working on their fears and potential evaluations in professional therapy.
It was now time to take this idea and develop it into a valuable product for the user group. To achieve this, a Product Design Specification (PDS) with a Human-Centred focus was used to set goals through objectives and constraints. They were split into 4 categories: Useful, Usable, Meaningful and Desirable. If you would like to view the finished A3 portfolio (20 pages) showing the PDS points, development and hero shot, please click here.
10 points were self-created, based on evidence from previous primary research, secondary journal paper studies and British Standards. Below are 4 examples alongside their justification. Following them are highlights from the development process that was carried out to satisfy them.
Usable Point
5 out of 5 users must be able to understand how to use the product and should be able to complete entering their personal obsessions and compulsions within the 0-3 errors range.
Justification
As this is an original idea, there won’t be much comparison to guide users in how to use the product. Therefore, users should be able to understand how this product works and helps them cope. They should also be able to enter their obsessions and compulsions in the 0-3 error range, this is because The British Standards Institute says that ‘lack of effectiveness can result in outcomes that could cause harm from use.’ (BS EN ISO 9241-11, 2018: 16) Even though the standard here is referring to physical harm, a non-effective process with this user group could result in psychological harm, as any frustration around such a sensitive task could be triggering.
By analysing the data, it was apparent that the process was still too complicated. To resolve this, anything that wasn’t essential to the operation was removed, additional onboarding was also added to guide the user through the process.
The type that has been used is an interactive walkthrough (IW) rather than a more traditional product tour. The benefit of an IW is that it encourages in the moment interaction and fosters learning rather than frustration. (Userpilot, 2022) It increases certainty of decision making for the user, which is an important aspect in limiting anxiety for those with OCD. (Nestadt, 2016)
To the right are screens where usability has now been greatly improved because of this, which was shown with a last run through of the process. This also showed that the error range was within the 0-3 range.
Wire framing screens was used throughout the development of this PDS point, in both user testing and analysis of errors and how to limit them. It was beneficial as it allowed a quick view of the whole process which inspired ways to rectify errors. Below is the final wireframe of the inputting obsessions and compulsions process.
Usable Point
5 out of 5 users must agree that they can input their obsessions/compulsions efficiently, to limit the anxiety experienced by doing this to a 3/10 maximum. (subjective self-report)
Justification
Efficiency, according to the British Standards Institute, are resources used in relation to results achieved. These include time and human effort amongst others. (BS EN ISO 9241, 2018) Human effort for those with OCD can differ, especially when having to talk about their own predisposition which could possibly be triggering. Therefore, the human effort expended during this task should be kept to a minimum.
As users most likely haven’t ever written down their obsessions or compulsions before, it was important to make sure this process was as efficient as possible. To do this a multi-stage task analysis was used, alongside the theory and application of the Reservoir of Good Will. These exercises focused on two main aspects of efficiency- quickness and demand.
Task Analysis
A multi-stage task analysis process was used to make this process as efficient as possible. It allowed for unnecessary steps to be cut and demanding interactions to be changed or removed. Below is the final task analysis and following is the reduction in quickness and demand this process yielded.
Quickness
The first task analysis had 22 steps from the user landing on the homepage to completing the process. The analysis above has only 9. All together a 60% increase in efficiency was achieved using this method.
Demand
By giving the demand types a score system of 1 to 4 depending on the level of demand to the user (vision-1, cognition-2, anxiety-3 and OCD triggering-4), I was able to take this quantified data and compare the difference on demand between the first and last analysis. The one above was much lower in user demand, going from 70 points to 37 overall, a reduction of nearly 50%. It was also extremely important to eliminate areas which are 'OCD triggering'. An example where this was achieved was by changing that the user had to write a description of their obsession into just using keywords which is also optional. This gives power to the user and also reduces the time exposed to this part.
Reservoir of Goodwill
Steve Krug in his book Don’t Make me Think, explains a theory called The Reservoir of Goodwill, which is an imaginary level users have when using a digital product. This level goes down every time a user experiences an issue or is frustrated, and on the flip side increases when they feel heard or find something useable. (2006)
Even though just a theory, It had great potential as a user testing method, so I adapted it into a form of usability testing.
Who and How
5 people with OCD (a mixture of mental and checking compulsion users) were told to navigate the 'obsession and compulsion entering process' on a high-fidelity XD prototype. They were also given a sheet to fill in with an empty bar for every screen (the reservoir), and told to mark on the bar where their current level was after every screen completion. Beside this was a box to write a comment on why their bar changed.
Discovery
This provided an invaluable method in locating common frustrations and finding areas that could be effecting efficiency. For instance, on the screen where users input their obsession key words and nickname, they were unsure of what to put and what was a correct type of answer even though it's just for their reference. To combat this, examples in grey were introduced, which disappeared when the user opened the field. Below is this example and how this small introduction increased the level when the users were consulted afterwards.
Each set of bars represents the level before and after the change for each user. As you can see in all instances the level increased as frustration was minimised. If you would like to experience the inputting obsessions and compulsions process, click the play button.
Meaningful Point
The product should provide the user with a sense of accomplishment as they progress through therapy and make steps in a positive direction with regards to their mentality.
Justification
There is effective treatment available for those who have OCD, but regardless the average person still goes 17 years without reaching out for help. (Pinto et al, 2006) This is because there are a large variety of barriers to therapy, on top of this it is well documented that improvement is difficult to reach with this treatment type and even tougher to sustain. (BeyondOCD, 2022) Therefore, as users make progress, they should be rewarded. Doing this can create intrinsic motivation that 'will encourage innate strivings for growth.' (Reeve, 2008: 111)
Accomplishment Through Therapy Stages
Secondary research revealed that In Cognitive BehaviouralTherapy (CBT), the NHS standard therapy for OCD, there are always 4 main stages to any plan, which lasts between six months to a year. (NHS, 2022) They are the Assessment Stage, Cognitive Stage, Behavioural Stage and Learning Stage. (CotswoldCBT, 2022) This provided a unique opportunity for showing accomplishment through symbolism, located in the therapy section of the app.
Symbolisms Role in Encouraging Personal Growth
For every stage of therapy that the user progresses through, they will receive another trophy for their achievement, which will be unlocked by their therapist. This is because symbols that allow a visual overview of personal growth and achievement have been shown to motivate and produce further growth, which in turn adds to the persons sense of accomplishment. (Casais etal, 2016) By showing that there are 4 possible trophies, it gains a ‘meaning of directedness and purpose, which will directly increase subjective well-being…as a sense of purpose is essential to keep people motivated.’ (Casais et al, 2018: 265) This is immensely important here, as therapy is an arduous and testing, but an essential journey that needs to be completed for these users.
Symbolisms Role in Stopping Social Comparison
The symbolism here has another purpose, it offers a distraction from social comparison, which is important as those with OCD often compare themselves to normal people as they themselves live a quasi-normal life, which often leads to depression because it outlines their shortfalls. (Angermeyer & Killian, 2005) In the original social comparison theory proposed by Leon Festinger, he says that without the visual symbolism of our personal performance, we will quickly default back to comparing ourselves to others. (1954) Therefore, without visual representation of progress, users might go back to comparing themselves to normal individuals, reducing their sense of accomplishment.
To experience the therapy section click the play button.
Accomplishment and Reward
To identify where in the experience accomplishment could be harnessed, journey maps for users with both mental and checking compulsions were constructed. These revealed a moment of opportunity, where positive emotions could be heightened through a behavioural changing method called Positive Thinking. A technique which can only be used in the third stage of therapy. When a user gets here, they will open the app to find the feature being unlocked. This is termed an unlocking mechanism and it is highly effective at rewarding users as it is suddenly exposed, (Wang & Sun, 2012) causing system 1 fast thinking to be used that will draw on the feeling of surprise and accomplishment.
In stage 3 of therapy the therapist will work on developing rational alternate thoughts to follow obsessional thoughts, which will be used in tandem with compulsions to develop new, healthier behaviours. This process is Positive Thinking. Which will be unlocked by the user when they get to stage 3. Positive thinking will be used in the moment of opportunity, after the user’s compulsion has been automated, they will receive a notification with their personalised positive thought that will reduce their anxiety even further and promote positive emotion and above all healthier behaviours.
Positive thinking would normally be performed manually by the patient, straight after they obsess. But large volumes of obsessing can make them forgetful which leads to this stage being skipped and the behaviour not being re-enforced enough. (Rachman, 2002) By automating it as a notification, it will strengthen the development of the behaviour and make sure it is completed every time.
If you would like to experience unlocking this feature yourself, click on the play button.
Desirable Point
Users must feel trust towards the product and comfortable enough to divulge their closest secrets with it.
Justification
In Ken J. Rotenberg's book, The Psychology of Trust, he says that 'the most common perception of trust is to believe that someone is good and honest and that they won't harm you.' (Rotenburg, 2018: 4) Those with OCD hide their condition from others as they often believe that they will be looked down upon, called crazy or avoided because of it. (Rememrswaal et al, 2016) Therefore for them to open up, they will have to feel like they can trust the product to not harm them in such ways.
A model of trust, first constructed by social Psychologist Morton Deutsch, and developed by Robert Hurley shows that in new relationships there are ‘situational factors’ that can be used to affect the level of trust between the two parties. Two of the most important factors are if there is benevolent concern being shown by the to be trusted party, and the feeling of security. (Hurley, 2006) For this PDS point I have used these factors to cultivate a more trusting relationship between my user and the Compulse app.
Product Personality Through a Design Persona
Benevolent concern is a powerful trait as it can ‘engender not just trust but loyalty’. (Hurley, 2006: 58) Benevolence is a character trait that I have built into the Compulse app through developing a personality for the product. Personalities can be used to shape a user experience and are the ‘key ingredient in building an emotional connection with an audience’. (Walter, 2011: 40) To build a personality, I constructed a Design Persona for the app.
Persona Traits
To show that Compulse is benevolent, it was key to emphasise human characteristics that show this trait. People who are benevolent are warm, friendly, kind, compassionate, polite and understanding. (Hanson, 2013)
Character Embodiment
Josh, who can be seen to the right is the centre of showing benevolence and is used through out the app. He shows these characteristics through his laid back demeanour, friendly posture and expressions, colour use and the typography that accompanies him.
Josh Example
The thumbs up animation, which can be seen on the right, is initiated when the user gets to the end of their first input of their obsession/compulsion. Here, the animation and typography work in tandem to give the user the feeling of accomplishment and acknowledges the gravity of the user taking about their symptoms, showing a real understanding of it. The animation itself it clunky in nature that incites a moment of digital delight for the user, distracting them from overthinking about the task.
Visual Lexicon- Colour
Research into emotional connection to certain colours for those with anxiety related disorders has shown that lighter blue is often associated with calm. (Simmons, 2011) Therefore it has been used as a background colour to create a calming emotional experience.
Besides using calming colours, visual demand was also kept low to reduce anxiety. By deploying a contrast plugin called STARK on XD, It was possible to check the ratio for the black text on blue (16.04:1) and the black text on white (21:1), which both had a high contrast level. All text and icon were also kept in line with the Apple Human Interface Guidelines (examples shown on the left). Contrast/following tested guidelines allows less demand on the user's visual system and makes sure all instructions are eligible, reducing the chance for error and allowing better certainty. Critical as those with OCD often experience extreme anxiety because of doubt, as they have diminished confidence in their ability to make decisions. (Dar, 2004)
Visual Lexicon- Typography
Typography is submissive and informal, often using questions and friendly language to put the user in the driving seat. Typography is always rewarding, and uses shorter words to give it a human touch, as if the user is talking to another person.
Visual Lexicon- Symbols
All symbols are flat and drop shadow is used for important elements. They are all 2D vectors and use only necessary lines, this is to keep the overall look uncluttered and avoid information overload. Something that has been shown to cause un-trust between anxious users in other studies. (Writes, 2020)
Feeling of Security- Group Brainstorming
As users are being asked to divulge secretive information about their obsessions and compulsions that they’ve hidden from others for a large amount of time, it is of paramount importance that they feel like this information is safe. Secrecy is kept by this group for a range of reasons, and it’s so imperative to their functioning that it is said to be a main aspect of the disorder. (Clarizio, 1991) Therefore, knowing that their information is safe was at the heart of this PDS point and trusting Compulse.
A group brainstorming session with 3 users with OCD was conducted. Firstly we looked at why it was important that this information is protected and then onto how and what would make them confident that this sensitive information was secure. The two main areas of worry were:
You lend someone your phone and they accidentally open the app and discover your secret.
To resolve this, password protection can be enabled from inside settings, and needs typing in every time the app is launched.
Someone sees you on the homepage of the app and wonders what the words mean.
To resolve this, a hide feature was introduced on the home screen in the centre. When pressed it will hide all words and won't allow the obsessions and compulsions to be accessed. To de-activate the same password is required.
The final solution involved using a clickable case that could be used discretely to automate compulsions for the user group. The click amount would be linked to a unique obsession and compulsion combination in the app, which is capable of automating both mental and checking compulsion types. Besides this, professional help could be accessed through the app, with a therapy section that specifies in helping the user with Cognitive Behavioural Therapy (CBT).
When a user would have an obsession triggered and would require the use of a compulsion, they would simply click the back of the case in their pocket, which would automate it. For example for checking compulsions, when a user enters their home and locks the door, but knows this is a potential trigger, they will tap their phone case . This will then send a notification to the phone that says the door has been locked. Later, when the user feels the need the check again, they simply look at their notification rather than going back to the door.
During user testing this method (which is slightly different for mental compulsions), the data showed that it reduced checking times by at least 50%. Saving over 4 hours a day which would normally be spent using compulsions. To see the full development of both digital and physical products, please check out my portfolio here.
I was very pleased with the project as a whole. The idea of making compulsions more efficient whilst promoting professional help is one that is completely original, as
evident by the lack of antecedents. This project highlighted to me the importance of consistent user research, testing and involvement. Without which this viable solution would’ve not been possible. To have a play around with all these features on the app, please click the play button below.
