The saying about big risks leading to big rewards often proves false. Sometimes, embracing risk can lead a person to prison — or to an incurable virus.

Or both.

The rate of HIV infection for Americans in the criminal justice system is up to five times higher than that of the general U.S. population, reports the Centers for Disease Control and Prevention. The double danger is why scientists at TCU’s Institute of Behavioral Research are working to curtail the virus’s spread among offenders.

Wayne Lehman, a senior research scientist at TCU’s Institute of Behavioral Research, leads a team developing strategies for HIV risk reduction in the criminal justice system. Photo by Robert W. Hart

But how to address transmission of a minuscule virus in America’s massive, cash-strapped criminal justice system? Could an app developed by TCU behavioral specialists serve as an effective health intervention for probationers?

Consider the possibilities: “I went to this party the other night,” an actress explains to her on-screen friend. Eyes downcast, she admits to waking up next to a known philanderer and not remembering what happened. She frets about being exposed to HIV but would rather not know if she is infected.

“The sooner you find out, the better off you’ll be,” suggests the friend.

The video ends, morphing into a touch-screen app asking the viewer to think about the scenario and evaluate possible courses of action. The viewer must choose: Should the actress learn about how untreated HIV might affect her body, or should she discuss her fears with a trusted adviser?

Spurring the app’s user to consider the possibilities, side by side, is the intervention, a high-tech approach that aims to create new thought patterns. The goal is to teach risk-takers a deliberative method of decision-making.

Working the System

Psychologist Saul Sells founded the Institute of Behavioral Research at TCU in 1962. From the early days, the institute focused on improving substance abuse treatment and played a key role in the first national evaluation of public drug rehabilitation, said Wayne Lehman, a senior research scientist at the institute.

People have two ways to make decisions, Lehman said. The first is “experiential, where you make very quick decisions based on your past experience. … You just do what feels good in the moment.”

The other, an analytical approach, is more time-consuming but also more effective. Lehman said many people don’t approach problems by thinking through the options and need to be taught that process.

In 2008, the National Institute on Drug Abuse awarded a TCU research team a $2.7 million grant to help incarcerated drug abusers pave the way to healthier futures via an analytical thinking process practiced in group therapy. The process is similar to a thought-modifying system known as WORK-IT.

A collaboration between the institute and TCU’s psychology department, WORK-IT was created in 1994 to help teach better decision-making. People tackle a problem from several angles and then practice making new decisions to create fresh experiences for their memory banks.

Funded with an additional $2.8 million grant in 2015 from the same agency, researchers are in phase two of a project called Sustainable HIV Risk Reduction Strategies for Criminal Justice Systems. For this phase, principal investigator Lehman and cohorts developed StaySafe, an Android app intended for probationers in drug treatment. Participants use WORK-IT in a virtual environment while sitting in probation offices.

“Knowledge is not enough. Are you motivated to act on that knowledge? And do you have the confidence to be able to avoid risk?”
Wayne Lehman, a senior research scientist at TCU’s Institute of Behavioral Research

Analytical thinking can be a transformative tool for people who have been convicted of crimes. Their rates of drug abuse eclipse those of the nonoffending public, said Jennifer Pankow, project director of the StaySafe grant.

Probationers are an at-risk group, said Pankow, an associate research scientist at the institute, especially if they are between prison and freedom from supervision. Criminal behavior, sexually transmitted diseases and drug use share a commonality: a predilection for embracing risk. “It isn’t just the health risk that they’re dealing with,” she said. “It’s the different challenges around their criminal thinking and their offending.”

Pankow helped train counselors for phase one, which targeted therapy groups in prisons. Designed for inmates with substance abuse problems about to re-enter society, phase one’s WaySafe project taught healthy behaviors through group discussion and visual mapping.

WaySafe was effective. Participants reported seeking HIV testing almost 1½ times more often than the control group, those involved in the traditional prison-based health education programs.

Staying Safe

After WaySafe, researchers wanted to extend their study to reach probationers in court-mandated substance abuse treatment.

In Tarrant County, around 200 probation officers are responsible for about 20,000 offenders, said Kelli Martin, research unit supervisor for the county’s probation department.

Illustration by Getty Images © Malte Mueller

Probation officers, often called to serve as rehabilitators, have the same goal as the behavioral researchers, Martin said. “We teach people to recognize and pay attention to the way that they think.”

But when one officer is responsible for up to 100 probationers, some will fall through the cracks, she said.

The institute’s researchers designed the StaySafe app around three core design concepts: “Simple, engaging, sustainable.” The app aims to disrupt automatic decisions, moving those choices from a repetition of prior experience into the realm of methodical analysis.

Researchers said tailoring WORK-IT to one person using a tablet was challenging. Previous implementations involved bouncing ideas off group members, where people received feedback and drew decision maps to visualize outcomes.

The major obstacle to transitioning to app-based therapy, Pankow said, was: “How do we stimulate the participant in a way so that they have to critique their own thinking?”

The solution was StaySafe. The app translates WORK-IT into self-directed, thought-provoking lessons. Pankow created storyboards based on problems a probationer might face in the real world, including divulging an HIV diagnosis or returning to the temptations of former stomping grounds.

Research associate Roxanne Muiruri wrote scripts for one-minute videos to bring the potential problems to life. TCU’s Center for Instructional Services filmed theatre students who acted out Muiruri’s roles.

To offset the approximate $50,000 cost to develop the Android app, TCU computer science students in a senior design course took on the programming challenge to assist the researchers.

Virtual Reality

After the app was finished, institute staffers distributed StaySafe to participating Texas community-supervision offices and a residential treatment facility. A poster advertised StaySafe and offered probationers a stipend to participate. The project was offered in Dallas, Tarrant and Harris counties from October 2016 through fall 2017.

Probationers who completed the initial survey were paid $20 and assigned randomly to either a control group, whose members completed two follow-up surveys, or to a group that used StaySafe for 12 sessions. Participants in the latter group worked through hypothetical problems at a pace no quicker than one each week.

In each StaySafe session, the app presents a list of problems related to risky behaviors and allows the person using it to start making decisions. The user picks a problem and watches a short video that shows actors faced with a person, place or thing that could trigger a risky decision.

An app to train probationers in better decision-making would be a cheaper alternative to traditional counseling, Jennifer Pankow says. Photo by Getty Images © Hero Images

A user then selects how the person in the video might respond. The vicarious experience was intentional, Pankow said, because of the contrast necessitated by different decisions. The app then presents consequences — for several affected people — and mimics the process of mapping out a decision tree.

After thinking through the best decision from several vantage points, the user considers how to prepare for success when a similar situation arises in real life.

Wrestling With Risk

The problems embedded in the app hide the deeper intention, which is a new way of wrestling with risk. App users “practice through this schema over and over again so it becomes much more accessible,” Lehman said. “We’re giving them practice thinking through things.”

The practice component is essential, which is why researchers suspect a participatory app is more effective than traditional educational material.

“Knowledge is not enough,” Lehman said. “Are you motivated to act on that knowledge? And do you have the confidence to be able to avoid risk?”

The app is ideal for probation offices, Pankow said. “The cost of interventions in these settings is huge. To pay counselors to run groups, this is very expensive,” she said. “To be able to have something that maybe has a small footprint but can be made available at a very low cost is absolutely critical.”

Lehman said the StaySafe app fulfilled the researchers’ goal of something simple, engaging and sustainable. And now it is scalable. In the future, the institute plans to distribute StaySafe for free to any interested probation office in the country.

Although Lehman said he is optimistic about the StaySafe app, he is also realistic. “We don’t expect people to all of a sudden quit making bad decisions. We hope that some will, and some will start making better decisions.”