Digital Mental Health in the Era of Techlash: Towards Humane Health Technology

Note to readers: This is a long-ish read (closer to 15 rather than 5 minutes)

As someone who studies mental health, I rarely stop to ask myself about its definition. Yet, definition is increasingly at the front of my mind when I think about the field of digital mental health.

I know all the modern textbook definitions, but find myself drawn to a definition that was put forward over 60 years ago by Erich Fromm in his book The Sane Society. One of the founders of what would come to be known as Humanistic Psychology, Fromm wrote “Mental health is characterized by the ability to love and to create, ….by a sense of identity based on one’s experience of self as the subject and agent of one’s powers, [and] by the grasp of reality inside and outside of ourselves, that is, by the development of objectivity and reason.”

I love this definition because of its focus on what seems to me to really make us human: loving, creating, and having a desire for knowledge. The field of digital mental health is moving forward at a breakneck speed without considering the basic question of how it might promote – or disrupt – these building blocks of a sane and humane society and of our individual mental health within it. Moreover, it is developing in a world of obsessive social media use, mobile phone addiction, fake news, digital data insecurity, internet trolls, and the Uber-fication of human service industries, all of which serve a single, primary objective of absolute efficiency – getting what we want as quickly and easily as possible at all times.

Here I highlight key challenges we face in creating humane and effective health technology in a toxic digital ecosystem, lay out a four-point road map, and, as a case study, describe the development of a micro-intervention app for stress- and anxiety-reduction I developed called Personal Zen.

The Promise of Digital Mental Health

The potential payoffs of digital mental health are of crucial importance now. We are facing an ever-growing mental health epidemic in the US and around the world. Over half of us will be diagnosed with a mental health disorder in our lifetime. And our kids are struggling. Approximately one in every 4–5 youth in the U.S. meets criteria for a mental disorder with severe impairment, and the vast majority of mental health disorders in adults first emerge in childhood and adolescence.

The particular promise of computerized and mobile interventions are that they can, if done properly, radically increase the availability and accessibility of empirically-validated treatments, while reducing cost and stigma.

The Toxic Digital Ecosystem and Techlash

We’re used to believing, with true tech-enthusiasm, that if only we can “disrupt” current healthcare delivery systems, we can solve all our problems. But we now realize with growing certainty that what the digital ecosystem truly excels at is making money for technology companies and pushing us towards ever-greater efficiency. It does this so well because it is precisely and purposefully designed to grab our attention, addict us, and keep us glued to our screens: This is the basis of the attention and surveillance economies. The result of this design focus is that digital technology exhausts us, distracts us, and detracts from our ability to do other things.

Awareness of this has caused the pendulum to swing the other way, and we’ve entered an era of “tech-lash” with growing outcry about mobile phone addiction, negative effects of social media on youth mental health, data security, the spread of fake news, unethical business practices, and the list goes on. We are angry at Silicon Valley because these powerful companies created ubiquitous products and put profit so far above our well-being, that it’s unclear what to do about it.

Such is the degree of techlash now that even scientists are seeing causation in correlation before solid facts are established. In 2017, researchers, usually a circumspect bunch, went so far as to suggest in the popular media that smartphones have psychologically destroyed a generation of youth, citing among other findings that during the period following the birth of the iPhone about 10 years ago, we have seen a doubling of suicide rates and increases in depression and anxiety across vast segments of society.

In its annual survey of students, the American College Health Association found a significant increase — to 62 percent in 2016 from 50 percent in 2011 — of undergraduates reporting “overwhelming anxiety” in the previous year. Surveys that look at experiences related to anxiety are also telling. In 1985, the Higher Education Research Institute at U.C.L.A. began asking incoming college freshmen if they “felt overwhelmed by all I had to do” during the previous year. In 1985, 18 percent said they did. By 2010, that number had increased to 29 percent. Last year, it surged to 41 percent. These are alarming statistics, but is this enough evidence that smartphones are causing these problems?

I believe not. I have come to doubt conventional wisdom that smartphones or social media are a unique cause of anxiety, depression, or suicide; instead, I see them as a factor among many. By primarily “blaming the machines” we obscure the impact of other factors of equal or perhaps greater importance, and lose opportunities to deeply examine a range of factors and how they might work together with digital technology to contribute to the suffering of youth and adults.

As the evidence comes in, how do we work in an arguably toxic digital ecosystem to ensure that – for adults and children – health technology heals rather than harms?

A Four-Point Road Map for Humane Digital Mental Health Technology

For health technology to be truly humane, it must meet these four criteria:

  1. Prioritize development of micro-interventions. An irony of digital mental health is that the well-honed attention economy techniques that keep people glued to screens will work against mental health promotion. Therefore, focus should be on creating micro-interventions that require as little screen time as possible. Micro-interventions are brief and frequent, easily fitting into a person’s routine at home or on-the-go. They are part of the broader spectrum of care, with low-intensity preventative or “gateway” treatments at one end and intensive stand-alone treatments on the other end. Development efforts in health technology should be focused now on the low-intensity end of the spectrum. Later, once a strong evidence base is built, resources should then be devoted across the spectrum to develop more intensive, resource-heavy and stand-alone treatments. Spectrum of careThis strategy is largely reversed in digital healthcare right now. Many companies are trying to digitize gold-standard treatments like cognitive behavioral therapy (CBT), which remains time-consuming and expensive. Moreover, it remains unclear whether CBT is effective in digital or telemedicine format. Making poorly-validated treatments widely available does not solve the mental healthcare crisis.

 

  1. Maximize high accessibility. Along with the development of brief, micro-interventions, digital mental health must be qualitatively more accessible than current treatment delivery systems – affordable, easy to access, used on-the-go, and engaging. Current psychological treatments are often time-consuming and expensive. Of the over 160 million Americans who will have mental health problems in their lifetime, 50% of us don’t seek any treatment with 44% of these untreated patients citing price as a barrier. Basic access is also highly limited – over 83 million Americans live in federally-designated Mental Health Professional Shortage Areas.

 

  1. Reduce stigma. The stigma of mental illness represents a significant barrier to mental healthcare access. Of the tens of millions of untreated Americans struggling with mental health, 10% cite the stigma of mental illness – and fearing others will find out – as a primary barrier. A benefit of digital and mobile mental health interventions is that when we access mental wellness tools on our devices, they become part of our enjoyable and daily digital lives, increasing the possibility of normalization. Developers can also aim to create interventions that are fun and engaging, rather than having the clinical and medical feel that might turn people away from seeking help in the first place.

 

  1. Make adaptive and personalized. The promise of machine learning, artificial intelligence, and big data for solving health problems are immense. The most sophisticated techniques for data generation and gathering have been used in the worlds of advertising and politics, but these emerging techniques have already made waves in terms of medical diagnosis and risk assessment. In mental health, the ability to dynamically evaluate a treatment target and personalize interventions accordingly are the future of mental healthcare. At this stage, few research-based mental health tools have built-in adaptive methods. This is among the most important areas in which academia and industry must come together, one that holds perhaps the greatest promise for true personalization of treatment.

Summary: Development of humane and effective digital mental health technology must optimize the accessibility and mobility of digital technology, shift focus towards brief, flexible, and personalized interventions, and reduce screen time in order to step off the attention economy treadmill.  This approach minimizes the harmful aspects of the digital ecosystem while capitalizing on its nimble, accessible, and stigma-reducing aspects.

Finding Personal Zen

I had the idea of humane health technology as a guiding principle when I created the app Personal Zen. Personal Zen is a stress- and anxiety-reduction exercise. The app embeds scientifically-based attention training techniques into an engaging and appealing format. Its scientific “active ingredient” is something called attention bias modification.

Attention biases are rigid and selective ways of paying attention to information in the world. Decades of research tell us that people who tend to be anxious or stressed detect negative information more quickly, and pay attention to it longer and intensely than people who are relatively less anxious and stressed.

This preference to pay attention to the negative is called the threat bias.  And here’s the kicker: The threat bias piggybacks on one of the triumphs of evolution – the ability to quickly and automatically notice danger, which in turn triggers us to fight or take flight to deal with the danger. But the threat bias highjacks and skews this evolutionary advantage. It acts as an unconscious information filter, an imbalance in what we pay attention to that makes us actually prefer and prioritize threat and negativity at the expense of the positive. When the threat bias becomes a rigid habit of looking at the world, it puts our fight/flight response on a hair trigger, and sky-rockets our feelings of stress and anxiety. We see monsters in the closet even when they’re not there.

Personal Zen is designed to retrain our attention to disengage from the negative in flexible ways so that we can better benefit from positive information all around us. This creates a stronger attention filter favoring the positive. As a micro-intervention, it was designed to be used briefly and on-the-go, so it can fit into anyone’s daily routine.

Findings suggest that this technique loosens the vicious cycle of stress and anxiety, immediately reducing distress as well as laying the groundwork for positive change. We’ve published three clinical trials of Personal Zen showing that even with short-term use, Personal Zen can reduce stress and anxiety. We’ve recently focused on the potential benefits of Personal Zen for a group of people in particular need of easy-to-access stress-reduction tools that can fit into their busy lives – pregnant women – and found that using Personal Zen for about 30 minutes a week for a month reduced the stress hormone cortisol. While much more work needs to be done, I believe that with this approach, we’re on the right track.

The Future is Now

The field of digital mental health is skyrocketing at a time when there are compelling arguments to reduce screen time. Humane digital mental healthcare must navigate this contradiction while taking the best that digital technology has to offer to actively promote the essence of mental health in us all: the ability to love and create, to have an empowered sense of self, and to embrace objectivity and reason. It’s up to us all, researchers, developers, and healthcare professionals, to get this right.

Blog Post for Psychology Today – Can’t Fight This Feeling: Technology and Teen Anxiety

Social media and digital technology must have an impact on our emotional lives because our social lives—whether analog or digital—always do. In my recent article for Psychology Today, I write about why we must move beyond “Is there an impact?” to “How, Why, and under What conditions is there an impact?”. Read the full article here.

Blast from The Past: The Day My Three-Year-Old Discovered Multitasking

Today we’re revisiting a post from a few years ago “The Day My Three-Year-Old Discovered Multitasking”:

I recently overheard a conversation between my three-year-old son, Kavi, and my husband. Kavi was about to go to bed and had only a couple minutes left to play. Dada asked him to choose how he wanted to spend his remaining time. Kavi said, “I have a great idea, dada! I can play iPad AND play Legos at the same time!!!”

Hoo boy, I thought. My son is becoming a multitasker at age three. Already dissatisfied with the pleasure of any single activity, he is trying to divide his attention between two things (one of which is a mobile device) thinking it will be more fun and he won’t have to miss out. Is this an expression of the dreaded FOMO, fear of missing out, rearing its head so early?

And thus followed a mental checklist of my potential parenting failures. Two stand out:

  1. I multitask too much in front of him. I am definitely a multitasker, but one who makes strong efforts to put away my devices when I am with my family. I don’t always succeed, so have I become a bad role model?
  2. I don’t encourage him to enjoy the process of doing and learning. As I’ve blogged about before, one way of thinking about styles of learning is making the following distinction: we can focus on and enjoy the process of learning, or we can learn with the goal of obtaining rewards (praise, grades, etc,…). If Kavi is so interested in multitasking, perhaps this is because he doesn’t fully enjoy the process of doing a single activity.

Then I thought on a more hopeful note, maybe I’ve done something very right, teaching him 21st century skills and facilitating his mental acuity:

  1. Multitasking in moderation is useful! Certainly, at this moment in time, people could be at a disadvantage if they are not able to take advantage of multitasking opportunities to gather information, learn, or accomplish goals – in moderation. So, the fact that it occurred to him to multitask two things he likes to do could simply indicate that his cognitive development is moving along nicely.
  2.  Maybe he is learning to augment his creativity via technology. Perhaps his thought was – well, I’m hitting a wall with new things to build with Legos so maybe I can use the iPad to come up with more ideas. But who knows what he was thinking. So I asked him.

The conversation went something like this:

Me: Hey sweetie, do you remember when you told daddy that you wanted to play iPad and Legos and the same time?

Kavi: mumbles something.

Me: What’s that?

Kavi: Yes, I think so.

Me: Why did you want to do iPad and Legos at the same time?

Kavi:  Because it’s the same kind of fun.

Me: The same kind of fun?

Kavi:  Yes. First you do iPad, then you do Legos. iPad, Legos, iPad, Legos….

Me:  But you also play Legos alone, just Legos.

Kavi: But that would be boring!

Me: Really? I see you do that all the time.

Kavi: Yes…..

At this point, I decided to drop it. So, what does this little bit of anecdotal evidence mean? I have no idea. But I think the bottom line is that I know my son and I’m not too worried. He is already quite good at focusing for long periods of time (he can build with Legos for hours if you let him). Perhaps, though, there is something I can do better. I could focus more on promoting his JOMO  – the joy of missing out. It’s the feeling that what you’re doing right now, at this moment, is exactly the perfect thing to do.

 

Is Your Child Using Devices Too Much? Apply the Delight Principle

Many of us parents worry about the potential negative effects of technology – particularly mobile technology – on our children. But we have precious little science out there that can help us figure out the costs and benefits, risks and returns. Heck, we’ve had television sets in our homes for over 80 years and we still don’t know a lot about its effects on kids.

mother child

But putting our kids in front of technology is sometimes hard to resist. Your kid is having a tantrum on the grocery line? Bring up a movie on the iPad. Children whining at the restaurant? Hand them your iPhone and see their little smiling faces and glazed-over eyes light up from the warm glow of the screen.

However, these solutions are often tinged with parental guilt and a nagging feeling that maybe we shouldn’t be doing this quite so much. To figure out how much is too much, I apply what I call the delight principle – and it’s perhaps not what it sounds like. It’s not experiencing the (yes) exquisite delight of  that whining/crying/fussing/annoying behavior stopping as quickly as if you pressed the mute button. Rather, it’s the idea that if we’re putting devices in our children’s hands so much that we’re losing opportunities to delight in them and enjoy their wonderful little selves, then we might want to reevaluate.

In a nutshell, devices can be used in a “disconnecting” way that, over time, can reduce a child’s experience of that  loving twinkle in your eye, that unconditional positive regard that is the cornerstone of a happy childhood.

This notion – show your child that you delight in them – is obvious in many ways.  But I think that in the cacophony of all the “expert” parenting advice out there – from free range parenting to attachment parenting – this simple instinct that every parent has is easy to lose track of. When children are NOT being delightful (often!), devices are not necessarily a parent’s best friend. Here are a few ways that delight can be blocked when devices are used to disconnect during frustrating situations:

1. Remember to twinkle: Children need to see themselves literally reflected in our eyes in the form of that loving twinkle. It’s not that we need to praise them (and indeed there is good research coming out now about the downside of praise) but rather we need to take joy in their accomplishments, mirror their journey of self-discovery, and be our children’s promoters (as distinct from praisers). Putting devices in front of our kids “too much” has the effect of directly, physically blocking that twinkle. We need to trust our guts as parents on how much twinkle we want to block and make a mindful choice.

2. Share your child’s world: Take time to see the world from your child’s perspective. Every parent knows that it’s a magical place. Explore the world together, discuss ideas, point out things that are interesting or puzzling or wonderful. Listen to what they have to say about it, and if they don’t have much to say, just be with their experience of it and share your experience. Using a device to share in your child’s world seems like one of the best possible uses of a device. So, when we bring out a device, we can choose to use it to connect with our children or to tune them out.

3. Help your child find their own inner delightful child: Just in case you were starting to think I am a proponent of “just twinkle and let the hard stuff go” – not the case. By #3 here, I mean I think we shouldn’t be afraid to talk to our child about being civilized and polite – yes, delightful – human beings. I think that children who are explicitly taught and socialized to be polite, compassionate, and empathic will on average be delightful children and will grow up to be delightful adults. And the converse is also true. I think too much device time reduces opportunities to guide our children towards being delightful. Moreover,  we have to believe that a child is delightful for this to even work. With too much device time I think it’s harder to know how delightful our children truly can be.

There are definitely times when I choose to use a device to press that mute button and just take a break. But when this starts to become a family habit (are they on the device every time you go out to dinner, precluding opportunities to actually talk with one another? Are they spending so much time watching tv that you don’t know how their day at school was? ), it might make sense to do a delight check and make sure the technology choices we’re making for our children sit right with us.

 

 

 

The Happiest iPhone on the Block: Why Managing Your Digital Life is Like Good Parenting

When I started blogging a little over a year ago, I was a true social media skeptic. I drew more inspiration from thinkers like Sherry Turkle than Anil Dash. But my experiences with social media have turned this on its head. I’m still a skeptic in the sense that, as a scientist, I believe we need to know a lot more about how social media affect our lives for better and for worse. But I don’t feel the kind of concern I used to feel. Perhaps I’ve been tempted by the siren song of technology, lulled by a false sense of security engendered by the all-consuming digital embrace… but I don’t think so. I actually feel more in control and less overwhelmed by social media and other digital forms of communication than ever before. I feel they are tools, which I can selectively choose among and harness. I believe that a sense of well-being and balance in social media use is possible if we use some simple practices. The best metaphor I can think of for these practices is that they are the types of things that an effective and sensitive parent does. Here are the top five “parenting strategies” I’ve used to manage my social media burden:

naughty child

  1. Establish rules and set limits. Children thrive when there are consistent limits and structure. In the same way, our technology use needs rules and limits. If I don’t set limits on when and how I use social media, I’m more likely to get sucked into the black hole of keeping up with every tweet/text/email/post/newsfeed. I’m more easily distracted by social media, less present with others, and more likely to waste time and be less efficient because of it. Like all good parents, I try to create structure that is firm but fair. Harsh discipline might work in the short term, but the child usually rebels. So, I try not to be unreasonable or unrealistic about the rules (e.g., “I can only check email once a day, and for no more than 10 minutes” doesn’t work). I’ve tried to find a set of guidelines that work with my life and make me happy.
  2. Monitor communication technology use. It’s 10 o’clock. Do you know how much social media you’ve used today? This is really about being mindful about how we’re using our technology. I prioritize my time – I only have so much time and attention in a day, and so I try to spend my mental and social capital wisely. I keep track and schedule times that I will use these tools, and know the times that they need to be put to bed.
  3. Reinforce good behavior. It’s not only the amount of time we use social media or communication technology. It’s about how we use it and what it brings to our lives. I try to select digital communities that brings something positive to my life and that cultivates a positive peer network.
  4. Selectively ignore. In parenting, the idea here is that if a child is showing a troublesome behavior, as long as it’s not destructive, it can be “extinguished” by just ignoring it. If there is no reaction, and no reward, there ceases to be a reason for the child to act that way. And then the child stops being a nuisance. In the similar vein, when I start to feel that my communication technology use is becoming burdensome and bossy, when I feel the pressure to respond to every message or push notification is too much, I start ignoring it. Most of us like the feeling of being connected, and hope that the dings and rings on our devices will bring something good into our lives or that stressful things can be averted and dealt with quickly. So, we start to check obsessively and end up spending dinner time with our family on a device, or walking into traffic with our eyes glued to our iPhone. When I begin to move in this direction, I reverse course and start to consciously and selectively ignore my devices in order to break the cycle.
  5. Adapt technology use to fit my life. One key to being a good parent, I believe, is structuring your life so that it can accommodate children in support of their well-being and happiness. Some (in my opinion) not-so-great parents do the opposite, they expect not to change their lives at all and that children should just fit in. In contrast to my list of strategies thus far, when it comes to mobile technology and social media I try to follow the inspiration of the questionable parent: I fit technology into my life so that I remain able to do what I want and need to do without being sidetracked. If my life is becoming  more stressful and less organized because of social media burden, then I’m probably doing the opposite.

So remember, when that naughty stream of Facebook status updates are just too much to handle, you’re a week behind on your twitter feed, the pesky email inbox just won’t empty out, and those 10 texts – that are going to go unanswered for another few days – won’t stop bugging you, ask yourself: what would mom do?

Blocks and books better than electronic games for your toddler?

Thanks for this post, Dona Matthews! 

Blocks and books better than electronic games for your toddler?

I think one important take-home message is that we need to think through how electronic toys could be designed to better foster communication  and creativity.

Emotional Attunement: Good Food for Babies’ Brains

Dona Matthews, Ph.D., leading expert on gifted development and education, offers us a fascinating and timely perspective on the deep connections between parents and children – even on the neurobiological level – and the potential dangers of replacing these connections with “electronic engagement-replacements.”

Emotional Attunement: Good Food for Babies’ Brains

Parenting and Multi-Tasking in the Digital Age

As a psychologist and mom of two young children, I’ve been thinking a lot about what it means to be a parent in the digital age. A lot of people have already talked about how we feel tethered to our digital devices, and need to multi-task in order to juggle the constant demands on our attention. We’re no longer on the information superhighway – we’re in the Cloud. Which is exactly how I feel a lot of the time – like my head is in a cloud – unless I very purposefully step back and focus on being in the present with my family and friends.

But there are several issues from the standpoint of developmental psychology that I think aren’t discussed enough. I’ll focus on just two, here. The first issue is a child’s need to be genuinely seen and heard – or mirrored – by parents. The second is that we are teaching our children profound lessons about how to relate to other human beings when we multi-task with our devices instead of being present with them in the moment.

Mirroring. Parenting wisdom a few generations ago asserted that children should be seen but not heard. This is really incorrect in several ways. There is a classic concept in child psychology (originated by Heinz Kohut) called mirroring. Mirroring refers to the healthy process by which parents mirror or reflect back to children what they are saying, feeling, experiencing, wondering. Parents also look at children with a “sparkle” in their eye – that look of pride, warmth, and love that tells children they are appreciated and esteemed. Through this mirroring, children learn to understand their own behaviors, thoughts and emotions. They also learn self-regard and self-appreciation. Simply put, children learn to see themselves through our eyes.

Without this mirroring, many child developmentalists believe that children will not feel fully valued as human beings and will not as quickly and deeply learn to understand how to interpret their experiences and feelings. Imagine a world in which no one really looks at you or hears what you have to say – maybe some of us can. But then imagine you’re a child, and not really able to make sense of the world that goes on around you and the complex feelings and experiences you have. How do you give all these things a name? Mirroring would help you interpret your world and yourself.

Multi-tasking on our devices all the time is a sure-fire way to interfere with our ability look our children in the eye, hear what they have to say, sensitively pick up on their feelings, and transmit that sparkle in the eye. The multitasking mode is the opposite of mirroring and of being present.

The lessons that multi-tasking teach our children. This is a complex issue because I DO NOT think that doing some multi-tasking around children will “damage” them. That is ridiculous. From the very beginning of our evolutionary history, moms and dads were doing other things while spending time with the kids. In many cultures today, children are expected to join in with whatever adults are doing, and spend lots of time amusing themselves and playing independently –more perhaps than is expected in the U.S. on average. These sorts of cultural/value/belief differences about how to raise kids are totally ok differences. That is, no child developmentalist will tell you that we should be worried about this.

However, in this particular culture within which I live, many of us raise our children to be individualistic, with beliefs and desires that even from the earliest childhood are prioritized. The flip side of this is that while we are respecting them as individuals, we also should have the goal (I believe) of teaching them to respect and cherish others as individuals. When we multi-task on our devices every time we spend time with our children, I think we are sending at least three messages that in some ways are contradictory to this goal:

1. We don’t need to fully pay attention to other people, or be fully present.

2. When the multi-tasking is about work – there is no boundary between work and personal.

3. Even when we’re with others, it’s normal to be tethered to a device.

So, the advice I give myself goes something like this – “Alright, sometimes I’ll multi-task. I’m busy and have things I just have to do. At the same time, I will keep it to a minimum when I’m with my children and identify times that are sacred, when the devices go off (e.g., bedtime, breakfast, dinner, afternoon play time, etc,…) and stick to this.

This is my best guess at how to handle it. But only time will tell – will the Millennials (and generations beyond) lose some of what we hope all children will learn? – To deeply value others and the time we spend together, and feel deeply valued in return.