Hmm….how much did I get right? In this guest blog for Brainscape, written eons ago in 2014, I talk about the gamification of mental health, my evidence-based anxiety- and stress-reduction app Personal Zen, and where the field of digital therapeutics – not yet called that! – needs to go.
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:
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. This 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.
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.
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.
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.
This post is from 5 years ago, July, 2013. I believe we’re all still thinking about and struggling with these same issues today!
Games that are not games. There is a serious barrier to the effective gamification of mental health. This barrier is that the games we psychologists and health professionals are coming up with are not fun. In fact, they are totally uncool, border on the condescending, and wouldn’t motivate anyone to play for more than 30 seconds. This is the case even though the bar is set quite low because these “games” address things that people really want, like boosting our intelligence and memory, reducing depression and stress, quitting smoking, … fill in the blank. I’ve been fascinated with this disconnect between Psychology’s view and real-world acceptability. This disconnect is plaguing other fields as well, such as in the development of “serious games” for education. In this larger context, I’ve been working on the development of an app that takes a scientifically proven approach to reducing stress and anxiety, and embeds the “active ingredient” of this intervention into a game that is fun – fun enough, we hope, for someone to want to play for much more than 30 seconds.
Fun versus health goals. In the midst of this ongoing development process, I had the pleasure of speaking with Nick Fortugno, co-founder of the game design company Playmatics. In addition to creating really fun games, like Diner Dash, he has created games to promote positive social change and is one of the visionary and forward-thinking advocates for the idea that serious games can and should be fun. So, he has a deep understanding of the barriers facing the gamification of mental health. As we were talking about these barriers, Nick said something that really got me thinking. He said, when we design games for education or health, we have to remember that “the game doesn’t care” about whether we’re making progress towards our goal. In other words, a game isn’t fun because it meets some criterion that we, the developers, have for success – like boosting our ability to remember, reducing symptoms of anxiety, or losing 5 pounds. A game is fun because it creates an aesthetic experience and facilitates game play that we want to come back to again and again. Therefore, I would argue that a “serious” goal embedded in a truly fun game is reached as a by-product of the fun.
The need for backward engineering. I think I am accurate in saying that very few people, myself included, who are trying to create serious games for wellness think like this – i.e., like a game designer – about the process of gamification. From what I can tell, game designers think very deeply about the experience they want the game to promote, and then they work through the pragmatics of the game play that will facilitate this experience. This backward engineering from the point of view of the aesthetic/experiential goal to the pragmatics of the game is the opposite of what psychologists do when they think about gamification. Instead, we have parallel streams of development in which (a) we know that our “game” (read scientific protocol) is truly boring, and (b) we have to somehow decrease the snore factor. We think: “Hm, here is my very rigid experimental protocol/computerized intervention. I must overlay this protocol with some cute little animated guys, perhaps with a fun back-story (wizards? aliens?) and then make sure users get points when they conform to the requirements of the protocol.” Sounds thrilling, huh? So fun? Exactly the recipe for the next Dots? Right…. So, we have a lot to learn from game designers, and I believe that crucial to the future of the endeavor of gamifying mental health is partnering with people who know how to create fun and understand the process of game design.
Pocket rituals. What would it be like if we created mental wellness tools, or even interventions for serious mental health problems, that were truly fun and that could become part of our array of habits and strategies for feeling better, reducing symptoms, performing more efficiently, or dealing with stress? These games, if “snackable” would become our pocket rituals, our chill pills. We could take out our device for 5, 10, or 15 minutes and be empowered to bring about a targeted, appreciable positive impact. The barriers to use should be minimal, the experience intrinsically rewarding – that is, it feels good to play – as well as reinforcing because it helps us meet our health goals. I think many psychologists feel that this approach is not easily conducive to a rigorous scientific approach. But if we fail to find a way to do this – good science and giving people tools they want to use – then the whole endeavor is dead in the water.
I think a lot about how our use of digital technology, social media, and mobile devices shapes how we feel, think, and behave; shapes our muscles and our memories. There is no doubt about the host of benefits afforded us by all of these technologies, but their costs are both obvious and hidden.
We know that sometimes we feel addicted to them. We know we devote an immense amount of time and attention to them. Although they should be working for us, we often feel that we are working for them. We may even feel more tired and stressed and discouraged after being on screens. Muscles tense, furrowed brows. No one feels free on screens.The cult of efficiency tells us that we can and must get more done.
We are learning more about the consciously addictive designs of these technologies, mobile devices in particular. They are meant to hook us in. We now have no doubt that our views and clicks, our “data”, are the basis of the attention and surveillance economy, a multi-multi-billion dollar behemoth of an industry. As a psychologist and neuroscience researcher, I think about states of mind and brain when we use these devices, mobile phones in particular.
So, in the great tradition of obsessive scientists throughout history, I have been conducting an experiment on myself. Instead of using my mobile device on my daily
subway commute, I now take a little notebook, about the size and shape of a small mobile device, and write poetry.
Some of the poetry is about my personal experience of technology, but most is not. The goal of the experiment is to track my subjective experience and assess how my state of mind changes when I think in poetry, express ideas in verse, write with a pen instead of click, swipe, click, swipe. No goals. Free-flowing thoughts. Efficiency the last thing on my mind.
Here are the poems I’ve written so far. I’m still collecting data. I’ll report back later in the summer and post more poems as I go.
If anyone wishes to join me in this experiment, please do so! Post your poems in the comments and I’ll post them on the blog (attributing them to you, the author, of course).
The Subway Poems
Show Instead of tell
I raise my hand
I talk to you and forget
What you said
Only half remember what I said
I wonder, in the flood, what is really worth saving
What happens when we suddenly start listening,
When we pay
Small conversations: “I’m here”; “I know what you want”
My husband holds the coffee cup
Shifting in its saucer
Zooming in on a screen
Except nothing like that
The opposite of a two-dimensional half-life
On the screen, our bodies shrink,
Contained in our headbox
Eyes and ears
Holding our breath
A laser pointer, robot madmen
Eyes created to gather information
Punch! Punch! Check off, check off!
We have made ourselves into the image of small people
Stuck in the trees, no forest views though they cry, “disrupt!” “innovate!”
Victims who have become victors
Powerful like sad, awkward puppeteers
Are you my kind?
Two of a kind, a kind of wonder
Kind of this and kind of that
Kinship is a slippery slope
An avalanche of decency
One step forward and three…
A tango, a pas de deux
Eliminate the excess
“i carry your heart with me(i carry it in
Anywhere I go
I am in a land of others, of those who are not
Kinship being a slick and clever bird
Oil-slick and floundering
As little friction as possible
Same in skin, same in heart, same in bones
A tribe of potentiality
The tip of the spear
The Tip of the Spear
The world seems full of tips of spears
Doing the bidding of the savages
I imagine a spear with a stone arrowhead
Bound with twine or
(am I making it up that people did this?…)
Animal guts or entrails
The tip of the spear is bound tightly as a
Clenched fist and
As a dream from which
You can’t awake
As tightly as hope
When you have nothing left
Building blocks totter
Sculpture of Chinese letters
Hold the pen tightly
Woman on Subway
We are all subjects in the kingdom of randomness
Among our uncertain narratives
Hard pressed to find a story that we can live by,
That we can inhabit
How could the vast indifference,
The imperfect glazed bowl
Of our universe
Not make sense?
Can’t you see the spark in every
Rose and thistle
In every question and it’s too certain answer?
So long ago, I can’t remember
The inferno is hard to explain to a child
It assumes knowledge that is like a quagmire
Every step deeper in
But more lost
Sucking, slurping, sticky marsh goo
They should come to know that they will be judged
And, if not found wanting,
That they will dance away from the platform edges, and eventually embark
We should have known that Silicon Valley’s creepy, peeping-tom, data-stealing incursion into our lives was going to end badly. There were red flags from the very beginning. How did we miss them? Why did we ever think that “disruption” was a good word? Doesn’t the acronym, FAANG, for these dominating, digital behemoths give us a clue?
I think an apt metaphor here for understanding how and why we all, systematically, ignored these red flags is the bad boyfriend/girlfriend phenomenon. Since I have had experiences with bad boyfriends (BBs), I will write from this perspective. But of course it applies equally to any romantic partner.
Most BB experiences follow three stages:
Although the BB was charming at first, red flags are there from the beginning. He soon starts letting you down and making you unhappy.
He takes advantage of your love for him to keep behaving badly.
It takes a long time for you to realize that BBs never really change.
Here is how this maps on to the big Silicon Valley companies:
1. The red flags are there from the beginning. Let’s start with Mark Zuckerberg and Facebook, arguably among the worst of the worst BBs. As recently described by Julia Carrie Wong, who was one of earliest users of the proto-Facebook site thefacebook.com, she recalls a leaked IM exchange between Mark Zuckerberg and his friend. It’s worth reading the article in full, but here is the IM exchange, originally published in Silicon Valley Insider:
ZUCK: yea so if you ever need info about anyone at harvard
ZUCK: just ask
ZUCK: i have over 4000 emails, pictures, addresses, sns
FRIEND: what!? how’d you manage that one?
ZUCK: people just submitted it
ZUCK: i don’t know why
ZUCK: they “trust me”
ZUCK: dumb fucks
This BB is just the worst. Trustworthy and innocent in front of you, backstabbing and demeaning behind your back. When you catch him, he acts innocent, surprised – just like Mark Zuckerberg acted when he testified in front of Congress last month. But this was his plan from the very beginning. You need to start paying attention now! It would be best if you broke up with him sooner rather than later.
2. He takes advantage of your love for him to keep behaving badly. But you don’t pay careful attention and you don’t break up with him. Instead, you keep rationalizing his bad behavior away, so he knows he can keep getting away with murder. Your relationship with Facebook is again a perfect example again. Take the Cambridge Analytica scandal – it’s old news! That story already broke back in 2015 in a Guardian report about Sen. Ted Cruz’s presidential campaign wrongfully obtaining data from tens of millions of users. You complained a bit, but forgot about it after a few weeks.
But let’s not forget, you have other BBs in your life. What about Google’s active hostility towards privacy? Whether it’s the creepy Street View violations when Google Maps first launched or, way back in 2012, when Google was fined a measly $22.5 million (less than .1% of Google CEO Larry Page’s net worth at the time) for overriding privacy settings in Apple’s Safari browser? Your response?: Privacy, schmivacy. Google’s old “don’t be evil” motto just means that anything less than evil is ok, right? Makes sense!
I may have deleted my Facebook account years ago, and use DuckDuckGo instead of Google to protect my privacy and personal data, but I should come clean and talk about my own darling, Amazon. Amazon, which doesn’t allow ample time for its employees to have bathroom breaks; which is running every mom-and-pop store on the planet out of business; which seems to value growth and efficiency above all, no matter what the consequences for individuals or society. I still love you Amazon because you make my life easier. I’m finding it very hard to leave you, even as you become like an evil robot overlord more and more every day, and my life becomes drearier and more draining after all the looking at clicking and swiping and buying on that no-longer-charming glowing screen?
3. BBs never really change. The current litany of Silicon Valley mea culpas are drowning us. It’s hard to hear anything over all that gnashing of teeth. But once that dies down, you know that your BB will try to go back to doing what he does best – whatever he wants without concern about the cost to you or anyone else. Don’t fool yourself. It’s way past time to wake up.
Techlash is now, and many of us, perhaps for the first time, perhaps in a more powerful way than ever before, are realizing that the digital ecosystem might have made our lives more efficient, but has also increased cruelty, indecency, ugliness, and inhumanity around us. In this ecosystem, negative information is amplified at the expense of positive information. The “connected” world isn’t happy. We feel free when we put those smartphones down. Scared, but free. Much like leaving a bad relationship. We have to double down on being human again.
We should have all paid attention. Don’t expect BBs to ever really change. If you’re stuck with one, like we probably are with our Silicon Valley BBs, just remember, it’s up to us to call the shots and make things better.
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.
The inadequacy of digital connection has left us yearning for the felt presence of other people. In my latest post for The Garrison Institute I explain why our love affair with digital may be over. Read my full post here.
I recently wrote a blog post for The Garrison Institute on how social media interactions can leave us yearning for deeper connections. You can read the full article, ‘The Power of Human Touch and What It Means for Our Digital Lives’ here.
I recently wrote a blog post for The Garrison Institute, on finding a middle ground when using technology to strengthen our inner lives. You can read the full article, ‘Between a Cyborg and a Hard Place‘ here.