The Science of Personal Zen

In 2011, I created the stress- and anxiety-reduction app Personal Zen. I’ve written a good bit about the origins of Personal Zen, and my approach to digital therapeutics. But I write much less about how Personal Zen actually works. So here goes…

Personal Zen works by shifting our cognitive biases – invisible habits of thinking and paying attention. When we get anxious or stressed, we pay too much attention to the negatives and have less ability to see the positives in life.

The threat bias hijacks our fear brain and acts as an unconscious information filter, an imbalance in what we pay attention to that makes us actually 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.

For example, imagine you’re giving a public speech, and there is a smart audience in front of you, bright lights beaming down. If I have an amped-up threat bias, I would very quickly and intensely notice that there is this one person in the audience who is frowning, shaking his or her head, maybe falling asleep. I will fail to notice all the interested and smiling faces in the audience, and get stuck on this person. The natural result – I feel more anxious and stressed, I am on the look-out for further negative information, and I ignore positive evidence that I’m doing a good job. In this way, the threat bias drives the vicious cycle of stress and anxiety, takes up mental bandwidth, and puts us at a disadvantage when there is no real danger to face – when the monsters in the closet are only in our mind.

Yet, there is an empowering message hidden in the idea of cognitive biases. Biases are essentially habits. When we have a bad habit, we are not broken inside, we just need to learn a new habit.

Personal Zen helps us form new mental habits. It embeds techniques that derail the threat bias, which in turn creates the space to learn new habits that help heal the anxious brain. Here’s how it works.

We see both an angry and pleasant face (our cartoon sprites) quickly pop up on the screen. The sprites then disappear, but only the pleasant sprite leaves a trail. Our task is to trace that winding trail. Because the angry and pleasant sprite appear at exactly the same time, our brain is forced to decide which to attend to first. By ALWAYS following the trail of the pleasant sprite, our brains learn to automatically focus first on the positive and disengage from the negative. We start building a new habit of attention: Follow the joy. It’s deceptively simple, but clinical trials show that using Personal Zen changes how our brains respond to threat and reduces stress and anxiety after as little as one session.

When I created Personal Zen, my fundamental dream was to create a mental wellness tool, or even an intervention for serious mental health problems, that is delightful and fun while also being highly effective. It has to be truly “snackable” so it can fit into our lives like a pocket ritual, a chill pill without the pharmacy, where in just a handful of minutes, we are empowered to create a moment of peace in our hectic lives and to find our own personal Zen.

Finding My Personal Zen

I’m excited to announce our new venture, Wise Therapeutics, and the launch of the brand new version of our flagship product, Personal Zen. I am writing this in the midst of the COVID-19 health crisis. My team at Wise Therapeutics and I are offering Personal Zen free for six months in order to make this stress- and anxiety-reduction tool universally available. As we adjust to life under quarantine and beyond, I hope Personal Zen can provide support and be a tool in your toolkit for pursuing well-being in the days to come.

It’s been quite a journey to get to this day. I created Personal Zen in 2011, energized by hope and optimism …. as well as a deep sense of failure.

I became a psychologist and a researcher out of hope – hope that I could help improve the tools we all have to overcome problems like anxiety and depression. But a decade into my career I discovered that while we have excellent treatments and research, we weren’t giving people treatments that work and fit into their lives; Instead, we create treatments that are too expensive, too time consuming, too hard to access, and perhaps most importantly, deeply stigmatizing.

In 2010, while I was pregnant with my second child, I was wrestling with these issues. I decided, perhaps because I was contemplating the birth of my daughter, to give birth to something else – an app for that! Cliches aside, the next decade was a whirlwind of activity as I built and scientifically validated Personal Zen.

Flash forward to 2019, when I co-founded Wise Therapeutics with my partner and dear friend Raj Amin, an absolute guru in the health tech space. We now have the field of digital therapeutics, something that didn’t exist in 2010, when it was very much the Wild West. We are in an era of great digital health tools and forward-thinking companies, but digital health still isn’t working as well as we’d anticipated back in 2010. Why?

Using technology in the service of health is a very sharp, double-edged sword, with high potential costs as well as benefits. These costs are largely due to the elephant in the room – digital technologies have not been designed for our health and well-being. They have been designed for corporate profit. As a result, digital experiences designed for “engagement” are really just designed to keep us looking at our screens to click and buy more. We’re all starting to feel the exhausting burden of this.

The Four Pillars of Personal Zen. So how can Personal Zen – or any digital therapeutic – live in this potentially toxic digital ecosystem? Personal Zen takes a fundamentally different approach, taking the best that technology has to offer while disrupting the digital disruptions of our lives and well-being. To do this, we pursue what you might call the Four Pillars of Personal Zen:

Science: From the beginning, and before many others appreciated the importance of clinical validation, we scientifically tested the effects of Personal Zen. Now, five randomized clinical trials later and counting, we give our community of users a scientifically honed tool, not snake oil.

Effortless: Personal Zen is designed to be non-invasive, used on-the-go, and no therapist required. Our goal is to bring barriers to an absolute minimum so that taking the first step towards mental wellness and stress reduction is easy and seamless. Use Personal Zen on the subway (like I do as a New Yorker). Use it before a big meeting. Use it on the toilet. Because as the next Pillar describes, it just takes a few minutes a day, a few days a week.

Micro-intervention: Personal Zen is all about the power of small. No need to get stuck on the screen for hours – we already struggle with that! As a micro-intervention, our research shows that the “active dosage” to reduce stress and anxiety is about 20-40 minutes a week. This can be divided over multiple days so the extra screen time is only 5 or 10 minutes anytime, anywhere. Slightly more concentrated use – around 20 minutes – can have immediate positive effects to boost resilience in the moment.

Delight: We believe that pursuing mental wellness should be delightful, not stigmatizing, not demoralizing, and not cold and clinical. We’ve designed Personal Zen to be a beautiful, elegant experience that you can reach for anytime.

Read more about how Personal Zen works here.

Blast From the Past….Digital Therapeutics in 2014

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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.

The Moment That Has Yet to Arrive

I had the pleasure of being on stage at the Rubin Museum with two wonderful artists (and human beings!), Candy Chang and James Reeves. In 2018, they created a participatory art installation for the Rubin Museum called A Monument for the Anxious and the HopefulEach day visitors added new hopes and anxieties, totaling over 53,000 anonymous submissions. I have been working with Candy and James over the past year to make sense of these submissions and what they reflect about the personal and the public, about intimate experiences of hope and anxiety and broader societal shifts. One of the most beautiful aspects of this project was the degree to which people engaged and found solace in the work.

Indeed, when my family and I entered the Rubin museum in 2018, as past visitors of the museum we were used to admiring the giant spiral staircase winding up the light-filled foyer and the exquisite Tibetan sculpture of a lion standing guard at the far wall. So, we were excited and a bit stunned to see something that seemed completely out of place in this museum devoted to Tibetan, Indian, and other Himalayan cultures – a giant wall, half blue and half red, covered with hundreds of white cards. As we approached, we saw that there was writing on each of these cards. It seemed like a secret message in plain sight, waiting to be decoded. This was The Monument for the Anxious and Hopeful. Visitors were invited to share their anxieties and hopes by finishing one of two sentences, printed out on thousands of cards: I am hopeful because …- or – I am anxious because…. Then, visitors placed the cards on hooks fixed to a wall, divided by two colors – blue for hopes and red for anxieties.

As we talked through what we were seeing, my then 6-year-old daughter Nandini was the first to get it, saying “They want us to make the art!” She took a card that said I am hopeful because and completed the sentence with one of the words she had mastered spelling – love – and proudly placed it one of the hooks fixed to the wall.

We came back to the Monument every few months to help “make the art.” We always took time to read the massive wall of cards. The shared concerns and moods wove together like a patchwork quilt, each piece different but somehow connected. Written by thousands of visitors over its year-long exhibition, the words on the cards seemed to move together like a wave, ebbing and flowing with thoughts and ideas, at times playing off each other, contradicting each other, and forming themes and variations.

News headlines often drove the focus –political dramas, gun violence, suicides – and other times, anxieties were deeply and painfully personal, about being loved, safe, accepted, about whether family and friends were okay. “I don’t know where to go next.” “Racism is destroying us.” “I don’t know if I will find love again.” “My daughter is struggling.” “I despise wisdom because it gives me false hope.”

Yet, the cards on the wall did speak of immense hope, conveying in a few words that we have still have love, dreams, and faith, so it will all work out in the end. “Love connects us.” “No matter how lonely you are, the world lends itself to your imagination.” “People with bad GPAs can still be successful!” “She said yes.”

On that first visit, my then 9-year-old son Kavi noticed an interesting pattern – the cards for anxiety were often the same as the cards for hope: I’m anxious because I have a job interview; I’m hopeful because I have a job interview. I’m anxious because people are fighting over politics; I’m hopeful because people are fighting over politics. Kavi asked, “How can we be anxious and hopeful about the same thing?”

As many parents know, having to explain something to a child forces us to get to the heart of the matter. When Kavi asked me that question, I thought, “I got this.” I told him, “Anxiety is a warning message to us – that our present reality and future dreams are out of sync.” He gave me a blank look. So then I told him, “Anxiety lives off our hope for a better future when the future is uncertain.” He raised one eyebrow. Finally, I told him, “We’re only anxious when we care, and there is so much to care about.” His eyes lit up because that he understood.

He, like the Monument’s creators, had a deep intuition that the anxiety we experience today – perhaps more at this moment of time than any other point in history – is born at least in part out of the sheer amount we know and care about. Candy and James described their inspiration for the piece:

“We live in a uniquely unsettled moment of technological, political, and social flux. Awash in endless currents of information delivered by glowing screens, each new headline, discovery, and development brings a fresh opportunity for hope or anxiety, depending upon our individual attitudes and philosophies. By definition, anxiety and hope are determined by a moment that has yet to arrive—but how often do we pause to fully consider our relationship with the future? Are we optimists or pessimists? And how do our private sensibilities square with the current collective mood?”

Anxiety and hope are defined by a moment that has yet to arrive.

The Monument shows in moving and concrete ways that anxiety and hope are intrinsically intertwined in our imagined future and that both are a way of thinking about the world yet to come. Not only hope, but anxiety also may yet allow us to tell the stories we need to heal our futures – and perhaps the present, too.

 

 

 

 

 

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.

Kindness is a 21st Century Skill

These are rapidly changing times, in part due to the frenetic pace of technological innovation. How we communicate, connect, love, hate, and elect presidents are forever altered. Given this, educators, parents, and corporations are focusing on cultivating 21st century skills – skills like problem solving, synthesizing information, interpreting, collaboration, and kindness. These are skills that prepare us for the increasingly complex life and work environments of the 21st century, and reflect the changing nature of work, communication, and how we use technology to facilitate our lives.

crying-boyI believe that of these, kindness is the most critical 21st century skill, whether your goal is a civil society or successful business. Kindness is at the hub of our pro-social selves and is the glue of civilization. It allows us to understand the world through another’s eyes and act meaningfully in that world.

What is kindness? Kindness means interacting with others in friendly, generous, and thoughtful ways. It means performing acts to benefit others without expectation of reward or benefit for oneself.

For that reason, forcing acts of kindness sabotages the motivation to be kind, and a display of good manners does not automatically mean that a person is kind. Good manners can exist in the absence of generosity and thoughtfulness, and can be motivated by the hope of reward and praise.

Kindness is distinct from other, related aspect of our pro-social selves. For example, sympathy refers to the concern for and understanding of someone else’s distress, feeling pity toward the misfortune of another, especially those perceived as suffering unfairly. In contrast, empathy is the capacity to experience what another person is experiencing, including thoughts, emotions, and sensations, all from the other person’s frame of reference. It leads to an attuned response from the observer. And compassion, perhaps the pinnacle of our pro-social self, is empathic and sympathetic awareness of another’s suffering coupled with the drive to alleviate it. Think Mother Theresa, although compassion does not need to be that elevated, complete, or grand.

So, kindness is at the hub of all these aspects of our pro-social selves.                         Kprosocial-selves-figure-2indness does not emerge out of a vacuum nor is it innate. Kindness instead is the result of core, crucial skills and capacities that lay the foundation for kind behavior and kindness as a moral compass. These capacities of the sine qua non of our pro-social selves: perspective taking, emotion regulation, moral reasoning, and modeling. Each of these skills allows kindness to emerge, and without them is impossible.

Here, I want to focus just on perspective taking. Perspective taking is the ability to put oneself in another person’s shoes, to understand that someone might think and feel differently than you do. Perspective taking allows us to feel sympathy and empathy.

In Psychology, perspective taking is part and parcel of Theory of Mind, which describes how we have a latent “theory” or belief about how the world works. This theory assumes that other people have minds, and that these minds think and feel and believe things that are distinct from what we think, believe and feel. In disorders such as Autism Spectrum Disorder, where social understanding is disrupted, Theory of Mind and perspective taking may not develop fully or in ways that we see in typical development. In very young children, Theory of Mind and perspective taking is evident when a toddler plays a trick on someone, or surprises someone. To be surprised, one must not know something that another person does know. They must have their own mind.

In our current political climate in the U.S. as well as nations all over the world, kindness and civility appear to be crumbling. Xenophobia and “us versus them” thinking is ascendant. One of the most effective ways to combat this, I believe, is to practice perspective taking, make a habit of trying to understand what and why a person might be experiencing the world in the way that they do. Practicing perspective taking will nourish kindness in us all.