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.

 

 

 

 

Blast from The Past – Politics and the Culture of Fear: Is There a Place for Digital Disruption?

With the election less than two weeks away, we’re revisiting a previous post on “Politics and the Culture of Fear: Is There a Place for Digital Disruption?”:

It feels as if we can’t escape the culture of fear and extremism that is pervading politics. Political discourse is more vitriolic than ever after San Bernardino and Paris, and during the months of partisan name-calling and ugly mud-slinging among candidates for the U.S. Presidential Race. And clearly, there are no easy solutions to unraveling this vicious cycle.

During the Christmas holiday, I had an experience that perfectly illustrated this to me. My family and I were at a friend’s house for a holiday event, and I overheard her guests talking as I walked through the kitchen. I heard, “The more he says, the more I like him.” Then, “He says the things we all think but are afraid to say.” I started to get that sick feeling in the pit of my stomach, hoping they weren’t talking about Donald Trump. Then I heard, “The only problem with building a wall between Mexico and the U.S. is that it will have to be so big that it’s impractical and expensive.”  I tried to talk myself off the ledge, saying to myself, “Don’t open your mouth, just keep walking, don’t say anything, it won’t help or change anyone’s mind…..” But then as I was about to turn the corner, safely avoiding a conversation that would surely have turned ugly, I heard, “Of course we should ban Muslims from entering the country. Look what they did in Paris.” So, I turned sharply on my heel and unwisely marched over to the little group sitting around the kitchen table.

“Excuse me,” I said, “but I couldn’t help but overhear your conversation, and I wish that you would consider the fact that excluding or persecuting people solely on the basis of their religion or ethnicity is how (voice rising) the Holocaust started.” And then, when the response to that grenade lob was dropped jaws and the explanation, “It would only be temporary,” I looked at them incredulously, probably with disgust on my face, and said, “That’s what Hitler said and” just in case they didn’t get it the first time, “that’s how the Holocaust started.” Then I abruptly left, muttering, “This was a mistake, I can’t talk about this…..”

I found this conversation terrifying – not only because the thought of Trump as Presidentimages is terrifying, nor because I was disappointed in myself because I lost my cool, and created an extreme, unbridgeable divide between our viewpoints by invoking the Holocaust. No, this conversation was most terrifying because these people were not bad people. They were the type of people I appreciate: good, kind, hard-working people who love their kids and their family.

So where does that leave us?

I don’t have a solution, and indeed, my own extreme reaction during the kitchen table conversation shows that I lack objectivity and am certainly part of the problem. I do, however, as a scientist believe that we can harness what we know about our minds and brains to neutralize this vicious cycle of social and political extremism. Could digital disruption help move us along a path to such change? There might not be an app for that, but below I list three steps I believe could put us on the road towards digital disruption of the political culture of fear.

1. Frame political extremism as an emotion regulation problem. Before any digital disruption can happen, we have to make sense of the problem and have a concept of what’s going wrong. We have all had one of those kitchen table conversations I described above. In these conversations, our emotions get the better of us – fear, disgust, anger. This is a problem in how we control our emotions and how our emotions control our thoughts, decisions, and actions – something psychologists call emotion regulation. The problem is that our strong emotions rarely convince our debating partners. Instead, they solidify the views everyone already holds, causing us to cling to them even more strongly and rigidly. Common ground is lost, and the divide between perspectives seems increasingly unbridgeable.

Imagine how a version of that kitchen table conversation happens on the political world stage, sabotaging attempts at diplomacy and mutual understanding. The result is not just upset and angry people. Now the result is that our emotions directly shape political discourse, legal decisions, and policies that can affect generations to come.

Thus, a first crucial step towards disruption of the political culture of fear is to frame political discourse in terms of emotion regulation – applying what we know about what goes wrong and how to fix it on the individual and group level.

2. Use technology to promote empathy. Recent research in political psychology suggests that empathy can help heal rancorous political divides. A recently-published study showed that when political advocates fail to understand the values of those they wish to persuade, this “moral empathy gap” causes their arguments to fail. However, when political arguments are reframed in the moral terms of the other side, they are more effective. For example, when asked about their views on universal healthcare, conservatives who heard “purity arguments” (e.g., sick people are disgusting and therefore we need to reduce sickness) were friendlier towards universal healthcare, compared to when they heard “fairness arguments,” which are more consistent with liberal values.

If we can use technology to bridge the moral empathy gap, we might be able to reduce political polarization and promote better emotion regulation, more compromise, and deepened understanding. Virtual Reality (VR) might be one such technology. I previously wrote about Chris Milk’s thought-provoking TED talk on VR as the “ultimate empathy machine.” By creating a sense of presence and of real interactions with people and worlds, VR forges empathic bridges leading to greater understanding and compassion. In his work with the UN, Chris Milk uses VR to vividly portray the plight of refugees to politicians and policy makers. How does seeing and experiencing the suffering of 5-year-old children in the refugee camps influence policy making?: Almost certainly for the better.

3. Use technology to calm the fearful brain. As political ideologies become increasingly polarized, neuroscience research suggests that the differences between liberal and conservative viewpoints may extend beyond policy preferences to fundamental differences in the “fearful brain.”

In a paper I wrote in 2014 with Dave Amodio, a professor at NYU, we found that children of liberal compared to conservative parents showed a stronger “N2” brain response to mildly threatening and conflicting information. A greater N2, derived from EEG, suggests more openness to uncertainty, ambiguity, and threat. A culture of fear, in politics or otherwise, is marked by the opposite of this: inflexibility and discomfort in the face of uncertainty and ambiguity, along with resistance to change. These aspects of fear are part of the foundation upon which intolerance is built.

What if we could create computerized interventions that promote our ability to cope with uncertainty and change – perhaps by strengthening the N2 response? My research on the stress reduction app Personal Zen, as well as other research, shows that this may be possible. More research is needed, but if science-driven digital mental health continues to evolve, reducing the political culture of fear could soon be in the palm of our hand.

Depression: A Coming Out Story

A wonderful and courageously honest blog post from Shira Renee Thomas on the experience and stigma of clinical Depression. The personal (and economic) burden of psychological disorders is profound, and greater than that of any other type of disease – including diabetes, cancer, and cardiovascular illnesses! Over 350 million people worldwide suffer from Depression. Yet, we’re only now waking up to the importance of thinking of Depression and other psychological diseases as a public health crisis that requires much, much more awareness and many more resources to reduce stigma and help alleviate individual suffering.

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Just Do It: A Conversation with a Shaolin Monk

What is going on in this picture? I’m the one on the right.

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Well, I was having a special moment with Shifu Shi Yan-Ming, a master of the Shaolin Kung Fu tradition. Our conversation was part of the Rubin Brainwave festival. I was fascinated to hear about his life, from the age of 5, as a Shaolin monk, training in the most rigorous Kung Fu discipline. The title of our conversation was “Discipline as Art” and as was obvious from his demonstration on stage, his physical prowess is impressive and beautiful. You can sense the focused energy he devotes to his art, the discipline of Kung Fu.

In many ways, my conversation with Shifu (an honorific indicating a master in martial arts) was an action meditation, an illustration of how he thinks about his place and relationship with the world.

Me, asking about his feats of Kung Fu training: “Why did you learn to break a brick with your head?”

Shifu, with a laugh: “Someone asked me to!”

Me: “How do you talk to your students about overcoming obstacles in their life, about dealing with emotional challenges?”

Shifu: “I tell them to just do it!”

Like Kung Fu, his philosophy is action-oriented and full of focused energy. When facing obstacles in your life – just do it. Nobody changes you, you change yourself.