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.