Digital technology and prevention in mental health: are we there yet?
Using digital technology to prevent mental illness is selling people a product to prevent something they never think will happen to them
The following is the text of a speech delivered by Mark Brown to the eMEN London Conference: Prevention with digital technologies during the session ‘How far have we come? How far can we go?’ on January 24th 2019 at London’s Barbican Centre.
One of the challenges in thinking about prevention in mental health is that there are different domains of prevention. Mental health remains closely allied to medical science and medico-scientific ideas. In the UK, even those of us who are sprightly and quick on our mental toes often find ourselves defaulting back to thinking about mental health in the language and vocabulary of the National Health Service. Even though, in theory, medico-scientific understandings of mental health and mental illness are supranational, in practice our ideas about what the purpose of prevention is looks more like the social, economic and service delivery systems of our country than they necessarily do each other. When we talk about the use of digital technology for prevention in mental health what are we actually talking about?
It’s my assertion that there is great potential for digital things to help prevent people becoming unwell, but to do that they have to start from understanding where people are actually at and how they use and regard technology.
Digital technology is the realm of desire
Digital technology in mental health exists in the realm of consumer preference. Digital technology is the realm of desire. It mostly lives on phones and screens alongside an infinite range of other things. What people choose to use the technology in their lives to achieve is overwhelmingly based upon them wanting to achieve that thing; whether it’s an improvement in their subjective wellbeing, reaching the next level of some hideous pay to play freemium game or just looking up people they used to know at school.
The first major challenge when thinking about prevention is that you are measuring its success by what doesn’t happen, not what does. At a population level we measure prevention by looking at reduction in demand. We see prevention in big numbers. That isn’t how people experience it.
Recently Andre from The Mental Elf and I interviewed Jonathan Tomlinson, a GP with a practice within walking distance of where this conference is taking place. We were talking to him about mental health and General Practice and what helps people to be well. Jon told us about salutogenesis, which looks at the factors that support human health and well-being, rather than at factors that cause disease. Jon was telling us about how many of his patients were just having a terrible time of things and who were unhappy and struggling as the result of things resulting from poverty, austerity, marginalisation and other real world factors. Many of them, said Jon, would fall below the threshold for diagnosing a mental health condition but that didn’t mean they weren’t dealing with lots and lots of stuff that might get on top of them.
He told us about a little picture he has above his desk in his consulting room. It’s a very rough drawing of a hand. On each digit is a different factor that influences how well you feel. The thumb says ‘social security’ The fingers say: ‘relationships’; ‘biology’; ‘body’; ‘mind’. On the wrist are the words ‘crisis planning’. The overall diagram is titled ‘Trauma care ‘salutogenesis’. Together they’re a map of the things that in the right balance help people to feel as best as they can be. Any of those factors being out of whack for you will mean that your health will suffer.
None of these factors exist independently of the social and economic conditions that people live in. None of them are exempt from being defined by social, emotional and personal understandings. Together they make up both objective measures of someone’s health and wellbeing and also their own subjective experience of whether they feel well or not.
If digital technology is going to focus upon preventing mental illness, then digital technology must act on these factors in ways that make sense to people. The digital product or project must deliver a benefit to the individual that gives them pleasure, or joy, or achievement. It must change something that they recognise as being meaningful to them.With prevention, this means selling a positive impact in the hope that a negative outcome will be averted.
Digital technology isn’t the problem, making stuff people want to use is
Digital products can, and do, interact with the people who use them in incredibly sophisticated ways. The data those interactions generate is increasingly being used in ever more complex ways that are beginning to change the world beyond the immediate world of the person whose interactions generated the data.
Digital technology is getting closer to being able to do most anything you might ask it do as digital technology. If we were having this conversation at a conference six years ago people would have been banging on about the infinite promise of Virtual Reality. Now you can buy VR in Argos. We spent ages talking about the technology of quantified self and last year I bought a knock-off fitbit in Aldi for a fiver and my phone collects more data about me than the sum of all research up to about 1930. The technology is not the challenge in prevention, so what is?
The defining reality of digital technology around mental health is not research but business models. On a very nuts and bolts level, we see the impact of digital technologies on prevention when people create digital things that have measurable positive effects upon mental health. This means that things need to actually get built and used by people. At present much research doesn’t recognise that user preference and user desire is the largest factor in whether something is actually used by people.
Research you are like a little baby
Research around digital technology in mental health is in its infancy. Many individual studies of interventions actual fail to describe in any detail what the actual digital product was in any great detail, and certainly not in enough detail that anyone else could iterate that digital product. Few studies take advantage of the possibilities that digital products present for new kinds of trial such as micro randomised control trials or momentary ecological measurements. A consistent theme through the work of David Mohr is the idea that we haven’t even begun to consider digital products as doing things that only digital products can.
Products that succeed are built on the carcasses of products that failed and died. Too often, research and development of digital interventions around mental health is a one shot thing: ‘we trialed it once and it didn’t work so we chucked it on the bonfire with al the other things we tried once’. To solve that research and development of such interventions needs to be brought together with consistent, sustained funding for exploration. At present, there are no public bodies who are the primary investors in this from of research and development in England. In terms of research we know huge amounts about what keeps people well but the bodies that hold that knowledge often don’t have the digital skills in house to make viable, desirable products. The people who do know how to make desirable digital products do not always have ethical or political positions that complement public health interventions. Indeed, some of the direct to consumer market for health and wellbeing technology would happily dismantle public services, regulations and ethical safeguards if they could get away with it. Unfortunately, they’re sometimes they’re the companies with the products people most like and use.
Who is paying dictates what gets built
Who pays for things dictates what gets built and how good it can be. At present, the people who would most benefit from digital technology that would support their wellbeing are not the target market because they tend to be poorer, less likely to be thinking about optimising their health and look most different from the kind of tech bros that make technology. Large swathes of the direct to consumer market that might act upon the prevention of mental ill-health targets and is purchased by people who love to feel it’s doing them good and who don’t really notice if it isn’t because they’re actually doing pretty ok.
I was speaking at a conference on using digital products to ‘disrupt’ the service delivery model of England’s national Improving Access to Psychological Therapies programme, something the New York Times called in wonderment in 2017 “England’s Mental Health Experiment: No-Cost Talk Therapy.” One of the points I was making was that people who benefit from IAPT are not people who are looking for IAPT specifically. They choose IAPT because they know it exists and it seems like the least worst option in terms of price, commitment, availability or trustworthiness. They don’t get up in the morning and think ‘Jesus christ I want to die, where can I access the government’s Improving Access to Psychological Therapies Programme?’ They get up, feel awful and want to not feel awful. They aren’t seeking a solution defined directly by what research regards as the most evidenced-based intervention for what might be regarded as symptomatic of a diagnosis. They’re just looking to feel less shit. The sell with digital prevention of mental ill-health is even harder and often amounts to ‘access this digital intervention specifically targeted at reducing the chance that this thing will happen to you that it’s never crossed your mind might happen to you.’
The commercial world is exceedingly comfortable with this idea. Their feedback loop is launch something and if people buy it, they win. There is a massive wellbeing industry selling pseudoscience based on the idea that eating this horrific concoction will prevent cancer; or buying this cream will stop your lover leaving you or buying this amulet will both block electromagnetic radiation and also possibly make you immortal. Household cleaning products still sell themselves on the same sexist idea that buying brand X will stop you being a bad mum. The art of advertising, marketing and its integration with product development makes products that have a strong positive selling point which also convey the negative implication of what would happen if you didn’t buy this great thing right now. This is uncomfortable ground for many in the wider health world.
Understanding what we do and what people want
I recently reviewed the first systematic review of digital mental health implementation for interventions aimed at those with a diagnosis of psychosis or bipolar disorder, by Golnar Aref-Adib and colleagues and published in The Lancet Psychiatry. I observed that:
“Digital interventions in mental health have long had the status of a ‘King Over the Water’; promising to remake the world and redefine everything about mental health treatment, but never quite arriving.
“Innovators tend to see such developments as ‘disruptions’ that might change at a fundamental level the models and systems by which mental health support is delivered, with potential to even make such services obsolete. Both look to scale as the goal, either through organisational and systematic implementation or through consumer choice. Both have an ambition to go big or go home; often in contrast to their actual number of users.
“The study of digital interventions for mental health and the mitigation of mental illness remains in its infancy, often lacking even the tools to understand the thing upon which its lens in focused. Digital interventions are designed artifacts which are deployed using particular devices, which in turn might be interacted with in a variety of conditions in a multiplicity of settings.
“Without a granularity in understanding and contrasting the digital interventions themselves; the conclusion of the review is a broad ‘some people liked them, some people didn’t and the ones that people liked were easier to implement and tended to have some positive results but only when staff liked them, too’. What is missing is the dimension of understanding the intervention as a level of implementation in itself.
“A digital intervention is an experience situated within someone’s life as much as it is a quantifiable medical phenomena. In medical terms, an injection can be a more or less pleasant experience depending on where or how you are administered it and for what reasons; but that experience does not alter the chemical composition of the solution forced down the barrel. With digital interventions, the application, device or program is the solution, the barrel, the needle and the context rolled into one experience.”
Digital developments in mental health, as with many digital developments in public services, are often dead in the water before they begin because they do not begin with the user. If we are talking about preventing mental ill-health, we literally cannot do that without the user being at the absolute centre of every single decision made. While prevention is measured at population levels; it’s experienced at individual ones.
If digital technology is to fulfill its promise for mental health it’s going to have to get an awful lot better at understanding people and what ails them; an awful lot better at understanding what elements of a digital intervention actually influence outcomes and an awful lot better at better at bringing together research, policy, development and marketing.
If we want to use technology to help people be well, it must make sense to the person using it in the context of their life, or they just won’t use it. The best case scenario is they’ll be polite during your research study into the digital thing, doing what you tell them and then they’ll quietly and stealthily never use it again and stop opening your email reminders and thirsty push notifications that bleat like a spurned lover imploring them to come back and that ‘it’ll be different this time’.
And we all really need it to be different this time.