A few days ago I came across a paper called “The Digital Future of Mental Health Care and Its Workforce” by Foley and Woollard. I had seen the paper previously as it was first published in February 2019. However, what caught my eye was that it was on Twitter and lambasted by a number of psychologists and psychotherapists.
Their responses were entirely in the negative and the very idea that digital interventions could possibly ever be useful in psychological/psychiatric activities was clearly an anathema to those commenting.
The very idea that psychotherapy could ever take place in a digital environment seemed to be a heresy to them and immediately phrases like “the therapeutic relationship” and “reading the body language of the client” were trotted out as fundamental reasons why digital interventions must fail.
As someone who has been working digitally for the last seven or eight years with clients who are in different time zones and war zones I find these claims unhelpful in as much as they do not follow the science (such as it is) nor do they follow the logic of development, especially in these strange times.
Telemedicine in its many different forms is growing very quickly and has developed some remarkable tools and made some incredible achievements in the last few years thanks to the flexibility of digital technology and the hardware that goes with it. I have little doubt that if I did a search, I would find surgeons who were railing against the idea of remote surgery when it was first introduced, yet now this is becoming a thing with an expertise and training all of its own.
This doesn’t mean to say that I have a complete unalloyed allegiance to digital technology in the talking therapies and other psychological interventions. Far from it, we are only at the beginning of this whole process but like most other technological creations there is continuous improvement, discovery and development.
There remain a vast range of issues in the use of digital technologies that are nowhere near resolution. For example, digital technology is currently only largely available to those who have an income sufficient to enable them to purchase some form of communications device that goes beyond the simple telephone. Indeed, a good many people who are in real need of support, the homeless, the stateless, the elderly, frequently do not have the means to be able to connect to more sophisticated forms of digital intervention. Nor do they necessarily have the education or ability to use it. Thus, it is those who are already in a more secure position, for example better educated with an income, that are able to access digital interventions. And, by definition, are in a better place to be able to benefit from them and probably in less need of them.
As Sinclair (2019) points out in his book “Lifespan” we are quite prepared to have hundreds of sensors around our modern cars to make them safer and more reliable. He also observes that we have taken significant steps into using biosensors to monitor our sleep, insulin balance, blood pressure, heart rate, etc. Yet the response to the idea of the use of technology in improving mental health is outrage! I wonder how many mental health professionals wear fitness trackers or apple watches that monitor everything (it seems) apart from their thoughts (more on this later). He goes on to say, “That’s why the current solutions, which are focused on curing individual diseases, are both very expensive and very ineffective when it comes to making big advances in prolonging our health spans”. This focus upon individual disease is great for the providers, much less good for the recipient.
Olshansky (2017) makes another observation about the way medicine goes about its business, “As soon as the disease appears, attack that disease as if nothing else is present; beat the disease down, and once you succeed, push the patient out the door until he or she faces the next challenge; then beat that one down. Repeat until failure.” This strikes me as being so reminiscent of the way that diagnosis is so essential for successful treatment of psychological distress. Much has been said about the utility or otherwise of mental health diagnoses, I don’t propose to spend any more time or waste futile words on that particular dispute.
However, let us not ignore Armitage’s subsequent investigations into individual medicine at the genomic and epigenomic levels to provide the possibility of personal medical interventions based on individual physiology. Again, I fail to understand why exploration and exploitation of technology cannot be accepted and explored for the benefit of our psychology as well as our physiology.
If we are to see digital interventions increase then we must consider equity of access, which was one of the key indicators of the English mental health services when the new service, Improving Access to Psychological Therapies (IAPT), was launched in 2008. I wonder whether if equity of access has even been achieved in more traditional services at this point in time; somehow, I doubt it.
With regard to subjective statements related to “the therapeutic relationship” or the inability to read body language on a screen , they strike me as Luddite statements in much the same way as people demanded a red flag to be waved in front of a motor car at the end of the 19th century; The same could be said about the resistance to the opening up of radio frequencies to enable the communication devices that we have today. There are so many examples of this kind of Luddite behaviour that are more an attempt to secure the expert role and the income of the professional that made the hysterical response that I saw to the paper laughable.
However, the paper itself is also inconsistent and in some respects uninformed. I made the observation about equity of access with regard to digital technologies above. Nowhere is this more important than in the delivery of public services such as the NHS. Digital technologies are not free. To access them a person needs a device upon which to access it and then a means of connection to enable access, such as a phone line or internet connection.
As a side issue, the authors of the paper are also an interesting bunch. All have a vested interest in the progress of digital interventions. There was not one member of the public referenced as a contributor. Though I am sure the main signatories would say that they are all members of the public – digital privilege!
At this time there are significant issues around sections of the population being able to access basic rights such as education effectively as a result of the pandemic due to lack of equipment, connection or privacy. These issues are even more pertinent to matters of health and possibly especially psychological health.
If digital interventions are to become common place and even desirable, then the means of access has to be equitable. While one could argue that there is inconsistent equity of access to the NHS, it is within the capability of an individual to attend at an accident and emergency department, or walk in centre for any medical of psychological/psychiatric consultation without the need for any form of technology.
If online consultations become part of the standard pantheon of interventions for psychological distress, then there is no longer equity of access for significant proportions of the population. Also, a simple trawl of the University of Liverpool library produced over 1000 papers related to digital interventions using CBT suggesting that these are fast developing forms of psychological interventions.
A small number of papers have considered equity of access in relation to the current service through a number of different papers, e.g. Brown, J. et al, (2018), Green et al, 2013, but far fewer than those extolling the efficacy accessibility of online therapy.
It is this last comment that brings me to the real point of this short essay. The rush to develop online therapies is all part of a marketing exercise that has gone on for the last 100 years where therapists relentlessly extol the virtues of their particular intervention in a way that suggests they have the holy grail or, in today’s language, a unique selling point (USP).
Commodification of health services has been growing steadily over the last fifty years. This development is consistent with the political shift that has taken place toward the centralised delivery of many services that at one time would been provided free of charge in small communities by the citizens of that community among themselves. Those communities would have included “experts” whose role would have been seen as a guide or elder.
This commodification has created a situation where common emotional distress has now to be managed by people who are specially trained, and the sufferer has little or no agency.
“Marie de Hennezel 2012 observes that the commodification of care has become big business and carries with it a double charge. First, there is the overt financial charge for the program or intervention consumed, and second, the hidden charge paid in the currency of personal agency and social capital” (Russell, 2020). In the current climate where non statutory organisations bid for NHS contracts there is always a fee to be paid and a profit to be made. What is meant by the “hidden charge” is that the commodification of healthcare disables, not only the individual, but the community in which they reside by making the assumption that communities need outside intervention from experts to resolve their social, legal, economic and health difficulties. Commodification infers that communities have no capacity of their own to find solution or resolution.
Moving on, the assumption that psychological wellbeing and technology are mutually exclusive seems bizarre to me especially when many psychologists are currently taking advantage of digital tech to sell their courses and training online during the pandemic (me included). Do they not need to read the body language of their trainees? Inconsistency rules.
I mentioned “reading thoughts” a few moments ago. Elon Musk is now working on something called “Neuralink” and is planning to be able to create human/machine links to enable more accurate diagnosis of brain disorders, amongst other things. Why not? Is mental health exempt from progress and technology. I think I the development of technology has to be carefully monitored and kept out of the hands of mad Frankesteinian zappers and druggers but there is an inevitability about the progression of mind/machine links. Research and experimentation is not going to stop because psychologists and psychotherapists don’t like it or don’t approve.
We know that the major determinants of societal and environmental security are based around the guarantee of the building blocks of life, reliable food sources, heat, light and safety (https://www.gov.uk/government/publications/health-profile-for-england/chapter-6-social-determinants-of-health). However, meaning and purpose are also fundamental to wellbeing, which may mean work but is much more likely to encompass creative and social activities as well. Digital technologies are far from ideal at the current time for providing these requirements in effective ways. Having said that, people, communities and organisations have reorganised in remarkable ways in the last few weeks to be able to communicate effectively both socially and professionally within their existing relationships and by creating new ones through the wonders of video conferencing and other digital platforms. No one can deny the adventurous spirit or inventiveness of human beings when provided with technology that is flexible and adaptable. After all, look what happened when the wheel, bricks, cement and electricity, were invented. I wonder if the hod carriers, cave dwellers and candle makers resisted these innovations as well?
If we are to be successful at managing distress in the world that is currently upon us, and the world that is to come, we are going to have to be able to zoom out and look at the global picture of what good mental health will look like and what the environment will be like that will sustain it; while at the same time peering down the microscope using every piece of technology the engineers can build for us to enable personalised and effective interventions, whether they be through deliberately targeted medically based psychological treatment, behavioural interventions, political (including propaganda & nudge), social interventions or just plain good old conversation.
Those who resist the ever-changing landscape of human psychology and suggest that technology should be resisted are the ones who will be swept away into the backwaters of psychological interventions as curiosities to be amused by and wondered at.
However, the ultimate arbiters in the current climate for the success or otherwise of psychological interventions are twofold:
- Those policy makers who determine what kind of a society we live in and the tools they use to mould it. Commodification being one that will be based upon a profit motive that will ultimately benefit the few; rather than a desired outcome that will benefit the many instead of the few by creating a more benign environment that is sustainable and secure
- The person on the receiving end. If people reject the commodified offering as ineffective and unhelpful then having a helpful conversation is much more likely to survive as a useful intervention for people who are distressed.
At the end of the day the choice lies with all of us. It largely depends on what we wish for, who holds the power to enable it and how badly we want it. Change is never easy and always resisted. We are going through probably the greatest period of change in human history and it is happening faster than anything that has happened previously, because now we have the technology to mitigate the worst effects – but we must use it wisely! That is the hard part.
Brown, J. (2018), Increasing access to psychological treatments for adults by improving uptake and equity: rationale and lessons from the UK, International Journal of Mental Health Systems. Nov 9, 2018, Vol. 12 Issue 1.
Green, Stuart A.; Poots, Alan J.; Marcano-Belisario, Jose; Samarasundera, Edgar; Green, John; Honeybourne, Emmi; Barnes, Ruth (2013) Mapping mental health service access: achieving equity through quality improvement. Journal of Public Health (J PUBLIC HEALTH), Jun; 35(2): 286-292. (7p)
Olansky, J. (2017) The future of Health, Journal of the American Geriatrics Society 66, no1, p195-97
Russell, C. (2020) Rekindling Democracy A Professional’s Guide to Working in Citizen Space, Kindle edition. Location 803.
Sinclair, D. (2019) Lifespan, Harper Collins, london.