The below is a speech made by Mark Brown opposing the motion “This house believes that clinical research is essential to develop a good mental health app” at the Elfie Debate – Can research really tell you how to make a good mental health app? which was held in London on December 2nd 2015 as part of Mindtech 2015.
The motion I’ve been asked to oppose tonight is: “’This house believes that clinical research is essential to develop a good mental health app”
Interestingly, this isn’t the original motion we were going to debate tonight. The original motion was: “Can research really tell you how to make a good mental health app?”
On the surface they sound like two very similar propositions, when in fact they are very, very different. This means that tonight’s debate is fought upon the ground of clinical researchers, bringing the discussion of mental health apps firmly under the heading of medicine. It means we’ll be debating risk, efficacy, morals and ethics. In this debate apps will become medical devices, with clinical researchers valiantly saving us from terrible, harmful, ineffective and dangerous apps.
On those grounds it is obvious to me that my colleagues defending this motion will win on those grounds. None of us want dangerous, harmful apps out there in the world seducing the unwary and sucking in the lost and worried with their snakeoil charms.
It seems to me that we have a situation analogous to the debate that once divided the field of public policy analysis. Once, public policy analysis was about studying the formulation and implementation of public policy to understand how it did and didn’t happen and how it did and didn’t work. Then some analysts questioned whether it was their job to sit on the sidelines just making knowledge. They thought ‘if we understand this stuff so well, we should start to get our hands dirty’. In their 1984 book ‘The Policy Process in the Modern Capitalist State’ Chris Ham and Michael Hill define the difference as being analysis OF policy versus analysis FOR policy.
Recently, in a discussion at the Mental Elf site about the lack of clinical evidence for many popular depression apps I said: “At the moment, rather than being a true partner The NHS is more like an in-law, tutting and shaking its head that tech is doing it wrong but giving no guidance as to how mental health apps might do it right.”
If researchers are not careful they will become gatekeepers of innovation rather than enablers, a dead hand upon ideas rather than an encouraging embrace. People developing apps want your knowledge and want your insight, but blimey are you often sniffy about actually getting it to them.
It would lovely to be able to subscribe to the idea that we are engaged in a glorious shining path toward enlightenment, with each researcher standing upon the shoulders of the generation of researchers before them, each new bit of research leading us closer to the promised land. But I don’t think that’s how it works in the real world. Clinical research is an industry like any other. And it’s not one that’s well aligned with the realities of making tech products happen, at least not in mental health in the UK.
In an ideal world academic and clinical research would be at the forefront of pushing the boundaries of what is possible via digital technology for better mental health. Instead clinical research is trailing behind. The cutting edge is elsewhere.
The clinical world underestimates the financial risk involved in creating genuinely useful mental health apps, is often blithely unaware that money is a ticking clock. The assumption is that everyone who is a non clinician who tries to create an app that will help people with their lives lived with mental health difficulty is at best a kind of good spirited bungler and at worst a venal wannabe tech oligarch.
The pipeline between mental health research and mental health implementation is broken, if it ever was established. Cutting edge mental health and tech research should be able to find its way to partners who can turn it into applications that have user experience at their heart. Academic and clinical research is often awful at the kind of quick hunch checking that user centred design requires. It often wants to have a hypothesis to test before speaking to any real people about what the hypothesis should be. Too often it confuses knowing with acting.
Whether you like it or not, Silicon Valley is not just a place. Silicon Valley is where clever people who know things, like clinical researchers, meet with people who have money and who can help take cleverness to market. Many of the technologies that made up the original iphone were developed in one way or another through public funding. It took someone who cared about the consumer to combine them into the world changing device we all have at least seen in the hands of others, in not in our own pocket.
I’ll let you into a secret, Docready, the tiny HTML5 app that helps young people get ready for their first ever visit to the GP which I was involved in the development of was based on no clinical research whatsoever. The concept and the final implementation of the app were all done by working closely with young people who actually have the problem that it solves: the fact that it’s really scary going to see your GP about your mental health.
It’s not a problem that came out of the clinical evidence base, it’s a problem that came out of the lived experience base, the problems people really have base. We’ve been knocked back for funds because we couldn’t prove where in the clinical evidence base the ideas comes from. Not everything that will help people with their lives lived with mental health difficulty is clinical. Although clinical research can help to understand what clinical impact it has, if any. A signal cane for a partially sighted person is a big intervention in their lives, but would you evaluated it using clinical research tools?
If my colleagues supporting this motion fail to define the how and when of clinical research rather than focusing on the why, I’d suggest you should reject the motion even if you mostly agree. Which you probably will.
Mark Brown is development director of Social Spider CIC. He is @markoneinfour on twitter.