Text of keynote speech given my Mark Brown to the Royal College of Nursing 21st International Network for Psychiatric Nursing Research conference: “Building new relationships in mental health nursing: opportunities and challenges” in Manchester on 18th September 2015.
The question I’m going to try to answer today for you is ‘how can digital technology make better mental health for all’.
I’m in an interesting position speaking to you today in that I am neither a nurse or a researcher. I don’t even work for the NHS.
I have mental health difficulties myself. Increasingly over the last couple of I’ve become known for turning up at events and shooting off my mouth about the interaction between digital technologies and mental health.
Digital technology really just means technology that doesn’t have moving parts, isn’t made out of cogs and pistons and crankshafts. In the context of today, what I mean by digital technology is things that use computing power and which can interact with the world and each other through connection to the internet. So we’re talking about computers, phones, tablets and the like but also the software, apps and programs that run on them.
Roughly speaking I’m going to be talking about why digital technology might make a difference to the industry of helping people; why we might avoid thinking about digital technology and why it seems scary; what digital technology means for mental health nursing and some ways in which we can actually help digital technology to happen that might make the world a better place.
One of the reasons I’m so enthusiastic about digital technology is that digital technology has changed my life. I stand before you as a kind of cyborg, like a kind of very low budget Six Million Dollar Man (For those of you that are a bit young, the Six Million Dollar Man was a man who was in a crash who was rebuilt with robotic parts. Imagine The Terminator in flares solving seventies crimes.)
Every day I rely upon digital technologies to offset my cognitive deficits; to help me to plan and manage my time; to stop me getting lost between appointments; to keep up with important information; to make it possible for me to work in conditions that do not exacerbate my condition and to make it possible to communicate with peers.
Without this technology I have to travel long distances to do important tasks; am at risk of missing out on information vital to my wellbeing and am in danger of losing my job through lack of adaptation and loss of effectiveness.
Through finding the right combination of digital technologies I’ve become far more able, independent and able to take part on my community.
It sounds amazing and complex. What is this special mental health technology?
It’s basically a combination of stuff like calendars, email, maps and the ability to store documents online. All of the amazing stuff that an average cheap laptop and a rubbish phone make possible when I can get online has changed my life. I don’t need to commute to the office; my phone reminds me of appointments, twitter and other social media keep me in touch with people and what’s happening. Nothing specialist. Nothing specifically mental health intended. Just basic stuff that everyone has if they have a computer or a smartphone. Just useful digital tools that I use to solve problems that I have and that offset my cognitive deficits and to mitigate the effects of my mental health difficulty.
These everyday, non-specialist apps and functions are often the difference between me being able to do my job and not being able to do any job at all. They aren’t even designed with a specialist mental health purpose in mind but make a massive difference to me and my wellbeing. Now, imagine we began to develop digital apps and services or to use digital tools in a way that would solve specific problems that people with mental health conditions experience; or to use digital technologies to provide new options for people to access the help we provide in way that suits them.
In mental health, our prime mechanism is people doing things while other people are in the room. That’s what we think of first. We think of support as being you, me, together. Or you, me, together plus some sort of medication or treatment.
This leads to us into a kind of trap when we think about the potential of digital technology in mental health.
As it stands, what delivering better mental health for all means depends on the professional platform from which we survey the question. To nurses it looks like nursing.
I can see why some people reject digital technology. One: it’s about digital and, wow, do some people have some fears about digital. Two: it’s about personal preference and choice which, again, some people have a problem with in a health context and Three: it’s about little messy things about people’s lives not big massive shiny things made out of numbers and it involves, GASP, spending time with people who might not even work for the NHS.
That can make it difficult to see where digital technology can fit in; especially if our primary experience of digital technology at work has been some god awful new IT system that takes four times longer to use than the way we used to do things. The NHS has a history of buying very big, very expensive and very crap IT. Luckily that’s not what I’m advocating.
So what can digital technology actually do?
Once digital technology was a world of desktop computers, each one whirring away on its own. Then the web arrived and suddenly each computer wasn’t on its own. Suddenly computers all around the world could talk to each other which meant that information didn’t need to stay in one place and one time and neither did services. Then smartphones came along and we realised that the internet didn’t have to be inside a computer plugged into the mains. It could be in our pocket or our bag. Suddenly information and communication and services could be wherever we are. Each year the cost of computing power goes down and the things that digital technology can make possible grows. The smartphone in your hand now is more powerful than that computer that sat on your desk.
It’s the combination of the internet and devices that has really changed things. Smartphones and tablets are versatile little devices with a variety of sensors which can do anything from knowing where you are in the world, to knowing what time it is to sensing vibration or knowing when you should leave the house to catch the train you booked.
Digital technology like this means that things, as long as they’re digital, no longer have to be in one place. As long as you have a device to access it, an online service can be provided to hundreds of different people in hundreds of places at once at very little extra cost. Or a patient record can be wherever the patient is while also being where a professional is.
Digital technology also means that you can use lots of different methods of doing the same thing. There’s lots of different ways to send an email; but all of them are still emails. If you have an android phone, you can change the keyboard if you don’t like the one you’ve got. People can carry a pocketful of tools wherever they go. We all, for a very low cost, can put together own own suite of useful things, communicate instantly with friends and strangers and interact with a variety of services.
Digital technology isn’t that ‘that weird thing on computers’, it’s a part of people’s lives. Increasingly it’s a layer of connectedness between people and between people and tools and information.
Digital means that we can spend time to develop tools for people to use which can be replicated with minimal cost. If we make it and get it right and it does a job well, we can extend the number of people who can benefit from it with very few additional resources.
Digital technology can sometimes make possible something that currently isn’t possible because it’s too difficult, to person-time intensive or needs to happen in one place at one time where someone can’t be.
We could, if we wanted, tomorrow instigate the biggest ever study into the effects of psychiatric medications if we wanted. People are already using wearables to track their heart rate, their activity, their sleep. People are already tracking moods and calories. We could just say ‘hey! people! contribute all of that data to us along with what medication you’re taking. Then we’ll try and see what it tells us’. We could find ways of personalising dosage of that medication from that data. It would tell us lots of things that we hadn’t thought to ask about. People could generate the data for themselves and then hand it over willingly, in all of its complexity for others to make sense of, like happens in the citizen science movement where people put up home-made weather stations in their gardens to collect local level climate data. But we can’t be arsed. Or more correctly, we just haven’t got our heads around the possibilities. I’ve been involved in the development of some digital tools and digital projects over the last couple of years; so it probably makes sense for me to actually give you an example of the potential in digital technology for making things happen in different ways.
I was lucky enough to be part of the team who development of Doc Ready, a very simple web based app that does one thing and one thing only: it helps young people (or anyone else) prepare for their first visit to the GP to talk about their mental health. It was delivered by a team comprising of Enabled by Design, FutureGov, Neon Tribe and my own company Social Spider.
The idea for Doc Ready came from young people being really unhappy about their experiences of talking to their GP about mental health, feeling that GPS often misunderstood. Their suggestion was for an app that would work like a Star Trek type translator for GPs that would turn teen speak into doctor speak. The problem that had been identified was a real one – young people feeling that GPs didn’t understand them – but the solution wasn’t quite right.
Still working with young people, we turned the idea around, recognising that it would be impossible to change the entire profession of general practice and came up with a tool that helped young people to prepare a checklist of what they wanted to talk about with their GP by giving them a cloud of different experiences, like ‘I feel sad’ or ‘I’m always late for school or work’ or ‘sometimes my thoughts make me scared’, which they could choose from to make a kind of agenda. The idea was that young people could use this tool to prepare but also that the tool would help them to see the kinds of things they were ‘allowed’ to say to their GP. It’s up for an international service design award in New York next month. We got the basic function right by involving young people at every stage of the process of development; getting to co-design, test, break and strip it down until it did one thing really well.
It’s already been used as the basis for a web app to help young people to prepare for CAMHS appointments commissioned by a Trust in the north of England with more versions in the pipeline.
So, with Doc Ready we didn’t directly treat young people’s mental health but we did find a way that young people could make things work a little better so that they could get help for what was really troubling them rather than doing that thing we all do of coming out of their doctor’s surgery saying ‘Damn! I wish I’d asked them about that!’
For me, the approach we took with Doc Ready is key to thinking about using digital technology to help people’s mental health. It’s not about big, grand things that replace entire care pathways. It’s about finding small well defined problems people really have then trying to solve those problems. A lot of the time the solution to the problem won’t be digital at all, but if it is digital we need to know that we’re getting it right because now, more than ever, we need better solutions to problems.
The state we are in
There are many things that we know to be true about what people should and shouldn’t do about their health. Science is awesome. But science and healthcare aren’t quite the same thing. Healthcare is what happens where technology, culture, practice, knowledge and resources meet people’s real lives.
In my view, we’ve reached, at least for the time being, the end of the era of big breakthroughs in health. At the very best we’re at the end of the era where a massive breakthrough will appear in enough time to sort out the gap between the funds we have available and the needs that we currently aren’t meeting. A lot of people need things they currently aren’t getting. We’re stuck with the treatments we have, many of the structures we have. We still, sadly, have the historic overhang of a system that finds it difficult to see mental health difficulty as chronic rather than episodic; far more comfortable with treatment than support.
I think the area where our advances will be made, at least in the short term, are in the sweating of what we do have; continuing to explore new ways of making a bigger impact. But we’re not going to get much that’s really new from traditional sources. And certainly not without a massive change in the way that’s funded.
If we make sure that we get digital right; it shouldn’t take any of the existing stuff we do that works away; it just provides an entirely new tool box to get things people need to happen to happen.
In a country where we’re lucky to live longer, but where we are more likely to spend more of our lives living with multiple health conditions and disabilities, digital technology presents us with a chance to solve some problems, mitigate others, or alter the condition of life around more.
What it’s looking like to me is that in situations where mental health need is rising, resources are falling and no great breakthrough is around the corner; we’re going to need to find ways of getting more out of what we’ve got.
In mental health, we are still stuck with the history of stigma, of being hidden away from communities, of our work being secret. The places where we work have the historical legacy of being big buildings on big campuses where people who were unwell were brought until they were well enough to be let out again. Mental health has felt like it was about bricks and mortar and staff. We still talk about mental health beds, despite the fact that the majority of people with long term conditions are not currently inpatients. In mental health , because system change is expensive and because we’ve never had enough money or enough people, we’ve tended to try to make patients like me fit the services we provide. Digital, if we get it right, can help us to do the opposite and to fit services and support to people.
Digital technology brings us together
As some of you will know, I tweet a lot. I think social media have created spaces where people can meet each other and learn.
By making possible connections that could only be made previously through arduous effort and often through being lucky enough to meet the right person in the right place at the right time; digital technology can connect us with people.
Social media makes it possible for us to connect more easily with colleagues and with the latest news and research, but it also makes it easier to connect with the people we’re meant to be doing this for: people like me. People who experience mental health difficulties themselves.
For the first time in history it’s possible for anyone with an interest in mental health to have direct access to people with mental health difficulties and their lives. The only ways in which we could collect data from people was if they were right in front of us, so we would observe. People learned about mental health difficulty second hand. The link between what we ‘knew’ academically about people with mental health difficulties and people with mental health difficulties themselves was broken.
Now, if you’re interested, the lives of people with mental health difficulties in their raw and unfiltered complexity are just a few clicks or taps away. If you go on twitter and look at the hashtag #mentalhealth you’ll see what I mean. For the first time it’s really possible for people who experience mental health difficulties and those that provide services to meet regularly and just hang out together. Not as client and health care professional but as people using social media to talk and share.
I’ve been running a year long project funded by Public Health England called A Day in the Life, where on four days across the last year people with mental health difficulties have just written about what those average normal days were like lived with mental health difficulties. We’ve collected over half a million words of candid first person material about the bits of life that research doesn’t usually see. We’ll be analysing it to see whether this first-of-its-kind tells us anything different about what life with mental health difficulties in England is like to more traditional forms of research.
Social media presents an opportunity for mental health professionals to become an organic part of the communities they serve by using social media to talk about what it’s like to do their job; to literally be a professional in public. Public professionals mix with people via social media (and often in real life too): they’re the person you talk to who is also a nurse, or a the person whose blog you read who is also a doctor. Public professionals are engagers and connectors by nature. For people like me, who aren’t in the NHS, public professionals are a point of entry, a way into understanding it better and a guide to navigating the complicated flows of information, misinformation, spin and rumour.
Social media is the biggest opportunity professionals working in mental health have ever had to be open about what we do and to help people to understand the joys, the frustrations, the debates, the difficulties and just why we care so much about doing what we do.
I’m one of the team behind the regular #weMHNs chats on twitter where mental health nurses and people who aren’t mental health nurses debate issues around the mental nursing. If you want to come join us, if you haven’t already, we’re @weMHNurses and we’d love to meet you.
Why we might avoid thinking about digital technology and why it seems scary
While digital technology is changing our lives every day, in mental health we’ve sometimes found it hard to really see how it should apply to us.
There’s sometimes an idea, one sometimes unfortunately propagated by telehealth providers, that technology will allow you to ‘do away’ with staff teams. Andrew McAfee Co-author of The Second Machine Age refers to this as digital encroachment, the direct replacement of human labour with machine labour. In mental health, as in other areas of public service delivery, there are some who feel this digital encroachment as literally that: an army of computer screens and ill-understood gadgets skulking in the shadows a bit like in The Terminator, ready to leap out and take away everything they hold dear, including their jobs.
It doesn’t have to be either/or with tech. Different people will want and need different things. As will staff of different services. Imagine what we could do if tech could free up more staff time to do the really important things that only humans can do? Tech needs to make things easier and better in ways that work for people.
It’s a myth that all human endeavours are equally likely to be completely disrupted by digital encroachment. Some things will always need direct human labour. Mental health nursing is one of them. We should think about digital technology as a friend that might make it possible for us to do more of the things that we actually think are important. If we, for example, made it possible us digital technology to reduce the burden of paperwork meaning we could spend more time with people, or could find ways that digital technology might help in a crisis then that has to be worth trying. In mental health nursing, the single most valuable resource is nursing. Let’s find ways that resource can be best used.
So how do we make this happen?
Often, the NHS has been blind to people as people. While this has a terrible effect on patient care it also has a terrible effect on the development of services and treatments. Often in the design of new services or interventions the actual patient, the person with the problem is the quietest voice around the table. Or in cases where the voice is loud, it’s the voice least likely to be put to a practical use. We often don’t really know anything about the lives of the people we’re trying to help. We can’t picture them, they’re just a hazy mass of statistics.
You can’t design anything from statistics. Design is about engineering solutions to problems that people have. There’s a weird thing that often happens when the idea of doing something different in health: the wrong people do the wrong bits of the job.
What need to do is to make sure that digital technology is solving problems people really have.
One of the really cool things about medical people is that you tend to be problem solvers; but you don’t need to be able to make an app or a website yourself to come up with a really good problem that someone should solve. People do that for a living; you just need to help them to know where to direct their efforts. In fact, the formula I would use for thinking about digital technology and innovation is:
Knowing what kinds of cool stuff technology can do + thinking about small, well defined problems = ideas for possible digital solutions.
Engineers like solving problems. Mental health professionals know about mental health. People know about their lives and how they feel about them. The mix of those three things makes good digital things happen.
I’ve spent a lot of the last eighteen months or so doing things that involve just being with people and trying to find out the problems they have with the way that things in lives work.
Looking toward digital in mental health gives us a chance to start small, to find little things that might help people by spending our time with people, by digging either into our own lives or into the lives of others. It gives us a chance to build things that might initially change the lives and health of a few people, then a few more. And then more. Sometimes the answer is a new thing. Sometimes the answer is an old thing in a new way or at a new time or in a new place. Sometimes the answer turns out not to be digital at all. There are lots of techniques and structures for creating people driven design that can help you work that out. All of them go from working out with people a possible problem, to testing whether it really is a problem by checking with people, to working with people to find a solution to that problem that works for them. All of them involve hanging out a lot with the people who have the problem. Which is awesome and more people should do it.
Let’s make the goal of better mental health the master of digital technology rather than its slave. Not paying attention to digital technology doesn’t mean it won’t happen in mental health. It just means that the digital technology in mental health will be bought and built by people who understand mental health less than we do. That’s why need to stay at the table, get our head around the possibilities and the things people need and influence what happens.
Digital technology is not a possible future, it’s an unfolding present. Digital is already changing things. A change you choose is much less painful than a change forced upon you. Together we have the opportunity to make the best of digital technology so that we can make the best use of ourselves, our skills and resources.
Because if we don’t, we know that someone, somewhere in the NHS will come along and commission the wrong digital things for the wrong reason, doing the wrong things in the wrong way. Probably for the wrong people.
And that would be bloody awful.
Mark Brown is development director of Social Spider CIC. He is @markoneinfour on twitter.