Mental health services have become focused on generating profits and the use of labour-saving technologies as a key way of achieving this. Iain Ferguson looks at recent developments.
Robots that can hold simple conversations and learn people’s interests are being deployed in UK care homes after a trial found they could improve mental health and reduce loneliness, according to a recent report in the Guardian. The researchers who developed the machines stressed that the aim was not to replace human carers with robots but “to help fill periods when, because of a stretched social care system, staff did not have time to keep residents company”.
No such qualifications about their use, however, were expressed by Advinia Healthcare – one of the largest providers of dementia care in the UK – which said it was “working towards implementing this into routine care” to “reduce anxiety and loneliness and provide continuity of care”. Many of us could think of far more effective and humane ways of reducing loneliness, both in care homes and in the community. A publicly owned national care service which employs more care staff on proper contracts, pays them a decent salary and allows them time to spend with their clients would be a good starting point. This would also address older people’s criticism of the robots that their conversations felt superficial and lacked “richness” and personalisation.
But as a government-commissioned report on mental health services published last year shows, in a context where health and social care services have been cut to the bone and where digital technologies such as robots promise rich pickings for the healthcare industry, the increased use of these technologies seems set to become the way forward not just in care homes but across all areas of mental health. The Digital Future of Mental Healthcare and its Workforce, written by psychiatrists Tom Foley and James Woodward, is a supplement to the 2018 Topol Review, established to explore how technology will affect healthcare and its workforce, focusing on the impact of digital health, genomics, robotics and artificial intelligence over the next 20 years.
This supplementary report explores these questions within mental health. Foley and Woodward begin by asserting that “mental health is a complex concept with deeply interrelated biological, psychological and social determinants”. This implies support for the bio-psychosocial model of mental health developed in the 1980s to supply the ‘missing social ingredient’ to biomedical psychiatry and to which many mental health professionals would still subscribe. The model is not without its limitations, not the least of which is that it implies an equivalence between these three factors. In reality, the evidence for social factors is far greater than that for the other two factors. Nevertheless, it does seek to promote a holistic approach to understanding mental health and mental distress. In fact, however, this is the only reference to social determinants in Foley and Woodward’s report.
Thereafter, it reflects throughout an unquestioning acceptance of the dominant biomedical psychiatry view that mental distress is about faulty brains and defective genes, not about what happens to people in their lives or the conditions in which they live and work. This is reflected in disorders’ that permeates the report and is reinforced by the photographs of brains and of neurons firing off which appear on almost every other page. Not surprisingly, then, it also shapes their view of the role of digital technology in mental healthcare. Current mental healthcare, the authors suggest, “is largely concerned with the faceto-face interaction between a person and a professional. Within a ‘digital medicine’ approach this interaction can be mediated by technology and the human/computer interface becomes increasingly important”.
No need to see an actual human being then. Online packages such as CCBT (computerised cognitive behavioural therapy), which aim to change the way you think about your problems of debt, unemployment or homelessness rather than dealing with the actual problems, will sort out your mental health for you. Austerity In a period of rising levels of mental distress, and with more cuts and austerity coming down the line, it’s not hard to see how the Tory government would be attracted to approaches such as CCBT which claim to offer “large scale, low cost, high capacity” solutions. There is little evidence, however, that either such packages or the algorithms in which Foley and Woodward place great faith to diagnose mental health problems can address what they themselves identify as the complexity of mental health.
The conclusion of one major study of CCBT, for example, was that despite a short-term reduction in depression at posttreatment, the effects at long-term follow-up were not significant, with an especially high drop-out rate. The “clinical usefulness of current CCBT for adult depression may need to be reconsidered downwards in terms of practical implementation and methodological validity”, the researchers concluded. This is hardly a surprise. One consistent finding from decades of research is that what makes the difference in counselling and psychotherapy is the quality of the relationship between the therapist and patient. If you’re disclosing the impact of, say, childhood sexual abuse on your mental health, you need to have trust in your therapist. You’re unlikely to have that kind of relationship with a computer.
An unthinking commitment to a biomedical model and a failure to appreciate the importance of the human relationship also shapes Foley and Woodward’s understanding of the role of technology in the assessment of mental distress. So for example, in this brave new world of digital mental healthcare, the monitoring of patients’ smartphones can be an alternative to actually sitting down with someone and exploring the roots of their distress: “Interaction with the phone, such as clicks, finger movements, scrolls, locks and unlocks, notifications, charges, app usage, call and SMS frequency, and calendar data, may all provide important indications of the patient’s mental state. An understanding of these associations is likely to develop throughout the next 10 years.”
Reliance on such ‘objective’ measures also leads Foley and Woodward to make great claims for the place of biomarkers in mental health. A biomarker is “an objective indication of medical state observed from outside the patient, which can be measured accurately and reproducibly”. In physical medicine a biomarker would be, for example, the identification of blocked heart arteries in someone experiencing chest pain. By digital biomarkers, Foley and Woodward are referring to factors such as heart rate, screen use and call frequency, which they argue “can be gathered from smartphones and other sensors, as well as social media interactions and usage of various services”.
It is on the basis of such ‘objective’ indicators and their authoritative interpretation by biomedical experts, not on the subjective meaning that they may have for those experiencing mental distress, that a diagnosis would be awarded and treatment prescribed. Such a power imbalance between mental health professionals and those in their care is of course far from new. Mental health is one of the few areas of healthcare where people can be detained and treated against their will. While in some cases this may be necessary to prevent the person from harming themselves or (much more rarely) others, it has also led to many people being subjected to coercive physical ‘treatments’ without their consent, from over-medication with powerful tranquillisers to electro-convulsive therapy, with black British men particularly affected.
A decade of cuts to already-underfunded mental health services, amid rising levels of mental distress, has seen the increased use of such coercive approaches. Yet in their report Foley and Woodward seem oblivious to these power imbalances and to the wider civil liberties implications of digital technology in mental healthcare. So for example they can blithely argue that “in recent years, people have shared increasing amounts of personal data on social media platforms. While there have been concerns about the potential mental health harm of social media, it is also widely believed that the data holds important clues to an individual’s mental state and can help to track changes over time. Researchers have used such data to extract phenotypic information, [but] widespread clinical uses have yet to emerge”.
And in the same way, digital technology can resolve the much-debated concern over people with mental health problems not taking their medication: “Ingestible sensor technology that can monitor concordance with medication has also been developed for use in the treatment of mental illness.” Symptoms Nowhere is the possibility considered that people may not take medication because the side-effects are so awful, or because they wish to explore non-medicalised ways of dealing with symptoms, such as the strategies offered by the Hearing Voices Networks.
There is nothing inherently oppressive about the digital technologies discussed by Foley and Woodward, nor about such technology more widely. On the contrary, and even with all their limitations, online platforms such as Zoom have helped reduce social isolation and made life more bearable during the coronavirus pandemic by allowing people to meet with family and friends. But the kind of proposals discussed here are very different. They are driven not by the needs or the views of those experiencing mental distress but by the technology itself, by the drive for profits of the healthcare industry and by an alienated biomedical psychiatry which sees people as disembodied brains and not as persons.
If we are serious about addressing rising levels of emotional misery and distress, we need to start not with robots and smartphones but by dealing with the social determinants of mental distress. As UN special rapporteur Dainius Puras argued in a scathing report on the impact of austerity on mental health following a visit to the UK in 2019, “people go to their doctors who prescribe medication, which is an inadequate response. If instead governments took issues such as inequality, poverty and discrimination seriously, then you can expect improving mental health”.
Iain Ferguson, Politics of the Mind: Marxism and Mental Distress Bookmarks