Category: The Next Computer

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The Dark Forest of the Internet The Next Computer Wellness when Always-On

Mental health tech cannot be like regular tech – Part 4

(Part 3 – My personal experience with seeking help with my mental health)

I’d called it simply Someone To Talk To.

Someone To Talk To – a chatbot

Background:
Several – most? – people with anxiety or mild depression would benefit tremendously from just having someone to talk to. Someone who is receptive and non-judgemental, and doesn’t have any other relationship with the person. It’d be ideal if people had someone like this to talk to in person, but it is impractical: not just because it involves travel for one or both people but also that it requires scheduling and therefore a set time, and that people may feel the need to talk at any point in the day. The mobile phone, a deeply personal device available 24×7, is ideal.

Now, this need goes far beyond mood-logging apps that ask for a rating or emoticon to describe one’s mood. Not only do people’s emotions vary significantly during the day (especially those that are anxious or mildly depressed), not only are they more likely than not to rate their overall day as negative, thereby further feeling down at their own constant negative rating of their days, but more importantly that their needs go beyond such a one-point (or even multi-point) rating. They need an outlet for thoughts and anxieties and fears, to put in words.

Another approach to this is journaling apps, including visually beautiful ones like Day One. Journaling apps take on many types, inluding 5 Minute Journals and Gratitude Journal. But the prospect of filling up a blank screenful, especially day after day, is too often overwhelming for someone who has low emotional bandwidth in the first place.

Here are the characteristics of what I think will make a good Someone To Talk To:

It will be conversational. It’ll feel like a chat (and in fact will be one, with pictures and links sent both ways just like in a regular chat) instead of a set of screens and buttons. The bot will be able to organize what one says, with context, into a journal of sorts for the person’s reference any time later. The person will be able to share with the bot not only text, but also pictures and other media. The bot should be able to respond with at least some context – gentle encouragement or reassurance – but must take great care to not overdo it or sound artificial. Not responding is better than responding like, well, a bot. The bot will also learn about the person over time – what the person seems to like and not, and whether that changes over time, specific people, persons, places that the person refers to and their relationship to the person. The person may give them appellations that are not their real names/descriptions, and that is by choice. The bot will know this.

It will be empathetic and sensitive. It will be designed knowing that a regimental approach of asking for a mood update, or a diary entry at the same time every day, as many apps seem to do, is counter-productive and causes more stress than it relieves. It will be designed knowing that on occasion a notification or picture or video or piece of music can trigger anxiety/sadness/distress in people and they may not even recognise it as such, much less know why. Finally, it will know when the person is looking for a response from it, and when it simply needs to ‘listen’, providing occasional acknowledgement of its ‘presence’.

It will be gently intelligent. While it will often initiate conversation, it won’t ask with every interaction if it felt right, or if the person liked it or not. Being the one expected to be ‘in charge’ of the bot-human relationship can feel challenging. If the bot is designed to be a stand-in for a human companion, it must do better than ask for feedback often (wouldn’t it be stressful to have a friend do so?) Just like making decisions, being made to pass judgement also brings pressure. It will never expect anything from the person it engages with, such as a response in a certain amount of time, or at all. It will also be able to gauge improvement or decline in mood over time and adjust accordingly.

In addition to being empathetic, sensitive and intelligent, it will also be realistic. It will never make empty promises about things always getting

As things turned out, I returned to my day job and never actually worked on this beyond a few simple test versions with a couple of other collaborators. But this, still, is exactly how I’d go about bridging the gap between dealing with mild mental health issues on one’s own, and full-fledged therapy.

(ends)

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The Dark Forest of the Internet The Next Computer Wellness when Always-On

Mental health tech cannot be like regular tech – Part 3

(Part 2 – What happens where you run a mental health service as a Valley-type startup)

Several years ago, I had had first-hand experience with poor mental health and sought help via in-person therapy and medication. During that time, I realized the following: 

  • mental health help is binary: either there’s nothing or there are sessions with a mental health professional
  • the financial cost puts it out of the reach of most people
  • the time investment makes it difficult to balance work, home and this

At the same time, I had observed how my health had deteriorated over time, beginning with mild depressive symptoms with a decrease in drive and discipline. Today, I know that in others depression first manifested as increased anxiety. At that point, you know something’s not right, but doesn’t seem anywhere close to needing to see a psychotherapist. So you plod along until things begin to slide faster. By the time you seek help or someone does on your behalf, you’ve suffered quite a bit. 

Therefore, I understood that

  • people needed – still need – something handy that didn’t warrant full-fledged medical care but provided some minimal level of support for those with mild symptoms. There are now several studies showing that a plurality of the population, especially urban, have poor mental health
  • because people would likely end up being somewhat dependent on it, it needed to be low-overhead enough to be offered free. 
  • and counterintuitively, it needed to be low-tech enough that its limits would be clear right away so that it would not disappoint later.

(Part 4 – My 2017 manifesto for such a service)

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The Dark Forest of the Internet The Next Computer Wellness when Always-On

Mental health tech cannot be like regular tech – Part 2

(Part 1 – the NYT investigates a mental health tech service for practices that aren’t in patients’ best interests)

Continuing our conversation about the NYT’s investigation into the practices at Talkspace, the remote mental health therapy app.

The problem stems from running a healthcare service like this as a business. Worse, a startup. Having spent the vast majority of my professional life at startups, I am all too familiar with the incentives to scale, to perform according to metrics, to employ ‘growth hacks’. When a healthcare startup employs these, the effects are much worse than a game or a social media app.

[the company] has questionable marketing practices and regards treatment transcripts as another data resource to be mined. Their accounts suggest that the needs of a venture capital-backed start-up to grow quickly can sometimes be in conflict with the core values of professional therapy, including strict confidentiality and patient welfare.

In 2015 and 2016, according to four former employees, the company sought to improve its ratings: It asked workers to write positive reviews. One employee said that Talkspace’s head of marketing at the time asked him to compile 100 fake reviews in a Google spreadsheet, so that employees could submit them to app stores.

When convenient, the company spins itself as a healthcare provider: “users can’t delete their transcripts, for example, because they are considered medical records.”, but those transcripts are used by the company for customer engagement and retention:

[A therapist on the platform] said that after she provided a client with links to therapy resources outside of Talkspace, a company representative contacted her, saying she should seek to keep her clients inside the app… “I was like, ‘How do you know I did that?’” Ms. Brennan said. “They said it was private, but it wasn’t.”

Finally, the disconnect between offering a private healthcare service and the exigencies of operating a startup is clear in the company’s public statements:

On Nov. 9, 2016, the morning after the election of Donald Trump, Mr. Frank wrote on Twitter: “Long night in NYC. Woke up this morning to record sales.” The Trump election tweets are examples of the sometimes unfiltered social media presence of Mr. Frank and Talkspace — an irreverence familiar among start-ups but unusual among organizations devoted to mental health care.

In 2016, a man named Ross complained on Twitter that the company’s subway ads “were designed to trigger you into needing their services.” Talkspace’s official Twitter account responded, “Ads for food make people hungry, right?” and added, “I get what you’re saying, Ross, but medical professionals need people to buy things.”

The problems of misincentives of private healthcare are well known and well debated, though nowhere close to being resolved. And startups get a lot more attention than a more traditional healthcare provider would. And Talkspace may have begun with noble ambitions. Regardless, what it has built isn’t anywhere what I think mental health care tech should look like.

How it approaches conflict between what is good for itself versus what is good for its customers – patients – diminishes trust. When it come to data privacy, to marketing, to its incentives for therapists, its responses indicate that it will choose its financial health over people’s mental health. Unfortunately, it’s likely similarly funded venture-backed tech companies in healthcare have similar conflicts and pressure.

(Part 3 – How I’d approached a simple mental-health chat service)

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The Dark Forest of the Internet The Next Computer Wellness when Always-On

Mental health tech cannot be like regular tech – Part 1

Earlier in August, the NYT published a longform investigation into the data and marketing practices of the mental health therapy provider Talkspace. It hit home for me.

So many of the NYT’s discoveries dismayed, even horrified me. I have sought mental health therapy myself several years ago, and about three years ago contemplated working on a different approach for a text-based service for people with anxiety and mild depression. We will talk about the specifics some time later. However, I thought in detail about, and spoke to mental health professionals about the technology, the ethics, the right audience, among other such issues. The way I thought about all of these was so very different from Talkspace.

The first is the way the service is marketed to potential customers and to therapists:

Talkspace is advertised to users as unlimited, “24/7” messaging therapy. “Your therapist will see your messages and respond to you throughout the day,” the company says. Therapists get a different pitch: “Set your business hours, and check in on your clients daily, five days per week.”’

This immediately reminded me of the worst of Groupon, which pitched to users that they’d never have to pay full price for anything again, while pitching to businesses that a single one-time mass discount would convert to loyal users willing to pay, well, full-price.

But Talkspace went beyond, adding this:

Talkspace introduced a new feature: a button that users could press after sending a message that required the therapist to respond within a certain time frame. If the therapists don’t respond in time, their pay can be docked.

Some therapists on the platform were alarmed, in part because the function required them to work on demand, rather than on their own schedule. More significantly, they asked: Is it harmful to give clients with anxiety and boundary issues a button to press for immediate gratification?

First, this reminded me of the worst of Uber. I have been told my more than one driver that they could only turn down a limited number of rider assignments a day, and had to be online at least a certain number of hours a day. After the rollout of the feature where drivers are assigned their next ride towards the end of the ongoing one, those drivers said they couldn’t even take time out to visit the restroom, leave alone lunch and snack breaks, because they also had to reach the next pickup in the time that the Uber app had estimated for the waiting rider.

Troubling as this is, these constraints are worse in the context of mental health because they introduce added anxiety for both the therapist and the patient, the former needing to be equanimous and the latter already suffering from some anxiety/depression.

(Part 2 – more about conflicts)

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The Next Computer Wellness when Always-On

Blue light and depression

There’s evidence that warm lighting aids sleep in humans. Now there’s a connection between the other kind of lighting, ‘blue light’, and depression. Blue light is the kind of light our computer and mobile screens commonly emit.

The researchers exposed lab mice to blue light for two hours every night for three weeks and then watched the mice closely to determine if the light exposure was having any discernable impact on their behavior. The researchers found that initially, the mice showed no signs of change at all. But after three weeks, the mice began to work less hard for a sugar reward and tried less hard to escape when presented with the possibility—both considered to be signs of depression in mice. The researchers also found that the depressive symptoms continued for up to three weeks, even after discontinuation of night light exposure.

And there’s some evidence of the cause

They found a specific kind of light receptor in the mouse retina that led to brain areas associated with mood: the nucleus accumbens and the dorsal perihabenular nucleus. When the researchers disconnected them, the mice did not become depressive due to exposure to blue light at night. The researchers also found that the pathways became much more active when processing blue light at night versus daytime—which, they suggest, explains why blue light during the day does not lead to depression.

Use warm lighting wherever you can. Ideally everywhere at home but especially in the rooms where you spend your evenings. Second, turn Night Shift on on your iPhones, iPads and Macs. In fact, on Macs, instead of Night Shift, use the excellent Flux, which progressively changes the tint on your screen as you get closer to bedtime. The Amazon Kindle Paperwhite, at least the first-gen, also emits blue light – so around bedtime it may be best to turn off the built in light and read in ambient warm lighting. And have a wind-down routine.

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Data Custody Decentralisation and Neutrality Privacy and Anonymity The Next Computer Wellness when Always-On

The New Middle – Part 2

(Part 1)

Take privacy. There is a near-critical mass of people aware and concerned about how much data faceless companies have about them without their informed consent and how disparate data sets may be combined to manipulate their choices. But many of them aren’t aware of browser-based ad-blockers, their capabilities, how to install and update them. Network-wide ad-blockers such as pi-hole are simply beyond them.

This will change. Privacy-consciousness is going to be an attractive positioning for a business to take in the near future, because the New Middle is searching for them. The email service Protonmail, the browser Brave, the password manager 1Password, the two-factor authentication service Authy (now part of Twilio), the self-hosted personal information manager Nextcloud – these are all the vanguard for well-designed privacy-centric software but I don’t think they have yet marketed to the New Middle, which still reads, watches and listens to the same things the Mainstream does. Apple is the lone company I see having already staked out an unshakeable positioning here. We have recently discussed Mozilla’s opportunity to own this market as well. There is an opportunity for hardware too – imagine a router with firmware that bundles pi-hole, that does not need OpenWRT to be user-installed (side note: Apple’s hardware is already privacy-conscious).

All this is still just one area – privacy. Think about similar New Middle companies in the other areas we listed above. Pervasive anonymity as a service, anonymous-only social network and communities. Attention preservation for you and your kids. ISPs and communications providers publicly committed to net neutrality. Since there are overlaps between many of these, companies can and will compete and win the New Middle in more than one of these areas. Lastly, for large-scale reach, they will need to raise capital. Many of these will do so via the public market. They’ll make for attractive investment opportunities.

(ends)

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Data Custody Decentralisation and Neutrality Making Money Online Privacy and Anonymity The Dark Forest of the Internet The Next Computer

Mozilla’s Grand Internet Opportunity – Part 2

(Part 1)

But it means so much more to be a viable alternative to the internet giants of today, particularly with regard to being a good steward of public information and interpersonal communication.

Imagine a neutral paid subscription service for the following:

  • Contacts, calendar, reminders/todos
  • Documents
  • Notes
  • Photos

Now imagine that neutral service expanding to include

  • A secure email service and client a la Protonmail
  • A private 1:1 and group messaging service a la Telegram
  • A private video-calling service – there is no good privacy oriented provider today. Telegram has claimed it will add video support later in 2020
  • Collaborative documents, such as that available with NextCloud Hub if you self-host

Let’s talk about self-hosting. Mozilla could improve upon the Nextcloud concept to bundle domain, hosting and productivity/communications right out of the box. We saw a few months ago how web hosting companies could be the new internet giants if only they could be more imaginative of their own role in the internet. Mozilla could be that web host.

The arc of awareness is bending inexorably towards a substitute to the centralised web that came to characterise the 2010s.

Tight bundling of PIM, media and messaging on mobile leaves little room for a third party. Microsoft has tried to be it, but has little to offer by way of differentiation. Mozilla on the other hand has a clear positioning – and two decades of delivering on its promises. It doesn’t need to win the majority of phone users today – it can count on a minority that cares growing into a plurality.

(Part 3 – Mozilla seems rather far from that vision today)

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Data Custody Decentralisation and Neutrality Making Money Online Privacy and Anonymity The Dark Forest of the Internet The Next Computer

Mozilla’s Grand Internet Opportunity – Part 1

Mozilla recently announced that it’d be laying off a quarter of its workforce. This also includes a “new focus on technology” and “a new focus on economics”.

The Verge’s article has the Mozilla Corp CEO say “… Mozilla will initially focus on products such as Pocket, its VPN service, its VR chatroom Hubs, and new “security and privacy” tools.”, although I cannot find that in the blog post she authored.

In the original blog post, the CEO stated that Mozilla’s long-term goal was “to build new experiences that people love and want, that have better values and better characteristics inside those products.”, which is neither here nor there.

I think Mozilla has a huge opportunity here, but its vision, at least as articulated publicly, is not broad enough.

The opportunity I see is the following: there is a growing section of people who have become aware, through increased press coverage, of the dominance of a few american internet companies and their own dependence on these companies [1]. They aren’t going to be Stallman-like in their use of technology any time soon – the trade off is far too unfavourable – but they are looking for reasonable alternatives and are willing to pay for them. Baker the CEO has said exactly this, that Mozilla plans to “build and invest in products and services that will give people alternatives to conventional Big Tech.”

Well to begin with, Mozilla should create a set of paid privacy-oriented products that anyone can setup on their phone to attain a basic level of privacy protection: the Firefox browser (exists), a VPN (available in a small set of countries), an DNS-sinkhole adblocker, a password manager and a second-factor authenticator app. They’ll need great documentation and guides about how to set this up – in this regard the Mozilla community is a great asset.

[1] See the reporter Kashmir Hill’s 2019 attempt to go a month and a half without services from Amazon, Apple, Facebook, Google and Microsoft.

(Part 2 – It gets even bigger)

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The Next Computer Wellness when Always-On

Feedback and motivation, app edition – Part 2

(Part 1)

Another app I use in my routine that makes good use of feedback for motivation is Apple Books (formerly iBooks).

You can set a daily reading goal – I’ve set it to twenty minutes, even though I will get a little more done every day. The app then tracks this as you read over the day, and sends you a notification when you’re hit it.

The app then logs streaks for the number of days that you’ve hit this goal. You can see this in the large screenshot at the top. For me, streaks are highly motivating [1]

Books also syncs daily reading across iOS devices. I could read in the balcony on my iPad, pace around reading on my iPhone when I’m winding down, and both will count towards a single reading goal. I’ll get the achievement notification on whatever device I happen to be using at the time.

Finally, you can also set a goal for the number of books you’d like to read in a year, and as you finish a book the app will add the cover to a virtual bookshelf. You can see this at the bottom of the large screenshot. While it’s certainly one way to get me to read more books on Apple Books than any other, it’s never going to cover all the books I read – some will be paper books, others audiobooks. I will, though, read books that I have bought on the Amazon Kindle bookstore in Apple Books (deDRM + Calibre) – to re-iterate, this is for books I’ve paid for.

These simple mechanisms promote good habits in a lightweight, low-stakes way. It’s a refreshing contrast to the dark patterns common throughout the internet.

[1] That works two ways. Because I find streaks a good motivator, I also find negative feedback, especially guilt, highly off-putting. A big reason I gave up learning a language on Duolingo was because it was highly streak-oriented, which was great, but if you missed a streak the app would surface icons and text stating how I’d made the Duolingo bird sad. For me, positivity works, negativity not at all.

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Data Custody Product Management The Next Computer Wellness when Always-On

Feedback and motivation, app edition – Part 1

We saw yesterday that I moved my Fitbit app to the home screen. This placement of the app is solely for me to log my water intake, available as a home screen quick action:

I have ended up using this despite me creating my own iOS Shortcut. Even though my shortcut is easy to launch, offers a menu of sizes instead of having to type an amount, and stores my intake and timestamp in an open plaintext format. This was puzzling to me.

When I reflected on this, I understood that the Ftibit app gave me a view of my progress towards the day’s goal (which I had set), and compared it with previous days’. My Shortcut logged data with less friction, but I have yet to build in any feedback about the day’s total intake.

That little gap, that failure to close the loop – led me to unconsciously gravitate towards something less elegant and more time-consuming. There’s a little bit of the Hooked framework at play here:

Trigger, Action and Investment are self-explanatory in this context. The reward here is not variable in the way checking for new email and for Instagram likes is, but it’s good to know how close I am to my daily intake goal – I’ve forgotten from the last time I logged my water intake and checked.

Understanding this has helped me be aware of how much I’m influenced by such signals. I’ll be more deliberate in building these into systems I create for myself, and to watch out for such patterns in systems I interact with, beyond obvious ones like badgers and notifications.

(Part 2 – another app in my routine that incorporates feedback and motivation)