We are living in the world of technological advances — shiny new objects, software design, chatbots, bitcoin, etc. While many of these have allowed people to access incredible resources that can help them learn, earn, and socialize, there are also strong, science-based warnings about how time on technology and social media negatively affects a person’s mental health, the ability and skill of interacting with humans, and the fabric of our relationships and communities.
With that in mind, there’s a need to balance the risks and benefits of utilizing technology within the mental health space — or risk doing more harm than good — or being unused.
What might that look like?
This is something our global mental health team in the department of mental health at the Johns Hopkins Bloomberg School of Public Health has been looking into. With funding and support from the USAID Victims of Torture Fund, we’ve been able to transform our innovative approach to mental health care into one that works across digital platforms.
Known as the Common Elements Treatment Approach, it utilizes long-studied cognitive-behavioral elements — such as cognitive restructuring, exposure, behavioral activation — like puzzle pieces that are put together to uniquely treat an extensive range of mental and behavioral problems with varying levels of severity across all age groups. Research shows stronger effectiveness and impact using CETA than single-problem programs.
At the onset of COVID-19, the U.S. Agency of International Development Victims of Torture supported our group in designing digital approaches to increase access, uptake, and sustainability of CETA. We began with assuring providers could deliver the CETA system of care to individuals and groups via technology and moved further to developing a digital application to train new providers in CETA to support scale up.
Through our own experiences, and studies about the impact, promise, and challenges of utilizing technology for mental health and psychosocial support in low- and middle-income countries, below are two principles we have found to be critical yet often missing in mental health technology.
Technology users should guide the development
“When people talk, listen completely … Most people never listen,” Ernest Hemingway once observed. With mental health, the same concept applies. All too often, directives come from higher levels, such as funders, ministries, or leaders in the field.
A prominent message right now in many fields — including mental health and psychosocial services, or MHPSS — is around the power and utility of technology, and that “it’s the future.” While technology certainly has the potential to improve aspects of MHPSS care and delivery, are we really listening to those using the technology? Is the technology serving providers and helping them treat people or is it just another new shiny object? Are the users okay with interacting with a chatbot and/or never seeing an MHPSS provider in person?
The answers to these questions are certainly not black and white and, in our experience, vary depending on culture, context, setting, and the users and providers themselves. For example, certain technology solutions need to be used to address specific needs such as lower reading or digital proficiency.
Strategic planning allows us to create a system of care that meets the needs of populations and specifically examines where digital advances could help, and in what form.
—That same targeting needs to be factored in for settings with lower internet and electricity access. Apps can seem amazing until there is no electricity or Wi-Fi to be able to use or download them. This causes frustration at the least and, in mental health care, a safety situation at the worst.
Imagine being on WhatsApp and having a client tell you they are thinking of killing themselves when the connection suddenly fails. Or imagine everyone’s excitement at the launch of a telehealth initiative except for someone experiencing interpersonal violence in their home, and cannot take a private call and knows any device will be monitored. Or imagine organizing orientation for new trainees via tablets only for supply-chain challenges to mean they aren’t delivered.
One thing is for sure, providers and users of MHPSS should be involved in the design and development processes every step of the way, with a constant feedback loop to get the most out of technology and to avoid such issues. Only through understanding the local context can the apps adequately cater to their target populations.
Strategy is everything
Dwight D. Eisenhower once said: “Plans are worthless, but planning is everything.”
Like other fields, the pressure to produce outcomes is strong in the development world. The message from funders and local stakeholders is often “scale up quickly” with little more than a brief nod to the idea of strategically planning a scale up or system of care in MHPSS.
In our 20 years of experience, we find that it’s a common expectation that an MHPSS system can be scaled up nationwide in a year or two for a very small budget. With technology, this is expected to be even quicker. This is a dangerous myth, especially if we stick to the “do no harm” principle.
In fact, the World Health Organization suggests that “it takes approximately one to two years to develop a mental health policy, and five to ten years to implement it.” Without taking time to plan, results will be inefficient and lead to poor functioning systems with poor health outcomes. Strategic planning needs to make a strong comeback quickly, especially with technology growing so rapidly.
Strategic planning allows us to create a system of care that meets the needs of populations and specifically examines where digital advances could help, and in what form. Planning ahead would allow MHPSS to not only focus on training health care providers in mental health practices but deal with other issues such as:
• How digital technology can improve access, effectiveness, efficiency, and/or cost.
• How to sustainably fund front-line providers and supervisors.
• Cost implications of the initial development of technology solutions, as well as maintenance and ongoing updates.
• Integration of MHPSS digital programs into existing technology.
The digital mental health world is booming and expanding rapidly, and has incredible potential if we are thoughtful. It is urgent for us to listen to front-line workers and strategically plan a way forward as we address questions around scale up and sustainability of MHPSS programming.
This post is made possible by a grant from USAID to the Johns Hopkins Bloomberg School of Public Health’s Department of Mental Health.
About the author
Dr. Laura Murray@LauraMurray_phd
Dr. Laura Murray, a clinical psychologist, is a senior scientist at Johns Hopkins Bloomberg School of Public Health. Murray has extensive expertise in a wide range of evidence-based treatments, including training, implementation, and evaluation. She has conducted evaluations ranging from qualitative understanding of mental/behavioral health, to full randomized trials of treatments all over the world, working with numerous health sectors. She has a passion for innovating new solutions to improve service quality and delivery with a systems approach. Murray publishes extensively in top journals, trains globally, regularly speaks at conferences and organizations, and consults with organizations on skills-training for stress, resilience, and leadership.
