By Dr Richard Graham, Consultant Psychiatrist, Clinical Lead, Good Thinking.
One in six adults in London will experience mental ill health in any week but almost two-thirds of those in need are not accessing support services. If we are to make London the healthiest city in the world, we need to support people with anxiety, depression and other conditions in new ways – including through online self-assessment. This is where the Good Thinking digital mental wellbeing service plays a vital role, with phase one involving a detailed discovery to test our belief that some Londoners want alternatives to traditional services when seeking mental health support and understanding that Londoners being time poor should embrace the opportunities of the digital world.
As our recent Good Thinking report noted, “The proliferation of smart phones and other devices is changing how we live, work, learn, communicate and much more. With busy, stressful lives, we increasingly turn to the technology in our pockets and expect the digital services we use to be available 24/7 and relevant to our individual needs.” In other words, help should be literally at hand.
Safety by design
But our goal was not just to offer effective support but safe. After many years of working in digital health and with UKCIS (the UK Government’s advisory body for online safety and security), I recognised three principles for digital health:
- Individuals with every level of need may access the service, including those in need of urgent support
- Those seeking help for a mental health concern may be struggling with other issues that contribute to it, such as a physical health problem, an abusive relationship or financial stress
- Further information about the problem would be required and systems must be in place to ask for that information – it cannot be shared naturally, as it could be offline.
Whatever the nature of the problem and whatever the level of need (including if someone is in crisis), it should be possible to get advice on what to do next.
This presented us with a challenge: How do we progress the development of our end-to-end digital service using the principles of ‘safety by design’? After reviewing the available symptom checkers and decision aids, we chose to work with Doctorlink whose algorithms had been thoroughly reviewed and tested in clinical settings for over a decade, we then created a bespoke algorithm for those with sleep problems. The logic here was that sleep problems are common and distressing but we cannot assume depression or anxiety are the most likely causes – for example, sleep apnoea is a common cause of sleep problems.
The Good Thinking self-assessment tool asks an individual questions about all relevant areas of their life (e.g. shift work), physical health (e.g. chronic pain) and mental health (e.g. stress at work). At the conclusion of the assessment they could receive up to 1,700 pieces of advice, relevant to their situation. It’s reassuring that we can address the sheer breadth of what causes sleep problems in a manner that perhaps only GPs can. When you seek specialist help, there’s always a risk that some areas are relatively neglected.
So, in addition to information about mental health and free, high-quality apps to help Londoners improve their mental health, there is also a safety net on Good Thinking – a self-assessment tool for that rare individual who needs help to understand their problem better. Well, that was the plan.
Move fast and break things
The famous Facebook mantra “Move fast and break things” fits very well with the agile nature of our project. Yet we underestimated that some of the things we would break would be our own ideas about the service and what was important within it.
Very soon after launch, self-assessment became the most popular resource on Good Thinking, which was unexpected so we then had to understand whether or not this was even a good thing. Could there be unintended consequences?
Fortunately, we were able to monitor these concerns and test the self-assessment tool which has now developed beyond the sleep algorithm. You can now directly access self-assessment for anxiety, low mood and stress. But why were Londoners so keen on self-assessment? In retrospect, I think we were witnessing a revolution in health and some further discovery work helped us to understand the processes at work.
Recently we have been talking to young people about the obstacles they might face in accessing mental health support. One of the most poignant issues that has emerged was that young people are often unsure whether their problem is “bad enough” for them to deserve support. In mental health, it is common to feel bad about feeling bad and individuals often feel someone else deserves the help more. When you add in the frequent media messages about overstretched and struggling health services, it is perhaps not surprising that some wait until they are very ill, or perhaps in crisis, before they seek help, it should not be that way.
People also have to struggle with the stress of information overload, even when it comes to their health. For all of the advice that might be helpful from a health peer in an online community, there will be dissenting voices suggesting something else. A Google search does not spare you from commercial interests when it comes to your health or from those that have spread misinformation.
So an individual may not be sure if they deserve help and, even if they are confident about seeking it, the range of information and advice is often overwhelming. The uncertainty as to whether you deserve help can be paralysing. It’s like sitting in a waiting room, feeling that a health problem has now improved and worrying that you’re about to waste a doctor’s time.
The freedom to explore
Self-assessment is empowering. It asks for information and gives you clarity followed by a nudge about what to do next. With the Good Thinking self-assessment tool, you will always get some advice on how you can improve your mental health. The computer never says ‘no’. The process helps you understand yourself better and what you need – it leads to good thinking.
But there is something even more important that is making self-assessment such a revolution. It relates to the possibilities of exploring and learning, which can enrich how we make use of health services.
To understand this, it’s useful to go back a few decades when a Canadian Psychologist, Donald Hebb, discovered that when we are free to explore, learn, even play, our brains develop better, we can solve problems more easily, and have healthier and longer lives. He described the situation of having opportunities to roam and learn as one of an enriched environment. When we are restricted, there can be negative health consequences.
The neuroscientist Susan Greenfield describes how an unboundaried and enriched environment can have a hugely powerful and positive impact: “More formal studies have shown just how powerful a factor the environment can be, when it is stimulating and novel and invites exploration…this type of stimulating environment, where there is no fixed task to perform but which nonetheless generates different types of experience, can have a surprising impact even when destiny seems otherwise to be determined strongly by genes.” [Mind Change, Greenfield 2013]
How often in health settings are we free to roam and explore? There is usually barely the time for a decision to be reached and curiosity and choice are often rare luxuries for both clinician and service user. Of course, there are occasions when immediate action is required (a health crisis, for example), but freedom, both in terms of time and choice, would be fantastically helpful in other situations.
Helping 250,000 Londoners
Here at Good Thinking, we’re working hard to provide an enriched health environment that can be trusted to support an individual explore a mental health issue and reach some understanding – at a pace, at a time and in a place that is right for them. This may be at 3am on a weekday or on a Sunday afternoon. It may be for a 57-year-old who can’t sleep or a 21-year-old experiencing exam stress.
With the launch of Good Thinking in November 2017, London became the first global city to deliver a city-wide digital mental wellbeing service. Since then, it has helped more than a quarter of a million Londoners and many have used the self-assessment tool.
On the service, there is no judgement over what or how much help is needed – you can just explore what you need for free. What started out as a safety net has become a doorway out of the limitations of our health services. Self-assessment is not just empowering, it is liberating.
To find out more, visit Good Thinking