There is a broad public and academic debate about the impact of digital and social media on our mental health. In an age when we should be more connected, we seem to be lonelier and more depressed than ever. In the words of the late Oliver Sacks, we are grappling with “a neurological catastrophe on a gigantic scale.”
Digital media may well be one of the sources of our mental health crisis. And yet, consumers are also turning to digital media for advice and relief as health and mindfulness apps flood the app store in unprecedented numbers. However, not all of these applications are successful, and so the question remains, how do we create digital media that strengthens rather than undercuts mental health and resilience?
This is a question that we have been trying to answer at ustwo in recent years, both in our client work and in our collaborations with clinicians and researchers. We have developed a number of mental health and wellness products including Moodnotes, a thought and mood journal based on Cognitive Behavioral Therapy (CBT), developed in partnership with the psychologists at Thriveport. With Pause and Sway, we partnered with founder and visionary Peter Cheng from Pauseable to develop “interactive meditations” centered on physical movement that take inspiration from traditional Tai Chi.
We learned a lot along the way. And while we cannot provide rigorous clinical evidence yet, we can offer general observations and findings that may apply more broadly to the design of digital experiences for mental health:
We believe that digital tools can increase patients’ engagement with and understanding of mental thought processes.
There is an incredible demand for simple, accessible information about mental health with lower barriers to entry than a therapy session or a meditation retreat. With Moodnotes and Sway, we managed to draw users into the experience through playful gestures instead of long psychological examination. In Moodnotes, users are seamlessly drawn into the CBT flow through a conversational interaction with a “face” representing their moods and feelings. In Pause and Sway, the app leverages the phone’s motion sensing ability to guide users through simple movement sequences that help them relax and focus attention. These rewarding initial experiences provide immediate physical reward.
Patient journaling can offer personalized insights.
Journaling -- the act of asking a patient to record their feelings, thoughts, and pain levels -- can be a powerful discovery and therapeutic tool. Journaling plays a critical role in CBT, which focuses on how a person's thoughts, beliefs, and attitudes can affect their feelings and behaviors. In our Moodnotes research, we found that users could not get enough of their “moodmetrics.” Many users were keen to understand how their mood altered in response to specific activities like eating and working out and environmental changes like the weather. We have also seen the power of patient journaling outside of mental health for other conditions, for example migraine and chronic pain management.
User retention is hard but possible.
Health and wellness apps have a notoriously low user retention rate, on average below 5%. We managed to maintain user retention on Moodnotes at more than twice that rate. Although Moodnotes is not unique in its use of a patient journal, the simplicity and playfulness of the “face” of the Moodnotes interface may be the reason that users have stuck with the app. However, to sustain engagement, digital mental health products need to offer both immediate rewards and long-term payoff through deeper insights. Playful, conversational interfaces can draw patients in, but to sustain their longer-term attention we need to present users with more challenging tasks -- similar to a game with increasing difficulty levels.
The design process needs to balance clinician needs with user needs, and evidence with intuition.
The lack of user-centricity that is evident in many health systems today leads to low patient engagement. Equally, typical digital approaches that promote “failing fast and breaking things” are inappropriate and don’t hold up to the medical duty of care. In our work on Moodnotes, we tried to balance the essential clinical perspective with the power of user-centered design to unveil emerging needs for which there is no “hard science” yet. Emerging design patterns for mental health will further help broaden the adoption of proven practices into digital mental health experiences.
Staying open to unanticipated usage and benefits.
One of the greatest highlights of working on mental health and mindfulness apps is the opportunity to have a real impact on a user’s life. The user reviews and feedback we received for Moodnotes, Pause, and Sway revealed usages and benefits that we would have never anticipated. One Moodnotes user, a single mom, has made checking in with Moodnotes a morning and nightly ritual for her and her children:
“I am a single mom and do moodnotes every morning and night with my two kids. I find this is a way that I can relax and sort out my feelings and it is also bonding with my kids to see what is going on in their life. At the end of each week we like to see what each other's moods are and we can talk to each other about how we impact each other's mood (eg. stress levels). When I first got this app I wasn't sure what to expect. But it is TOTALLY worth the 4 dollars. I think that every family, or person should use it.”
Like Oliver Sacks we may feel that we are held captive to digital media that seem to offer few opportunities for privacy and solitary reflection: “Those trapped in this virtual world are never alone, never able to concentrate and appreciate in their own way, silently.” But as we have discovered building digital products like Moodnotes, Pause and Sway, there is immense power in our palm-sized companions to help us be more aware of our inner selves, and live more mindfully.
__If you are at SXSW this year, please join Kate Niederhoffer and me for a longer discussion on the topic on March 13, 12.30pm, at the JDMarriott Salon 5. __