Therapy works in mysterious ways. Even for the doctors who practice it and the patients who pay for it, the therapeutic process is almost by definition inexplicable. It takes place in a private world, seeks to work upon intangible objects, and thus, for as long as it has existed, has had its critics: in one of Freud’s most famous lectures on the topic, he noted that “to many physicians, psychotherapy . . . appears as a product of modern mysticism, and in comparison to our physicochemical remedies the application of which is based on physiological insight, it appears quite unscientific.”
Over a century later, therapy and the medical field of mental health that sprung up around it are less embattled; the examination of our internal emotions, by ourselves or others, is a key part of how we evaluate our own well-being. One-third of American adults report poor mental health status, and 42 percent say they’ve seen a therapist or counselor at some point in their lives, with another 36 percent saying they’re open to doing so in the future. Given that human beings living in the early twenty-first century seem no more insulated from anxiety and depression than those living in the early twentieth, it was only a matter of time before Silicon Valley’s inexorable march of “progress” reached the terrain of the human psyche. And so, around the year 2012, roughly coincident with the centenary of Freud’s introduction of psychoanalysis to the United States, the credo of “there’s an app for that” reached the ultimate that—that which lies within. Dozens of so-called mental-health apps began to appear in news articles and on subway banners, promising a therapy process that could fit in your pocket.
Much like climate change in the liberal imagination, depression in these programs is an effect without a cause.
These apps are now legion. There’s Talkspace, for instance, which allows you to have text-message conversations with a real-life therapist; Woebot, which allows you to have similar conversations with an artificial-intelligence therapist; UpLift, which offers a twelve-week course to help you understand why you’re depressed (“Learn about Thought Errors, a big contributor to low mood”); and Moodnotes, which allows you to journal about your mental state and monitors your entries for patterns in your emotions. The most limited of the apps, Shine, merely sends out daily messages of affirmation via Facebook or text message, while the most aggressive prototype, StudentLife, tracked a user’s location, phone use, and even listened for ambient sound to tell whether that user was depressed. The approach differs, but the stated objective of all these apps is the same, and essentially therapeutic: to help the user better understand their inner life by making them more aware of it. This can be accomplished with or without a “therapist” interlocutor or even an algorithmic imitation of one.
Most of these apps use as a theoretical basis the psychosocial intervention called Cognitive-Behavioral Therapy, which focuses on raising awareness of negative emotions and the situations that produce them, with the goal, as the app Sanvello puts it, of helping you “live the life you want.” Some apps go even further and drift into the territory of “mindfulness,” a catchall term for meditative stress reduction popularized by Jon Kabat-Zinn, a student of Zen Buddhism and retired professor of medicine. As a result the universe of the apps is often a pacific one—in Sanvello, you choose tropical or seaside background themes and begin by selecting a set of reasonable goals for achieving contentment (“feel happier”, “find hope”); the app Therachat styles its therapy seminars as “guided journeys.” Much like climate change in the liberal imagination, depression in these programs is an effect without a cause, an authorless obstacle that comes from nowhere and that “we” can take on together. The solution—nay, the cure—is right within reach from the moment you link the app to your Facebook account in order to register and login.
There is, obviously, a lot of money to be made by selling this particular form of reassurance; investors seeded more than eight billion dollars into digital health companies last year, and some apps have valuations in the hundreds of millions—while the popular meditation program Calm is now valued at $1 billion. For many companies, the profit model consists of subscriptions and in-app purchases—the “premium” version of Sanvello, for instance, costs $8.99 a month, while Talkspace can cost as much as $396 a month. But the economic value of these programs goes beyond the money users actually spend on their services: A study published in April monitored the data-sharing practices of thirty-six mental health and smoking cessation apps and found that twenty-nine share key data about user behavior with services provided by Facebook and Google but that only a dozen accurately disclosed this in their privacy policies. The study didn’t specify what kind of data was shared, but it did note that “the transmission of even basic details . . . alongside [personal] identifiers potentially enables third parties to generate linkable information about [a user’s] mental health status.” A separate March study reviewing data practices of medicine-related apps (such as pill-reminder programs and pharmacy-service apps) found that 80 percent shared user data—including sex, weight, height, drug dosage, and ingestion method.
Even if Talkspace doesn’t tell Facebook that Jake Bittle said he felt depressed on Monday while sitting on his Brooklyn couch, the non-identifying data still provides tech giants with precious information about people who are, in the eyes of the company, just consumers. The grist mill of big data represents an attempt to conduct a behavioral analysis complete enough to paint a full picture of the human psyche. Given that this picture already includes data about our eating habits, exercise habits, purchasing patterns, and menstrual cycles, it’s reasonable to expect that it would inevitably also include data about our mental well-being. And so the information flows right from our AI therapist into the Silicon Valley storehouses.
When you download a therapy app and follow its instructions, it’s not exactly clear what is supposed to happen.
That’s too bad about my data, you could imagine someone thinking, but maybe it’s worth it if the apps actually help? Hard to say: Medical studies that have evaluated these apps are divided on the question of their efficacy. Some articles have found that users report abatement in feelings of depression or loneliness after using the app, while others found no significant change. Some psychologists have questioned whether the therapeutic techniques some apps recommend are consistent with the present medical consensus, while others have warned about the negative consequences of widespread access to a treatment strategy that is not subject to accreditation or review by a standards body. After all, when you download a therapy app and follow its instructions, it’s not exactly clear what is supposed to happen—how do I know when I’m “living the life I want”?—which means it’s impossible to tell whether the app is working or not.
To some extent, though, the same can be said for in-person therapy. Though the field of psychology is subject to exhaustive professional standards (ask anyone who’s ever opened the Diagnostic and Statistical Manual of Mental Disorders), therapy is deeply personal—so much so that therapists, patients, and outside observers frequently disagree about whether one is “making progress.” In medical literature, too, there is no meaningful consensus about how therapy works, whether it works, or what it would mean for it to “succeed.” Many people, myself included, do not realize that the therapeutic process has benefited them until well after they have begun or ended it; even then, the nature of that benefit can be almost spiritually difficult to articulate. The counsel offered by an app like UpLift or Mood may be less sophisticated than that dispensed by a trained therapist, and it is certainly less scientific, but just as with traditional therapy, it is impossible to show conclusively that the app does not work. At worst, such apps may provide shoddy imitations of therapy, knock-offs designed solely in service of some firm’s bottom line; at best, though, they may simply reproduce in more accessible form one of the longstanding conundrums of psychology—how do we know what makes us feel the way we do?
The question of whether these apps are demonstrably effective at alleviating depression is less interesting than the question of why the market is so saturated with them in the first place. We frequently speak of mental illness as “stigmatized,” but at least in young, urban, middle-class segments of American society, this no longer seems to be the case. Existential dread is now one among many inconveniences that you might as well digitally outsource, but the fact that we can now find an app for curing depression is just one symptom of a larger shift in the discourse around mental illness. The same consumerist culture that once shunned mention of depression now also seeks to cannibalize its language for use in advertising and media.
A ubiquitous truism about marketing holds that advertisements sell us a better and more beautiful version of ourselves—if you smoke Virginia Slims, you will be skinny; if you take Cialis, you will be able to play catch with your son—but increasingly advertising seems to appeal to a vision of well-off millennials as lazy, depressed homebodies, prone to ordering food online every night and binging Netflix for eight hours at a time. You order delivery from the restaurant across the street not because you’re awesome or want to be awesome, but precisely because you’re not, these ads tell us, and that’s just fine. If the end goal of Instagram and Candy Crush was always to numb us into contentment, isn’t it easier just to come out and say we will take away your pain?
Much ink has been spilled about the odious trend of corporate social media accounts pretending to be people, but fewer commentators have considered why masquerading as a depressed person in particular might be a viable marketing strategy. Steak-Umm, which produces thinly sliced frozen steaks, went on a Twitter rant last year about how young people are “isolated from real communities” and “living w/ unchecked personal/mental health problems,” while the juice brand SunnyD put it more succinctly in February, tweeting, “I can’t do this anymore.” In early May, Burger King rolled out a line of “Real Meals” tailored to less-than-glamorous moods—there’s an angry meal, a sad meal, a “DGAF” meal. The company claimed the promotion was more than just an obvious spoof of the McDonald’s Happy Meal.
These stunts are not only pathetic attempts at millennial advertising, they’re also signs that the conception of young people as alienated beings, desperately in need of relief from the torrent that meets them when they get out of bed, has made it all the way from the therapist’s office to the C-suite. Like “bipolar” and “OCD,” “depression” in the popular imagination is no longer just a diagnosis but rather an amorphous and extremely public way of naming one or more conditions of modern life. It is no longer something we are discouraged from addressing but rather something about which we are constantly being induced to speak, if only to ape the Big Mood of the zeitgeist. That’s not to say that there isn’t an actually existing medical condition called depression, but only that the word now carries with it a far broader set of meanings than its clinical definition would imply. We live not just in a society full of depressed people, but also in a depressed society, one addicted to using depression as fodder for memes, jokes, and pop culture.
Brain chemistry and childhood trauma go a long way toward explaining a person’s particular struggles with mental health, but you could be forgiven for wondering whether there is also something larger at work here—whether the material arrangement of society itself, in other words, is contributing to a malaise that various authorities nevertheless encourage us to believe is exclusively individual. After all, as one meme has it, “we live in a society”: one that requires many of us to work inhumane hours without fair compensation or medical care; one that in the sparse gaps between those working hours bombards us with junk food, mass culture, demonstrably addictive social media, and the vague promise of incremental political reform; and one that, meanwhile, listens to our phone conversations, tracks our most minute movements, and recommends us purchase after purchase based on what we Google while on a bathroom breaks. A lucky few—mostly white males—reap the incalculable rewards of oil trading and angel investment while the rest of us remain broke, unhealthy, phone-addled, hopeless, and bored.
The navel-gazing recommended by apps like these has the potential to entice us away from larger questions about the structural forces that generate a great deal of our suffering.
The clinical psychologist and philosopher David Smail, writing about the therapeutic process in his book Power, Responsibility, and Freedom, argues that most people’s suffering is a question “neither of medicine nor of ‘therapy’. . . [but] of morality and, by extension, politics.” Smail’s work builds on a skepticism of psychotherapy established in the work of Marxist theorists like Marcuse but is imbued with his perspective as a veteran of the medical establishment. The formalism of clinical psychology, he writes, leads too many people to view their well-being as a matter of medical diagnosis rather than as the result of externally imposed conditions—chief among them “the machinery of global capitalism,” which “has enormous effects on vast numbers of people in the world who are themselves in no position to see into its operation.”
Smail was nothing if not polemical, writing quite controversially that “psychological distress and emotional suffering are [not] the result of individual faults, flaws or medical disorders, but arise from the social organizations in which all of us are located.” But you don’ have to believe that mental health is exclusively a political problem in order to understand that it has a political dimension. Much of the exhaustion and disenchantment we experience on a daily basis does not come from inside our own mind, or even our own brain, but rather from the world outside. Clinical psychology can be helpful in directing our attention to the conditions of that outside world, but it cannot go very far toward changing them.
At first blush the proliferation of depression apps might seem to provide a partial remedy for Smail’s critique of the therapeutic medical establishment. If an app, in blurring the lines of clinical and colloquial psychology, helps to collapse the distinction between clinical depression and merely feeling bad, then there might be less confusion about where our suffering comes from, fewer occasions to mistake political problems for personal ones. But the impact of apps like these, to the extent that it can be predicted, is more likely to run in the opposite direction. Even without the formal rigor of academic medicine, they nevertheless insist on turning all analysis into diagnosis, routing the remedy for alienation through what Smail calls “the interior validity of people’s utterances, acts and intentions.” In the Moodpath universe there is no negative situation, no emotional hardship that cannot be exorcised through a process of growth. Though some apps may prescribe exercising, changing your diet, or even seeking professional psychiatric advice, they still ultimately suggest that your suffering starts and ends inside you, that it can always be mitigated or managed by a process of moral discipline and self-awareness.
Still, given the exorbitant cost of healthcare, not to mention the skyrocketing price of most prescription drugs, the appeal of this form of relief is clear. And to the extent that an app like UpLift provides a kind of digital triage, making it marginally easier for its users to get through the day, it’s hard to dismiss it outright. Yet the fact remains that the navel-gazing recommended by apps like these has the potential to entice us away from larger questions about the structural forces that generate a great deal of our suffering. Similarly misleading is our recent societal tendency to see depression as a kind of cultural common denominator, the most “relatable” of all memes.
There are many things about our daily lives that we are powerless to control, many injustices so enormous and obvious they might never show up in our mood journals. We have at least as many problems that can be solved by looking outward as problems that can be solved by looking inward.
Originally posted by The Baffler on 2019-07-11 11:17:38