The Inclusive Digital Mental Health Bootcamp 2022

While digital mental health apps have the potential to reduce the treatment gap in mental healthcare if designed poorly and in a one-size-fits-all manner, they can cause significant damage, reproducing social inequalities, fortifying harmful stereotypical narratives about well-being and affect the help-seeking behaviour of individuals by alienating them.

The growing prevalence of the use of digital mental health apps, worldwide and in India, is evidenced by the ever-increasing funding to mental health app developing companies, the millions of downloads that these apps have amassed, as well as, the increase in the use of features within each app, like an increase in therapy-uptake within an app. While many believe such apps have the potential to close the treatment gap, the simple truth remains that digital apps, simply by existing in the digital space, are, by default, exclusionary.

The level of exclusion arising from problems such as the (gendered) digital divide, low digital literacy, low general literacy levels, etc is compounded by the culturally irrelevant and alienating content and design of these apps. Expensive self-help resources, a lack of diversity in the rosters of therapists on the apps and AIs coded to be socially blind and stringently solution-focused turn away the small portion of the population that do have access to these apps.

The Inclusive Digital Mental Health Bootcamp 2022

While determinants of the level of access to technology and education are too large for mental health professionals and small app developers to tackle, they can come together to make the content of digital mental health apps inclusive so as to ensure that at least all those who have access to smartphones and are digitally literate, are able to access care resources to the fullest possible extent. It is to facilitate such dialogue that Belongg hosted the ‘Inclusive Digital Mental Health Bootcamp 2022’ on 30.10.22.

First, to assess the need for inclusive content (self-help modules, therapist directory and AI chatbots), Belongg undertook a rapid pre-Bootcamp user research study with 5 participants, all of whom had different minority identities. Participants downloaded five of the most downloaded mental health apps on PlayStore identified by Belongg and used them for at least one week. We then conducted in-depth interviews with them and found that all five participants felt the apps lacked nuance and provided very generalised content for a common set of issues and did not find their identities to be reflected in the content of any of the apps.

Key Findings From The Bootcamp

We are presenting key highlights and takeaways from the Bootcamp across the way the problem of un-inclusive apps is experienced, the categories of solutions that were found most useful, pitfalls that should be avoided, and principles that should be kept in mind.

The Problem Of Inaccessible Mental Health Apps

• Bandwidth and resource shortages in small companies and startups are key barriers to adapting apps to be more accessible to users with disabilities.

  • A user interface designer of a popular mental health app pointed out that modifying apps to be more accessible i.e. with text-to-voice converters, custom text formatting, etc. and developing content to cater to various social groups requires much manpower and that the company focuses on building on what they’ve created, making only the changes that their small team can pull off.

  • The intent to make their apps accessible should hence be married with tactical and affordable support for app developers to take the steps in that direction.

Useful Solutions

• Language was a point of discussion – the use of ‘woke’ language in therapy and the value of multilingualism as a skill to promote inclusion in the therapeutic setting.

  • Bootcamp participants pointed out that ‘woke’ language is not necessarily inclusive as ‘woke’ discourse is primarily upper class and caste. Minority individuals may not be familiar with such language and may hold a completely different vocabulary of acceptable words. Therapists must hence approach such interactions with humility, recognizing the (hegemonic and patronising) sources of ‘woke’ knowledge.

  • Dalit students, for example, it was pointed out, do not feel comfortable speaking English. The multilingualism of on-campus counsellors is hence important so as to ensure that student counselling services do reach them.

• The therapeutic value of a diverse and representative roster of therapists in digital apps is high; the psychological gains of users being matched with the therapist on grounds of social identities are significant.

  • In the pre-Bootcamp study carried out by Belongg, Dalit, queer and Muslim participants did not see therapists whom they felt they could be matched with, in the apps and felt that being recommended a therapist based on a short questionnaire about their mood was, at best, confusing and were therefore unlikely to encourage them to take the next step, i.e. to reach out to the therapist.

  • Therapists in the Bootcamp believed that all therapists were inclusive and that stating their identities or identity-centric specializations might alienate other users. This implication that therapists who outline their social position might alienate clients is worth unpacking.

• Adopting a customized approach based on the user’s social background to make chatbots more culturally informed and empathetic.

• Increasing the outreach and efficiency of mental health apps by coupling them with offline mental healthcare services.

Important Principles That Must Underpin App Development Efforts

• The value of constantly learning, updating and challenging knowledge, beliefs and skills of therapists and app developers thereby making their practices more inclusive.

  • Therapists must constantly interact with each other as well as with other professionals to challenge and learn from each other.

  • The need for therapists to remain updated on sociopolitical affairs was also highlighted.

  • A participant pointed out that there is abundant information online and workshops being conducted, leaving mental health professionals with no excuse to remain rigid in their thinking, knowledge and practice.

• Innovative ways to capture the user’s identities while still protecting their privacy in case of a data breach.

  • Eg: By using personas: the user can be asked “Have you ever faced caste-based discrimination?”, “Are you often stopped by the police without reason?” etc.

  • By doing so, apps can develop a fairly accurate picture of the user’s social identities without directly inquiring about them and accumulating identifying labels.

• The value of co-designing with minority community members and constantly engaging with user feedback to make apps more inclusive, and the barriers to applying the participatory approach when it comes to health and mental health apps.

  • App developers have a range of professionals including mental health professionals on their designing team but typically don’t have lead users with marginalised identities at the table who are representative of those who will use the app. Eg: Involving individuals with different sexualities in designing an app for queer persons

• The need for striking a balance between personalising notifications and addressing the exceedingly vast and negative effect of mental health stigma on the user’s self-perception.

  • Self-stigma of mental illness is elevated when content related to mental disorders, which is common in mental health apps as they tend to take a pathologizing approach to care, identifying users by their level of symptoms, is earmarked with their names.

  • Breach of personal content renders women especially vulnerable as they may be in abusive relationships wherein private information in the hands of the perpetrator can worsen their situation.

Macro-Questions That Deserve More Attention & Discussion

• Therapists questioned what it means to be an inclusive therapist and raised important questions about the validity of certifications to claim one is sensitive to the issues of a certain group such as the queer community.

  • Certifications are often expensive and therapists pointed out that it may be unfair to judge a professional’s competence based on them.

  • It was also pointed out that becoming identity-affirming is a long process of constant self-reflection, empathy, education and unlearning that cannot be concentrated into a few sessions and credits.

  • Time and again, the importance of therapists engaging with the social and political, following the news and understanding the cultural, historical can political backgrounds of different social groups in the country, was highlighted.