An alternative academic guide to twitter

I wrote this originally nearly a year ago but never pressed ‘publish’. I’ve been seeing lots of calls to twitter of late though that seem to encourage exactly the kind of thing I think twitter shouldn’t be used for, so I decided this might be worth posting after all. Comments welcome!

Rule #1: Stop tweeting at conferences.

Perhaps more than any other suggestion, I’m seeing this recommended as a good thing for newbie academic tweeps to do, as it’s a good way of mastering twitter and gets you attention on a hashtag, and also is a fundamentally useful thing for people who couldn’t attend the conference to follow. I have no problem with tweeting about conferences per se (I’d be a hypocrite if I did). My issue is the kind of bland, no-comment tweeting that seems to emerge. Increasingly people seem to be kindly tweeting the conference agenda rather than adding any value – tweets like “Now Prof X is on stage to talk about his study on Y”, “At the Z workshop learning about Z”. You don’t have to dissect every talk or make very personal observations, but add a little something – are you enjoying the Z workshop? Would you recommend it? Are there resources you got from it that you can signpost other people to? Was the study interesting? Is Prof X a fab speaker that other people should catch? Are you pleased to see Y getting more attention?

At the very least try to capture something of the content of the talks, if you’re aiming for the ‘roving reporter’ style tweets aimed at people who couldn’t attend the conference themselves. Saying “Prof X argues largest study of Y to date shows it should be a priority for GPs”, or “Study confirms previous findings that Y particularly affects BME groups” for example rather than just “Prof X reports his study of Y”. I increasingly see conference streams filling up with the latter, which makes it into a sort of pointless narration of exactly what’s happening. “Prof X is taking the stage.” “The audience is made up of people who are attending the conference.” I wonder if this is because people are nervous about adding any kind of opinion or worry about tweeting ‘the wrong thing’. I think this is natural, particularly if you’re a student or junior researcher and worried Prof X might read your tweet. I think in this case it’s fine to stick to the facts, but try to make the facts about the research, rather than describing the conference itself in rather inane detail.

Rule #2. Don’t link to your papers. (Or do, but Own The Brag).

Another rule recommending the exact opposite of all the standard advice, because I’m a contrary so-and-so. Do not use twitter to post links to your academic papers!

If you follow me on twitter you will have spotted I’m completely cheating here because I do this quite regularly. But my issue is that you should at least acknowledge this for what it is – shameless self promotion. Own it! Be proud! “I worked bloody hard on this and I’m delighted it’s finally published and EVERYBODY READ IT!” Don’t do a humblepromote (a variety of humble brag that I’ve just made up) – “Can’t believe little old me has a paper in Lancet #crazy”.

Also, and I’ve discussed this before, don’t think that your citation rate is going to skyrocket because of twitter. I think if you post a link to a paper on twitter than you should be doing so because you genuinely want your followers to look at and potentially engage with you about it. This engagement might well be criticism or disagreement. I see some academics post links to their papers and then ignore any tweets sent to them about it, which just adds to the frustrating sense that academics use twitter as a one way advertising stream.

conversation

Twitter is best when you interact, not announce.

 Rule #3: Follow loads of people.

I’ve increasingly seen recommendations to limit your followers, because you can’t possibly keep up with that many accounts, as if twitter is some darling bonsai tree you need to keep tidy. I think this assumes though that you’d ever try to read everything that everybody posts. I experience twitter more like a rolling news feed and I catch whatever I catch, and following lots of people means that news feed is more diverse, more interesting and I find out about lots of things I never would have otherwise.

 Rule #4: Post pictures of cats! (Be informal)

It’s become the standard at ‘social media workshops’ and the like to make some comment about how, yes, twitter is more informal, but you don’t have to go crazy and be one of those people who keeps tweeting pictures of their cats. Usually at this point I post another cat picture immediately out of spite. (I shall hereforth refer to this as Knowles Law – Every time you tell someone not to tweet personally, someone tweets a picture of a kitten.)

kittens in mugs

In fact, have two kittens!

I must admit though that when I first started on twitter I was a bit surprised by how personal some accounts were, and how personal in often quite a mundane, ‘this is what my bus journey today was like’ way, in contrast to the perception that you use tweets to distill and disseminate Thoughts of Note. My primary interest in those early days was following Ben Goldacre about science whilst thinking about how lovely his hair was, and he would tweet quite often about his lunch or tv shows he was enjoying. What I noticed was that this kind of rounded out the other tweets, about bad science or trial design. They stopped sounding like lines that could just be taken from an article and became actual comments that a genuine person was making. I think this gave an authenticity to the tweets, and it’s something I think in research particularly we could use more of. It makes researchers into real people, who really do care about what they do.

I think it changes the tone of debates as well. One of my favourite sayings is “Truth springs from argument amongst friends”, because of that last part – I think being friends, respecting the other person, assuming the best of them (rather than assuming they’re just being difficult or contrary for the sake of it) means that an ‘argument’ is more fruitful and certainly more amicable. I get into various friendly conversations with people, about cats (of course) but also tv shows, music, etc, and I think this means that when we talk about ‘professional’ issues such as research, it makes those conversations into genuine interactions rather than two people sparring with each other. I think realising that someone you professionally disagree with is someone that you personally get on really well with is always a useful lesson.

I would also genuinely query what people who are on twitter in a purely professional sense get out of it. If it’s all just vanilla statements about your work or retweets from University news accounts, then you might as well just set up a bot that randomly spews out lines from your Uni webpage. Or just post a single tweet linking to your Uni webpage and leave it at that. My personal suspicion is that these people don’t know what they’re getting out of it either, would often rather not be on it, and are only because someone told them to be (probably under the guise of some rubbish about it improving their citation count).

One final note here though: I want to take care to distinguish being ‘informal’ from being ‘unprofessional’. I see some academics who don’t talk about personal things but they also seem to think the informality of twitter means they can be a bit of an unprofessional jerk. If you’re playing the role of Researcher With Opinions – as opposed to Individual Owning Those Opinions – you can perhaps fall more easily into being rather unpleasant, because it’s not really You that’s being sarcastic or mocking or dismissive. It’s all just part of the debate after all, you’re a devil’s advocate (bleurgh), you’re professionally rather than personally disagreeing (even if the person you’re disagreeing with finds it very personal indeed). But if you’re You, and You are being sarcastic or mocking or dismissive, then You might want to stop. I think of informality on twitter as the kind of informality I might have with colleagues at a conference. I will talk about ‘personal’ things (though not necessarily private things – talking about likes and dislikes isn’t the same as confessionals) but, I hope, I’m still being a ‘professional’ in terms of how I behave toward others and how I represent myself. You can be informal and still respectful, and I think showing respect toward people you interact with on twitter is hugely important, and something twitter itself could do with more of.

 

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Health Research Should Be Crowd-Funded Through Kickstarter

This is the text of my *humble cough* winning Dangerous Ideas Soapbox presentation at yesterday’s SAPC conference. Not entirely sure how much of this I got in during the 2 minute (and strictly adhered to) time slot, but this is what I intended to cover!

Kickstarter is a crowdfunding platform. You don’t have a product which people click on and you sell – you ask for investment up front and if you don’t get enough promised custom then your product does not get made. You have to make a pitch, you have to promise what will happen, convince people to invest in you, you have to do this within a time limit. What if, after passing peer review, rather than being given the funds for your research, you had to make a pitch on a platform like this for patients to commit to your project and only if you get enough support would the funds be released? Patients after all, as taxpayers, are paying for this research and this would give them an explicit vote with their cash.

Sadly not the actual slide I used in the pitch...

Sadly not the actual slide I used in the pitch…

This is actually very consistent with current policy and with the current philosophy funders claim to have. A patient driven research agenda, research that reflects patient priorities, research that engages patients. So let’s put our money where our mouth is and give patients the purse strings.

Yet, despite it being a natural evolution of our claimed approach, most people I’ve mentioned to have thought this was crazy or it sent them into palpitations – and that’s why this is a dangerous idea because this provokes some difficult thinking. This is about forcing us to ask whether we really want patient-driven research – do we not trust them with the money? Do we not trust the public to know what research is needed? or do we not trust ourselves to communicate to the public what research is needed and justify why our studies should go ahead?

Also, it is scary, there are risks. If you don’t do a convincing pitch, if you don’t get patient backing, you don’t get the funds. But there’s a motto that’s used in silicon valley that I think is apt here – Fail Faster. Maybe if you can’t drum up support in advance, you need to stop and reconsider. Think about the 45% of publicly funded trials which fail to meet recruitment targets once they’re up, running, and spending public money.

And maybe patient supportd research would help with those problems of recruitment and retention  – think of platforms run by and with patients, such as Patients like me. Patients choose what they want to research, and the site has 250,000 ‘data donors’ engaged and participating in studies – how many trials can claim the same?

This model would not only bring to life the idea of ‘patient driven research’, it could herald a new way of working with patients, for patients, with their commitment to help us see research through.

Posted in Presentations/Publications, Thinking about research, Trials | Tagged , , , , | 1 Comment

3 reasons why it’s ok to be a “control”

Hi all – I wrote this to coincide with Clinical Trials Day, and then managed to miss it completely. Smooth move, Knowles! Nevertheless, I still think it’s an interesting topic and one which I’d really love to hear peoples’ views on, so here it is better late than never!

The inspiration for this post is that I’ve often observed negative attitudes toward trials due to people being putting in the ‘control group’,  meaning that half of all the people in the trial have the new treatment withheld from them. When I’ve recruited participants into trials for example they often look disappointed if they’re allocated to the control group. I wanted to dig into that a bit, and try to explain why being in the control group is no bad thing, and perhaps is the most important thing anyone can do to help us make progress in health research. So, here are 3 points on why it’s ok to be in the control group in a trial:

1. “Control” in complex trials will rarely mean “you’ll be prevented from receiving treatment during the trial.” New treatments don’t have to be better than nothing these days- we have lots of somethings. They have to be better than the treatment you would have gotten anyway.

This is why ” control” arms are increasingly “treatment as usual” or “TAU” arms. In a pragmatic trial (one where you try to minimise the interference the trial has with things-as-they-are-usually, so you’re leaving situations and decisions to run largely as they would if the trial wasn’t there), you will typically avoid placing any restrictions on which treatments the TAU participants get. For example, in a trial we did looking at computerised therapy, we didn’t restrict access to any other therapies or medication on offer. The reason is that we’re not aiming to get a pure sense of what our trial therapy adds to people who get no other treatment – we want to look at people getting whatever treatments the NHS currently has to offer, and see if adding computerised therapy into that has any additional impact. This is why the name “control” is a bit misleading these days – we often only ‘control’ whether you access the new treatment as well, rather than controlling anything else.

2. New does not mean better.Only just over half of trials find that the ‘new’ treatment is better than the existing one.

As any Parks & Rec fan will appreciate, not all new ideas are good ideas...

As any Parks & Rec fan will appreciate, not all new ideas are good ideas…

What I find interesting in the discussions on trials is that often it’s framed as the ethical dilemma being that you deliberately withhold an effective treatment from the control patients. This doesn’t follow though, if you accept that you don’t know if a treatment is effective or not until you’ve done the trial. And as the statistic above shows, a lot of the time that ‘new’ treatment wasn’t any better anyway. To look at this another way, I’ve seen arguments that every trial with a control arm should promise to provide the new treatment to all the control patients once the trial is finished. But this again assumes that the new treatment works. If we find out it doesn’t work, what’s the equivalent for ‘correcting’ the fact that we gave everyone in the intervention arm a dud? We can’t go back in time and take it off them again. The point is we don’t know whether the treatment is better or not. That’s what the trial is for in the first place.

3.If anything, the control arm is the most important.It’s the only way we really find out if the new treatment is worth using.

I’ve had participants in the past who, upon hearing they’ve been randomised to the control arm, assume they’re effectively out of the study and won’t be hearing from us again. This can be problematic as it’s actually critical that we hear about the progress of people in the control arm.

This is because quite often people tend to get better (or their symptoms change) over time anyway. If we only looked at people who got a new treatment, and they get better, we might automatically think it’s because of that treatment. If we can compare them to people who didn’t have the treatment though, and it turns out everyone got better, then this shows that the new treatment is a bit of a waste of time and/or money, as it didn’t actually improve things for the people who received it in comparison to what would have happened anyway. So, the only way we know if the treatment actually added anything and made a difference is by looking at the people in the control arm. They’re absolutely essential to finding out if something works – or not.

Symptoms often change over time on their own - to know if symptom change was due to a treatment, we have to have something to compare it to.

Symptoms often change over time on their own – to know if symptom change was due to a treatment, we have to have something to compare it to.

So, that’s my 3 point list for why being in the control group isn’t as bad as I think it’s assumed to be, and why actually it’s probably the most important position in the trial. Let me know in the comments if you agree, disagree, or think I’ve missed anything out!

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Eliza Vs R2-D2 – who’s the better robot therapist?

R2-D2 cat.  Because.

R2-D2 cat.
Because.

The tale of Eliza is a bit of a standard one in cognitive psychology lectures. Eliza is a text based programme that you can ‘talk’ to, and one which is modelled as a kind of therapist. An early example of how natural language processing could work,  her creator, Joseph Weizenbaum, chose to make her emulate Rogerian therapy essentially because Rogerian therapists are non-directive, focused on mirroring what their client says, and this style was something that an NLP bot could try to replicate. The programme didn’t need any additional knowledge or protocols – it could just respond to the text entered by the user themselves. The story goes that, to Weizenbaum’s horror, some of his lab staff actually started to believe “she” was a real therapist, and indeed kicked off somewhat when they realised all their innermost thoughts and desires were being recorded on a log on Weizenbaum’s computer.

Screen Shot 2015-03-04 at 16.30.25

I’d love to know more about this – did the users really think for example that the programme was a person (Weizenbaum seemed to think so, and dedicated much of his later scholarly work to admonishing those who anthropomorphised technologies). Or did they just find some benefit in getting their thoughts down into text, and having a programme that helped spur them to work through them?

Eliza gets referred to quite often as the first “computer therapist”, and I think the attitudes of Weizenbaum Vs The Staff still sum up quite well the different reactions to whether computers should be involved in therapy at all. Is this a terrible technological encroachment on something fundamentally human, a soulless ‘trick’ with programming that would be a bad joke gone too far if used for ‘real’ therapeutic purposes, or is it something valuable, something engaging, something that could genuinely help?

My feeling is that the answer is somewhere in the middle. I agree with Weizenbaum that trying to create a genuine ‘computer therapist’ is a daft idea. I actually did some training in Rogerian therapy while I was a PhD student, and it is an incredibly human and personal thing – it’s about having another living, breathing person there with you, to help you reflect on your own words. A patient in a study I did about computerised therapy coined the phrase “the verbal cuddle” – the emotional, physical embrace of actually speaking to another human being. You can’t replicate that.

Even Robots need hugs! And also appear to try to cop a quick feel whilst doing so. Watch the hands, Romeo!

Although even robots need hugs! And also appear to try to cop a quick feel whilst doing so. Watch the hands, Romeo!

That I think is the key point – replication doesn’t work. But perhaps what technology can do is offer something different. Patients in the study I mentioned who really, really liked computerised therapy weren’t those who thought the computer programme did a stand up job of imitating a real therapist, they were those who liked what it did differently. The fact that they could access therapy at home, at any time of the day. The fact that they didn’t need to talk to someone – that the therapy was private, and that it was something they could work through at their own pace. Maybe that’s what Weizenbaum’s staff liked as well. In the stories I can find, it doesn’t say they freaked out about the computer not being a real person – they freaked out when creepy Mr W said he’d read their private text.

This brings us – finally – to R2-D2. This fab post at the Medium tackles the age old problem of why R2-D2 is awesome but C-3PO is kind of a pain. The author nails this down to the very problem discussed above – that the best technologies are those that do things we can’t, whilst those that try to replicate or replace things we already do aren’t as valuable and can be just annoying, especially if they try to emulate human characteristics or interactions (Microsoft Word’s hideous Clippy being cited as an example. NO I AM NOT WRITING A FREAKING LETTER CLIPPY GO AWAY). I think this is very true in mental health technology – attempts to make the programme talk ‘like a therapist’ or giving it a fake therapist just seems to rub people up the wrong way. It emphasises what is artificial, rather than making it seem more personal.

Huh. As if anyone mourned.

Huh. As if anyone mourned.

This paragraph sums it up best:

R2-D2 excels in areas where humans are deficient: deep computation, endurance in extreme conditions, and selfless consciousness. R2-D2 is a computer that compensates for human deficiencies — it shines where humans fail…

R2-D2 aspires to be a great computer.
C-3PO aspires to be a mediocre human.
We need great computers, not mediocre humans.”

 Mental health technology I think is a perfect example of this. Some online CBT programmes, like MoodGYM, seem to try to emulate aspects of ‘real’ therapy – even down to insisting you do a one hour session each week, like you would with a ‘proper’ therapist. This seems like nonsense, if we embrace the idea that we should exploit what computers do that is different. They don’t have a waiting list of patients and an office you need to attend. They can be ever present, or present on the move, or only activated when you need them.

Making programmes that try to emulate human therapeutic interactions only serves to highlight what’s missing – that you aren’t sharing this experience with a real person. But using what technology can do differently to think about how we could deliver therapy differently – that could work. That could get us away from Eliza, and mean our ‘computer therapists’ start to look, and act, more like R2-D2 than C-3po. They might be more valuable that way – and I’m sure they’d be a lot less annoying.

Notes

You can play with an online version of Eliza here. The slightly creepy thing is that because the bot just churns out instant answers based on your text, it responds instantly, and the answer appears at the exact same time that you see your own response on screen. It’s reminds me of the ‘Midnight’ episode of Doctor Who, or those bald guys in Fringe…

 

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How To Win At Academic Presentations

You really can’t escape presentations as a researcher. If you want to submit your work to a conference, then you’ll need to be willing to present (unless you only ever want to do posters. In which case what on earth is wrong with you?). Most job or training interviews will ask you to deliver a presentation. You’ll also quite often give less formal presentations as part of project meetings. And of course lots of researchers also ‘present’ when they’re teaching.

There are of course some things that will automatically captivate your audience. Ooh kitty!!

Despite this, how to give a good presentation is something you’re typically left to work out for yourself. It’s similar to ‘how to write well’ which you also just have to try to pick up as you go along. I do wonder if perhaps this explains why lots of academics are quite poor writers – and, yes, poor presenters.

Both presenting and writing are skills, and mastering them takes time. But I do think there’s some general advice that can be helpful when thinking about presentations. This is developed both from my experience of presenting and also my experience of being in the audience, for both good and bad talks.

Before I start though, I think any advice should come with two caveats:

1. Your best presentation style will be the one you’re most comfortable with.

This might mean that some of the advice below just doesn’t work for you. If you feel much more confident with text heavy slides and you struggle to make slides more visual without losing the flow of your argument, then by all means stick to this. What I would suggest is that it’s worth at least experimenting with the tips below. Volunteer for an internal presentation (journal or methods clubs are good for this) and have a go at presenting in a different way to usual.

2. All advice is easier said than done, and I’m sure I don’t follow my own recommendations half the time!

This is perhaps less a caveat than a confession. I really just want to acknowledge that presenting can be hard, that it’s not a skill we get a lot of explicit guidance on as researchers, and that often we’re just doing the best we can in the time available. The tips below are meant to be helpful suggestions, and not a critique of anyone who does things differently.

So, here’s my top tips for academic presentations:

What to say

  • There are three things you must do: Tell them what you’re going to tell them. Tell them. Tell them what you’ve told them.
  • Do not miss any of the above steps!
  • The first part should be actually telling them something about the content – “I’m going to talk to you today about why we’re missing the potential of eHealth by ignoring user needs” for example. Not one of those slides that just reads “OVERVIEW: Introduction. Methods. Results. Conclusions.” That’s not actually telling them anything, and it’s dull dull dull.
  • The recap is your chance to hammer your point (or what you hope is your point) home. What’s the take home titbit that you want the audience to remember? If they were to go up to their colleagues tomorrow and say “I saw an interesting talk yesterday that showed ….” – what do you want that last part to be?
  • Talks, like research papers and essays, are not a detective novel. You don’t have to make the audience wait until the end to find out what the conclusion is. This is actually more true the shorter the presentation is. If you’ve only got 5 minutes, you need to give them the take home message really really soon.
  • Only include data and diagrams you will explain. This goes for both qualitative and quantitative. If you are going to present huge tables of analyses, then at least be nice enough to highlight the bits you expect the audience to look at. Sometimes I get the impression people just stick these in to prove they did them. If you’re going to include big chunks of transcripts from interview data, then again make sure you highlight the main points.
  • Don’t fill your talk with bits that are anticipated question rebuttals. I get this impression a lot in PhD student talks (though possibly the fault is their supervisors from over use of the “your reviewer will pick that up as a problem!!!” refrain). This is when people go into huge detail about a particular method or finding, or a very defensive justification of a theory or interpretation. If someone wants to critique you on these issues, let them do so in the Q&A (this doesn’t stop you preparing for them. You can still write notes for yourself about how to respond to possible comments, which can be very helpful). Don’t however mess up the flow of your talk or take time away from more interesting parts just because you want to nervously pre-empt someone picking a hole in your methodology.

How to say it

  • Within the time limit! Lots of people seem to struggle with this (if the number of people going over time at conferences is anything to go by). I think sticking to time is less about it being a good talk (though probably the two correlate) and more about respecting both your audience and the other speakers whose time you’re cutting into. This is another good reason to use the “state the findings first” approach mentioned above, as then even if you have to skip your final slides you’ve already made your point.
  • If you’re really fretting about the idea of skipping to your last slides to quickly summarise the conclusions, just think of it this way: you’re immediately making your Q&A part easier on yourself, as pretty much whatever someone asks you can say “Well actually that was something I was going to cover in slide 7” and then go back to that and discuss it. That’s kind of cheeky though, so don’t tell anyone I told you…
  • Visual! The slide should not be your exact talk, in text form, while you stand and read it out. There should be some kind of added value of me coming to hear you speak, or at the very least you shouldn’t bore me to death by just reading word-for-word from a slide that I finished reading in 30 secs but you’ll be reading out loud for 3 minutes. Similarly, put as little text on as possible – just the headlines if you can. It can be hard in academic talks to go easy on the text, but you can try at least to split up the text heavy slides with a few images, and white space on the slides will make what you do include much easier to absorb!
Do. Not. Just. Read. Slides.

Do. Not. Just. Read. Slides.

  • You don’t automatically have to use PowerPoint, though I’d probably advise caution until academic conferences catch up with the times and offer stable internet connections/ anything other than archaic laptops and projectors. I’ve seen quite a few presentations using Prezi, and my issue in most cases has been Why are you using this instead of PowerPoint? Specifically, Prezi enables non-linear presentations – and I can think of lots of great uses for this, such as showing a changing process, showing how certain things nest inside others, covering different spots before swooping out to the big picture and so on. But quite often people still do a standard linear presentation – they just give the audience mild motion sickness while doing so. Think about the platform you’re using and whether it adds anything. I’ve seen someone do a great presentation just using Stich It for example, which is a programme that stitches together different webpages into a slideshow. This worked because the format matched and aided the talk, which was going through different representations of work online.
  • Watch this. It’s brilliant.

Finally, I think the most important thing I can say is “You are a better speaker than you think you are, and no-one thinks you look nervous.” Practically everyone I know has said at some point “Oh that went really badly, I bet everyone could tell I was nervous” and genuinely in not a single case has that been true. Remember you are far more aware of your body and any slight differences in your voice than anyone else in the audience. They are also far more interested in the talk and the slides than wondering if you look a bit peaky. And even if they do, if anything I think it can make them more sympathetic! We’ve all been there after all.

The other fear I know everyone has is that someone in the audience will make their life miserable during the Q&A. Again, most audiences I’ve known are friendly. Most conferences now have half a dozen parallel sessions competing for audience interest, so remember that if they’re turned up to yours it’s because they are genuinely interested in what you have to present. Yes, they might ask hard questions, but because they really want to know the answer – they think the work you do is important and so we should ask important questions about it. There’s also nothing wrong with saying “I hadn’t thought about that.” Maybe follow with “That’s really useful to bring up thank you – could we perhaps a quick chat about it after the talk?” This stops you getting embroiled in a live debate on stage (if you’re the kind of person who doesn’t enjoy that!), will probably flatter the person asking the question, and best of all gives you an opportunity to have a proper discussion with someone who might be able to help you.

I guess it’s possible that there could be a conference where your boss’s worst enemy is there and deliberately attempting to trip you up or humiliate you. If this ever does happen though, be assured that the rest of the audience can spot it a mile off, and insolent people like me are probably already making disparaging comments about them on twitter😉

Update 5.2.13: Twitter directed me to this great resource which is definitely worth checking out – a BMJ blogs series on presentation skills  by Ross Fisher (aka @ffolliet)

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Is therapy by Skype such a bad idea?

This story caught my eye over the weekend – some proposals by an NHS trust to outsource mental health therapy to workers abroad who would communicate with service users via Skype. The BBC report says the idea – which was not at all well received – has already been dismissed, but the part that struck me was the way in which the idea of using Skype was attacked alongside the plans for outsourcing. One quote says for example “”That [the trust] could even consider Skype shows how little the board understands of the work of its staff and the needs of its service users.” So, what’s so bad about Skype?

First off, I should say that I agree with the union that this would have been a bad plan. But we disagree on an important issue. I think this looks bad because of the outsourcing, not because of the Skype. I think with the challenges mental health services are facing they need to keep a skilled and experienced workforce, and they certainly don’t need to threaten jobs and create insecurity. I’m sad though that the defence employed is to suggest that therapy itself is threatened by the idea of digital contact, and that people receiving therapy in anyway that isn’t the traditional face to face delivery would be a bad thing.

The fact is that services will need to change and evolve. This could mean letting go of established ways of working with patients. It doesn’t have to mean letting go of staff however. Integrating digital services into current treatment models should be about getting the best of both, in combination – not creating an either/or trade off. Technology should be used to complement the way therapists work, not replace it.

In the research this is referred to as “blended protocols”, where treatment involves digital services being providing in addition to or interaction with therapist contact, and reviews of online therapies find this way has better effects compared to standalone therapies with no therapist involvement. One thing to notice however is that this ‘blending’ can happen digitally – for example by having therapist contact by email, phone, or indeed Skype. Blended therapy therefore doesn’t necessarily still mean providing traditional face to face support.

So – seems like I’m on board with the proposal? The problem however is that the trust isn’t looking to ‘blend’ digital services with its existing staff, but also to outsource the therapist’s work. Presumably this would mean that everyone gets ‘distance therapy’, which I think loses of the key aspects available by blending services: flexibility. A service which effectively manages a number of its users online may actually be able to provide more face-to-face time for those who need and prefer this. This would be efficient for the service, and also could achieve one of those amorphous ‘personalisation’ goals, of offering people the format of therapy they prefer.

Remote technologies like Skype could allow more, er, 'people' to access therapy from home.

Remote technologies like Skype could allow more, er, ‘people’ to access therapy from home.

This raises the next key point – that rather than just being about efficiency, it should be about what service users themselves want. If they express that they want and they need face to face contact over Skype then we should listen. Certainly some service users I’ve spoken to about online therapies have said exactly that. But others relished the opportunity to use online treatments. My concern is for those service users, the ones who would benefit from exactly those digital services, who risk having their needs ignored if we treat this only as a fight to keep therapists jobs. People who can’t take the time out to spend an hour in face to face therapy due to work, caring responsibilities, or problems travelling. People who actually feel more comfortable, would be more likely to engage with treatment, if they can use digital services. Those people don’t have a union, and as far as I know they can’t get a piece on the BBC. Framing this as an either/or issue, as an evil digital takeover at the expense of staff, isn’t fair to those patients. Again, the key is flexibility – the option of digital OR face to face should be there.

Nevertheless, it’s a cold hard reminder to those of us babbling eagerly about “the potential of blended protocols” that there are people eager to make ‘efficiency savings’ who will look at digital services as a super way of cutting out those burdensome, expensive, experienced and skilled staff. The research does not support this as an approach. And neither should we.

Picture from https://phua.wordpress.com/2012/02/28/skyping-your-cat/
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Marvellous Capability: Mental health and ‘people dependent technology’.

Internet and Everyone (Brain Pickings)

This is a lovely page, from a book called ‘The Internet and Everyone’ by John Chris Jones, which I came across on the Brain Pickings site a few years ago. It rang true to me then, and even moreso now, that the philosophy the author talks about is one we really should try to embrace when designing mental health technologies. In this section on “people dependent technology” he makes a plea that:

“We design everything on the assumption that people are not heartless or stupid but marvellously capable, given the chance”

I love that phrase, ‘marvellously capable’. Certainly the first generation of mental health technologies I’ve come across, the online packages of digital CBT for example, seem designed as if the people using them are heartless (in the sense of unemotional or willing to drudge through drudgery with no personal sense of frustration or need – quite the opposite of course to how people really are, and certainly people experiencing a mental health problem) and stupid (in the sense of needing the most obvious things explained ad tedium but given no opportunity to be flexible, creative or to personalise the system the way they see fit.)

He also writes:

“The main obstacles to this at present are not so much the machines or technical processes, but the presence of our other selves…enforcing rules of behaviour and design which assume that ‘users know nothing and producers know all.”

The last bit is becoming something of a mantra of mine – I’ve spoken before on this blog about the need to ‘follow the user‘ and how technology provides us with great examples of ‘bricolage’, of users blending and mending tech into their own lives in ways that suit them, and ways that the original producers and designers should learn from.

But the first bit really strikes me as well – the idea that is ‘our other selves’ that we insert into software that really prevents people from doing what is best. Those online CBT packages for example are designed almost as if to deliver therapy the way a therapist would – you have a 1 hour session, you sit and listen and are expected to learn, and you get given homework that you report on next time. It’s absolutely daft of course that a technology, which could be made so flexible and integrated so much more elegantly into everyday life, is still following a set 1-hour-a-week routine as if the patient is turning up at their therapist’s office for their regular slot. But I think it goes deeper than that. The fact that the programme still assumes the role of the patient is to receive information and respond to instruction – this doesn’t seem like a design that recognises people as “marvellously capable, given the chance.”

I think this is a great shame. I think it would be very sad if we abandon the idea of mental health technology because this first generation got in the way of people, rather than supporting them to do better. I think this is especially true given we have such a clear path laid out for making the next generation better – follow the user, and embrace the idea of “people-dependent technology”. The technology depends, not on us as the designers, to be clever and assume we know what to produce, but instead on the people who are using it.

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