How technology is helping to remove the stigma attached to mental health – An interview with Dr Jay Spence
Interview between Dr Jay Spence (co-founder & CEO of Uprise) & Paul Muir (Compliance Advocacy Solutions)
PM – thank you for your time today Jay. Is there a golden thread that sets the context for our conversation on mental health and Uprise?
JS – the main thing for me is to end the idea that mental health problems are happening to someone else. Statistically, 1 in 2 people will have a mental diagnosis in their lifetime, so that equates to mental health problems being normal, rather than exceptional. The problem is that we don’t think of our symptoms as being a sign of a mental illness. Waking up a few times a night, feeling restless and on edge, difficulty relaxing and finding it hard to control worries are thought of as normal experiences. However, they are also signs of a mental illness called Generalised Anxiety Disorder (GAD). These symptoms are cues that we need to start focusing on our mental health. Instead, people suffer through them when they don’t need to be. Most people think about mental illness in terms of things like schizophrenia and severe depression. That is occurring for a percentage of the population however, it’s near the end of the bell curve on the spectrum. Mental illness will happen for at least half of us as we sit in the middle of the spectrum and our stress levels go up & down, occasionally dipping into the range of a disorder like GAD. The symptoms that we are experiencing we don’t have to live with. We don’t need to just endure the symptoms and because effective skills are available to resolve them. People see this as just my life, my life is stressful and that’s normal & I’ll suck it up. If people recognise symptoms like waking at night and difficulty controlling worries this as a mental health issue and got on top of it early they would be able to do something about it. At the heart of it, we need to change the stigma so people can see this as normal and take action on it.
PM – if you maintain your mental health is there still a percentage of people who will experience a mental disorder?
JS – Yes there is a percentage of population that doesn’t respond to treatment very well. We don’t have perfect treatments. The best treatments we have, work for about 70% so there is always a group of people who come through periods of wellness and back to periods of relapse.
PM – So what about the view held by many including, within the insurance industry, that once you have a mental illness you will always have a mental illness?
JS – Its excluding the idea of recovery. There are a percentage of people who will be relapsing for most of their life but there is also a percentage of people who, if they get good treatment, will get better & won’t relapse. An insurance policy that excludes on the basis of mental health is neglecting to recognise that this is a person who has been categorised as having something that is temporary rather than permanent – there is an opportunity that insurers are missing out on.
PM – Let’s backtrack a little. Tell me about yourself Jay. Where did you start and where did your interest in technology solutions arise?
JS – I’m a clinical psychologist and worked in private practice for over 10 years. What got me into internet-based treatments was that I was very fortunate to be at St Vincent’s hospital when one of the early anxiety internet treatment clinics was being set up in Australia. I met two incredible people, Professor Gavin Andrews and Dr Nick Titov, both of whom created what is now a reasonably established industry and definitely an established scientific intervention known as an eHealth intervention.
PM – tell me more about eHealth interventions.
JS – Typically, it is either a purely digital or a digital intervention assisted with a telephone or text-based support from another person. eHealth interventions are usually confused with skype counselling or doing video therapy by phone or chat. ehealth interventions are an evidenced based approach that’s been developed over a 10 year period with a specific set of skills taught in a specific order, tailored for specific groups of people. The mechanisms of supporting people through the process are highly researched methods of: ‘when do you send this text message’ or ‘when do you make this phone call’, ‘what do you say on this phone call’ etc. Each step has been researched and refined to where we now have a long protocol. What the evidence shows is that eHealth interventions are as effective as a face to face interventions but is done at approximately 13% of the cost and time needed. It’s not for all conditions but it is for common conditions.
PM – does that mean it’s the end of therapy? How do you put the personal touch into a digital intervention?
JS – It’s definitely not the end of therapy. eHealth intervention forms part of a step towards therapy. Think about this like a funnel. An eHealth intervention widens the funnel. Previously the funnel was very narrow because you had to rely upon someone who is either stressed, depressed or anxious asking for help and going to a GP. Those conditions often preclude someone from seeking help. If you’re depressed it’s extremely difficult to ask for help but the system was set up in a way it was needing people to do that. Treatment outcomes are therefore poorer and there are a whole host of problems when you get a small entry point into the system. What eHealth does is that it widens the entry point because it’s easier to start an App, log on to a website or start an SMS chat. All of those things lower the barriers to entry. At the first level of eHealth you treat large numbers of people at very low cost because its digital. However, a large number will drop out without a personal touch. So, with the next level you pair people with a coach. At the final level is a group of people remaining that need face to face therapy so you will always need therapists for the end of the funnel.
PM – because of the widened funnel and early intervention, does that mean that the end group needing face to face therapy would have been larger but for eHealth?
JS –eHealth means that a government, an insurer or an employer can support a very large number of people that otherwise would not have accessed mental health services. In particular, the widened funnel reduces the burden upon a small number of clinicians providing costly face to face treatment enabling them to concentrate upon those who need their expertise the most.
PM – how well accepted is eHealth?
JS – These steps are already being built into our health care system at the moment. There are a large number of clinics set up, mainly in Universities. My view, is that in a few years when you go to your GP you are as likely to get an eHealth referral intervention as you are to get a script.
PM – I imagine that the last 10 years hasn’t been a smooth ride for you, what’s the passion that drives you & keeps you going?
JS – It hasn’t been easy. It’s about the numbers of people out there with either unrecognised or untreated mental health issues who are basically just suffering on their own. It’s a huge number of people.
PM – is there such a thing as the ‘day to day stresses of life’? Is that just something we should accept or is that an indicator of somethings wrong?
JS – That’s a great question & the crux of the issue. What I would put to you is: should we accept it if there is actually a way to relieve it? Yes, we could accept it, but why not provide support if there is a cost-effective way to do that at scale? The issue isn’t treatment as we have really good treatments; the issue isn’t skills training for mental health, we already have skills training methodologies. The issue is getting this information out to large numbers of people. The issue is awareness and educating people about when and why they would need to do this.
PM – could you expand upon that?
JS – If you stratify this, there is a very small percentage of people who suffer from mental illness and they oscillate between well and unwell. There is a larger number who start out unwell, get treatment, and recover and then an even larger number that swing between periods of stress and down into mental health issues then back up. We know that productivity for mental illness losses alone is about $59billion per year in the Australian economy. It’s a problem that is crying out to be solved as it does have a dollar value attaching to it.
PM – why hasn’t it been solved. Why aren’t businesses more active?
JS – Stigma. The stigma is that mental health issues happen to someone else and there is the fear and complexity that it’s too hard and you can’t easily and objectively detect it, so it tends to get swept under the rug.
PM – Are you seeing a change in that attitude, the stigma in organisations?
JS – Its slow but it’s getting there. There are leading edge organisations who are investing in this as they know that looking after the welfare of their employees is the right thing to do.
PM – Can you name those organisations?
JS – Lend Lease, IAG. Telstra, PayPal to name a few. They are the early adopter companies.
PM – ok let’s talk about Uprise. How does Uprise work?
JS – The problem that we are trying to solve for a business is uptake. Typically, organisations have an employee counselling service (or EAP) and those services are used by about 3% of employees yet companies know that about 20% of their employees have a mental health issue. What Uprise does is drive utilisation through our platform to support more people. The technology does 3 things:
- A detection algorithm that helps to do identification of people who might need support;
- A low-cost resiliency training piece that teaches people mental fitness skills so that they can essentially look after themselves which they do via an App; and
- A step where they can get linked to a coach that can support them through a program and do monitoring
We then integrate with a company’s EAP so if someone does need face to face we can refer them.
PM – how hard was it to move your concept into a technology solution?
JS (laughs) – A lot harder than I originally thought. The easy thing was to build a proof of concept and show that it worked. It was fairly easy to show ‘how do we detect, how do we supply information at scale and how do we link someone to a coach’. The harder thing is scaling that up – dealing with security issues at an enterprise level, hiring issues; all of the normal problems for a growing company.
PM – one of the issues I see with start-up technology is that large organisations have their existing system(s), so every third-party system that is bolted on is extra risk for them. Has that been an issue for you?
JS – We built Uprise as a stand-alone system as we realised that it was a barrier to integrate with organisations current systems. More importantly, we want the information to sit entirely separately because of issues to do with confidentiality. Nonetheless, there is complexity that comes through maintaining the system and keeping ahead of your competitors. You have to be thinking about the next 2-3 steps.
PM – how do you guarantee that confidentiality is maintained? How do you deal with the security of sensitive information?
JS – You have to hire security experts to make sure that the way information is handled within the Uprise system and between our employees is consistent with the Privacy principles for health information in Australia and the HIPPA principles (Health Insurance Portability and Accountability Act of 1996) in USA. It’s a combination of encryption through the platform, training for employees on how they manage information and employers never receiving identifiable data. Employers only receive aggregate level reports.
PM – Are employees concerned that providing data in the system will impact their employability? I note that employers don’t receive identifiable data, however was this an issue?
JS – That was a really big issue for us early on because we came in marketing a mental health product to the company. It caused an uptake problem because it immediately made people think about ‘am I disclosing my depression to someone who may not offer me a promotion based upon my mental health issue’. We had to change our branding significantly to resolve that.
PM – what has the feedback on Uprise been like? What has surprised you?
JS – Mostly we are focused upon collecting data as the wellbeing industry has been plagued by lots of claims but not a lot of data. We have a data set now that is looking at statistically significant changes in wellbeing & stress and some return on investment data for organisations such as changes in productivity and turnover levels. As we have been able to build up that dataset it becomes more appealing to employers, what they are looking for is “if I buy this, how fast do I get my money back?” It’s an easier thing to say to an executive team “I save xx number of high performing people leaving per year due to stress” and it pays for itself. The most surprising thing has been the profile of people who come in. What I was expecting to see was a higher number of complex cases of mental illness in blue collar workforce than white collar, where I thought it may not be quite as complicated. What we have found is the white-collar issues are just as complicated, they are just much better at hiding them. We have seen some people who have been suicidal for some months sitting at the top of their company in senior positions but they’ve never spoken to anyone about it whereas I thought that would more likely be a blue collar male worker who is isolated and doesn’t talk to anyone.
PM – what happens if you see someone with a serious mental health issue?
JS – We’re providing a step before therapy so a lot of the people who come in say ‘I don’t think my problems are that serious enough to need therapy’ but once they are in the program & reflect on what’s happening with them they realise they probably would benefit from seeing somebody. Its shifting away from thinking, ‘this is nothing and I need to push on’ to having a positive experience with Uprise and thinking “If I went and spoke to somebody I would probably improve even more out of this.” What Uprise does is to facilitate that as a referral either out to a clinician in the community or sometimes back to the employee counselling service.
PM – ok let’s be a little controversial. The insurance exemption under the Disability Discrimination Act. Does it surprise you that insurers are allowed to discriminate against people with a mental health issue?
JS – It doesn’t surprise me because on the surface it does look like a sound financial position to not include people who will be complex and costly. However, what I would urge the insurance industry to do would be to partner up with academic institutions who have developed easier ways to detect differing levels of mental health risk. What I think insurers might not be aware of is the amount of progress that’s been made by researchers into mechanisms for detection. We aren’t there yet in identifying ‘this person will suffer from mental illness and this person wont’ however we are a lot better than we used to be. There are 12 questions that can accurately detect whether someone is going to experience a mental health issue within the next 12 months, it’s incredible that you can detect mental health risk from just 12 questions. It came out of research by a team led by Professor Nick Glozier. We are only going to get better and better.
PM – so clearly insurers can take a risk-based approach to this rather than excluding in general?
JS – Yes, however this has to happen with government too. Government needs to step in and help this group who experience mental health at some time (which is pretty much all of us), and see this as a group you can’t discriminate against. This is a policy issue. Once that’s in place you need to get insurers to see the moral and financial value in finding solutions. I imagine thats what gets an insurance person out of bed each morning is how they will make someone’s life easier. That’s a moral issue. It has to make financial sense as well. I imagine insurers don’t want to keep writing these exclusions, they want to find ways to help people.
PM – Does Uprise have a wider application beyond the employer/employee relationship for example between an insurer and their customers?
JS – How may Uprise help an insurer? In a number of ways, I’ll talk through a couple of early use cases. Take for example an insurance policy for a small business. One of the ways that a small business may go out of business turns upon how stressful is it to run this business and financial pressures start a downward cycle with little support being offered. If you can change this so that the small business owner is more resilient to run their business that may be the difference with someone being able to cope with very stressful situations. Imagine if the small business owner could get support from an insurer to help them with resilience enabling them to get back on track and successfully run their business.
PM – That’s really interesting. You’re suggesting that if an insurer sells an SME policy, they could partner with Uprise to provide resilience assistance to the business owner as an additional service? It will keep them in business which provides a better financial outcome for the insurer, the small business owner and Uprise.
JS – yes, I think the numbers around this makes sense. You can provide some of these resiliency skills at a very low cost and it only has to grab a couple of people to make it financially worthwhile. I imagine that having an insurer who provides this service to small business owners would create a loyal client with resultant financial benefits.
PM – so it starts to change the insurance ecosystem from purely paying claims when something goes wrong to providing support in maintaining mental fitness and wellbeing?
JS – yes absolutely. Health insurers have run the pilots, collected the information, figured out what works and scaling it up. Life insurers are still running the pilots and are still scoping to figure out what a service offering looks like. Another big use space is total disability. Consider the case of a person who is feeling depressed and goes to see their GP. The GP reminds them that they have disability protection under their Super. They lodge a claim under their life insurance and they are incentivised due to salary continuance to stay off work when their mental health will be far better off if they get back to work. The system is stacked up against them, it doesn’t really help them to have an insurance policy purely as a wages substitute.
PM – this is a similar concept to workers compensation, where that system is focused upon returning to work not just compensation.
JS – The research around this is really clear. If we don’t have jobs as human beings we tend not to cope very well. We need to create value through societal contribution. If we can’t do that, we are on a road to depression.
PM – Where could Uprise play a role?
JS – digital intervention can respond relatively quickly whereas making an appointment with a clinician make take some time. It would identify a claim in its early stages and respond rapidly
PM – so we come back to the insurance ecosystem whereby Uprise can assist at multiple points in the insurance lifecycle – providing support in managing a person’s mental fitness and early intervention and a smooth transition through the (usually stressful) claims process facilitating a return to mental wellbeing.
JS – the faster that you can get support in there (when there is a claim) the less likely that person will be off work for long periods.
PM – so early intervention is the key, and that’s a role that technology can play?
JS – Yes that’s what Uprise can provide to insurers.
PM – what I like is that you can access Uprise in your own private space without going through the stress of making an appointment with your GP. Especially convenient for us males who like to ignore things, hoping they will go away.
JS – Stigma is still a huge barrier and probably the most critical impediment to resolving mental health issues. I don’t think you have to look to hard to find the messages in our culture – work hard, push through, don’t think negatively. All of this language is the way that we stigmatise mental health.
PM – As a small Australian start-up company…is there still work to do in Australia or are you looking beyond?
JS – I like Australia as a way to get a proof of concept going and work on that to get into a larger market. It’s about trying to support as many people as possible. The two markets that we are looking at are the USA and China. We’re just about to start our 1st trial in Shanghai and Shenzhen and we have pilots running in the USA at the moment. The pilots are all focused on the employer/employee model.
PM – what’s the reception been like?
JS – Very good. Mental health is in its early stages in China still focusing upon awareness of the problem. USA is more mature with a number of other start-up’s looking at this problem partnering with insurers.
PM – In Australia, who is your competition?
JS – either digital resiliency training or face to face services like the employee counselling providers. Uprise’s unique value proposition is that we sit in between them. Uprise is the early intervention digital training piece plus coaching that triages face to face. We link it across the three whilst others look at each segment in isolation.
PM – so what’s next for you, what are you currently thinking about?
JS – Most health care companies are looking to incorporate AI and machine learning into their systems. For Uprise, it’s about creating a better user journey to provide the right type of support at the right time. Machine learning and AI is really easy to do badly and really hard to do well. The question in psychological treatment is ‘what works for who, when and how.’ What does a person at work who is arguing with a colleague and is stressed need compared to what does somebody who is at work, drinking a lot and going through a divorce and not telling anyone, need? At the moment we have a universal protocol that works for the vast majority of people. Over time AI will be able to create hundreds of pathways that connects people to the right information at the right time, because its learning over time. What does user A need? What does user B need? How effective was that for them? The next phase is individualisation – personalised digital mental health
PM – thank you so much for your time Jay. That was insightful and fascinating. I look forward to following the Uprise journey as it not only supports people with their mental fitness through eHealth but breaks down the stigma attaching to mental illness.
JS – my pleasure, thank you.
Read more about Uprise https://uprise.co/about/