Therapeutic companionship and its technological imagination

My name is Maria and I'm a person suffering from depression. For most of the time I have been completely alone with this topic, because I just did not find any peers. But I’m actually not alone because in Germany there are about five million people diagnosed with depression. Once I decided that I needed therapy, I faced a waiting time of three to six months. [...] Then most people are finding themselves in CBT - and to put it short: the core of CBT is to improve negative behaviour patterns into positive behaviour patterns. This means that actually the therapy is not necessarily only taking place behind the closed doors of the therapist; actually it is taking place in daily life and right here and now, whenever I need something to calm down.... We have been sitting together, thinking about how we can improve this problem, [...] and we decided that our mission is to empower people suffering from depression to reclaim their lives as an important process of healing (Excerpt of an oral presentation).

.. .the ticking of a clock starts floating through the surrounding speakers while music begins to play, growing increasingly louder: ‘Time goes by.. .so slowly’. Maria finishes her last sentence against the rising volume of the music and then quickly heads off the stage. She had just presented DepressApp to an audience of psychologists, psychiatrists, health insurance agents and entrepreneurs at the peripheries of a mental health care congress in 2017. The ticking of the clock and the music were both part of a meticulously scripted and performed startup slam pitch.

The developers position their ‘product’ against the limits of access to psychotherapy and constraints of outpatient care in Germany. According to a 2017 survey by the German Association for Psychiatry, Psychotherapy and Psychosomatics, the average waiting time for an initial consultation adds up to 12.5 weeks. To enter regular ambulatory psychotherapeutic care, the waiting times are estimated to be even higher.5 Not only is the app supposed to bridge these waiting times, but also once the patient has entered therapy foster communication between a therapist and a patient by providing a dashboard that allows a patient’s assessment at a spatial distance. Therapeutic engagements also take place outside ‘the closed doors of the therapist' throughout the daily life - ‘right here and now’, in Maria’s words. DepressApp is thus designed to serve as a faithful companion that people can consult and use whenever the need for instant soothing orientation arises.

The way DepressApp was envisioned, designed and pitched as an everyday companion against the structural constraints of access to psychotherapeutic care in Germany can be referred to as the workings of ‘technological imagination’ (Balsamo, 2011), that is, the ways in which designers and entrepreneurs think with technology in order to transform current modes of mental health care. DepressApp, run on a mobile phone, enters through the user’s hand into an intimate and habitual everyday relationship that might also alter the way it is perceived as an object ‘always at hand to being almost always in the hand and close to the body' (Lasen, 2004, cited in Richardson, 2007: 210).

While it was common for my interlocutors to deploy the app at home, most of them also used it in public, for example, when waiting for the bus or for appointments, sitting in restaurants or when taking walks. One participant stressed that using an app had the great advantage of being less visible than analogue writing on mood protocol sheets, given the ordinariness of smartphones usage in public life:

I fiddle around with my smartphone all the time, playing games or just chatting with friends. People are not able to tell the difference between this casual kind of usage and me tracking my mood. [...] With mood charts on paper it would be a whole different story. I would be ashamed if other people could see me doing this.

Another advantage that has been stressed by some participants lies in the degrees of practicability and functionality: instead of filling in tonnes and tonnes of paper sheets that might get lost or be forgotten, an app saves the data for later use and keeps them locked with a security code. An integrated, time-adjustable push-notification reminds users to log their moods. According to one participant, who was already familiar with analogue mood diaries during CBT:

Every time I feel my phone vibrating in my pocket and see the reminder urging me to make another mood log sets a moment of introspection in motion [...] this external stimulus is so helpful. [...] When I was instructed by my therapist to document my ups and downs manually on paper sheets, I tended to forget or even get nervous about it, because I had to hide the sheets from my roommates and was not orderly enough to archive them properly.

As the user explained, the built-in vibration alarm prompted ‘introspection’ ; for him, it felt as ‘if a therapist was kindly, but emphatically urging me to do my homework'. The app, understood as an everyday therapeutic companion, allowed him to tacitly comply with a self-constructed regime of mood-management and -control, thereby keeping his emotional well-being in check. This has been seen as particularly help-fiil when one is desperately waiting for access to regular therapeutic treatment.

Overcoming constraints of time and space constitute one powerful discursive motive in assembling DepressApp as a therapeutic companion. This is reflected in the app’s portrayal as a ‘24-hours therapist’ or a ‘pocket therapist’ (see Figure 8.1). It is this perceived potential of being used as a standalone therapeutic solution that makes the technology alluring, yet - as will be shown - also problematic.

One interviewee, Sebastian, for instance, perceived DepressApp as a form of therapeutic treatment in itself: ‘I’ve began to administer treatment with DepressApp in November 2016 [...]. I can’t say much about the therapeutic effect on my depression since the actual effects are supposed to kick in just three or four weeks from now [that is, around February 2017]’. Sebastian’s expectations were high: after losing his long-time job during his mid-thirties, he sank into a ‘deep hole’, and although he got diagnosed with depression, for more than three months he was desperately searching for a place to start psychotherapy. During this time,

Depiction of a mood-tracking app in a popular German psychology magazine. © j

Figure 8.1 Depiction of a mood-tracking app in a popular German psychology magazine. © j

he was introduced to DepressApp by a fellow self-help group member and began to use it several times every day to assuage his longing for alleviation. During our first conversations he stressed that he at least had the app to guide him through these times of affliction: ‘It’s relieving to have the app. It feels like a personal therapist who teaches me awareness with regard to my emotions, with the only difference, that it is available all the time’. Yet Sebastian, who was initially enthusiastic about the app, soon became dissatisfied with it:

Although I can consult the app at any time, I have the impression that I don’t learn much anymore. [...] I still track my mood three-times a day, but just following the graph, my ups and downs on the chart, does not alone help me. It’s like a one-way street: You have your digital diary with all the data and some information about depression, but in the end, it is up to me to decide what the data means. This often overwhelms me.

Sebastian's symptoms worsened rapidly and he quit using DepressApp after being admitted to a psychiatric hospital.

Another interlocutor who expressed disappointment over the therapeutic effects that DepressApp purports to bring, referred to the app as if it were a

The lure of self-disclosure 133 psychotherapeutic drug: ‘I've not learnt much. But perhaps I was just not long enough on it [nicht lang genug genommen], I guess, if I would be on the app for one or two years, then I would also have experienced therapeutic effects’. When she used the app, she was also proactively searching for a therapist, and again, at a time of longing for regular psychotherapeutic treatment, DepressApp was conceived of as a powerful vehicle for alleviation, one rhetorically, though perhaps unconsciously linked to psychopharmaceutic drugs.

While the majority of the users I interviewed did not expect the app to become a substitute to regular psychotherapeutic treatment, people who were desperately looking for help tended to have high expectations when integrating DepressApp into then day-to-day life, even perceiving the use of DepressApp as therapeutic itself. However, the app’s conditions of use explicitly warn against its adoption in severe depression when unaccompanied by psychotherapeutic treatment. This warning can be understood as a ‘therapeutic disclaimer’: although the promotion of the therapeutic companion insinuates notions of ‘quasi-therapeutic’ effects by way of self-help practices, the developers relativise its efficacy as a standalone technology. As has been briefly demonstrated by the two cases above, the therapeutic disclaimer creates a paradoxical impression of the app’s potentials and its use. DepressApp presents itself in terms of a desired proximate technology that one can carry along and consult at anytime and anywhere - this is the vision of the therapeutic companion; at the same time the app is questioned and perceived of as a distant technology that evokes powerful expectations, which it is perhaps unable to meet.

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