There’s an old urban legend around the rivalry the existed in pop music between the Beatles and the Beach Boys in the 60’s. In 1966 the Beach Boys released Pet Sounds, which combined experimental approaches to music and the traditional harmonies and lyrics the Beach Boys were known for. The results included some classic pop songs, like “God Only Knows” and “Wouldn’t It Be Nice” and were said to be inspired in part by Brian Wilson’s appreciation for the Beatles Rubber Soul album. In 1967, they were working on Smile, an album that they thought would be even more revolutionary in its musical art than Pet Sounds. In the midst of recording, they were given an early preview of the Beatles upcoming album, Sgt. Pepper’s Lonely Hearts Club Band. And when they heard it, they were blown away. Here were the Beatles, creating the very album they aspired to, while their work seemed to pale in comparison. The members of the Beach Boys were overwhelmed, particularly lead songwriter Brian Wilson, who had been battling mental health and substance abuse issues for years. This moment exacerbated his already existing depression and recording on Smile began to fall apart.
I thought about this story often as I had the opportunity to review “Should I Break Up With My Boyfriend”, a new mobile app for iOS devices by developer Sarah Gray and designer Daniel Stanford*. I have been working for the last 6 months on the creation of CohesiveSelf®, a mobile application designed to help individuals track their mood and access tools to help improve their emotional states. CohesiveSelf® includes audio files for relaxation, deep breathing, and guided imagery to help individuals manage difficult points in their life.
As for Should I Break Up With My Boyfriend, its premise is simple: rate your boyfriend over a 14 day period on a five point scale from “Totally Over Him” to “Totally in Love”. The app guides you to set up a daily reminder using iOS push notification and also allows you to write a brief note describing the details around your feelings for that day. While you can add ratings at any time in addition to the ones you scheduled, your ratings stay hidden until the full period of “boyfriend evaluation” is complete. This aspect is ingenious, as previous ratings are then less likely to influence each additional rating. This creates a laser focus on each moment within the relationship, assuring that each individual instance of rating stands on its own and is unaffected by knowledge or expectations related to previous entries.
At the end of the 14 day period of collecting ratings, you are given advice based on both the average of your ratings as well as the standard deviation. This use of standard deviation is key to the effectiveness of the advice, because it helps identify the “swings” between the daily ratings. As a result, in addition to being able to view a final average rating, the user can assess whether they are willing to endure the relationship’s “craters” in order to enjoy its “peaks”.
In addition to this analysis and advice, Should I Break Up With My Boyfriend also offers something else: fun, playful, and engaging design. The visual and audio elements are incredibly cool, and include an adorable, fuzzy female creature whose expressions and body language change with each range of ratings. The “Totally Over Him” rating, for example, is presented through dark storm clouds and lightning, a sad little chime, and a clap of thunder. As a psychologist specializing in adolescents and young adults, the appeal to young women in this demographic is quickly evident. And as you continue to use the app, you realize that what it offers is a special mix of real analytic tracking of emotions in a playful and engaging wrapper.
Which brings me back to CohesiveSelf® and my own “Sgt. Pepper” moment. One question lingered after experiencing Should I Break Up With My Boyfriend: in my interest in creating an app with great utility, did I put enough emphasis on fun and ease of use? Did I remember that one of the best parts of the mobile experience is the ability to have fun? Why else would apps like Angry Birds and Words With Friends be multi-million sellers? However, instead of being discouraged by the genius of Should I Break Up With My Boyfriend, I resolved to make sure that being witness to fun, engaging design creates inspiration that drives ongoing development and moves CohesiveSelf® (which debuted on the iOS App Store last week!) onward and upward.
As for Smile, Brian Wilson completed his original vision for it in 2004, over 38 years after recording began and despite a lifetime battling mental health and substance abuse issues. And if that’s not inspirational, I don’t know what is.
* – In the interest of full disclosure Sarah Gray and her partner at MercuryApp, Corey Haines served as technical advisors to me through early stage software development.
The Game Layer
The idea of the “Game Layer” has been on my mind a lot lately after reading Thomas Goetz’s wonderful Wired article on the power of feedback loops and viewing the above video of Seth Priebatsch’s TED talk on his vision of this decade becoming the decade of games. Priebatsch is a fascinating young entrepreneur who dropped out of Princeton at age 19 to start SCVNGR, a company that combines mobile technology and location-based services to create “game experiences” for different businesses. Priebatsch is a passionate speaker who believes in the power of “game mechanics” to promote engagement. In addition to the ones outlined in his TED talk, SCVNGR has an entire “playdeck” of game mechanics that includes includes a number of dynamics inherent in games. Some of these include ideas related to reinforcement paradigms and schedules (Variable Ratio, Fixed Interval) and others related to the sense of accomplishment and drive that games give us, such as progression dynamics and blissful productivity.
In a world of Foursquare mayorships and GrouponNow, it’s not hard to see how the “Game Layer” can apply to retail businesses: your favorite coffee shop can offer “Levels” of customer loyalty, with increasing benefits and rewards as you spend more time (and money) within their establishment. You feel the rewards of getting great deals and being treated like a regular while they have created a loyal customer who gives them repeat business. However, trying to envision how it would apply outside of social media and retail business can be challenging.
As a clinical psychologist, I can’t help but recognize the roots of Seth Priebatsch and SCVNGR’s game mechanics, from Social Psychology and social learning theory to Behaviorism (and its modern counterpart, Behavior Analysis). I also wonder about bringing this information “full circle” in a manner that concepts such as the “Game Layer” and gamification influencing healthcare broadly and emotional health in particular. Some of the features of gamification that have been interesting to me have come from the Goetz Feedback Loop article and Chirag Patel’s presentation at Chicago’s Techweek. These have included Vitality’s Glowcaps, an effort to aid in medication compliance, and Greengoose, a company that is looking to incentivize healthy activity. However, there does not appear to be much currently going on in the mental health/behavioral health sphere to create the “Game Layer” in a way that produces greater emotional well-being. There seems to be tremendous opportunity in several domains within behavioral health treatment, but I’d like to talk about two in particular:
Treatment of Chronic Mental Health Issues
As a psychologist working both within a fairly large non-profit social services agency as well as in private practice, I have had the opportunity to get exposed to several facets of the mental health system. One area that the overall system struggles in is in treatment of individuals with chronic mental health conditions such as Bipolar Disorder and Schizophrenia and other psychotic disorders. Intensive, 24-hour treatment and monitoring is expensive and often unsuccessful, limiting an individual’s ability to develop the independent living skills they need to manage their treatment successfully. However, treatment in community settings also has challenges. Some specific issues for this population that may benefit from game dynamics include the areas around maintaining connection to supports and ongoing medication compliance. Incentives and progression dynamics related to connection to caseworkers, care coordinators, and providers may add some strength in initiating and developing the important relationships required for ongoing treatment. Additionally, the game layer could provide a boost to medication monitoring and compliance through technology such as “smart’ medication dispensing devices, awards and progression for taking medication, and time-sensitive bonuses for taking medication within recommended or required time-frames.
Psychotherapy in Private Practice Settings
One of the issues for providers in private practice is that you meet with an individual for an hour a week and need to make the most of that time as only one hour of a total of 168 hours that week within that individuals experience. Within that time-frame, you need time to help understand their experience, gain insight into their challenges, and work with them to develop skills to meet those challenges. Within that one hour, you need to create understanding, acceptance, and change that will influence the other 167 hours of that individual’s life.
As a cognitive-behavioral therapist, the notion of concrete mental skills and practice of those skills outside of sessions is key to how I work. It is also something that fits the needs of my clients, who are primarily adolescents and young adults who are looking for material changes in themselves and their situations. Our current technology holds some promise in providing avenues to practice skills such as deep breathing, guided imagery, and progressive muscle relaxation. A game layer could make this technology even more effective by providing opportunity for reinforcement and rewards related to the practice of these mental skills. Game mechanics such as level systems and awards can bring about a sense of progression that can encourage further engagement in mental skills development and a greater perspective on the change that has taken place over time through measurable progression.
Caveat: The Moral Hazard of Game Play
One interesting dynamic that Priebatsch has discussed in talks and has in the SCVNGR “playdeck” is the “Moral Hazard of Game Play”. In the SCVNGR playdeck, this is defined as “the risk that by rewarding people manipulatively in a game you remove the actual moral value of the action and replace it with an ersatz game-based reward.” In other words, if you provide artificial incentives for an action, the intrinsic value of that action may be lost and replaced by action for the sake of just reaping the rewards. An example of this is grading in education. Through our current educational system, we have, in many ways, replaced the intrinsic value of learning with an emphasis on getting top grades. The notion of the moral value of self-actualization through learning becomes lost as top grades (and not knowledge) becomes the new goal. And the emphasis on grading creates behavioral side-effects such as cheating. This is an interesting concept for both physical and emotional health, since we would never want a strong emphasis on game mechanics and incentives to replace our true reason for providing psychotherapy: improving emotional well-being.
USA Network’s new show, Necessary Roughness follows in the grand tradition of the network’s disposable melodramas, from recent series like Burn Notice and Royal Pains to the 90’s detective show Silk Stalkings. Not to be confused with the 1991 football-themed comedy starring Scott Bakula and Sinbad, this show focuses on the work of a “tough as nails” female therapist from Long Island named Dr. Danielle “Dani” Santino. Although she is in the midst of several stressors, including divorce and a defiant teenage daughter, she agrees to go out to a club with the requisite boozy, outspoken friend. Dr. Dani proceeds to have a one night stand with the local pro football team’s athletic trainer where she conveniently “cures” him of smoking with hypnosis the next morning. As a result of her hypnosis skills, she is hired by the team’s Head Coach and presented with a challenging task. They need her to help the team’s star wide receiver, Terrence “TK” King, overcome a mental performance issue around dropped passes. TK, vaguely reminiscent of another dual initialed star wide receiver, is, (of course) resistant initially but then learns the value of Dr. Dani’s approaches and goes on to score a game-winning touchdown just before the closing credits roll.
Overall, for mental health professionals in general and for sport psychology professionals specifically, the show has brought with it a lot of worry and hand-wringing. In a world where there remains a great deal of stigma around seeking help for personal and performance issues and a lot of misconceptions around this work, this worry is certainly justified. This is especially the case as we examine the content of Necessary Roughness, which is filled with inaccuracies (e.g.., hypnotherapy involves simple suggestions that provide near-instantaneous “cures”) and ethical issues and violations galore around practicing outside of your expertise, client privacy and confidentiality, dual relationships, boundary violations, lack of empathy, inappropriate self-disclosure, and the question of having your professionalism and effectiveness compromised by personal problems.
However, even in the midst of the melodrama, misinformation, and concerning representations of therapy present in Necessary Roughness, there are some things that the show does get right about the field of Sport Psycholgy:
- Sport Psychology Consultants are people too – Just like anyone else, we deal with stresses and adverse life events that affect everyone. This aspect of Dr. Dani’s life is portrayed with some accuracy, with her experiences of infidelity and divorce, unsupportive family members, and rebellious and defiant children. However, unlike many professionals, sport psychology consultants and other mental health professionals must take special care to make sure that their issues do not compromise their ability to provide effective treatment. This places a strong emphasis on self-awareness within the profession.
- It is often not the athlete’s choice to be there – Whether it’s a coach, general manager, athletic administrator, or, for youth athletes, a parent, it is often someone else who directs the client towards sport psychology services. This puts a special emphasis on the professional to explain the potential benefits of mental skills for sport early on in a manner that can help to build rapport and instill hope in the client. Additionally, the professional needs to emphasize issues of confidentiality and what information can or cannot be shared with the referral source. This is often referred to as “informed consent”, which must be obtained in order to ethically treat an individual.
- Sport Psychology is not a “quick fix” – After the first session with Dr. Dani, a hypnotic suggestion that the football is a baby and that TK must not “drop the baby” is not successful and his performance problems continue. The session the show presents between Dr. Dani and TK is a poor representation of what is entailed when sport psychology professionals engage a client in mental skills training for sport. However, the small point that mental skills, including increasing focus and concentration, managing physiological arousal, and developing positive cognitive approaches towards training and competition cannot be learned in one day is accurate. Numerous studies have demonstrated the effectiveness of sport psychology interventions (some examples linked here and here) but it is clear that skill-building takes time, effort, and practice both on the part of the professional and the client.
- Traumatic experiences in childhood often have long lasting effects – Part of the story of TK in the pilot episode revolves around him coming to terms with his emotions around his mother’s death by drug overdose, issues of father loss, and a history of placements in the foster care system. Although these issues are fairly lightly glossed over and primarily serve to move forward the connection of TK and Dr. Dani, I did appreciate the story making the connection between TK’s recklessness and emotional volatility and his traumatic past. While many individuals believe in the adage that “whatever does not kill us makes us stronger”, the reality is that adverse childhood events and early trauma have dramatic and long lasting effects on people. In one recent study children who had experienced multiple forms of trauma such as those of TK were 30 times more likely to have behavioral, academic, and physical problems. On a more positive note, the field of mental health is moving more often into the use of evidenced-based approaches to help those who have experienced trauma. One particular evidenced-based approach, Trauma Focused Cognitive Behavioral Therapy (TF-CBT) emphasizes psychoeducation around trauma, building emotion regulation and cognitive skills, and the development of a narrative story of the individual’s experience to help them gain a sense of mastery over their trauma experiences.
- There are a lot of unqualified professionals out there working with athletes – Despite the efforts of organizations like the Association for Applied Sport Psychology who provide a “Certified Consultant” credential and offer a listing of their certified consultants and the American Psychological Association, which has published proficiency guidelines for psychologists who provide sport psychology services, the field of sport psychology is, at best, loosely regulated. In fact, the mental health professional that the show is purported to be based on, Donna Dannenfelser does not appear to be a licensed mental health professional or have a history of graduate or post-graduate training in sport psychology. There are a myriad group of individuals out there that make Sport Psychology the “Wild West” of treatment modalities, filled with “confidence coaches”, “mental skills trainers”, “sports performance consultants”, and “sports psychologists” (notice the ‘s’). In additon there are a number of licensed mental health professionals in a number of areas from counseling to psychology to social work who, lacking training in sport psychology, pair an interest in sports or experience as an athlete with savvy marketing efforts to serve a population for whom they are not qualified.
I do not really believe in the the adage that “any press is good press” and I will likely continue to cringe at the inaccuracies and ethical concerns anytime I watch Necessary Roughness. However, it would be a very positive thing if this show is successful and in some ways demystifies some aspects of sport psychology and therapy for the public and causes them to consider seeking out a professional that has specific sport psychology training and carries proper certification or licensing.
Craig W. Cypher, Psy.D.
Dr. Craig Cypher is a licensed psychologist in New York State specializing in individual and family psychotherapy, training, and consultation. His private practice specializes in services for children, adolescents, young adults, and famillies and is located in Rochester, NY. He considers himself to be a sport psychology professional with a specialty in youth sports and trained under US Olympic Committee certified psychologist Gloria Balague, Ph.D. as a graduate student at the Illinois School of Professional Psychology in Chicago.