Behavioral surveillance is coming to America via the cell phone. Positive psychology and well being are coming to American healthcare via Obamacare which incentivizes the implementation of wellness programs. Together they are dramatically increasing the volume of personal data collected on ordinary citizens and exposing those citizens to targeted messages, incentives and interventions designed to modify the thoughts, feelings and behaviors the surveillers (aka thought police) want to encourage. And, the genius of this system is that the citizens are voluntarily choosing to be surveilled and modified.
Today these systems are being applied to healthcare but the robust venture funding for these applications suggest the backers have already begun to imagine extending the reach to product promotions, politics, preventive policing and national security.
Take a look at ginger.io, a product of the MIT media labs. On its website Ginger.io describes itself as a mental healthcare company whose “mission is to drive better behavioral health outcomes through the use of passive mobile data and behavioral analytics.” However, to investors and academic audiences the CEO of Ginger.io describes the company as “a big data company posing as a health care company.” Direct backers of Ginger.io include venture capital firms; indirect backers include the Department of Defense (DOD).
Ginger.io offers it’s application to health plans for patients who are depressed. Users downloads an application to their cell phones that collects for analyiss. This data includes the metadata on call, email and text that is already collected by the telecoms but also cellphone sensor data that is not. Data from sensors, like the accelerometer which tells the phone you have changed the orientation of the device so the display can change from portrait to landscape, can also be used to determine when you are getting exercise. GPS data reveals the places a person visits. Phone and text data reveal levels of socialization and social networks. Analysis of vocal tone and prosody reveal emotional state. Light and motion sensors indicate when the user is sleeping. A recent survey indicates 91% of users keep their smart phones within 3 feet 24 hours a day, so the data is a goldmine.
Once installed ginger.io sends a continuous stream of data for big data analysis. Within a few days a behavioral baseline profile is created. Deviations from normal behavior are then easy to spot. In its current incarnation, ginger.io statisticians are developing algorithms to signal such things as deepening depression and risk of suicide.
In addition to behavioral surveillance and data analytics, the ginger.io ap provides behavioral intervention technologies (“bits”) in the form of targeted messages. For instance, the ginger.io ap provides daily self help tips to depressives in a number of health plans around the country. Typical messages encourage (or to use Cass Sunstein’s term, ‘nudge’) the user to get more exercise, smile more, look on the bright side, socialize more, and the like. These interventions are based on positive psychology, a movement that will be explored below. As this technology matures messages can be tailored to the individual’s specific problems.
Arguably, behavioral surveillance and the ginger.io interventions have a place. The cell phone could replace the ankle bracelet for some parolees. Monitoring groups, such as active duty military and veterans, known to have high suicide rates and low willingness to seek help could be helpful. And, a sudden increase in people spending more time in bed might indicate the spread of a contagious disease like Ebola.
However, behavioral health is a small market. Outpatient behavioral health probably accounts for less than 2% of most health plans expenditures. And the percentage of health plan patients receiving mental health care is a small fraction of the total number of health plan patients. So big data’s opportunity to accumulate large population datasets in mental health is limited.
Not so in wellness. Wellness programs are a big and growing business thanks to Obamacare incentives. Companies that a implement wellness programs can save to up to 30% of health insurance premiums, deductibles, and other costs regardless of the effectiveness of the programs. As a result the number of businesses imposing wellness plans has doubled in the last year to 46%.
The heart of wellness programs is positive psychology. The term positive psychology was invented by Martin Seligman in 1998 to extend psychology’s reach from diagnosis and treatment of mental illness to enhancing the lives of normal people. Positive psychology purports to promote health and well being by incenting high levels of exercise and sociality; supporting prosocial attitudes such as enthusiasm, happiness, bouyancy, group harmony, respect for authority; and discouraging bad habits such as smoking and overeating.
Positive psychology is an ideology that promotes conformity and mandated cheerfulness. The science behind it is pathetic. According to James Coyne, PhD, a psychological research expert known for his hooey detector, “Studies of positive psychology interventions are conducted, published, and evaluated in a gated community where vigorous peer review is (not) sought…” The field “… has failed to produce a quality literature demonstrating positive interventions can indeed contribute to human well-being. Positive psychology intervention research has been insulated from widely accepted standards for doing intervention research.”
Positive psychology is a kind of cult. Coyne remarks that “the positive psychology community is averse to criticism, even constructive criticism from within its ranks. There is dictatorial one-person rule on the (Positive Psychology) listserv. Dissenters routinely vanish without any due process or notice to the rest of the listserv community, much like disappearances under a Latin American dictatorship.”
No matter. The field of psychology has often been subject to fads of various sorts, from the orgone box to nude therapy to sensitivity training to encounter groups. What positive psychology has going for it is a distinguished psychologist like Seligman marketing it. Seligman has obtained massive grant funding for the fledgling enterprise. His positive psychology center at the University of Pennsylvania received a 31 million dollar single source contract from the DOD a few years ago, and the American Psychological Association received 125 million for providing positive psychology training to the military. The DOD seems particularly enamored of positive psychology and continues to lavish funds on centers and researchers. One of Ginger.ios collaborators, Stephen Schuller, Ph.D., works at Northwestern University’s Center for Behavioral Intervention Technologies, partly funded by the DOD, developing online positive psychology treatments. Incidentally, before Seligman’s positive psychology center took off, he was marketing positive psychology merchandise through a website, which provided, among other things, a monthly letter from the man himself.
Applications that combine behavior surveillance with positive psychology interventions are particularly well suited for wellness programs. The technology and abundance of data lend credence to a program that creates a lot of activity but once built has very little marginal cost. If these applications successfully migrate to wellness programs the opportunity for behavioral surveillance of a vast swath of the American population –85% of Americans are in a health plan—is at hand.
But how many Americans queue up to download spyware on their cell phones? Probably lots. Americans are getting used to the erosion of personal privacy. Surveillance is becoming ubiquitous and not just by the NSA. For example, 30% of Progressive insureds willingly install a car monitor so the company can surveil their driving habits. All it takes is a discount on premiums.
A wellness program is technically voluntary, but it can be an offer employees can not afford to refuse. Case in point: Honeywell International charges employees who decline the program an extra $500 a year in premiums and they lose out on as much as $1500 a year in out of pocket cost support. As a result only about 10% of employees opt out of the program. The upshot is that health plans are a vector by which behavioral surveillance of the American population could be achieved “voluntarily” and by private companies.
Who else might be interested in this data? Obviously the usual suspects: NSA, CIA, FBI, DOD, Homeland Security and the like. What about political parties? Researchers tell us that behavioral surveillance can chart the spread of political ideas that move through a community like a virus. Wall St? The same researchers say they can foretell the movements of the Dow Jones Industrial average. Police? Think of rooting out thought crime, thought criminals, and those with subversive tendencies. Corporations? What workforce won’t benefit from culling out rebellious or uncheerful “associates.”
The ultimate destination of the marriage of behavioral surveillance, positive psychology, and behavioral intervention technologies will not just be about observing what happens; it will be about shaping what is happening. As Dr Johan Bollen, a leading researcher in the field has observed, the promise of big data is to “to better manipulate trends, opinions and mass psychology.”
What could go wrong?
Weaponizing Psychology: Why the American Psychological Association Caved to Torture
With the publication of the James Risen’s book “Pay Any Price: Greed, Power and Endless War”and the release of the Senate Torture report, it has become abundantly clear that the American Psychological Association colluded with the CIA and DOD in enabling torture. A large number of military psychologists as well as private vendor psychologists participated in torture. The American Psychological Association provided ethical cover for the psychologists as well as for the Bush administration. A small number of the top leadership of the APA, including presidents Koocher and Levant, successfully pushed through guidelines designed to enable psychologists to participate in “torture by another name”despite the fact that the membership disapproved of them. APA actions included: holding secret meetings with the DOD and CIA in order to craft guidelines that would enable torture; lying to its membership and the public repeatedly about salient facts; undemocratically promulgating guidelines without allowing the council of representatives review or to vote on the guidelines; resisting calls by the broad membership to rescind the torture policies; demeaning and bullying whistleblowers who objected that the task force set up to review Bush interrogation policies was corrupt and stacked with military psychologists who had participated in torture; denying that psychologists participated in torture when they knew otherwise; and refusing to take action against psychologists who participated in torture. (1)
Why did the American Psychological Association take this unethical course when every other healthcare discipline, including the American Medical Association, the American Nursing Association, and the American Psychiatric Association, did the very opposite and in no uncertain terms absolutely forbade their members from participating in torture?
To understand how this happened, we need to consider the economically distressed position of the field of psychology in the early 2000s. While this is not an excuse for what happened, it explains why some in the APA leadership were responsive to anything that might relieve this distress.
By the early 2000s, clinical psychology which represents the largest percentage of APA members, was in serious trouble. Psychologists incomes had been falling precipitously for years. Between 1990 and 2010 reimbursements from commercial insurance—the largest share of many psychologists income– had fallen 33% in absolute terms and 59% in inflation-adjusted terms. (2)
The precipitous collapse in psychologists incomes was due to a number of factors. First, was the increase in the number of providers offering psychotherapeutic services. In the 1960’s psychologists were the first non-medical profession to win the right to insurance reimbursement for psychotherapy. By 1980, other disciplines, including social work, and mental health counselors had become mandated providers. Thus, there was a large increase in the number of clinicians in the market. And most of these clinicians held a master’s degree and would work for lower fees.
A second factor was the arrival of fluoxetine– prozac– to the market in 1987. Prozac became spectacularly successful. It worked on the most common psychiatric problem, depression, without causing unpleasant side effects and it was easy to use and prescribe. Soon regular GPs were prescribing prozac in record numbers while psychiatrists retooled their practices to focus on higher paying medication management over lower paying psychotherapy.
Within a matter of a few years mental health practice was reinvented in America. Between 1998 and 2007 the proportion of patients in outpatient mental health facilities receiving psychotherapy alone fell by one third from 15.9 percent to 10.5 percent, while the number of patient receiving medication alone increased from 44.1% to 57.4%. (3) Not only were fewer patients going for psychotherapy, but the average number of sessions of care had dropped. This was due in no small measure to the baleful impact of managed care.
Concomitant with the declining fortunes of individual psychologists, was the increasingly parlous condition of the American Psychological Association itself. The Association’s desperation is reflected in two deceitful practices. The first was misleading psychologists about their dues in order to increase the organization’s income. In the 2000s clinical psychologists were led to believe that they were required to pay a special assessment ($140) in addition to their regular dues in order to maintain membership in the organization. Only in 2010 did the APA acknowledge that the special assessment was not mandatory; in the 10 years preceding there was never a disclaimer that the assessment was optional. (4) The other deceit concerns its defensiveness about its membership rolls. APA membership declined in tandem with the decline in the incomes of their members. But, as John Grohol, has pointed out, the APA has exaggerated the size of its membership on its website for years, even despite being called out on this. (5)
Declining demand for psychotherapy, new treatment choices, and increasing numbers of psychotherapists, many of whom would take lower fees, an organization in crisis were the perfect storm that put the field of clinical psychology under siege in the years before and during the the arrival of the so called global war on terror.
Aware of these developments, specifically the erosion of income and the loss of status of psychologists, the APA made concerted efforts to reverse these trends. On the political front, it worked with the psychologist, Pat Deleon, Ph.D., who would become APA president in 2000. DeLeon was a top assistant to Daniel Inouye who was the chairman of the Senate Defense Appropriations subcommittee which oversaw the largest chunk of federal discretionary spending. For nearly 25 years DeLeon was the APAs man on capital hill and effectively lobbied on behalf of the APA for increased funding for research, training and employment (mainly the VA) for psychologists.
On the intellectual front the APA, by the early 2000s, had begun supporting the evidenced based practice (EBP) movement which it believed would have major ramifications for the future of psychology. The evidenced based practice position holds that some therapies (most developed in manualized, scripted form by psychologists) are more effective than others and that ethical providers must choose the most efficacious approach. (6) This APA position which is incorporated in its ethics guidelines, is, however, contradicted by overwhelming research support for the so called “Dodo bird hypothesis” which has consistently found in empirical studies and meta-analyses that all therapies result in comparable outcomes. In other words, that the specific therapies for specific problems approach (EBP) championed by the APA is largely a myth. (7) Behind APAs support for evidenced-based practice was not so much science as it was its concern for the eroding status of psychologists in the marketplace. Should the EBP movement prevail, a “major ramification” would be that insurers would demand that clinicians use manualized treatments created by psychologists. This would result in psychology gaining pre-eminent status in the world of psychotherapeutic practice.
Psychiatrists, nurses, and physicians in general in the early 2000’s were in a very different economic situation. Unlike psychologists whose numbers were plentiful, there was an undersupply of physicians and nurses in the US, and, in the case of psychiatrists, a severe undersupply. The AMA or American Psychiatric Association could take the high road and denounce torture absolutely without harming their members incomes. This is not to denigrate the principled stands of these organizations, but only to state a fact. On the other hand, for the American Psychological Association to spurn the overtures of the DOD, CIA, and the Executive branch of government, carried more risk for the APA and the income of its members.
For the plain fact is that the field of clinical psychology depends on the DOD for its very livelihood. The DOD channels most of its 400 million dollar behavioral science research budget to psychologists. Fully 5% of all licensed psychologists in the US (almost 4000 clinicians) are employed by the Veteran’s Administration—and the VA pays their hefty APA dues! The VA, moreover, provides 15% of all APA accredited internships in clinical psychology and 40% of post doctoral training programs.
The APA has been unusually candid about their dependence on and vulnerability to DOD budgetary issues. Geoff Mumford, a high APA official, himself implicated in the torture scandal, wrote in 2006 that supporting the McCain Amendment prohibiting torture “…would likely put in jeopardy funding for …psychology and psychologists.” (8)
That the APA went all in and came through for the DOD, the CIA, and the Bush administration is now a matter of record. On offer to psychology for participating in the torture regime was money and power, and the conferrence of prestige and credibility on a beleaguered profession that was reeling from scientific developments and practice changes.
The APA has taken withering criticism from a broad range of medical ethicists for its unwillingness to unambiguously repudiate participating in “torture by another name.” Yet it continues to resist the desires of its membership. A member-initiated resolution was passed overwhelmingly in 2009 by the membership to restrict psychologist participation in any operation that violated the Geneva Conventions or the United Nations Convention Against Torture. The referendum was made official APA policy yet the APA leadership refuses to this this day to implement it citing technical reasons.
But the APAs fealty to the DOD has not gone unrewarded. Martin and Jessen the psychologists who started a company to provide torture services (along with the retired head of Behavioral Science for the CIA) made 81 million dollars for providing said services to the US Army. The number of psychologists employed by the VA has skyrocketed since 2000. Martin E. P. Seligman, former APA president, who has been implicated in the enhanced interrogation program, was awarded a 31 million dollar no bid, single source contract for his Comprehensive Fitness Soldier Training (CSF) program (which is not a training program but an experiment.) And in 2011 the APA announced a 125 million dollar US Army/APA collaboration to further deploy the experimental CSF program. (9)
Medical ethicists say that the Bush era torture program architected and overseen by psychologists will go down as one of the greatest scandals in the history of medical ethics, on a par with the Tuskeegee experiments of the mid twentieth century. This will happen because a small cabal of insiders in the APA traded honesty and ethical conduct for the kudos of the powerful. In becoming a player on the national scene, an incalculably large stain has been left on the profession of psychology.
A Version of this essay appeared in Counterpunch
2. http://ivanjmiller.com/disparity_action.html
3. https://news.brown.edu/articles/2013/08/psychotherapy
4. http://nationalpsychologist.com/2013/06/apapo-dues-assessment-draws-new-lawsuit/101886.html
5. http://psychcentral.com/blog/archives/2012/07/13/why-the-apa-is-losing-members/
6. http://en.wikipedia.org/wiki/Dodo_bird_verdict
7. http://www.apa.org/practice/resources/evidence/evidence-based-statement.pdf
8. Mumford, G. (2006, March). When legislative objectives are in conflict. Monitor on Psychology, 37(3),68.
9. http://www.truth-out.org/archive/component/k2/item/93742:armys-spiritual-fitness-test-comes-under-fire