Therapy Bots: Making Mental Healthcare more accessible with Conversational AI
Last year I asked my mother, who is a Presbyterian minister to officiate at my wedding. She was happy to be asked but she told me that one of her conditions for any couple she marries is that they undergo premarital counselling. To be honest, I balked a little at this. Did she think there was something wrong with us? She told me that being engaged is a cloud-nine state of being. Everything is rose-tinted. It’s vital to talk about important issues before the wedding so both partners know where they stand. It’s about compatibility and becoming a team.
I was a little skeptical but I talked to my fiancé and he was open to the idea, so we started looking for marriage counsellors. Our health insurance would cover a few sessions of marital counselling but there was a limited number of in-network therapists in our area, and they all had long waiting lists. I looked into therapists who were out of network but the cost was astronomical. I was getting frustrated with this requirement and stressing about it with my partner. We were starting to see the need for premarital counselling but we couldn’t find anyone that could see us before the wedding.
Then I received an email from my wedding planning app with special discount offers. There was a 50% discount offered for premarital counselling! How serendipitous! I clicked on the link and discovered this was for a marital therapy mobile application called Lasting. It offered talk-based therapy programs facilitated by a chatbot for different relationship stages and issues. I read about it and it seemed ideal! The one-year subscription fee was about a quarter of what we would pay for one in-person therapy session.
There were readings and videos and assessment surveys to determine where my partner and I stood on certain issues and what our feelings were about the upcoming marriage. We signed up on a shared account so we both had access from our mobile phones. You can subscribe to daily conversation prompts and there are themed session programs you can enroll in for every relationship stage or marital issue. We enrolled in the premarital counselling program. The chatbot texted us each a discussion topic and then would bring us together for conversation. The Lasting chatbot would ask us questions and suggest activities and conversation topics both individually and as a couple. In addition to the talk sessions, there were readings and information graphics about many topics.
Rather than the six insurance covered sessions we would have had with an in-person marriage and family therapist we had daily discussions and reflection on everything from family issues, communication, sex, money, values, family relationships, and conflicts. The fact that these sessions were facilitated by a chatbot was freeing to a certain extent. There was no awkwardness of discussing personal matters with a stranger. There was no fear of being judged. The chatbot acted as a bridge between us, opening up discussions on serious matters. It brought us closer together and gave us a safe space to learn how to communicate about sensitive topics. To my surprise, we have continued to use the Lasting app during this whole first year of marriage and it has been very valuable, especially with the challenges of the Covid 19 pandemic and its effect on all aspects of normal life, including relationships and mental health. We continue to receive the discussion prompts from the chatbot and if either of us finds one that stands out, it opens the discussion. It gives us the opportunity to remain intentional in cultivating the health of our relationship.
Even without the strain of the pandemic, mental illness and accessing mental health care is a huge issue. According to the World Health Organization, one out of every four people will suffer from a mental illness in their lifetime. One in ten people worldwide need mental health care and by the year 2030, depression will be the number one cause of disability. These problems have only been exacerbated by the challenges of the pandemic and the effects of isolation and lack of social interaction, as well as the economic challenges of losing work and the relational problems brought on by these changes.
The solution is mental health care. But the problem is accessibility. Mental health care is very expensive and insurance coverage is minimal. There is a shortage of providers and long waiting lists. My search for a simple course of marriage counselling showed me just how difficult it can be to access therapy. On top of these challenges, there is still an unfortunate stigma surrounding mental illness and this can prevent people from seeking help. A recent study in the journal Psychological Medicine, showed that up to 75% of those experiencing mental and emotional difficulties will not seek help and participants cited the stigma surrounding mental illness as the number one reason for their reluctance to seek help. The need is great but the resources are few and there are many roadblocks for those who may want to seek help.
In response to this need, tech companies have developed artificial intelligence chatbots and apps for mobile phones that aim to be the first line of support for those in need of mental health care and counselling. Chatbots like Woebot, Kokobot, Wysa and Tess can serve as facilitators for understanding the conditions of the people who use them, and they can provide help in managing and documenting moods, scheduling appointments, reminders to take medication, and they can suggest other forms of self-care like exercise and meditation. These applications can also be prescribed to patients as a way to manage day-to-day care. They are part of a holistic and integrated approach to mental health care in addition to in-person therapy sessions and physician appointments.
These chatbot applications were developed by panels of experts including teams of psychiatrists and other mental health experts. They are primarily built on the concept of Cognitive Behavioral Therapy (CBT) which is a mental health management technique based on changing the way people think and behave through talk and reframing negative thoughts into positive ones as well as replacing negative patterns of behavior with positive ones.
The benefits of these applications are manifold. They can proactively check on people and are available to listen and chat anytime, 24/7. They have no waiting lists or session limits. They can recommend activities that promote mental health and wellbeing. People can use them to document and manage their moods so they can see patterns emerge and learn new ways of dealing with negative thoughts and behaviors. Because of the stigma attached to mental health issues, many users may find it more comfortable to talk to a chatbot rather than a real person. They are also much more accessible as they can be used anywhere no matter the time or day. They are, quite literally, in the palm of the hand. The cost is minimal compared to in-person therapy or health care and thus offers a service that is accessible to a wide variety of people from different socioeconomic backgrounds.
At this time, these chatbots primarily rely on Natural Language Processing for text and speech. They can process short descriptions of mood and recognize keywords and phrases that pertain to different moods and respond accordingly. There are limitations, the chatbots cannot process things like body language or facial expressions or voice inflections and so are working with limited context but this is gradually changing.
Designing empathetic AI is a goal and is gradually becoming reality. Sentiment analysis can extract emotional sentiments from images, video, audio or text input. Sentiment analysis can even be used to sense emotions just by looking at the characteristics of facial expressions and listening to the tone of a voice. These techniques are becoming more sophisticated and will eventually help chatbots understand and recognize the emotional state of the person using the app so they can respond in an empathetic manner. The possibilities for this technology are staggering and have huge implications for mental health care in the future.
Just yesterday, I watched a promotional video featuring Moxie, a companion robot for children designed by Embodied Inc. Moxie promotes play-based learning but also promotes kindness and teaches emotional coping skills and wellbeing exercises. Moxie can respond to a story read to it. Moxie makes jokes and asks about specific aspects of a child’s day. Moxie responds with kindness and empathy and offers comfort and solidarity when a child expresses difficult emotions. I found it quite emotional when Moxie told a child to take hold of its hand. Moxie is just an example of what is possible within the realms of empathetic AI.
Of course, there are limitations to digital mental health apps. They should not be used as a diagnostic tool and there are dangers in over-simplifying mental health issues. They are best used in conjunction with in-person mental health care. There are also challenges with privacy and confidentiality. Health care is sensitive information and these products should always be designed with the utmost attention paid to privacy and security. Ethics and privacy in design cannot be an afterthought but must be paramount.
However, even with their limitations, it cannot be denied that these chatbots are changing the landscape of mental health care and helping to make it more accessible to everyone, not just the wealthy. With advances in empathetic AI, it is astounding to think of what is possible to help us all live healthier and happier lives.
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