South Florida Sun-Sentinel (Sunday)
Bot therapist is always on call
With AI to deploy techniques, Woebot aims to fill need for affordable care, but critics wary of approach
“I understand that you’re experiencing a relationship problem, is that right?” Yes.
“OK, I’m delighted that you want to work on this, K. I’ve good and bad news for you. … Which do you want to hear first?”
Good news.
“The good news is, I have very powerful skills that I can teach you! These skills have really helped a lot of people build better relationships.”
And the bad news? “The bad news is that you would have to be willing to accept 100% of the responsibility for changing the relationship.”
Why?
“Because you’re only ever going to be able to have control over your part of it.”
This conversation may sound like a fairly typical therapist’s session, but in this case, it was directed by Woebot, a therapeutic chatbot, with the psychiatrist’s couch swapped for a smartphone screen.
The app presents itself as an automated therapist when finding a real one can feel like a logistical and financial impossibility.
During the pandemic, about 4 in 10 adults in the United States reported that they had symptoms of anxiety or depression, according to the Kaiser Family Foundation. At the same time, the federal government warns of a critical shortage of therapists and psychiatrists.
Woebot Health says the pandemic has driven up demand for its services. The number of its daily users doubled and is now in the tens of thousands, said company founder and president Alison Darcy, who is a psychologist.
Digital mental health has become a multibillion-dollar industry and includes more than 10,000 apps, according to an estimate by the American Psychiatric Association. The apps range from guided meditation (Headspace) and mood tracking (MoodKit) to text therapy by licensed counselors (Talkspace and BetterHelp).
But Woebot, introduced in 2017, is one of only a handful of apps that use artificial intelligence to deploy the principles of cognitive behavioral therapy, a common technique used to treat anxiety and depression. Woebot aims to use natural language processing and learned responses to mimic conversation, remember past sessions and deliver advice around sleep, worry and stress.
“If we can deliver some of the things that the human can deliver,” Darcy said, “then we actually can create something that’s truly scalable, that has the capability to reduce the incidence of suffering in the population.”
Almost all psychologists and academics agree with Darcy on the problem:
There is not enough affordable mental health care for everyone who needs it. But they are divided on her solution: Some say bot therapy can work under the right conditions, while others consider the very concept paradoxical and ineffective.
At issue is the nature of therapy itself. Can therapy by bot make people understand themselves better? Can it change longheld patterns of behavior through a series of questions and exercises? Or is human connection essential to that endeavor?
Hannah Zeavin, author of the forthcoming book “The Distance Cure: A History of Teletherapy,” says the health care system is so broken that “it makes sense that there’s space for disruption.”
But, she added, not all disruption is equal. She calls automated therapy a “fantasy” that is more focused on accessibility and fun than actually helping people.
Woebot’s use of cognitive behavioral therapy, or CBT, has a philosophical and practical logic to it. Unlike forms of psychotherapy that probe the root causes of psychological problems, CBT seeks to help people identify their distorted ways of thinking and understand how that affects their behavior in negative ways. By changing these self-defeating patterns, therapists hope to improve symptoms of depression and anxiety.
Because cognitive behavioral therapy is structured and skill-oriented, many mental health experts think it can be employed, at least in part, by algorithm.
“You can deliver it pretty readily in a digital framework, help people grasp these concepts and practice the exercises that help them think in a more rational manner,” said Jesse Wright, a psychiatrist who studies digital forms of CBT and is director of the University of Louisville Depression Center.
Wright said studies have shown that computer algorithms could take someone through a standard CBT process, step by step, and get results similar to in-person therapy. Those programs generally follow a set number of sessions and require some guidance from a human clinician.
But most smartphone apps don’t work that way, he said. People tend to use therapy apps in short, fragmented spurts, without clinician oversight.
And some automated conversations can be clunky and frustrating when the bot fails to pick up on the user’s exact meaning. Wright said AI is not advanced enough to reliably duplicate a natural conversation.
Much of the debate over therapeutic bots comes down to expectations. On its website, Woebot promises to “automate both the process and content of therapy,” but Darcy is careful not to call Woebot medical treatment or even formal therapy.
Instead, she says, the bot delivers “digital therapeutics.” And Woebot’s terms of service call it a “pure self-help” program that is not meant for emergencies. Woebot says it is programmed to recognize suicidal language and urge users to seek out a human alternative.
In that way, Woebot does not approach true therapy. Like many mental health apps, the free version of
Woebot is not subject to strict oversight from the Food and Drug Administration because it falls under the category of “general wellness” product.
But Woebot is striving for something more. With $22 million of venture capital in hand, Woebot is seeking clearance from the FDA to develop its algorithm to help treat two psychiatric diagnoses — postpartum depression and adolescent depression — and then sell the program to health systems.
The idea, Darcy says, is not to replace human therapists with bots; she thinks it’s important to have both. “It’s like saying if every time you’re hungry, you must go to a Michelin star restaurant, when actually a sandwich is going to be OK,” she said. “Woebot is a sandwich. A very good sandwich.”