Can Artificial Intelligence Replace Human Therapists?
Three experts discuss the promise—and problems—of relying on algorithms for our mental health.
Three experts discuss the promise—and problems—of relying on algorithms for our mental health.
Could artificial intelligence reduce the need for human therapists?
Websites, smartphone apps and social-media sites are dispensing mental-health advice, often using artificial intelligence. Meanwhile, clinicians and researchers are looking to AI to help define mental illness more objectively, identify high-risk people and ensure quality of care.
Some experts believe AI can make treatment more accessible and affordable. There has long been a severe shortage of mental-health professionals, and since the Covid pandemic, the need for support is greater than ever. For instance, users can have conversations with AI-powered chatbots, allowing then to get help anytime, anywhere, often for less money than traditional therapy.
The algorithms underpinning these endeavours learn by combing through large amounts of data generated from social-media posts, smartphone data, electronic health records, therapy-session transcripts, brain scans and other sources to identify patterns that are difficult for humans to discern.
Despite the promise, there are some big concerns. The efficacy of some products is questionable, a problem only made worse by the fact that private companies don’t always share information about how their AI works. Problems about accuracy raise concerns about amplifying bad advice to people who may be vulnerable or incapable of critical thinking, as well as fears of perpetuating racial or cultural biases. Concerns also persist about private information being shared in unexpected ways or with unintended parties.
The Wall Street Journal hosted a conversation via email and Google Doc about these issues with John Torous, director of the digital-psychiatry division at Beth Israel Deaconess Medical Center and assistant professor at Harvard Medical School; Adam Miner, an instructor at the Stanford School of Medicine; and Zac Imel, professor and director of clinical training at the University of Utah and co-founder of LYSSN.io, a company using AI to evaluate psychotherapy. Here’s an edited transcript of the discussion.
WSJ: What is the most exciting way AI and machine learning are being used to diagnose mental disorders and improve treatments?
DR. MINER: AI can speed up access to appropriate services, like crisis response. The current Covid pandemic is a strong example where we see both the potential for AI to help facilitate access and triage, while also bringing up privacy and misinformation risks. This challenge—deciding which interventions and information to champion—is an issue in both pandemics and in mental health care, where we have many different treatments for many different problems.
DR. IMEL: In the near term, I am most excited about using AI to augment or guide therapists, such as giving feedback after the session or even providing tools to support self-reflection. Passive phone-sensing apps [that run in the background on users’ phones and attempt to monitor users’ moods] could be exciting if they predict later changes in depression and suggest interventions to do something early. Also, research on remote sensing in addiction, using tools to detect when a person might be at risk of relapse and suggesting an intervention or coping skills, is exciting.
DR. TOROUS: On a research front, AI can help us unlock some of the complexities of the brain and work toward understanding these illnesses better, which can help us offer new, effective treatment. We can generate a vast amount of data about the brain from genetics, neuroimaging, cognitive assessments and now even smartphone signals. We can utilize AI to find patterns that may help us unlock why people develop mental illness, who responds best to certain treatments and who may need help immediately. Using new data combined with AI will likely help us unlock the potential of creating new personalized and even preventive treatments.
WSJ: Do you think automated programs that use AI-driven chatbots are an alternative to therapy?
DR. TOROUS: In a recent paper I co-authored, we looked at the more recent chatbot literature to see what the evidence says about what they really do. Overall, it was clear that while the idea is exciting, we are not yet seeing evidence matching marketing claims. Many of the studies have problems. They are small. They are difficult to generalize to patients with mental illness. They look at feasibility outcomes instead of clinical-improvement endpoints. And many studies do not feature a control group to compare results.
DR. MINER: I don’t think it is an “us vs. them, human vs. AI” situation with chatbots. The important backdrop is that we, as a community, understand we have real access issues and some people might not be ready or able to get help from a human. If chatbots prove safe and effective, we could see a world where patients access treatment and decide if and when they want another person involved. Clinicians would be able to spend time where they are most useful and wanted.
WSJ: Are there cases where AI is more accurate or better than human psychologists, therapists or psychiatrists?
DR. IMEL: Right now, it’s pretty hard to imagine replacing human therapists. Conversational AI is not good at things we take for granted in human conversation, like remembering what was said 10 minutes ago or last week and responding appropriately.
DR. MINER: This is certainly where there is both excitement and frustration. I can’t remember what I had for lunch three days ago, and an AI system can recall all of Wikipedia in seconds. For raw processing power and memory, it isn’t even a contest between humans and AI systems. However, Dr. Imel’s point is crucial around conversations: Things humans do without effort in conversation are currently beyond the most powerful AI system.
An AI system that is always available and can hold thousands of simple conversations at the same time may create better access, but the quality of the conversations may suffer. This is why companies and researchers are looking at AI-human collaboration as a reasonable next step.
DR. IMEL: For example, studies show AI can help “rewrite” text statements to be more empathic. AI isn’t writing the statement, but trained to help a potential listener possibly tweak it.
WSJ: As the technology improves, do you see chatbots or smartphone apps siphoning off any patients who might otherwise seek help from therapists?
DR. TOROUS: As more people use apps as an introduction to care, it will likely increase awareness and interest of mental health and the demand for in-person care. I have not met a single therapist or psychiatrist who is worried about losing business to apps; rather, app companies are trying to hire more therapists and psychiatrists to meet the rising need for clinicians supporting apps.
DR. IMEL: Mental-health treatment has a lot in common with teaching. Yes, there are things technology can do in order to standardise skill building and increase access, but as parents have learned in the last year, there is no replacing what a teacher does. Humans are imperfect, we get tired and are inconsistent, but we are pretty good at connecting with other humans. The future of technology in mental health is not about replacing humans, it’s about supporting them.
WSJ: What about schools or companies using apps in situations when they might otherwise hire human therapists?
DR. MINER: One challenge we are facing is that the deployment of apps in schools and at work often lacks the rigorous evaluation we expect in other types of medical interventions. Because apps can be developed and deployed so quickly, and their content can change rapidly, prior approaches to quality assessment, such as multiyear randomized trials, are not feasible if we are to keep up with the volume and speed of app development.
WSJ: Can AI be used for diagnoses and interventions?
DR. IMEL: I might be a bit of a downer here—building AI to replace current diagnostic practices in mental health is challenging. Determining if someone meets criteria for major depression right now is nothing like finding a tumour in a CT scan—something that is expensive, labour-intensive and prone to errors of attention, and where AI is already proving helpful. Depression is measured very well with a nine-question survey.
DR. MINER: I agree that diagnosis and treatment are so nuanced that AI has a long way to go before taking over those tasks from a human.
Through sensors, AI can measure symptoms, like sleep disturbances, pressured speech or other changes in behaviour. However, it is unclear if these measurements fully capture the nuance, judgment and context of human decision making. An AI system may capture a person’s voice and movement, which is likely related to a diagnosis like major depressive disorder. But without more context and judgment, crucial information can be left out. This is especially important when there are cultural differences that could account for diagnosis-relevant behaviour.
Ensuring new technologies are designed with awareness of cultural differences in normative language or behaviour is crucial to engender trust in groups who have been marginalised based on race, age, or other identities.
WSJ: Is privacy also a concern?
DR. MINER: We’ve developed laws over the years to protect mental-health conversations between humans. As apps or other services start asking to be a part of these conversations, users should be able to expect transparency about how their personal experiences will be used and shared.
DR. TOROUS: In prior research, our team identified smartphone apps [used for depression and smoking cessation that] shared data with commercial entities. This is a red flag that the industry needs to pause and change course. Without trust, it is not possible to offer effective mental health care.
DR. MINER: We undervalue and poorly design for trust in AI for healthcare, especially mental health. Medicine has designed processes and policies to engender trust, and AI systems are likely following different rules. The first step is to clarify what is important to patients and clinicians in terms of how information is captured and shared for sensitive disclosures.
Reprinted by permission of The Wall Street Journal, Copyright 2021 Dow Jones & Company. Inc. All Rights Reserved Worldwide. Original date of publication: March 27, 2021.
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You’ll never guess where they found a little extra room when renovating this west coast house
There was a time, not too long ago, when the most important must-have for would-be renovators was space. It was all about space to be together and space to be apart.
But as house prices increase across the country, the conversation has started to shift from size for the sake of it towards more flexible, well-designed spaces better suited to contemporary living.
For the owners of this 1920s weatherboard workers’ cottage in Fremantle, the emphasis was less on having an abundance of room and more about creating cohesive environments that could still maintain their own distinct moods. Key to achieving this was manipulating the floorplan in such a way that it could draw in light, giving the impression at least of a larger footprint.
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Positioned on a site that fell three metres from street level, the humble four-room residence had been added to over the years. First order of business for local architect Philip Stejskal was to strip the house back to its original state.
“In this case, they were not quality additions,” Stejskal says. “Sometimes it is important to make sure later additions are not lean-tos.”
The decision to demolish was not taken lightly.
“Sometimes they can be as historically significant as the original building and need to be considered — I wouldn’t want people to demolish our addition in 50 years’ time.”
Northern light hits the site diagonally, so the design solution was to open up the side of the house via a spacious courtyard to maximise opportunities to draw natural light in. However, this had a knock-on effect.
“We had to make space in the middle of the site to get light in,” Stejskal says. “That was one of the first moves, but that created another issue because we would be looking onto the back of the neighbouring building at less appealing things, like their aircon unit.”
To draw attention away from the undesirable view, Stejskal designed a modern-day ‘folly’.
“It’s a chimney and lookout and it was created to give us something nice to look at in the living space and in the kitchen,” Stejskal says.
“With a growing family, the idea was to create a space where people could find a bit of solitude. It does have views to the wider locality but you can also see the port and you can connect to the street as well.”
A garden tap has also been installed to allow for a herb garden at the top of the steps.
“That’s the plan anyway,” he says.
Conjuring up space has been at the core of this project, from the basement-style garaging to the use of the central courtyard to create a pavilion-like addition.
The original cottage now consists of two bedrooms, with a central hallway leading onto a spacious reception and living area. Here, the large kitchen and dining spaces wrap around the courtyard, offering easy access to outdoor spaces via large sliding doors.
Moments of solitude and privacy have been secreted throughout the floorplan, with clever placement of built-in window seats and the crow’s nest lookout on the roof, ideal for morning coffee and sunset drinks.
The house has three bedrooms, including a spacious master suite with walk-in robe and ensuite overlooking the back garden. Adjustable blades on the bedroom windows allow for the control of light, as well as privacy. Although the house was designed pre COVID, it offers the sensibility so many sought through that time — sanctuary, comfort and retreat.
“When the clients came to us, they wanted a house that was flexible enough to cater for the unknown and changes in the family into the future,” Stejskal says. “We gave the owners a series of spaces and a certain variety or moods, regardless of the occasion. We wanted it to be a space that would support that.”
Mood has also been manipulated through the choice of materials. Stejskal has used common materials such as timber and brick, but in unexpected ways to create spaces that are at once sumptuous but also in keeping with the origins of the existing building.
Externally, the brickwork has been finished in beaded pointing, a style of bricklaying that has a softening effect on the varied colours of bricks. For the flooring, crazy paving in the courtyard contrasts with the controlled lines of tiles laid in a stack bond pattern. Close attention has also been paid to the use of veneer on select joinery in the house, championing the beauty of Australian timbers with a lustrous finish.
“The joinery is finished in spotted gum veneer that has been rotary cut,” says Stejskal. “It is peeled off the log like you peel an apple to give you this different grain.”
Even the laundry has been carefully considered.
“The laundry is like a zen space with bare stone,” he says. “We wanted these different moods and the landscape of rooms. We wanted to create a rich tapestry in this house.”
The owners now each experience the house differently, highlighting separate aspects of the building as their favourite parts. It’s quite an achievement when the site is not enormous. Maybe it’s not size that matters so much after all.
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