Robot Therapy

This article about digital therapy and the NHS’s BetterHelp programme written by Eva Wiseman was originally published in August 2021 in the Guardian. To read the full article click here.

“She’s sitting on a purple armchair, nodding slowly as she talks. “When was the last time you felt really happy?” Her voice is low and measured, with the gently broken glottal quality that one might expect of a computer simulation, her ethnicity undefined, her cardigan beige. Ellie, an artificial intelligence therapist created with funding from the US government agency responsible for the development of military technologies, is capable of reading 60 non-verbal cues a second. She wears a watch and a look of blank empathy. On the split screen, her patient repeats her question. “Hmm, when was the last time I felt really happy?” He’s a young white man who appears to find the interaction unremarkable, which I find remarkable. She detects his “low gaze attention” as he answers, and nods, and prods, and mirrors his facial expressions. And I realise I am nodding, too.

The future of therapy arrived faster than planned. Over the past decade the appearance of mental health care has radically changed, evolving from soft conversations held in small rooms, to encompass teletherapy (at a distance), text-based therapy (through messaging apps), chatbots that perform cognitive behavioural therapy, online platforms that match you to a therapist and, soon, AI therapy with a “non-human” therapist like Ellie. In 2020 the pandemic brought about a mental health crisis and these online services were pushed blinking into the light. As Covid gnawed its way through communities, record numbers of children and adults sought NHS help for problems such as anxiety and depression, and private online therapy platforms, such as BetterHelp, saw a spike in users. The future was here, for around £60 a week.

It makes sense doesn’t it? It makes kind, thoughtful sense to democratise therapy, a service previously only widely available to the wealthy, especially at a time of unprecedented suffering. This was the purpose when in 2008 the NHS launched its Improving Access to Psychological Therapies (IAPT) programme – “The most ambitious programme of talking therapies in the world.” It was designed to make therapy more accessible and if you call your GP with anxiety today, you are likely to be referred to an IAPT. If you search for therapy apps on your phone, you can download hundreds of services ranging from adult colouring books and feelings diaries to Woebot, an AI chatbot that uses CBT techniques and Minions GIFs to improve users’ moods. The therapy industry is thriving.

Yet the rise of therapies that no longer require a therapist, or even sometimes another person listening, is a tricky development. Dr Kate Anthony, CEO of the Online Therapy Institute acknowledges the resistance, but maintains: “As professionals and clients, the concept of distance communication for therapy is no longer considered with suspicion. Technology is not a natural fit for the therapeutic experience, but the pandemic proved it to be a good fit where desired or necessary.” She sees the future of therapy as a combination of in-room and online sessions, led by each individual’s needs.

“I’m excited by the current work of Tim Berners-Lee in addressing what he calls ‘the toxic internet’.” Anthony applauds his ambition to advance the web as a public good and a basic right. “I see parallels with good mental health as a basic right, facilitated by technological advances to join up the human race in working towards it.” What does the future of therapy look like, in her opinion? “We need to address digital exclusion urgently to ensure no one is discriminated against in their search for good mental health,” says Anthony. “The world has been concentrating so hard on the bad effects of the pandemic on mental health that we are in danger of missing the good opportunities it offers.” She hopes to see people designing their own “mental health journey in a profession that embraces rather than rejects technology at work. The way the world communicates is electronic and therapy is communication – why are we being so slow as a profession to adapt?”

Leah signed up to BetterHelp during lockdown. She was 41 and was in crisis. Her father had recently died and her relationship with her mother, who had started a new relationship with someone Leah could see was scamming her out of her savings, was strained. Talkspace (which was valued at $1.4bn when it announced plans to go public in January of this year) and BetterHelp (which is based in Silicon Valley) are two of the biggest apps in the mental health space. Clients use the platforms to exchange messages and hold video sessions with licensed therapists at a lower cost than traditional therapy. Such apps advertise on YouTube and Instagram, sometimes with pop art cartoons of crying girls, often in bed. “Swipe left to talk about your broken heart,” reads a cartoon speech bubble on one. “Swipe left to start feeling happier.”

“I wanted to get counselling,” Leah tells me by email, “but I didn’t want to expose myself to Covid. For me the convenience was ideal, and the price was a lot cheaper than conventional counselling.”

I got in touch with a number of users of automated therapy apps and platforms, some of whom found them useful (they appreciated the ease and the affordability – one man told me he felt more comfortable talking online to a therapist and that it had helped him open up) but, inevitably, it was the people who’d had bad experiences who were most keen to talk to me.

The point is to game the numbers: we saw X people, they were happier. After a month of texting, Leah said she felt that the first counsellor she was assigned was unequipped to handle her problems and that she needed a trauma specialist. “But you don’t get to pick your therapist, they pick you and you just have to hope you get someone with good experience.” Leah said she saved screenshots of their texts and sent them to the next therapist she was matched with, having clarified that she specialised in trauma. Half an hour into their first video session some weeks later, the new therapist stopped her. “She said that trauma was not her speciality and recommended I search for another therapist.” Leah said the experience left her feeling worse, having had to revisit her childhood trauma alone. “I felt rejected by the very people who were supposed to help me,” she says.

I asked a BetterHelp spokesperson for a response. “Our system uses millions of data points to suggest a match based on the member’s preferences, as well as demographics, issues and the outcomes of each individual therapist with similar situations. We hope for each match to be perfect, but that won’t always be the case given how personal and nuanced the therapeutic relationship can be.” Over the last eight years, the spokesperson said, “Our network of more than 18,000 licensed, accredited and board- certified therapists have assisted more than 1 million people to face life’s challenges. We facilitate more than 5m messages, chats, voice calls and video sessions on a monthly basis, and we strive to ensure every one of our members receives the best level of care.”

I came fresh to counselling at the beginning of the first lockdown, when therapists were still trying to navigate the new reality, of home, school, clinic and office all existing within the same small house. Discussing birth trauma and parenting on the phone, I could hear the counsellor’s children arguing in the background. A friend of mine was distracted from a guided meditation by her therapist’s WhatsApp alert ringing out every half-minute. But as the pandemic progressed, routines have been established and for many patients the ease and comfort of modern therapy means they have no plans to go back. Which makes me wonder, what might be lost?

Elizabeth Cotton, a former psychotherapist working in the NHS, is an academic based at Cardiff Metropolitan University whose recent research is focused on the “Uberisation of mental health”. She carried out a series of surveys (including three about the impact of Covid on working life in mental health) and has published them under the title The Future of Therapy. We speak on Zoom, of course, and I marvel inwardly at how we have taught ourselves to communicate in this new land, our own faces hovering meanly to the right. “Essentially,” she says, her argument is that “an industrialisation has taken place, a downgrading of therapy, which opens the doors to digital providers, and what is emerging now is the Uberisation of mental health services.”

IAPT, Cotton says, is a good example. The rules of IAPT services are, “that 50% of people will recover, that they will be seen by somebody and will have treatment within a set period of time”. But, she adds: “Now we know that many of these figures are completely fabricated.” In confidential surveys therapists told her how figures can be manipulated – users can be asked to retake questionnaires to show an improvement in mood. If someone is re-referred back into the service they can count as a new patient. An initial assessment can be counted as treatment. And in our capitalist society, successful treatment, it has been argued, serves the state more than the individual, the aim being getting the patient back to work as soon as possible. A big problem comes, Cotton says, if performance data is used to prove online services are more effective than traditional therapy, where similar data simply does not exist.

A couple of years ago, Cotton was at a conference about AI where a speaker who had been involved in setting up the original IAPT scheme was talking about plans for the whole service to eventually become digitalised. “The implication being that they will use more and more AI. And a friend of mine asked the question, ‘So who asked for this?’ And he said: ‘Nobody, but we’re going to do it anyway.’” Cotton sighs, as if slipping underwater. “That’s not to say that young people don’t like using apps and all of those… debates.” She waves away the arguments as if swiping a screen, “but in terms of real distress and what somebody is asking for when they’re asking for therapy, this isn’t it. Except, that’s not the point. The point is to game the numbers: we saw X number of people, they were happier, it only costs this much.” There are still some good services, she wants to stress, great therapists, great managers, good systems, “But the model is designed in a particular way, to downgrade the service. To shorten the interventions, to reduce the number of highly trained clinicians that you need to take on a supervisory role rather than a direct clinical role. To reduce expectations. To reduce what people think is a treatment.”

One concern she has about online therapy platforms is the introduction of what she calls “Therapeutic Tinder” and how that changes a person’s relationship with their therapist. “They’re sold on the basis that you can see a therapist at any point in time and a text conversation becomes an appropriate way of having therapy. And if you don’t like your therapist, you just change them next week. What does that do to the therapeutic alliance, if you’re constantly at risk of being swiped, does that affect your practice?” She has no doubt that it does. “Good therapy means you can absolutely loathe the sight of your therapist. Now the impulse is to be more attractive as a therapist. The pressure is always to go light, rather than go deep.” Whenever innovation promises to provide cheaper access to something millions of people want, big businesses enter and monopolise the market. Which is dangerous when the product is better mental health. If a therapeutic relationship is based on trust and communication, then putting that relationship in the hands of tech companies, an industry rarely applauded for its trustworthiness or safety, threatens its very foundations. The more we talk, the more terrifying her vision of the future of therapy seems.

Therapy is based on trust, and tech is rarely applauded for that. “There was a mental health crisis summit in 2019,” Cotton says, “and the audience was full of mums, mums of young men who had killed themselves.” She quivers, apologises for crying, gathers herself. These were mothers who were angry, because they believed their children had not received adequate care and then they had lost them. “That’s something I think is really under-articulated – the danger of this model is that the responsibility for recovery ultimately falls back on the individual. When you’re feeling shit about yourself and you feel you failed therapy (because the figures say 50% recovered from it), it becomes your problem. It’s the individualising of social problems. And there are consequences for that. And that’s never addressed. It’s a funny kind of white noise in the profession, a room with hundreds of people who had experienced the devastation of their families, because their kids did not get the right care.”

Our conversation felt like the opposite of counselling. I shut my laptop with a tickly sense of doom. The debate around the future of therapy seemed suddenly to have melted into an ink blot and every time the paper moves another image reveals itself, heart, snake, skull.

The gold standard of therapy remains two people in a room, one talking, the other listening. In Britain right now, that level of care is reserved for the very wealthiest and the very sickest, while those in between have traditionally relied on luck and compromise. The new therapy platforms will undoubtedly offer more people more help than they could previously access – some people will be failed and some might be badly referred, but there will be many more who benefit, whether from CBT or text-based therapy or AI, or finding solace in simply saying their feelings out loud. “I don’t always understand everything you write,” Woebot the AI chatbot offers, “but sometimes the act of sharing is just as good.”

The morning after speaking to Elizabeth Cotton the weather was fine and I shook off the doominess with a walk through the park I’d visited daily throughout the pandemic. Over the lockdowns, I have come to know every tree, repetition and new pandemic eyes learning the boundaries and occasional benefits of our new tense lives. At home I brush my hair for a Zoom meeting and later meet a friend’s new baby on FaceTime, and again I file the lessons we have learned about how to communicate over the months we’ve been unable to sit together in rooms, and talk. The ways in which technology assists and smooths our interactions, but also the new mirrored obstacles it presents. As the future of therapy unfolds, with evolving technology offering greater access to more people, these lessons will continue. The job will be to listen.”