Can Artificial Intelligence Replace Human Therapists?

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.

Leaps forward

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.

Judgment calls

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.

In Singapore, it’s not unusual for total strangers to ask, “Have you eaten yet?” A greeting akin to “Good morning,” it invariably leads to follow-up questions. What did you eat? Where did you eat it? Was it good? Greeters reserve the right to judge your responses and offer advice, solicited or otherwise, on where you should eat next.

Locals will often joke that gastronomic opinions can make (and break) relationships and that eating is a national pastime. And why wouldn’t it be? In a nexus of colliding cultures—a place where Malays, Indians, Chinese and Europeans have brushed shoulders and shared meals for centuries—the mix of flavours coming out of kitchens in this country is enough to make you believe in world peace.

While Michelin stars spangle Singapore’s restaurant scene , to truly understand the city’s relationship with food, you have to venture to the hawker centres. A core aspect of daily life, hawker centres sprang up in numbers during the 1970s, built by authorities looking to sanitise and formalise the city’s street-food scene. Today, 121 government-run hawker centres feature food stalls that specialise in dishes from the country’s various ethnic groups. In one of the world’s most expensive cities, hawker dishes are shockingly cheap: A full meal can cost as little as $3.

Over the course of many visits to Singapore, I’ve fallen in love with these places—and with the scavenger hunts to find meals I’ll never forget: delicate bowls of laksa noodle soup, where brisk lashes of heat interrupt addictive swirls of umami; impossibly flaky roti prata dipped in curry; the beautiful simplicity of an immaculately roasted duck leg. In a futuristic and at times sterile city, hawker centres throw back to the past and offer a rare glimpse of something human in scale. To an outsider like me, sitting at a table amid the din of the lunch-hour rush can feel like glimpsing the city’s soul through all the concrete and glitz.

So I’ve been alarmed in recent years to hear about the supposed demise of hawker centres. Would-be hawkers have to bid for stalls from the government, and rents are climbing . An upwardly mobile generation doesn’t want to take over from their parents. On a recent trip to Singapore, I enlisted my brother, who lives there, and as we ate our way across the city, we searched for signs of life—and hopefully a peek into what the future holds.

At Amoy Street Food Centre, near the central business district, 32-year-old Kai Jin Thng has done the math. To turn a profit at his stall, Jin’s Noodle , he says, he has to churn out at least 150 $4 bowls of kolo mee , a Malaysian dish featuring savoury pork over a bed of springy noodles, in 120 minutes of lunch service. With his sister as sous-chef, he slings the bowls with frenetic focus.

Thng dropped out of school as a teenager to work in his father’s stall selling wonton mee , a staple noodle dish, and is quick to say no when I ask if he wants his daughter to take over the stall one day.

“The tradition is fading and I believe that in the next 10 or 15 years, it’s only going to get worse,” Thng said. “The new generation prefers to put on their tie and their white collar—nobody really wants to get their hands dirty.”

In 2020, the National Environment Agency , which oversees hawker centres, put the median age of hawkers at 60. When I did encounter younger people like Thng in the trade, I found they persevered out of stubbornness, a desire to innovate on a deep-seated tradition—or some combination of both.

Later that afternoon, looking for a momentary reprieve from Singapore’s crushing humidity, we ducked into Market Street Hawker Centre and bought juice made from fresh calamansi, a small citrus fruit.

Jamilah Beevi, 29, was working the shop with her father, who, at 64, has been a hawker since he was 12. “I originally stepped in out of filial duty,” she said. “But I find it to be really fulfilling work…I see it as a generational shop, so I don’t want to let that die.” When I asked her father when he’d retire, he confidently said he’d hang up his apron next year. “He’s been saying that for many years,” Beevi said, laughing.

More than one Singaporean told me that to truly appreciate what’s at stake in the hawker tradition’s threatened collapse, I’d need to leave the neighbourhoods where most tourists spend their time, and venture to the Heartland, the residential communities outside the central business district. There, hawker centres, often combined with markets, are strategically located near dense housing developments, where they cater to the 77% of Singaporeans who live in government-subsidised apartments.

We ate laksa from a stall at Ghim Moh Market and Food Centre, where families enjoyed their Sunday. At Redhill Food Centre, a similar chorus of chattering voices and clattering cutlery filled the space, as diners lined up for prawn noodles and chicken rice. Near our table, a couple hungrily unwrapped a package of durian, a coveted fruit banned from public transportation and some hotels for its strong aroma. It all seemed like business as usual.

Then we went to Blackgoat . Tucked in a corner of the Jalan Batu housing development, Blackgoat doesn’t look like an average hawker operation. An unusually large staff of six swirled around a stall where Fikri Amin Bin Rohaimi, 24, presided over a fiery grill and a seriously ambitious menu. A veteran of the three-Michelin-star Zén , Rohaimi started selling burgers from his apartment kitchen in 2019, before opening a hawker stall last year. We ordered everything on the menu and enjoyed a feast that would astound had it come out of a fully equipped restaurant kitchen; that it was all made in a 130-square-foot space seemed miraculous.

Mussels swam in a mushroom broth, spiked with Thai basil and chives. Huge, tender tiger prawns were grilled to perfection and smothered in toasted garlic and olive oil. Lamb was coated in a whisper of Sichuan peppercorns; Wagyu beef, in a homemade makrut-lime sauce. Then Ethel Yam, Blackgoat’s pastry chef prepared a date pudding with a mushroom semifreddo and a panna cotta drizzled in chamomile syrup. A group of elderly residents from the nearby towers watched, while sipping tiny glasses of Tiger beer.

Since opening his stall, Rohaimi told me, he’s seen his food referred to as “restaurant-level hawker food,” a categorisation he rejects, feeling it discounts what’s possible at a hawker centre. “If you eat hawker food, you know that it can often be much better than anything at a restaurant.”

He wants to open a restaurant eventually—or, leveraging his in-progress biomedical engineering degree, a food lab. But he sees the modern hawker centre not just as a steppingstone, but a place to experiment. “Because you only have to manage so many things, unlike at a restaurant, a hawker stall right now gives us a kind of limitlessness to try new things,” he said.

Using high-grade Australian beef and employing a whole staff, Rohaimi must charge more than typical hawker stalls, though his food, around $12 per 100 grams of steak, still costs far less than high-end restaurant fare. He’s found that people will pay for quality, he says, even if he first has to convince them to try the food.

At Yishun Park Hawker Centre (now temporarily closed for renovations), Nurl Asyraffie, 33, has encountered a similar dynamic since he started Kerabu by Arang , a stall specialising in “modern Malay food.” The day we came, he was selling ayam percik , a grilled chicken leg smothered in a bewitching turmeric-based marinade. As we ate, a hawker from another stall came over to inquire how much we’d paid. When we said around $10 a plate, she looked skeptical: “At least it’s a lot of food.”

Asyraffie, who opened the stall after a spell in private dining and at big-name restaurants in the region, says he’s used to dubious reactions. “I think the way you get people’s trust is you need to deliver,” he said. “Singapore is a melting pot; we’re used to trying new things, and we will pay for food we think is worth it.” He says a lot of the same older “uncles” who gawked at his prices, are now regulars. “New hawkers like me can fill a gap in the market, slightly higher than your chicken rice, but lower than a restaurant.”

But economics is only half the battle for a new generation of hawkers, says Seng Wun Song, a 64-year-old, semiretired economist who delves into the inner workings of Singapore’s food-and-beverage industry as a hobby. He thinks locals and tourists who come to hawker centers to look for “authentic” Singaporean food need to rethink what that amorphous catchall word really means. What people consider “heritage food,” he explains, is a mix of Malay, Chinese, Indian and European dishes that emerged from the country’s founding. “But Singapore is a trading hub where people come and go, and heritage moves and changes. Hawker food isn’t dying; it’s evolving so that it doesn’t die.”

Can Artificial Intelligence Replace Human Therapists?

Three experts discuss the promise—and problems—of relying on algorithms for our mental health.

Leaps forward

Judgment calls

No trip to Singapore is complete without a meal (or 12) at its hawker centers, where stalls sell multicultural dishes from generations-old recipes. But rising costs and demographic change are threatening the beloved tradition.