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.

What’s more important than being a good employee right now? Looking like a good employee in the eyes of AI productivity trackers that more managers are using to evaluate their teams.

Employee-monitoring systems are especially popular at tech companies and are also used by other white-collar firms that want to probe how people spend company time. The scary thing: You might not even know you’re being watched because many states don’t require disclosure.

Metrics can include performance data that is undoubtedly relevant, such as sales results. But it also can employ dubious proxies like keyboard strokes and how often your computer screen goes into sleep mode.

We generally accepted, or at least understood, heightened surveillance during the work-from-home era. Back then it seemed reasonable for bosses to keep tabs on employees they couldn’t see.

Yet the oversight has only escalated, and tensions are rising, too.

A group of former Meta Platforms employees alleges in a lawsuit that the company used a “constellation of internal artificial-intelligence systems” when it began laying off about 10% of its workforce in May. Meta says humans make termination calls.

However that case shakes out, a couple of things are clear. Companies eager to gauge which employees are locked in now have sophisticated AI monitoring systems at their disposal. And they believe they have leverage in a tepid labor market.

So while we may chafe at having our worth reduced to numbers on the boss’s productivity dashboard, we have to play the game as it’s being played. Here are some tips, based on conversations with people who make employee monitoring systems—and others who game the systems.

Be meticulous about your calendar

Calendar integration is one way that productivity trackers have gotten more advanced and, ostensibly, fairer.

Let’s say you make an old-fashioned phone call or attend an in-person meeting. Your Outlook or Slack status may switch to “away,” making you appear as inactive as if you were taking an extended coffee break.

Employee monitors like one made by a company called Insightful cross-check your online status with your calendar to see whether there is a valid reason for your apparent inactivity. If that call or meeting is on your schedule, then the system will recognize that you are busy offline. If nothing is on the books, it could look like you’re slacking off.

Hit the activity sweet spot, around 80%

Let’s not go any further without addressing the underlying question: How much downtime is permissible during the workday? After all, people have been scared to let managers see anything non-work-related on their screens since personal computers first arrived in offices.

No one knows this better than Roger Wagner, who is widely credited with creating the first “boss button” in the early 1980s. He designed a keyboard shortcut to instantly display a spreadsheet if the boss walked by your cubicle while you were playing a computer game. Boss buttons have been features of countless diversions since. (I confess to using one built into a March Madness streaming app.)

Wagner, the founder of computer-education company 1010 Technologies, says his original design was a joke—more of a commentary on overbearing managers than a cover for lazy employees. Good bosses understand workers need mental breaks throughout the day, he says.

This matches what I heard from Insightful Chief Executive Ivan Petrovic. He says customers that use his company’s workforce-management platform don’t expect employees to stay on task 100% of the time.

“On average companies are aiming for 60% to 80% of your time being utilized for work during the day,” he says.

Go ahead and exhale. It’s probably OK to watch an occasional YouTube video at your desk.

And if you’re going to artificially inflate your activity level, be careful. Hitting 90% could look suspicious.

Get physical

So don’t leave your mouse jiggler on all day. Choose the right one if you must resort to shenanigans.

There are lots of software applications that mimic the movements of a computer mouse, so you can appear to be working while away from your desk. There are also devices that plug into computer ports and do the same thing.

Corporate cybersecurity systems increasingly block these apps and devices, and productivity trackers claim to be able to detect them. But some workers swear by mouse docks, like one made by Tech8 USA, that keep cursors moving. The company originally made mouse-moving software but now focuses on physical jigglers.

“People are drawn to mechanical solutions because they’re so simple and don’t require software,” says Tech8 Marketing Director Sam Matthews. “As monitoring technology becomes more sophisticated, that distinction has become even more relevant.”

Use AI, but not too much

Another popular metric for employee-monitoring systems is AI usage. Companies want to know who is embracing new tools, and it can be tempting to think more is better.

“There’s a performative aspect where employees overblow their usage of AI so that they appear relevant in the organization,” says Andrea Derler, principal researcher at Visier, which helps companies track and analyze employee work habits.

In a recent Visier survey of 1,000 U.S. workers, 48% admitted to exaggerating their AI usage.

This is already an outdated strategy. Using AI for everything used to score points for experimentation. Now it can seem wasteful because many companies are watching AI token spending more carefully.

Look, productivity theater has always been part of work. Most of us aren’t trying to cheat the system, but expectations are changing so quickly that we need to be savvy about what the latest employee trackers are looking for.

Sometimes it takes a little gamesmanship to get full credit for our contributions.