Chatbot Therapy

A chatbot is "a computer program that conducts a conversation" with you. The original chatbot was a program call ELIZA written in the early 1960s that used a simple pattern-matching script to simulate the interaction between a patient and a psychotherapist (played by ELIZA, e.g. Figure 1).

These days chatbots are everywhere in the form of  Artificial Intelligence (AI) "personal assistants" such as the iPhone Siri, Google Now, or Amazon Alexa that answer your questions and carry out your commands from a mobile device. Twitter is overun with Twitterbots that can follow you and generate automated messages such as @ messages or retweets in response to tweets. Indeed, some suspect that many of the "active users" on Twitter are bots rather than actual humans. Finally Facebook has established the Messenger Platform that allows developers to build chatbots for the Messenger texting service in a similar vein to Twitterbots.

Following the lead of ELIZA, some chatbots are being used in the healthcare realm. The possibilities are especially intriguing for mental health in which treatment often takes the form of a conversation. One big advantage of a chatbot over a human therapist is that it can easily scale to meet the needs of numerous people in far-flung places as long as there is mobile connectivity. One such region is the Middle East where there are a lot of Syrian refugees suffering from the trauma of war (The New Yorker):

"Almost three-quarters of the Syrian refugees in the country disclosed one or more “problematic behaviors,” such as excessive nervousness, continuous crying, self-isolation, and trouble sleeping. Only thirteen per cent of those at Za’atari stated that they had received any sort of mental-health care since arriving in Jordan. Addressing these needs in the traditional way, by deploying thousands of Arabic-speaking therapists into conflict zones, would have been impossible."

As alluded to above, the chatbot counselors "need no plane tickets, food, protection, or salaries. They can easily handle caseloads in the tens of thousands, and they can be available at any time, via text message, to anyone with a mobile phone." Furthermore, communicating in Arabic is no problem with powerful machine translation algorithms.

To address this need, two Silicon Valley entrepreneurs have started a company X2AI that designed a psychotherapy chatbot named Karim that could be run as a texting service on a mobile device. They tested Karim out on a small group of about sixty Syrians living near Beirut in Lebanon.

As one might imagine, there were a variety of hurdles to overcome from the cultural to the technical. For example, the very concept of a nonhuman chatbot confused some of the users. Many more iterations to refine the product will be necessary to smooth out these bumps. It is too early and too preliminary to assess whether Karim has had a positive effect on the patients, but offering a resource to those who may not have access to more traditional resources is an experiment worth doing.

More broadly, the company has expanded its product line-up to target a variety of subjects:

"Karim is only one member of X2AI’s polylingual family of chatbots. Others include Emma, a Dutch-language bot designed to help people with mild anxiety and fear; Nema, an English-language bot that specializes in pediatric diabetes care; and Tess, a highly adaptable English-language bot that can perform cognitive-behavioral therapy, motivational interviewing, and various other techniques."

It is important to note that these chatbot counselors are meant to complement human professional therapists, not replace them. Indeed, they should be viewed as assistants who offer help and support and not medical treatment (which entails much stricter qualifications):

"X2AI describes its bots as therapeutic assistants, which means that they offer help and support rather than treatment. The distinction matters both legally and ethically. “If you make a claim that you’re treating people, then you’re practicing medicine,” Rauws told me recently. “There’s a lot more evidence required before you can make that claim confidently.” As a result, the A.I.s have human minders—typically employees of the health-care company that licensed the bots, not of X2AI itself—who can “ghost in” at will, assuming manual control over conversations."

Another benefit of the chatbot is that it possesses perfect recall of every interaction with the patient, i.e. there is a record of the conversations that can be stored in the chatbot memory. This ability to "remember" every conversation, as well as use AI technology to probe extensive diagnostic databases should help the chatbot assemble a composite portrait of the subject from disparate pieces of data:

"Good data about the efficacy of A.I. therapists is scarce, since the technology is so young. But David Spiegel, a professor of psychiatry at Stanford who is unaffiliated with X2AI, told me that he found their diagnostic capacities promising. With perfect recall of every past patient interaction and the ability to integrate dozens of seemingly disparate criteria into a diagnosis, he noted, “a computer could potentially come up with a much more specific delineation of a problem.”

One question is whether chatbots can detect subtle nuances in tone or affect that can reveal valuable information about mental state. Interestingly, the answer appears to be a qualified yes:

"Where human therapists rely on body language and vocal tone to make inferences about a patient’s mood, the X2AI bots detect patterns in how phrasing, diction, typing speed, sentence length, grammatical voice (active versus passive), and other parameters correlate with different emotional states. In principle, this imbues the system with the capacity to notice latent emotions, just as human therapists do."

There are important limitations, however. The bottom line is that humans respond best to other humans rather than to a computer:

"Still, Spiegel could not imagine a bot ever offering patients the crucial therapeutic experience of feeling that someone else, despite knowing your flaws and vulnerabilities, cares about you. He was also skeptical that A.I.s could ever elicit the phenomenon of transference, which occurs when patients redirect feelings from a past relationship toward a therapist—often considered an important part of treatment. “There are aspects of psychotherapy that may always be beyond the reach of computers,” Spiegel said. “I’m not worried about being put out of business."

In the near future, the Chatbot Therapist should prove to be a valuable complement to the human therapist, but not a replacement.

Figure 1. A conversation with ELIZA the original Chatbot Therapist. One can interact with an ELIZA program at websites such as this.