As she speaks, she sits on a purple chair and nods slowly. What was the last time that you felt truly happy? Her voice is soft and low, with the broken glottal quality one would expect from a computer simulation. Her ethnicity is unknown, her cardigan beige. Ellie, an artificial intelligence therapist, was created using funding from the US government agency that is responsible for developing military technologies. She can read 60 non-verbal cues per second. She is wearing a watch and has a blank look of empathy. Her patient repeats her question on the split screen. Hmm, when was my last feeling really happy? This is a young white man, which I find quite remarkable. As he answers, she detects his low gaze and nods. I realize that I am nodding as well.
The future of therapy came sooner than expected. The evolution of mental health care has been rapid. It evolved from small conversations in small rooms to include teletherapy, text-based therapy (through messaging app), chatbots that perform cognitive behavioral therapy, online platforms that match people to therapists, and soon AI therapy with an AI therapist like Ellie. These online services began to emerge after the 2020 pandemic, which caused a major mental health crisis. Covid was gnawing its way through communities. Record numbers of people sought NHS help for anxiety and depression. Private online therapy platforms like BetterHelp saw an increase in usage. For around 60 people per week, the future was here.
It seems logical, doesn't it? It is a thoughtful and kind decision to make therapy more accessible to all, particularly in a time of such extreme suffering. In 2008, the NHS launched the Improving Access to Psychological Therapies programme (IAPT). This programme was created to make therapy more affordable. If you call your GP today with anxiety, they will likely refer you to an IAPT. You can search your phone for therapy apps and download hundreds of them. These services include adult coloring books, feelings diaries, and Woebot, an AI chatbot which uses CBT techniques and Minions GIFs in order to improve users' moods. The therapy industry is flourishing.
However, the rapid rise in therapies that don't require a therapist or another person listening is a difficult development. Dr. Kate Anthony, CEO at the Online Therapy Institute, acknowledges that there has been resistance. However, she maintains that both professionals and clients are now open to the idea of using distance communication for therapy. Although technology isn't a natural fit for therapeutic experiences, the pandemic showed it to be. Dr. Kate Anthony maintains that distance communication for therapy is no longer a suspicion.
I am excited about the work that Tim Berners-Lee is doing to address what he refers to as the toxic internet. Anthony also applauds this effort to make the web a public good and a fundamental right. There are parallels between good mental health and a basic human right. Technology has made it possible to connect the human race in pursuing this goal. Anthony says that digital exclusion must be addressed urgently in order to ensure that no one is excluded from their quest for good mental health. The world has been so focused on the negative effects of the mental health pandemic that it is threatening to miss the opportunities for good mental health. Anthony hopes that people will design their own mental health journeys in a profession that accepts and uses technology. We communicate electronically and therapy is communication. Why is it so difficult for us to change as a profession?
Leah signed up for BetterHelp during lockdown. She was 41 years old and in crisis. Her father had just died, and her relationship was difficult with her mother. She had begun a new relationship, which Leah saw as a scammer, with someone Leah knew was taking her savings. Talkspace, which was valued at $1.4bn in January when it announced its plans to go public, and BetterHelp (which is located in Silicon Valley), are two of the most popular apps in the mental healthcare space. The platforms allow clients to communicate with licensed therapists and have video sessions. This is cheaper than traditional therapy. These apps are advertised on YouTube and Instagram with cartoons of crying girls often in bed. Swipe leaves to talk about your broken heart. A cartoon speech bubble appears on one. Swipe decided to feel happier.
Leah told me via email that I wanted counselling. However, I was not ready to be exposed to Covid. I found the convenience to be ideal and the cost was much lower than traditional counselling.
I spoke to several users of automated therapy platforms and apps. Some found them helpful. One man said he felt more comfortable speaking online to a therapist because it was easier and cheaper. But, in the end, it was those who had had bad experiences that were most eager to speak to me.
It's all about playing the numbers. We saw X people and they were happier
Leah felt that the counsellor she was assigned wasn't equipped to deal with her issues and suggested that she seek out a trauma specialist. You don't get to choose your therapist. They pick you. Leah stated that she took screenshots of the texts and sent them to her next therapist after clarifying that she specialized in trauma. The new therapist pulled out of their first video session after half an hour. Leah stated that the new therapist said trauma wasn't her specialty and suggested she search for another therapist. She says that I felt rejected by those who were supposed to help.
I reached out to a spokesperson at BetterHelp for clarification. Our system analyzes millions of data points to recommend a match. This includes members' preferences as well as demographics and the outcomes of each therapist who has had similar experiences. Although we hope that every match will be perfect, it is not always possible. On a monthly basis we facilitate over 5m messages, voice calls, and video sessions. We strive to ensure that every member receives the highest level of care.
At the start of the first lockdown I was new to counselling. Therapists were still trying their best to navigate the new reality of school, home, and clinic all living in the same house. Talking about parenting and birth trauma over the phone, I could also hear my counsellor's children fighting. My friend was distracted by a WhatsApp alert from her therapists that rang out every half-minute, interrupting her guided meditation. As the pandemic progressed though, many patients have established routines and don't plan to return. I wonder what could be lost.
Elizabeth Cotton is an ex-psychotherapist who worked in the NHS. She is now an academic at Cardiff Metropolitan University. Her recent research is on the Uberization of mental health. She conducted a number of surveys, including three on the effect of Covid on mental health workers' lives. These were published under the title The Future of Therapy. We talk on Zoom, and I am astonished at how we have learned to communicate in this new world, with our faces looming in the background. She argues that there has been an industrialization, a downgrading in therapy, which has opened the doors for digital providers. What is happening now is the Uberisation mental health services.
Cotton says that IAPT is an excellent example. IAPT services have a set of rules. They require that at least 50% of patients will be able to recover. That they are seen by someone and that they receive treatment within a certain time period. She adds, "But now we know that many figures are completely fabricated." Therapists have told her in confidential surveys how figures can easily be manipulated. Users can be asked to complete questionnaires again to demonstrate an improvement in mood. Re-referred patients can be counted as new patients if they are referred back to the service. A first assessment can count as treatment. In capitalist societies, success in treatment is more important than the individual. The goal of successful treatment is to get the patient back on the job as quickly as possible. Cotton states that online services can be more effective than traditional therapies if they are backed up with performance data. Similar data does not exist.
Cotton was present at an AI conference a few years back where a speaker, who was involved in the initial IAPT scheme's creation, was discussing plans for the entire service to be digitalized. They will be using more AI, this is the implication. A friend of mine asked Cotton the question: So who asked? He replied, "Nobody, but we're going to do it anyway." Cotton sighs as if slipping under water. It's not that young people don't like apps or all of the debates. But in terms of real distress, and what someone is asking for when they ask for therapy, this isnt. But that's not the point. It's all about playing the numbers. We saw X amount of people, they were happier, and it only costs that much. But, the model was designed to lower the quality of the service. To reduce the intervention time and the number of highly-trained clinicians, you will need to assume a supervisory rather than a clinical role. To reduce expectations. To decrease the perception of treatment.
She is concerned about the introduction of Therapeutic Tinder, or online therapy platforms. This can change a person's relationship with their therapist. These platforms are sold on the premise that you can consult a therapist anytime and a text conversation is a good way to have therapy. You can even change your therapist next week if you don't like them. How does this affect the therapeutic alliance? If you are constantly at risk of being swiped from your practice, how does it impact your practice? She is certain. You can hate the sight of your therapist if you have good therapy. The temptation is to appear more attractive as a therapist. Big businesses are able to monopolize the market by entering when innovation promises cheaper access to something millions want. This is especially dangerous when the product is better for mental health. It is dangerous to put trust and communication at the heart of a therapeutic relationship. This industry is rarely praised for its safety or trustworthiness. Her vision for the future of therapy is more frightening the more we talk.
Trust is the foundation of therapy, and tech is seldom praised for it.
Cotton says that there was a summit on mental health in 2019. There were many mothers, young men who had committed suicide, and she tries to console herself. These mothers were upset because they felt their children were not receiving adequate care, and they lost them. This is a dangerous model. The individual is ultimately responsible for their recovery. It becomes your problem when you are feeling bad about yourself. This is the individualization of social problems. There are consequences. That is never discussed. It's funny because it is a strange kind of white noise in this profession. A room filled with hundreds of people who have experienced the devastation in their families due to the fact that their children didn't get the right care.
The conversation felt more like counselling than it was. With a tingly feeling of doom, I closed my laptop. The whole debate about the future of therapy appeared to melt into an inkblot, and every time the paper moves, another image emerges, heart, snake or skull.
Two people are the gold standard for therapy. One person talks and the other listens. Currently, in Britain, this level of care is reserved only for the wealthy and the most sick. Those who are less fortunate have relied on luck and compromise. While some people might fail and others may be referred poorly, the new platforms will offer more help than ever before. However, there will be many people who will benefit from CBT, text-based therapy, AI or simply sharing their feelings loudly. Woebot, the AI chatbot, doesn't always understand what you write. But sometimes, the act of sharing can be just as valuable.
After speaking with Elizabeth Cotton, the weather was beautiful and I took a walk in the park that I had been to daily during the pandemic. Through the lockdowns I have come to know each tree, every repetition, and new pandemic eyes, learning the limits and sometimes the benefits of our new tense life. At home, I wash my hair and meet up with a friend for a Zoom meeting. Later, I also meet a new baby via FaceTime. I then file the lessons learned and the lessons that we have shared about communication over the months when we were unable to be together in a room, or talk. We are constantly amazed at the ways technology can help us communicate and make our lives easier. But it also presents new challenges. These lessons will be repeated as technology advances and makes it easier to access more people. Listening will be the job of the future.
