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Social and Scholarly Significance

Understanding AI agents

Methodological Insights

Major themes/findings

Wrap up & Discussion

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Chatbots vs Conversational AI

Retrieval-based vs Conversation-based

Text-based vs. audiovisual

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Context - Mental Health in America

The national representative survey conducted by APA in 2023 recorded the dynamics of stress among people of all ages in the United States. The pandemic played a significant role in increasing the need for mental healthcare.

Young population report highest effects of stress

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A nation recovering from collective trauma

The COVID-19 pandemic, global conflicts, racism and racial injustice, inflation, and climate-related disasters are all weighing on the collective consciousness of Americans

The national public health emergency around Covid-19 officially ended on May 11, 2023, and while the return to "normal" has been celebrated by many, results from the most recent Stress in America™ survey paint a different picture. Psychologists with APA say a superficial characterization of day-to-day life being more normal is obscuring the posttraumatic effects that have altered our mental and physical health.

When reviewing this year's survey data, APA psychologists widely agreed there is mounting evidence that our society is experiencing the psychological impacts of a collective trauma.

"The Covid-19 pandemic created a collective experience among Americans. While the early-pandemic lockdowns may seem like the distant past, the aftermath remains," said Arthur C. Evans Jr., PhD, APA's chief executive officer.

Further, widespread trauma has not been limited to the pandemic. Global conflict, racism and racial injustice, inflation, and climate-related disasters are all weighing on the collective consciousness of Americans.

Stress in America 2023: A Nation Recovering from Collective Trauma examines the lasting psychological impacts of this combination of era-defining crises. An inspection of pre- and post-pandemic mental and physical health reveals signs of collective trauma among all age cohorts.

The data suggests the long-term stress sustained since the Covid-19 pandemic began has had a significant impact on well-being, evidenced by an increase in chronic illnesses-especially among those between the ages of 35 and 44, which increased from 48% reported in 2019 to 58% in 2023. Adults ages 35 to 44 also experienced the highest increase in mental health diagnoses-from 31% reported in 2019 to 45% in 2023-though adults ages 18 to 34 still reported the highest rate of mental illnesses at 50% in 2023.

Psychological science has revealed that long-term stress creates risks for a variety of mental health challenges, may make us feel more sensitive even to daily hassles, can have broader impacts on our general life outlook and goals, and affects the body's physiological response to stressors in ways that have notable implications for our physical health. Coping with long-term stress requires a different set of skills than adjusting to temporary stressors.

Stress puts the body on high alert and ongoing stress can accumulate, causing inflammation, wearing on the immune system, and increasing the risk of a host of ailments, including digestive issues, heart disease, weight gain, and stroke.

"We cannot ignore the fact that we have been significantly changed by the loss of more than one million Americans, as well as the shift in our workplaces, school systems, and culture at large. To move toward posttraumatic growth, we must first identify and understand the psychological wounds that remain," said Evans.

The collective trauma of a confluence of crises leaves lasting impact

When examining this year's survey data, APA psychologists noted many people had generally positive perceptions of their physical health even when they also reported being diagnosed with a chronic condition. For example, despite high ratings of physical health (81% rated their physical health as good or better), two-thirds of adults (66%) said they have been told by a health care provider that they have a chronic illness -including high blood pressure (28%), high cholesterol (24%), or arthritis (17%).

Further, 81% of adults reported their mental health as good or better, while more than one-third (37%) said they have a diagnosed mental health condition-a 5 percentage point increase from prepandemic levels (32% in 2019). Most cited anxiety disorder (24%) or depression (23%).

The data also shows a tendency among respondents to downplay stress; around two-thirds of adults (67%) reported feeling like their problems are not "bad enough" to be stressed about, because they know others have it worse. Other top reasons adults reported they or a family member may give for not seeking treatment included the belief that therapy doesn't work (40%), lack of time (39%), or lack of insurance (37%).

When it comes to stress management, many are struggling to cope and are bearing the burden alone. Around three in five adults (62%) said they don't talk about their stress overall because they don't want to burden others. Although finances are a top stressor, talking about them is off the table. In fact, only 52% of adults said they are comfortable talking with others about money/finances, and more than two in five adults (45%) said they feel embarrassed talking about money or their financial situation with others.

Around three in five adults (61%) said people around them just expect them to get over their stress. Nearly half (47%) said they wish they had someone to help them manage their stress. Some adults (36%) said they don't know where to start when it comes to managing their stress, and a third (33%) said they feel completely stressed out no matter what they do to manage their stress. In fact, two-thirds of adults (66%) said that, in the last 12 months, they could have used more emotional support than they received, and around a quarter (26%) cited the need for a lot more support. More than two in five adults (44%) said they don't feel anyone understands what they are going through, and more than half (52%) said they wish they had someone to turn to for advice and/or support.

Another consequence of a society under stress is that nearly three in 10 adults (28%) said they have struggled with or had difficulty planning for their future in the past month because of stress. Additionally, a third of adults (33%) said they have too much stress in their day-to-day lives to think about the future.

A widespread feeling of discontent from what they are seeing in the media also serves as a prominent source of stress. Half of adults (50%) said it stresses them that the news is not focusing on what is most important to them on a day-to-day basis and three in five (59%) said it stresses them that politicians aren't talking about things that are most important to them. On top of it all, few reported confidence about the direction our country is going (34%) or said they feel that their government representatives have their best interests in mind (31%).

Psychological impacts of pandemic-era stress felt across age cohorts and lifestyles

A closer look at age-based stress also revealed that though the stress level for the general population has remained relatively steady, the increase is significantly higher for the 35 to 44 age cohort:

18 to 34, 2023 vs. 2019 was 6 vs. 5.7

35 to 44, 2023 vs. 2019 was 5.7 vs. 5.2

45 to 64, 2023 vs. 2019 was 5 vs. 4.9

65+, 2023 vs. 2019 was 3.4 vs. 3.6

The future of our nation (68%) and violence and crime (61%) were reported as significant sources of stress in adults' lives. These were followed by the U.S. debt (57%), mass shootings (56%), social divisiveness (55%), and health care (54%).

Among the day-to-day stress categories, health-related stressors (65%), money (63%), and the economy (64%) were reported among the top significant sources of stress in adults' lives. Those ages 35 to 44 reported having the most factors that cause them significantly more stress today than in 2019, which include money, the economy, family responsibilities, personal safety, and discrimination. Those ages 65+ were the only age group to cite multiple sources as less stressful today than in 2019.
[Related: Gen Z adults and younger millennials are "completely overwhelmed" by stress]

A closer look at ages 18 to 34

The top significant sources of stress reported among the 18 to 34 age cohort in 2023 were health-related and money (both 82%). Of the three categories covered under health-related (family-related, physical health, or mental health), mental health as a stressor was the highest at 72%, which also was the highest among all age cohorts. The largest increases in major stressors reported since 2019 for the 18-34 age group were due to the economy (from 52% in 2019 to 72% in 2023) and housing costs (from 57% in 2019 to 70% in 2023).

A closer look at ages 35 to 44

The top significant sources of stress reported in 2023 among the 35 to 44 age cohort were money (77%) and the economy (74%). Adults ages 35 to 44 who reported money as a significant source of stress were more likely than those 18 to 34 and 65+ to say paying for essentials causes them stress (67% vs. 58% and 53%).

A closer look at ages 45 to 64

Adults ages 45 to 64 were most likely to report money and the economy (both 63%) and health-related (62%) as top significant stressors in 2023. The biggest increase in stressors from 2019 was the economy (up from 45%).

A closer look at ages 65+

The top significant sources of stress reported in 2023 among adults 65+ were the economy (47%) and health-related (45%). The only major stressor that increased in recent years was the economy (from 36% in 2019 to 47% in 2023).

This age cohort was more likely than those ages 18 to 34 and 35 to 44 to report the ability to get things done even when they are feeling stressed (78% vs. 71%, each). They were also more likely than those ages 18 to 34, 35 to 44, and 45 to 64 to say that when they feel stressed, they can get over it quickly (71% vs. 51%, 59%, and 59%).

Further, this tendency to push through stress may be a result of downplaying their stress; adults ages 65+ were more likely than their younger counterparts to feel like their problems are not "bad enough" to be stressed about because they know others have it worse (74% vs. 65% of ages 18 to 34, 63% of ages 35 to 44, and 67% of ages 45 to 64). This "tough it out" mentality may be deterring those in need from seeking help.

A closer look at life stages

In addition to the age-based stress analysis, the survey findings revealed stress trends among varying life stages and lifestyles, including parents, single adult households, and retired adults. For example, in 2023, parents of children under age 18 were more likely than other adults to report a variety of stressors and effects of stress.

Women say they're stressed, misunderstood, and alone

This year's survey found that women continue to report higher stress levels than men and could have used more support. Women reported a higher average level of stress than men (5.3 vs. 4.8 out of 10) and were more likely to rate their stress levels between an eight and 10 than men (27% vs. 21%). Women also were more likely than men to report that they could have used more emotional support than they received in the last 12 months (68% vs. 63%).
[Related: Women in America are stressed-and psychologists aren't surprised]
This year, people of all genders reported that health and finances were among the top sources of stress. But women were more likely than men to report feeling "consumed" by their worries about money (50% vs. 44%). Among those who cite money as a significant source of stress, women were more likely than men to report both paying for essentials (66% vs. 55%) and unexpected expenses (60% vs. 49%) cause them stress. Women were also more likely than men to cite family responsibilities (58% vs. 52%) and relationships (49% vs. 44%) as key stressors in their lives.

What's more, women were more likely than men to say they "strongly agree" that no one understands how stressed they are (22% vs. 17%) and were less likely to report that they can quickly get over stress (54% vs. 65%).

Discrimination and disparities in stress pervade

Discrimination is not only a stressor in some adults' minds, but perhaps a very real presence in their everyday life and potentially a harm to their personal safety. Although financial and health-related stress are top of mind for adults in the U.S., discrimination and personal safety also are concerns. Nearly two in five (39%) said that personal safety is a significant source of stress in their lives, in congruence with more than a quarter (27%) who said discrimination is as well. For those who have experienced at least one act of discrimination, many attributed it to their age (36%), their race (28%), or their gender (22%).

Everyday discrimination is significant for LGBTQIA+ adults. For example, LGBTQIA+ adults were more likely than those who do not identify as LGBTQIA+ to:

Cite discrimination as a significant stressor (45% vs. 24%).

Say they don't feel comfortable voicing their experiences around others for fear of how they would react (57% vs. 44%).

Not feel accepted in their community (43% vs. 25%).

Similar trends are seen among adults with disabilities. Adults with a disability were more likely than adults without a disability to:

Cite discrimination as a significant stressor (34% vs. 22%).

Say they don't feel comfortable voicing their experiences around others for fear of how they would react (57% vs. 40%).

Not feel accepted in their community (40% vs. 21%).

When looking across racial/ethnic identities, Black and Latino/a/e adults were more likely than Asian and White adults to cite discrimination as a significant stressor (43% and 40% vs. 31% and 19%). Black adults were more likely than White adults to have ever experienced a range of acts of discrimination.

Latino/a/e adults were more likely to have experienced various forms of everyday discrimination than White adults. They also were more likely than White and Black adults to say they don't feel comfortable voicing their experiences around others for fear of how they would react (53% vs. 45% and 42%). In addition, this population was more likely than White adults to not feel accepted in their community (33% vs. 27%).

Though adults reported being open to talking about various topics, some are off limits; many reported they never talk with others about their stress related to discrimination (58%). White, older, adults without children under 18, and non-LGBTQIA+ adults were significantly more likely to say they never talk about discrimination, personal safety, or mental health compared with Latino/a/e, Black, Asian, younger adults, parents, and LGBTQIA+ adults.

Additionally, while adults may want to get involved in bettering their community, stress may play a role in their drive to act-and this disproportionately impacts marginalized communities. More than two in five adults (46%) said they care about what happens in their community, but their day-to-day stress distracts them from acting.

Understanding the impacts of stress-what researchers want you to know

The continued prevalence and severity of stress has made it a critical area of research for psychologists, who have conducted hundreds of investigations on the topic over the years. Their work has helped uncover the wide-ranging sources and consequences of stress-and identify buffers and solutions to this universal, but unequal, experience.

These are some of the important things they have found.

1. Stress can manifest in the body.

2. Physical effects of stress can be damaging even when you appear "fine" on the outside.

3. Effects don't end when the stressful experience ends.

4. Social support is good for everyone.

5. Some coping mechanisms don't suffice in unbearable situations.

6. You need stress-and often grow from it.

Read 6 things researchers want you to know about stress for more details

Methodology

The 2023 Stress in America™ survey was conducted online within the United States by The Harris Poll on behalf of APA between August 4-26, 2023, among 3,185 adults ages 18+ who reside in the U.S. that serve as a nationally representative sample. In addition, oversamples were collected in addition to the national sample to allow for increased totals by race/ethnicity: 805 Black, 811 Latino/a/e, and 800 Asian individuals. Interviews were conducted in English and Spanish.

Data is weighted where necessary to reflect their proportions in the population based on the 2022 Current Population Survey by the U.S. Census Bureau and PEW NPORS 2022 (for frequency of internet use). Weighting variables included age by gender, race/ethnicity, education, region, household income, size of household, and frequency of internet use. Latino/a/e adults also were weighted for acculturation, taking into account respondents' household language as well as their ability to read and speak in English and Spanish. Country of origin (U.S./non-U.S.) also was included for Latino/a/e and Asian subgroups. Propensity score weighting was used to adjust for respondents' tendency to be online. A propensity score allows researchers to adjust for attitudinal and behavioral differences between those who are online vs. those who are not, those who join online panels vs. those who do not, and those who responded to this survey vs. those who did not.

Respondents for this survey were selected from among those who have agreed to participate in our surveys. The sampling precision of Harris online polls is measured by using a Bayesian credible interval. For this study, the sample data for the "national sample" is accurate to within ± 2.5 percentage points using a 95% confidence level. This credible interval will be wider among subsets of the surveyed population of interest.

The sample data for the Black sample (national sample and oversample) is accurate to within ± 4.8 percentage points using a 95% confidence level.

The sample data for the Latino/a/e sample (national sample and oversample) is accurate to within ± 5.5 percentage points using a 95% confidence level.

The sample data for the Asian sample (national sample and oversample) is accurate to within ± 4.8 percentage points using a 95% confidence level.

All sample surveys and polls, whether or not they use probability sampling, are subject to other multiple sources of error which are most often not possible to quantify or estimate, including, but not limited to coverage error, error associated with nonresponse, error associated with question wording and response options, and postsurvey weighting and adjustments.

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Stress in America 2023: A nation recovering from collective trauma

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APA's survey data suggests that the COVID-19 pandemic, global conflict, racism and racial injustice, inflation, and climate-related disasters are all weighing on the collective consciousness of Americans

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Context - Use of AI in Mental Healthcare

According to One Mind PsyberGuide, there are around 20, 000 mental health apps on the digital market. (Clay, 2015)

Amidst the mental health care shortage, young people turn to AI Chatbots for help. (Chkareuli, 2023)

Support for using AI to deal with mental health problems among the US population is not as strong as support for using robotics for surgery, skin, and pain management. (PEW Research Center, 2023)

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In the past few years, 10,000 to 20,000 apps have stampeded into the mental health space, offering to "disrupt" traditional therapy. With the frenzy around AI innovations like ChatGPT, the claim that chatbots can provide mental health care is on the horizon.

The numbers explain why: Pandemic stresses led to millions more Americans seeking treatment. At the same time, there has long been a shortage of mental health professionals in the United States; more than half of all counties lack psychiatrists. Given the Affordable Care Act's mandate that insurers offer parity between mental and physical health coverage, there is a gaping chasm between demand and supply.

For entrepreneurs, that presents a market bonanza. At the South by Southwest conference in March, where health startups displayed their products, there was a near-religious conviction that AI could rebuild health care, offering apps and machines that could diagnose and treat all kinds of illnesses, replacing doctors and nurses.

Unfortunately, in the mental health space, evidence of effectiveness is lacking. Few of the many apps on the market have independent outcomes research showing they help; most haven't been scrutinized at all by the FDA. Though marketed to treat conditions such as anxiety, attention-deficit/hyperactivity disorder, and depression, or to predict suicidal tendencies, many warn users (in small print) that they are " not intended to be medical, behavioral health or other healthcare service" or " not an FDA cleared product."

There are good reasons to be cautious in the face of this marketing juggernaut.

Decades ago, Joseph Weizenbaum, a professor at the Massachusetts Institute of Technology and considered one of the fathers of artificial intelligence, predicted AI would never make a good therapist, though it could be made to sound like one. In fact, his original AI program, created in the 1960s, was a psychotherapist named ELIZA, which used word and pattern recognition combined with natural language programming to sound like a therapist:

Woman: Well, my boyfriend made me come here.
ELIZA: Your boyfriend made you come here?
Woman: He says I'm depressed much of the time.
ELIZA: I am sorry to hear that you are depressed.
Woman: It's true. I am unhappy.
ELIZA: Do you think coming here will help you not to be unhappy?

Though hailed as an AI triumph, ELIZA's "success" terrified Weizenbaum, whom I once interviewed. He said students would interact with the machine as if Eliza were an actual therapist, when what he'd created was "a party trick," he said.

He foresaw the evolution of far more sophisticated programs like ChatGPT. But "the experiences a computer might gain under such circumstances are not human experiences," he told me. "The computer will not, for example, experience loneliness in any sense that we understand it."

The same goes for anxiety or ecstasy, emotions so neurologically complex that scientists have not been able pinpoint their neural origins. Can a chatbot achieve transference, the empathic flow between patient and doctor that is central to many types of therapy?

"The core tenet of medicine is that it's a relationship between human and human - and AI can't love," said Bon Ku, director of the Health Design Lab at Thomas Jefferson University and a pioneer in medical innovation. "I have a human therapist, and that will never be replaced by AI."

Ku said he'd like to see AI used instead to reduce practitioners' tasks like record-keeping and data entry to "free up more time for humans to connect."

Subscribe to KFF Health News' free Morning Briefing.

While some mental health apps may ultimately prove worthy, there is evidence that some can do harm. One researcher noted that some users faulted these apps for their "scripted nature and lack of adaptability beyond textbook cases of mild anxiety and depression."

It may prove tempting for insurers to offer up apps and chatbots to meet the mental health parity requirement. After all, that would be a cheap and simple solution, compared with the difficulty of offering a panel of human therapists, especially since many take no insurance because they consider insurers' payments too low.

Perhaps seeing the flood of AI hitting the market, the Department of Labor announced last year it was ramping up efforts to ensure better insurer compliance with the mental health parity requirement.

The FDA likewise said late last year it " intends to exercise enforcement discretion" over a range of mental health apps, which it will vet as medical devices. So far, not one has been approved. And only a very few have gotten the agency's breakthrough device designation, which fast-tracks reviews and studies on devices that show potential.

These apps mostly offer what therapists call structured therapy - in which patients have specific problems and the app can respond with a workbook-like approach. For example, Woebot combines exercises for mindfulness and self-care (with answers written by teams of therapists) for postpartum depression. Wysa, another app that has received a breakthrough device designation, delivers cognitive behavioral therapy for anxiety, depression, and chronic pain.

But gathering reliable scientific data about how well app-based treatments function will take time. "The problem is that there is very little evidence now for the agency to reach any conclusions," said Kedar Mate, head of the Boston-based Institute for Healthcare Improvement.

Until we have that research, we don't know whether app-based mental health care does better than Weizenbaum's ELIZA. AI may certainly improve as the years go by, but at this point, for insurers to claim that providing access to an app is anything close to meeting the mental health parity requirement is woefully premature.

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An AI Chatbot May Be Your Next Therapist. Will It Actually Help Your Mental Health? - KFF Health News

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Given a dire shortage of human behavioral health providers in the U.S., it may prove tempting for insurers to offer up apps and chatbots to meet the federal mental health parity requirement. But artificial intelligence, by definition fake, can't master the empathic flow between patient and doctor that's central to therapy.

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The most recent systematic review and meta-analysis of the effectiveness of CA agents in mental healthcare, as opposed to previous research on rule-based agents.

The focus is on the user experience of using CA agents for mental health support

Provides suggestions on different types of CA and their effectiveness on mental health outcomes in different contexts, and among different populations.

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What's the Difference Between a Chatbot and Conversational AI?

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ELIZA - The First AI chatbot created in the 1960s by Joseph Weizenbaum

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ELIZA - The First AI chatbot created in the 1960s by Joseph Weizenbaum

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MIT researcher Joseph Weizenbaum predicted that "AI would never make a good therapist, though it could be made to sound like one." (Rosenthal, 2023)

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They're always bugging us about something or other. CAN YOU THINK OF A SPECIFIC EXAMPLE

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What's the difference between these two?

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Difference between Systematic Review and Meta-Analysis

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Difference between Systematic Review and Meta-Analysis

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Systematic review vs meta-analysis | What’s the difference?

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Initial search results (after duplicates removed): 7834 articles

Systematic Review: 35 articles

Meta-Analysis: 15 randomized trials

Publication date range: Inception of each database-2023

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1. Out of 35 studies:

Quasi-experimental (n=19)

Randomized trial (n=16)

2. Overall, 17, 123 participants from 15 countries

3. The majority of articles (n=27) were published in 2020

4. Participants age range: 11-92

5. 50% of studies involved non-clinical population

6. CAs are commonly used to deliver psychotherapy and psychoeducational content

7. Platforms: Smartphones and tablets

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Positive vs Negative Experiences with CA

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Positive vs Negative Experiences with CA

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1. Is there anything important I missed while presenting the article?

2. How do you explain heterogeneity in results, and what's your evaluation of the authors' statistical techniques to deal with that limitation?

3. The study findings have an overall positive tone, meaning that the CA agents can be promising during the mental healthcare crisis. Could you explain the motives and reasons for dominating positivity in the conversation despite raising concerns about the ethics and security of AI agents in mental healthcare? (e.g. refer to Pew survey)

4. How would you explain the meta-analysis findings regarding CAs larger effect on depression but no effect on anxiety?

5. The studies compare clinical and non-clinical populations while analyzing the CAs effect size. What methodological observation could you make on this specific decision?

6. How can CAs deal with the intercultural context?

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1. Population: People of all ages

2. Interventions: AI-based Conversational Agents - "software agents or bots that leverage NLP, machine learning, or other AI models and techniques to simulate the human-like conversations."(H. Li et al., 2023, p.10)

3. Comparator: studies with comparisons

4. Outcome: psychological distress or well-being

5. Study: Any experimental study design

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Using AI-based CAs found to be related to:

Significantly greater reduction in psychological distress (g=0.7)

Statistically insignificant improvements in general well-being (g=0.32)

Positive influence on ameliorating depression, but not so significant impact on anxiety.

Heterogeneous outcomes

(Potential reasons: performance bias, and attribution bias)

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CAs can decrease the psychological distress in the following conditions:

A larger positive impact comes from generative (vs. retrieval) multimodal and voice-based (vs. text-based) agents.

Effect is stronger with tablets, smartphones, instant chats vs computer

Middle age/older adults experience a more noticeable impact vs young adults

Reduction in psychological distress was more noticeable among the clinical/subclinical population vs. the non-clinical population

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A chatbot helped more people access mental-health services

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A chatbot helped more people access mental-health services

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A chatbot helped more people access mental-health services

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A chatbot helped more people access mental-health services

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The Limbic chatbot, which screens people seeking help for mental-health problems, led to a significant increase in referrals among minority communities in England.

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Can AI Chatbots Ever Replace Human Therapists?

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Can AI Chatbots Ever Replace Human Therapists?

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This morning, my wellness coach reminded me to savor each exciting moment in my day, but to always take time to rest and recharge. It's good advice-good enough that I would believe it came from a human, instead of an artificial intelligence algorithm anthropomorphized as a cartoon panda.

My panda-shaped algorithm lives in the Earkick app. Each day, I can use Earkick to describe my mood through writing, voice note, or video. Roughly 20 seconds later, its algorithm has analyzed my statement for signs of anxiety and spit out a personalized, conversational recommendation for how I can feel my best.

Earkick is one of a small army of chatbots, Woebot perhaps best-known among them, that promise to use the power of AI to support mental wellness. Describe a problem to one of these chatbots and it can answer with what feels like empathy, offering suggestions or asking follow-up questions just as a human clinician would-and with a pretty good rate of success, according to research on the topic. Early evidence suggests chatbots can deliver elements of cognitive behavioral therapy and other mental-health tools well enough to reduce symptoms of depression and stress at least a little, and Earkick's data find that people who use the app for about five months report a 34% improvement in mood and 32% reduction in anxiety. In one poll, 80% of people who'd used ChatGPT for mental-health advice found it a good alternative to regular therapy.

But is it really? Therapy, after all, is a practice traditionally built on human interaction, on trust and intimacy and emotional intelligence. Studies repeatedly show that the relationship between therapist and client is one of the best predictors for success in treatment, which means it's "critical that the patient feels a sense of trust with the therapist, that they experience the therapist as being warm and understanding and empathic, and that they feel the therapist is someone they can talk to," says David Tolin, an adjunct professor of psychiatry at Yale University School of Medicine and a past president of the Association for Behavioral and Cognitive Therapies.

There is research to suggest that people can develop connections with "conversational agents" like chatbots. And with access to traditional providers hugely inadequate, there are clear potential benefits to relying on them as substitutes. But can AI truly duplicate the experience of talking and growing close to a human therapist-and should it?

"I say this in part as a practicing therapist," Tolin says. "There is something I would find a little sad if we eventually replaced the human connection with a computer connection."

To a much greater extent than medical specialties built on biomarkers and test results, mental-health care relies on the subjective: how a patient describes their symptoms, how their clinician perceives them, internal shifts and breakthroughs that can't be easily measured with numbers. In some ways, this means the field is crying out for AI, with its ability to find patterns and meaning in huge swaths of information that humans can't easily parse. (Indeed, preliminary research suggests AI could help doctors pick the right antidepressant for a particular patient, or study their speech or writing for signs of mental distress.) But the ineffability of therapy also makes it difficult to duplicate.

Traditional therapy is not perfect by any means, but by some estimates, about three-quarters of people who try it see some improvement. It's not always clear why it works, though. The " Dodo Bird Verdict," a long-standing but controversial theory, proposes that different styles of therapy are more or less equal in terms of efficacy, which suggests psychological methods alone aren't what helps patients. Instead, the benefits of therapy may come, in part, from a difficult-to-quantify mixture of factors including the strength of the therapeutic relationship, the act of consciously carving out time and space for mental well-being, or simply knowing a person is listening to you when you talk, says J.P. Grodniewicz, a philosopher who has researched and written about limitations of AI in therapy.

"Maybe psychotherapy is not really about a particular technique," he says. "Maybe it's about co-creating a context in which someone might be growing as a person, exploring themselves, maybe facing existential fears, having someone with whom they can speak about [difficult topics]."

Without being able to clearly define the ingredients in that cocktail and how they come together to improve mental health, it's difficult-if not impossible-to train an algorithm to duplicate the experience, Grodniewicz says.

Peter Foltz, a machine-learning researcher at the University of Colorado, Boulder, agrees the lack of hard data in mental-health care presents challenges. An algorithm, after all, is only as good as the data it's trained on.

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"What you really want to be able to do is tie the characterizations made by AI to some particular kinds of evidence," Foltz says. "And in mental health, really what we're looking at is some kind of neuropsychological change in the brain or the mind...and there needs to be a lot more research to be very clear about what we're measuring."

And yet, when looking at things that do lend themselves to measurement-like how people self-report their symptoms-preliminary studies show that chatbots can improve patients' depression, anxiety, and other issues. Some studies also suggest that processing trauma and emotions through writing is an effective coping strategy, which implies a self-guided mental-health app could be beneficial even if it doesn't perfectly duplicate the experience of lying on a therapist's couch.

"The ultimate question is whether a treatment works," Tolin says. "If it does, then we're happy." More research is required to confirm that AI-assisted therapy actually works, Tolin says, and especially to determine whether it can be used on its own or only in conjunction with a traditional provider. But if studies consistently show that it's effective, it may be more important to know that it works than to know exactly how it works.

In the meantime, however, there's another big question to answer: "If we did develop a perfect artificial-intelligence therapist," Tolin says, "would anybody want to see it?"

So far, it seems most people would not. Recent polls have found that only 20% to 25% of U.S. adults are comfortable with the idea of AI-assisted mental health care, and less than 40% think AI will "help more than it hurts " in the medical field.

Tolin isn't terribly surprised by that resistance. Humans crave connection, and they're already not getting enough of it. Loneliness is considered an epidemic in the U.S., and less than 40% of U.S. adults say they feel "very connected" to other people, according to Gallup data. It may be possible to develop a connection to an app or chatbot, but Tolin doubts whether it would be a fulfilling alternative.

"If I told you that I was going to replace your best friend with a computer, you probably would be unhappy," Tolin says. "There would be something deeply unsatisfying about that, because it's not a person. I think the same principles may apply to a therapist as well."

That points to a potentially larger hurdle for the field to overcome. An algorithm will never be a human-no matter how convincingly it mimics one.
If you or someone you know may be experiencing a mental-health crisis or contemplating suicide, call or text 988. In emergencies, call 911, or seek care from a local hospital or mental health provider.

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Can AI Chatbots Ever Replace Human Therapists?

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AI chatbots that support mental health show promise in treating anxiety and depression. But can they ever replace human therapists?

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Therapy by chatbot? The promise and challenges in using AI for mental health

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Therapy by chatbot? The promise and challenges in using AI for mental health

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Just a year ago, Chukurah Ali had fulfilled a dream of owning her own bakery - Coco's Desserts in St. Louis, Mo. - which specialized in the sort of custom-made ornate wedding cakes often featured in baking show competitions. Ali, a single mom, supported her daughter and mother by baking recipes she learned from her beloved grandmother.

But last February, all that fell apart, after a car accident left Ali hobbled by injury, from head to knee. "I could barely talk, I could barely move," she says, sobbing. "I felt like I was worthless because I could barely provide for my family."

As darkness and depression engulfed Ali, help seemed out of reach; she couldn't find an available therapist, nor could she get there without a car, or pay for it. She had no health insurance, after having to shut down her bakery.

So her orthopedist suggested a mental-health app called Wysa. Its chatbot-only service is free, though it also offers teletherapy services with a human for a fee ranging from $15 to $30 a week; that fee is sometimes covered by insurance. The chatbot, which Wysa co-founder Ramakant Vempati describes as a "friendly" and "empathetic" tool, asks questions like, "How are you feeling?" or "What's bothering you?" The computer then analyzes the words and phrases in the answers to deliver supportive messages, or advice about managing chronic pain, for example, or grief - all served up from a database of responses that have been prewritten by a psychologist trained in cognitive behavioral therapy.

That is how Ali found herself on a new frontier of technology and mental health. Advances in artificial intelligence - such as Chat GPT - are increasingly being looked to as a way to help screen for, or support, people who dealing with isolation, or milddepression or anxiety. Human emotions are tracked, analyzed and responded to, using machine learning that tries to monitor a patient's mood, or mimic a human therapist's interactionswith a patient. It's an area garnering lots of interest, in part because of its potential to overcome the common kinds of financial and logistical barriers to care, such as those Ali faced.

Potential pitfalls and risks of chatbot therapy

There is, of course, still plenty of debate and skepticism about the capacity of machines to read or respond accurately to the whole spectrum of human emotion - and the potential pitfalls of when the approach fails. (Controversy flared up on social media recently over a canceled experiment involving chatbot-assisted therapeutic messages.)

My worry is [teens] will turn away from other mental health interventions, saying, 'Oh well, I already tried this and it didn't work.'

"The hype and promise is way ahead of the research that shows its effectiveness," says Serife Tekin, a philosophy professor and researcher in mental health ethics at the University of Texas San Antonio. Algorithms are still not at a point where they can mimic the complexities of human emotion, let alone emulate empathetic care, she says.

Tekin says there's a risk that teenagers, for example, might attempt AI-driven therapy, find it lacking, then refuse the real thing with a human being. "My worry is they will turn away from other mental health interventions saying, 'Oh well, I already tried this and it didn't work,' " she says.

But proponents of chatbot therapy say the approach may also be the only realistic and affordable way to address a gaping worldwide need for more mental health care, at a time when there are simply not enough professionals to help all the people who could benefit.

Someone dealing with stress in a family relationship, for example, might benefit from a reminder to meditate. Or apps that encourage forms of journaling might boost a user's confidence by pointing when out where they make progress.

Proponents call the chatbot a 'guided self-help ally'

It's best thought of as a "guided self-help ally," says Athena Robinson, chief clinical officer for Woebot Health, an AI-driven chatbot service. "Woebot listens to the user's inputs in the moment through text-based messaging to understand if they want to work on a particular problem," Robinson says, then offers a variety of tools to choose from, based on methods scientifically proven to be effective.

Many people will not embrace opening up to a robot.

ChukurahAli says it felt silly to her too, initially. "I'm like, 'OK, I'm talking to a bot, it's not gonna do nothing; I want to talk to a therapist," Ali says, then adds, as if she still cannot believe it herself: "But that bot helped!"

At a practical level, she says, the chatbot was extremely easy and accessible. Confined to her bed, she could text it at 3 a.m.

"How are you feeling today?" the chatbot would ask.

"I'm not feeling it," Ali says she sometimes would respond.

The chatbot would then suggest things that might soothe her, or take her mind off the pain - like deep breathing, listening to calming music, or trying a simple exercise she could do in bed. Ali says things the chatbot said reminded her of the in-person therapy she did years earlier. "It's not a person, but, it makes you feel like it's a person," she says, "because it's asking you all the right questions."

Technology has gotten good at identifying and labeling emotions fairly accurately, based on motion and facial expressions, a person's online activity, phrasing and vocal tone, says Rosalind Picard, director of MIT's Affective Computing Research Group. "We know we can elicit the feeling that the AI cares for you," she says. But, because all AI systems actually do is respond based on a series of inputs, people interacting with the systems often find that longer conversations ultimately feel empty, sterile and superficial.

While AI may not fully simulate one-on-one individual counseling, its proponents say there are plenty of other existing and future uses where it could be used to support or improve human counseling.

AI might improve mental health services in other ways

"What I'm talking about in terms of the future of AI is not just helping doctors and [health] systems to get better, but helping to do more prevention on the front end," Picard says, by reading early signals of stress, for example, then offering suggestions to bolster a person's resilience. Picard, for example, is looking at various ways technology might flag a patient's worsening mood - using data collected from motion sensors on the body, activity on apps, or posts on social media.

Technology might also help improve the efficacy of treatment by notifying therapists when patients skip medications, or by keeping detailed notes about a patient's tone or behavior during sessions.

Maybe the most controversial applications of AI in the therapy realm are the chatbots that interact directly with patients like Chukurah Ali.

What's the risk?

Chatbots may not appeal to everyone, or could be misused or mistaken. Skeptics point to instances where computers misunderstood users, and generated potentially damaging messages.

But research also shows some people interacting with these chatbots actually prefer the machines; they feel less stigma in asking for help, knowing there's no human at the other end.

Ali says that as oddas it might sound to some people, after nearly a year, she still relies on her chatbot.

"I think the most I talked to that bot was like 7 times a day," she says, laughing. She says that rather than replacing her human health care providers, the chatbot has helped lift her spirits enough so she keeps those appointments. Because of the steady coaching by her chatbot, she says, she's more likely to get up and go to a physical therapy appointment, instead of canceling it because she feels blue.

That's precisely why Ali's doctor, Washington University orthopedist Abby Cheng, suggested she use the app. Cheng treats physical ailments, but says almost always the mental health challenges that accompany those problems hold people back in recovery. Addressing the mental-health challenge, in turn, is complicated because patients often run into a lack of therapists, transportation, insurance, time or money, says Cheng, who is conducting her own studies based on patients' use of the Wysa app.

"In order to address this huge mental health crisis we have in our nation - and even globally - I think digital treatments and AI can play a role in that, and at least fill some of that gap in the shortage of providers and resources that people have," Cheng says.

Not meant for crisis intervention

But getting to such a future will require navigating thorny issues like the need for regulation, protecting patient privacy and issues of legal liability. Who bears responsibility if the technology goes wrong?

Many similar apps on the market, including those from Woebot or Pyx Health, repeatedly warn users that they are not designed to intervene in acute crisis situations. And even AI's proponents argue computers aren't ready, and may never be ready, to replace human therapists - especially for handling people in crisis.

"We have not reached a point where, in an affordable, scalable way, AI can understand every sort of response that a human might give, particularly those in crisis," says Cindy Jordan, CEO of Pyx Health, which has an app designed to communicate with people who feel chronically lonely.

The hype and promise is way ahead of the research that shows its effectiveness.

Jordan says Pyx's goal is to broaden access to care - the service is now offered in 62 U.S. markets and is paid for by Medicaid and Medicare. But she also balances that against worries thatthe chatbot might respond to a suicidal person, " 'Oh, I'm sorry to hear that.' Or worse, 'I don't understand you.' " That makes her nervous, she says, so as a backup, Pyx staffs a call center with people who call users when the system flags them as potentially in crisis.

Woebot, a text-based mental health service, warns users up front about the limitations of its service, and warnings that it should not be used for crisis intervention or management. If a user's text indicates a severe problem, the service will refer patients to other therapeutic or emergency resources.

Cross-cultural research on effectiveness of chatbot therapy is still sparse

Athena Robinson, chief clinical officer for Woebot, says such disclosures are critical. Also, she says, "it is imperative that what's available to the public is clinically and rigorously tested," she says. Data using Woebot, she says, has been published in peer-reviewed scientific journals. And some of its applications, including for post-partum depression and substance use disorder, are part of ongoing clinical research studies. The company continues to test its products' effectiveness in addressing mental health conditions for things like post-partum depression, or substance use disorder.

But in the U.S. and elsewhere, there is no clear regulatory approval process for such services before they go to market. (Last year Wysa did receive a designation that allows it to work with Food and Drug Administration on the further development of its product.)

It's important that clinical studies - especially those that cut across different countries and ethnicities - continue to be done to hone the technology's intelligence and its ability to read different cultures and personalities, says Aniket Bera, an associate professor of computer science at Purdue.

"Mental-health related problems are heavily individualized problems," Bera says, yet the available data on chatbot therapy is heavily weighted toward white males. That bias, he says, makes the technology more likely to misunderstand cultural cues from people like him, who grew up in India, for example.

"I don't know if it will ever be equal to an empathetic human," Bera says, but "I guess that part of my life's journey is to come close."

And, in the meantime, for people like Chukurah Ali, the technology is already a welcome stand-in. She says she has recommended the Wysa app to many of her friends. She says she also finds herself passing along advice she's picked up from the app, asking friends, "Oh, what you gonna do today to make you feel better? How about you try this today?"

It isn't just the technology that is trying to act human, she says, and laughs. She's now begun mimicking the technology.

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Therapy by chatbot? The promise and challenges in using AI for mental health

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Just a year ago, Chukurah Ali had fulfilled a dream of owning her own bakery - Coco's Desserts in St. Louis, Mo. - which specialized in the sort of custom-made ornate wedding cakes often featured in baking show competitions. Ali, a single mom, supported her daughter and mother by baking recipes she learned from her beloved grandmother.