Visualise a therapy scene from any random Hollywood flick playing out, and the obvious elements will be a disgruntled patient with vague looks, seemingly lost, coyly sitting in a small cabin and recounting troubles in incoherent babbles, sometimes having a meltdown while the psychiatrist looks on.
Reality check. Most therapies in the world around you do not happen this way, except that the therapist in the room is human. But, what if you have a digital companion for your 4 am conversations, a confidant of work-related stress. You could celebrate, lament or discuss personal relations with a medium of sorts.
To be precise, a chatbot like Woebot, a therapeutic at that, is designed to listen to psychological needs any time of the day. It checks in with users on a daily basis, remembers their responses and offer suggestions like a therapist — often recasting negative thoughts. Chatbots or, for that matter, emergency distress helplines are important support systems to fend off crises, guiding callers through suicidal thoughts, clinical depression, psychotic breaks, or manic episodes. As Nimesh G Desai, director, Institute of Human Behaviour & Allied Sciences (IHBAS), says, “Helplines adopt the befriending technique as they come to people’s aid without judging them. It reduces isolation and loneliness, gives reassurance from a friend on the other side who can be helpful at the time of suicidal thoughts.”
AI to the rescue
As per a July 2019 report published by the World Economic Forum on better mental health for all via the ethical adoption of technologies, in collaboration with Accenture, mental health disorders are among the leading causes of morbidity and mortality worldwide and can cost the global economy about $16 trillion by 2030. The report also suggests an estimated 300 million people worldwide suffer from depression, while suicide is the second leading cause of death among young people. In the US and the UK, over 50% people with mental illness are left to deal with it without any medical care. Such large diagnostic and care gaps call for novel solutions. Smartphones, wearable sensors and cloud-based, deep-learning AI tools offer new opportunities to increase access to mental healthcare. But machines, howsoever intelligent, do not have an EQ (emotional quotient). They can interpret patients’ answers in depth but cannot sense discomfort, body language and other nuances that only a human can observe.
With the increase in psychiatric disorders like depression, bipolar affective disorder, schizophrenia and other psychoses like dementia or autism, there is hindrance in seeking effective treatment, especially among youngsters who often lack time or are hesitant to seek a therapist. Instead, they like to pour their hearts out to a digital companion.
Savitha Kuttan, CEO of Omnicuris, a socio-medical enterprise that works with state governments to provide online digital continuous medical education (CME) of doctors, believes working with patients not willing to open up is very difficult. “Their hesitance might stem from shyness, guilt, embarrassment, or scepticism about professional counselling. Young patients, who are pushed into getting professional help by their parents, display rebelliousness and refuse to cooperate. So, at times, it becomes difficult for the therapist to address issues without getting enough information,” she says.
Technology is being used at the work front, too, to tackle stress. Thrive Global, a software service platform, works with KPMG, Microsoft, American Express, The Guardian Life Insurance Company of America, among others, to help employees combat stress-related problems and provide micro-steps that are too small to fail at. Some steps like ‘switch off your phone 30 minutes before going to bed’ or ‘it’s okay to not be connected 24×7’ or ‘close your eyes and breathe for one minute in the morning’ will be part of their sessions. “A great way to raise awareness about the causes of stress in the lives of employees is through our live webinars or facilitator-led sessions on habit stacking that work well in conditioning the mind,” says Marcus Ranney, general manager, India, of the company, adding that by partnering with leading institutes like
Stanford Medicine, they bring the latest behaviour change technology through digital means. Even educational institutes, for instance the Indian Institutes of Technology (IIT), which attract the top engineering students, have witnessed a spate of suicides in recent years. The pressure of living up to being an IITian is simply too much for some. Hence, IIT Kharagpur has come up with innovative methods to help students de-stress. The administration has started cutting off electricity for an hour on some evenings to encourage students to leave their rooms, go out and spend time with their peers. The campus has also tied up with Your Dost, an online counselling and emotional wellness
service, for its students to report distress without having to reveal their identities.
WHO’s Mental Health Action Plan 2013-2020 suggests that health systems have not yet adequately responded to the burden of mental disorders. As a consequence, the gap between the need for treatment and its provision is wide all over the world. In low- and middle-income countries, between 76% and 85% of people with mental disorders receive no treatment, the report reveals. In high-income countries, between 35% and 50% of people with mental disorders are in the same situation, it states. People with mental illness require social support and help in accessing educational programmes or finding employment and housing, which enable them to live and be active in their communities. Prakriti Poddar, expert in mental health and the managing trustee of Poddar Foundation, works closely with schools, government organisations, gram panchayats, social workers and communities to create a support network. She finds a huge paucity of mental health experts in India. “Whatever limited number of psychiatrists, psychologists and therapists are available, are largely based in top tier cities. In smaller towns and villages, people don’t understand the meaning of mental health. Lack of awareness thrives. Chatbots do not have the capability at this point to replace a therapist. For people who are hesitant to visit a doctor on account of stigma, chatbots can offer a basic level of help,” says Poddar.
India has a staggering shortage of mental health experts in the country, and digital interfaces are emerging as viable alternatives for reducing this gap, and making psychiatric diagnosis and treatment accessible and affordable. But does a mental health chatbot help, and to what extent?
Merits & demerits
Besides their 24×7 availability, bots reduce the fear associated with being judged by a fellow human being for having emotional or mental health concerns. A telemental health practitioner-cum-clinical psychologist, Smriti Sawhney Joshi, who leads designing psycho-therapeutic interventions for Wysa (an AI-based ‘emotionally intelligent’ bot), says, “For many, chatbots could act as a virtual coach, helping in individual venting. It responds to the emotions and uses evidence-based cognitive-behavioural techniques (CBT), meditation, breathing, yoga, motivational interviewing and micro-actions to help build mental resilience skills.” Kuttan of Omnicuris says, adding, “Machine learning can also be used to customise plans and help patients stay motivated with the help of gaming techniques. For instance, users can move through carefully designed virtual environments and perform tasks that get progressively harder. The performance results help researchers assess their motivation levels, and design treatments to keep them committed.”
Chatbots can be used to monitor one’s mood or track exercise/sleep routine as is done by a therapist. They provide companionship and therapy support that can lessen the load on therapists. It emerges as an option for people who have problem with accessibility and affordability, in terms of time, distance, and finances.
Shyam Bhat, lead psychiatrist at mind.fit, offers mental wellness solutions through yoga, meditation and therapy — both online via an app or offline through therapy rooms located across prominent cities in India. He finds chatbots very scalable and inexpensive. “For people suffering from autism, chatbots could be a good transition,” he says, adding that a therapist’s session works on manual interventions and is capable of getting into the psyche of a human mind. “Therapies are time-consuming. A therapist will spend at least an hour per session, but there are far too many people suffering from mental illness as compared to the professionals in the world, so a bot may come handy.
Prevention can empower people. Since we can’t undermine the results of the therapists at the same time, an app helps automate a lot of process. It acts like a virtual therapist that can detect subtleties accordingly, and at the same time provide an option to meet an actual therapist. Hence, anxiety and depression can minimise if you learn to manage your stress through an app,” he adds.
At Thriive Art & Soul, a wellness portal offering services of verified alternative therapists, CEO Pinky Daga has built in a support system with a ‘call now’ feature, where a user can instantly connect with a therapist, and speak about any issue personally.
Among a few limitations, bots do not replace treatment especially for people with serious conditions. As Samir Parikh, director, department of mental health and behavioural sciences, and chairperson of Fortis National Mental Health Council at Fortis Healthcare, Gurugram, says, “There is definitely potential in how artificial intelligence can contribute to improving mental health. Chatbots have their place in simpler aspects such as screening, providing psycho-education and basic cognitive and behavioural strategies. But they cannot replace the more nuanced interpersonal dynamics that are key to guiding treatment in psychotherapy.”
Helplines make the last-minute changes possible by providing information to callers on treatment centres or other alterations as per individuals’ needs. “Some people do not want to share personal data with a bot, and many doubt the effectiveness of a ‘machine’ helping manage emotional issues versus a professional. Sometimes there are tech issues like the bot may seem repetitive or a break in the flow of conversation may happen due to network issues, impacting user experience negatively,” feels Joshi of Wysa. Confidentiality, universality of application, lack of standardisation and monitoring, over-dependence on the bots are a few concerns, apart from response in a formulaic way when they can’t contextualise what the user says. A trained, helpful and empathetic human can perform in a better way.
“Chatbots even explicitly clarify that they are not an alternative to conventional therapy. Some are not effective in detecting and responding to child sexual abuse, drug use and eating disorders. There are moral and ethical dilemmas that necessitate the requirement of online safety laws, making it mandatory for companies developing such apps to protect their users or pay heavy fines if they don’t deliver,” adds Kuttan.
Expensive or not?
Managing and improving mental health with Wysa is free, barring a small fee for using premium tools or for coaching session subscription for a month, which costs about `2000 on an Android-based device. If the app is downloaded from iOS, it costs $10 for the digital premium and $50 for a monthly-coach subscription. As per a WEF report, in almost half of the world’s countries, the ratio of psychiatrists to people is 4 or less to every 100,000. This acute shortage of mental healthcare means that people who need it regularly need to go to private professionals, who are not affordable. “On an average, people who have to make regular visits to the psychiatrist end up spending close to approx `8,000 a month. Online consultation can make therapy accessible to a geographically wider audience,” says Kuttan.
A growing area of psychological (non-pharmaceutical) therapies for anxiety, depression and addiction called cognitive bias modification therapy (CBMT), used by mind.fit, comes as a great help. “The sessions charges at mind.fit are around `1,000, and we have constructed the app at a level where a psychiatrist can get a context of what the problem is,” says Bhatt.
Do helplines really help?
Helplines serve as temporary relaxation for stressed students during examination or for youngsters with relationship issues. Desai of IHBAS suggests, “The feeling of ambivalence in the final moment is universal. So, a friendly listener can kill the balance as helplines de-stigmatise by anonymity.” On an average, IHBAS gets 15 suicidal cases on account of depression, schizophrenia, personal crisis every week.
With the increase in suicide rate, only a handful of helplines are working towards emotional bandaging. Sumaitri Aasra, a Delhi-based voluntary organisation, helps people in their extreme distress by running a crisis intervention centre for those in depression or having suicidal tendencies. They have helplines too, which are open Monday to Friday from 2pm to 10pm and Saturday-Sunday 10 am to 10 pm.
Parikh of Fortis feels that helplines and chatbots can play a key role in making mental health affordable. “Lack of reach and accessibility, crisis intervention, basic initial support can be provided through helplines. This encourages free preventive care and utilises digital media to create awareness and bridge the deficit of experts in the country,” he says.
During moments of crisis or at odd hours, a hotline or a chatbot is one of the first resources people can turn to. A recent report quotes Shalini Rajneesh, principal secretary (health and family welfare), Karnataka, saying the number of callers to crisis helplines in India, seeking counselling, has increased from 11,531 in 2013-14 to 57,473 calls in 2016-17. This refers to the importance of increasing the number and accessibility of suicide helplines in India to handle greater call volume and provide quality care.
Another example is The Vandrevala Foundation, a non-profit organisation in Mumbai. When Arun John, executive vice-president, was setting up the helpline about 12 years ago, he faced major setbacks as most helplines were not 24×7 and were manned by caregivers or patients who had healed themselves. They used to give heavily biased advice to the callers. John set up a mechanism to receive a call log register. From 400 calls a month in 2009, the year when the foundation was established, the foundation has been receiving about 6,000 calls a month and 100 mails a day this year. “The age group ranges from eight to 80, and we now keep a log of calls with a retrieval system where we can spot repeat patients and give them immediate help,” he says. Of all the calls Vandrevala Helpline got in 2019, 1.90% were cases of suicide and repeat self-harm; 23.35% for depression; 19.78% on relationship issues; 4.25% for daily life issues and 1.90% for occupational hazards.
The foundation is also building an app on text messaging service, which will offer counselling through SMS and WhatsApp messages. The software and logistics for the text helpline are in the final stages and the service is likely to begin in February. “When it comes to discussing mental health issues, it takes a lot of courage to talk about it. There are many people who freeze when counsellors pick up their call. At times, they are not calling from a conducive setting. A parent or a relative may have stepped into their room or there may be some other reason why they cannot talk freely over phone. This is why we thought of having a crisis intervention text helpline, where the person in need can seek help in comfort. By doing an analysis of our calls, we have learned that most of the callers are in the 18 to 35 age group, who are very savvy with text messaging,” adds John.
There have been instances where the helplines have failed to provide adequate support to the callers. “Either the numbers are not valid or updated on specific sources, the lines are continuously busy, the callers do not get a response or get very poor counselling. The volume of calls received is one of the major reasons behind the poor response rate. This can improve the dire situation with online counselling and chatbots,” feels Kuttan of Omnicuris.
On the contrary, Poddar feels helplines have limited reach. “There is lack of awareness. If an individual doesn’t understand that she requires help and there is a possibility of finding help in a therapist, nothing can be done. No help will work unless we are able to generate a wider positive discussion about mental health to educate people on when and how to seek help without being stigmatised,” she says.