The world’s mounting mental health crisis isn’t just about the vast numbers of people falling ill. It’s about the tiny number of people available to treat them.
Wherever you live, it’s highly probable that there simply are not nearly enough psychiatrists and psychotherapists. The overwhelming majority of countries have fewer than 200 psychiatrists for every million people.
The result is often long waiting times, eye-watering fees for private attention and/or the overprescription of antidepressants by family doctors with few other options.
Now, however, technology is seeking to fill the vacuum with a formidable dashboard of apps, chatbots, avatars and digital counsellors that promise everything from daily check-ins and mood tracking to cognitive behavioural therapy and preventive “mental health hygiene”. The big question is: are they any good?
The majority of these platforms are for-profit businesses and, as such, the global mental health software market had an estimated value of $1.35bn in 2017.
Some experts in the mental health field are cautiously optimistic. The British Association for Counselling and Psychotherapy (BACP), the profession’s regulatory body, found in a recent survey of 1,987 members that 61% already use digital platforms in their therapeutic work, ranging from messaging to video conferencing. The deputy chair of the BACP, Fiona Ballantine Dykes, says that with text-based online platforms, “there are benefits to the anonymity, since sometimes it is really difficult to sit in front of a person and talk to them. If this is something that can encourage people to take a first step to counselling or help signpost them to other services, then that is fantastic.”
Esther Schmidt, NHS children’s services commissioning lead in Swindon, says that these anonymised online services “seem to reach some people from BME [black and minority ethnic] and minority groups in a way that face-to-face services probably wouldn’t because of stigma around cultural assumptions of mental health”. She notes that these services “will become an increasing part of treatment, especially for places with geographical challenges”.
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Yet not everyone is a fan. Sarah Niblock, the chief executive of the UK Council for Psychotherapy (UKCP), the sector’s regulatory body, has her concerns. “While the immediacy and accessibility of online mental health platforms can be seen as a definite positive, the anonymity can be troubling,” she says. “There’s no evidence that these platforms can provide a lasting alternative to face-to-face therapy, since the therapeutic relationship between practitioner and client is what allows the person to confront issues which have been deeply buried.” It’s this confrontation that makes the therapist’s office a potentially daunting experience.
By far the most popular of all these services are mindfulness apps. Drawing on meditative therapies, platforms such as Headspace have been valued at $250m, and its rival Calm has been downloaded more than 45m times.
While these services mainly use the digital format as an accessible alternative to physical diaries or self-help guides, there has been a new spate of apps that offer counselling services and peer support groups via a digital platform.
Perhaps the most popular of these, in the UK at least, is Kooth, a service targeted at 11- to 18-year-olds, allowing them to anonymously discuss their mental health experiences with peers, as well as take part in text-based counselling sessions with remote therapists. User numbers are expected to top 100,000 this year, from 20,000 in 2015, and 95% of users say they would recommend it to a friend. Co-founder Zoe Blake credits Kooth’s success to digital anonymity. “There’s a disinhibition factor associated with counselling via text, where young people feel the lack of eye contact or judging allows them to be themselves,” she says. “Over 86% of our users have said they prefer the online environment to face-to-face counselling.”
Ben Griffiths, 16, has been using Kooth for the past 18 months. “There’s definitely less stigma around using Kooth,” he says. “When you go to a counselling session in school, it’s hard to be private about it because people can see where you are going – whereas with Kooth it’s anonymous, you can have as many sessions as you need, and it helps stop your small stresses from developing into something bigger, like depression.”
Blake emphasises that Kooth is an early-intervention service, designed to address the exam-related stresses experienced by users such as Griffiths, rather than for crisis management. “We’re not replacing face-to-face counselling,” she says, “we’re getting the counsellors to do only the things they can do, without taking up unnecessary time on preliminaries.”
While Kooth is facilitated by counsellors with a minimum of three years’ experience, other platforms integrate digital aspects further, using artificial intelligence to take the place of a trained human interface. Silicon Valley firms Woebot and X2AI, as well as Indian startup Wysa, all use scripted chatbots to engage with their users, scanning text to machine-learn cues that they then respond to.
Wysa is operated by a penguin avatar that users can chat to, as if using WhatsApp, describing itself as “your life coach and friend”, while Woebot’s interface is more constructed. It conducts daily “check-ins” that monitor users’ moods (from “happy” to “angry”, “tired”, or “sad”) as well as allowing users to write “chat stories” to explore emotions in greater detail.
For instance, on clicking that I was “sad” on one Woebot check-in, it recommended a “thought challenger” exercise to identify my negative thoughts and pick apart the reasons for their existence with a series of short responses.
While the experience can feel forced and jarring at times (interspersing emojis with phrases such as “coinky-dink” and “cognitive dissonance”), these chatbots are extremely popular: Woebot receives an exchange of 2m messages a week, X2AI covers 4 million people in the US and Wysa has more than 600,000 users globally. Woebot co-founder Alison Darcy defines her platform not as a prediagnosis tool but instead one that “helps people at the point of the single encounter, changing the conversation away from the domain of the clinic towards the understanding that everyone has mental health, which has to be taken care of every day”. In this way, she believes that logging on and communicating with the app for just 10 minutes a day can have a more powerful effect than the “one-hour lecture” of a counselling session.
Similarly, Wysa co-founder Ramakant Vempati says that “labelling and diagnosis is completely irrelevant to the lived experience of a condition. What people want is a safe space to be able to talk, an empathetic experience. So Wysa’s like having a journal which can write back to you.”
Yet these complex and rapid technological developments have not always had positive results. A recent test conducted by the BBC found that both Wysa and Woebot failed to notice messages containing allegations of underage sexual abuse, responding in one case that the user should “rewrite your negative thought so that it’s more balanced”.
But Niblock of UKCP points out: “People should be unafraid to work with psychotherapists, since you need the ability, no matter how ashamed or guilty you feel about something, to tell that to a person who then says, ‘I hear you’, and who isn’t judging. This is where therapy is transformational, and a chatbot cannot replace being supported by a human being.”
If reliance on AI chatbots is a step too far, then perhaps digital interventions as part of a holistic treatment is the solution. In this vein, workplace mental health platform Unmind produces informational content, which is signposted to the user by AI, to create a combination of cognitive behavioural therapy and guided self-help.
Clinical psychologist and Unmind co-founder Nick Taylor says without digital mental health treatment, the £34.9bn cost of mental ill health at work in the UK last year will only increase. “From a clinical perspective, it’s really frustrating that when you see someone for the first time, you think, ‘If only I’d met you six months before, I could’ve had much more of an impact’,” he says.
“We wouldn’t leave a broken leg for six months without going to the doctor, but that’s what happens with mental health, and it’s incredibly damaging.”
To remedy this, Unmind aims to remove the negative stigma around mental health. “Diagnostic assessment searches for problems, and you can’t use that for a population that is well,” Taylor says. “It’s not appropriate to ask someone who is well if they’re suicidal – it’ll put them off engaging with their mental health full-stop. So, our platform allows you to track your wellbeing and, while we’re not diagnostic, we can develop a good idea of how well someone is, based on how they interact with the platform, and that allows us to assign content or signpost to other services.”
Unmind is only available through employers who have paid for access, and its current users include more than 100,000 employees of John Lewis and Yorkshire Building Society, but the company is in talks to expand into the US – where 65% of the population of non-metropolitan counties do not have access to a psychiatrist.
Perhaps early digital engagement with our mental health could reduce the stigma of the therapist’s office, especially if it is not easily accessible. As digital incursions into our life become natural – none of the companies I spoke to reported concerns from their users on data usage – these mental wellbeing platforms could become as commonplace as Facebook or Twitter. “Mental health is the number one best thing about being a human being,” Taylor says, “so it’s frustrating that we always see it in a negative light – we need the right care at the right time and we shouldn’t be ashamed of it.”
• Ammar Kalia is a Guardian journalist and holder of a Scott Trust bursary
• In the UK, Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Hotline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14. Hotlines in other countries can be found here.
