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The synthetic therapist
Some people prefer to bare their souls to computers
rather than to fellow humans
P
eople have always noticed Yrsa
Sverrisdottir. First it was ballet,
which she performed intensively
while growing up in Iceland. Then
it was science, which she excelled
at and which brought her to the
stage at conferences. And starting
in 2010, when she moved to the
University of Oxford in the United
Kingdom to study the neurophysiology of the
heart, it was her appearance. With her Nor-
dic features framed by radiant blonde hair, “I
just stand out here,” she says. “I can’t help it.”
After she arrived in the United Kingdom,
she found that she no longer enjoyed the
attention. She began to feel uncomfortable
in crowds. Her relationships suffered. There
had been some obvious stressors, such as
the deaths of both of her parents. But the
unease didn’t let up. By 2012, she says, “I felt
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By John Bohannon
like I was losing control.” Then she met Fjola
Helgadottir, one of the few other Icelanders
in town. Helgadottir, a clinical psychology
researcher at Oxford, had created a com-
puter program to help people identify and
manage psychological problems on their
own. Sverrisdottir decided to give it a try.
The program, based on a technique
called cognitive behavioral therapy (CBT)
and dubbed CBTpsych, begins with sev-
eral days of interactive questioning. “It
was exhausting,” Sverrisdottir says. The
interrogation started easily enough with
basic personal details, but then began to
probe more deeply. Months of back and
forth followed as the program forced her
to examine her anxieties and to identify
distressing thoughts. CBTpsych diagnosed
her as having social anxiety, and the in-
sight rang true. Deep down, Sverrisdottir
Published by AAAS
Ellie, a virtual health agent,
monitors patients’ expressions,
gestures, and voice.
realized, “I didn’t want people to see me.”
Then the program assumed the role of
full-fledged therapist, guiding her through
a regimen of real-world exercises for tak-
ing control. It sounds like a typical success
story for clinical psychology. But no human
psychologist was involved.
CBTpsych is far from the only computer-
PHOTO: USC INSTITUTE FOR CREATIVE TECHNOLOGIES
ized psychotherapy tool available, nor the
most sophisticated. Ellie, a system built at
the University of Southern California (USC)
in Los Angeles, uses artificial intelligence
(AI) and virtual reality to break down barri-
ers between computers and humans. Origi-
nally funded by the U.S. military, its focus
is on diagnosing and treating psychological
trauma. Because patients interact with a
digital system, the project is generating a
rare trove of data about psychotherapy itself.
The aim, says Albert “Skip” Rizzo, the USC
sciencemag.org SCIENCE
psychologist who leads the effort, is nothing
short of “dragging clinical psychology kick-
ing and screaming into the 21st century.”
A 19 June editorial in The New York Times
deemed computerized psychotherapy “ef-
fective against an astonishing variety of
disorders.” The penetration of the Internet
into far-flung communities could also bring
mental health treatment to vast numbers of
people who otherwise have no access.
But whether clinical psychologists will
accept AI into their practice is uncertain.
Nor is it clear that the tools of AI can carry
computerized psychotherapy beyond its so
far limited capacity, says Selmer Bringsjord,
a cognitive scientist and AI researcher at
Rensselaer Polytechnic Institute in Troy, New
York. “It is incredibly ambitious.”
ALL OF TODAY’S VIRTUAL psychologists
trace their origins to ELIZA, a computer pro-
gram created half a century ago. Named after
the young woman in Pygmalion who rapidly
acquires sophisticated language, ELIZA was
nothing more than a few thousand lines of
code written by Joseph Weizenbaum and
other computer scientists at the Massachu-
setts Institute of Technology
(MIT) in the early 1960s to study
human-computer interaction.
ELIZA followed rules that de- The goal is “dragging clinical psychology
termined how to respond during
a dialogue. The most convinc-
kicking and screaming into the 21st century.”
ing results came from a rule set Albert “Skip” Rizzo, University of Southern California
called DOCTOR that simulated a
psychotherapist: By turning patients’ state-
ments around as questions, the program
coaxed them to do most of the talking. For
instance, in response to a patient saying, “I
feel helpless,” the computer might respond,
“Why do you think you feel that way?” (You
can talk to ELIZA yourself at http://psych.ful-
lerton.edu/mbirnbaum/psych101/Eliza.htm.)
People engaged readily with ELIZA,
perhaps more for its novelty than its con-
versational skills, but AI researchers were
unimpressed. “The idea that you could make
a convincing AI system that didn’t really
have any intelligence was seen as cheating,”
says Terry Winograd, a computer scientist at
Stanford University in Palo Alto, California,
who was a Ph.D. student down the hall from
Weizenbaum. This was a wildly optimistic
time for the field, with many researchers an-
ticipating computers with human-level gen-
eral intelligence right around the corner.
But work on artificial general intelligence
didn’t pan out, and funding and interest
dried up in what has come to be known as
the “AI winter.” It wasn’t until the turn of the
new millennium that mainstream interest in
AI resurged, driven by advances in “narrow
AI,” focusing on specific problems such as
voice recognition and machine vision.
SCIENCE sciencemag.org
Conversational “chatbots” such as ELIZA
are still viewed as a parlor trick by most com-
puter scientists (Science, 9 January, p. 116).
But the chatbots are finding a new niche in
clinical psychology. Their success may hinge
on the very thing that AI researchers eschew:
the ability of an unintelligent computer to
trick people into believing that they are talk-
ing to an intelligent, empathetic person.
THAT ISN’T EASY, as Rizzo is keenly aware.
What most often breaks the spell for a pa-
tient conversing with Ellie isn’t the content
of the conversation, because the computer
hews closely to a script that Rizzo’s team
based on traditional clinical therapy ses-
sions. “The problem is entrainment,” he
says, referring to the way that humans sub-
consciously track and mirror each other’s
emotions during a conversation.
For example, a patient might say to
Ellie, “Today was not the best day,” but the
voice recognition software misses the
“not.” So Ellie smiles and exclaims, “That’s
great!” For an AI system striving to bond
with a human patient and earn trust, Rizzo
says, “that’s a disaster.”
To improve entrainment, a camera tracks a
patient’s psychological signals: facial expres-
sion, posture, hand movement, and voice
dynamics. Ellie crunches those data in an at-
tempt to gauge emotional state.
The patterns can be subtle, says Louis-
Philippe Morency, a computer scientist at
USC who has led the development of the AI
that underlies Ellie. For instance, he says,
a person’s voice may shift “from breathy
to tense.” The team devised algorithms to
match patterns to a likely emotional state.
It’s imperfect, he says, but “our experiments
showed strong correlation with [a patient’s]
psychological distress level.”
Other patterns unfold over multiple ses-
sions. For instance, the team’s work with
U.S. veterans suffering from post-traumatic
stress disorder (PTSD) revealed that “smile
dynamics” are a strong predictor of depres-
sion. The pattern is so subtle that it took
a computer to detect it: Smiling frequency
remained the same in depressed patients,
on average, but the duration and intensity
of their smiles was reduced.
Even if Ellie were to achieve perfect en-
trainment, Rizzo says, it “is really just an en-
hanced ELIZA.” The AI under the hood can
only sustain about a 20-minute conversation
Published by AAAS
before the spell breaks, which limits the sys-
tem’s usefulness for diagnosis and treatment
of most psychological problems. Without
sophisticated natural language processing
and semantic knowledge, Ellie will never
fool people into believing that they are talk-
ing to a human. But that’s okay, Rizzo says:
Becoming too humanlike might backfire.
One counterintuitive finding from Rizzo’s lab
came from telling some patients that Ellie is
a puppet controlled by a human while telling
others she is fully autonomous. The patients
told there was a puppeteer were less engaged
and less willing to open up during therapy.
That’s no surprise to AI researchers
like Winograd. “This goes right back to
ELIZA,” he says. “If you don’t feel judged,
you open up.”
Ethical and privacy issues may loom if AI
therapy goes mainstream. Winograd worries
that online services may not be forthcoming
about whether there is a human in the loop.
“There is a place for deceiving people for
their own good, such as using placebos in
medicine,” he says. But when it comes to
AI psychology, “you have to make it clear to
people that they are talking to a machine
and not a human.”
If patients readily open up
to a machine, will clinicians be
needed at all? Rizzo is adamant
that a human must always be
involved because machines can-
not genuinely empathize with
patients. And Ellie, he points
out, has a long way to go before being ready
for prime time: The program does not yet
have the ability to learn from individual pa-
tients. Rizzo envisions AI systems as a way
to gather baseline data, providing psycholo-
gists with the equivalent of a standard bat-
tery of blood tests. “The goal isn’t to replace
people,” he says, “but to create tools for hu-
man caregivers.”
Helgadottir has a bolder vision. Although
computers are not going to replace thera-
pists anytime soon, she says, “I do believe
that in some circumstances computerized
therapy can be successful with no human
intervention … in many ways people are not
well suited to be therapists.” A computer
may be more probing and objective.
Sverrisdottir’s experience suggests that
CBTpsych, at least, can make a difference.
Under the program’s tutelage, she says,
“very slowly, I started to analyze myself
when I’m amongst other people.” She identi-
fied a pattern of “negative thoughts about
people judging me.”
She might have got there with a human
therapist, she says. But in the years since she
first started talking to a computer about the
trouble swirling in her mind, Sverrisdotter
says, “I have been able to change it.” ■
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