Issue Number 233 May 15, 2018

This free Information Age Education Newsletter is edited by Dave Moursund and produced by Ken Loge. The newsletter is one component of the Information Age Education (IAE) publications.

All back issues of the newsletter and subscription information are available online. In addition, seven free books based on the newsletters are available: Joy of Learning; Validity and Credibility of Information; Education for Students’ Futures; Understanding and Mastering Complexity; Consciousness and Morality: Recent Research Developments; Creating an Appropriate 21st Century Education; and Common Core State Standards for Education in America.

Improving College Students’ and Others’ Mental Health with Conversational Agents

Mary Harrsch
Networks and Management Information Systems (Retired)
University of Oregon College of Education

Mental illness is common in the United States. About one in four adults suffers from some form of mental illness in a given year (Holmes, 1/14/2015).

This level of occurrence is even higher for college students—perhaps as high as one in two according to the article, Delivering Cognitive Behavior Therapy to Young Adults with Symptoms of Depression and Anxiety Using a Fully Automated Conversational Agent (Woebot): A Randomized Controlled Trial (Fitzpatrick, et al., April-June, 2017.) In a related article, Depression and College Students, Michael Kerr points out that financial worries due to high debt and poor employment prospects coupled with failed relationships, lack of sleep, poor eating habits, and not enough exercise frequently result in the development of depression (Kerr, 3/29/2012). There are also many life transitions and challenges to a student’s identity. Quoting from Margarita Tartakovsky’s article, Depression and Anxiety Among College Students (Tartakovsky, 7/17/2016):

…college calls for a significant transition, where “students experience many firsts, including new lifestyle, friends, roommates, exposure to new cultures and alternate ways of thinking,” observes Hilary Silver, M.S.W., a licensed clinical social worker and mental health expert for Campus Calm.
….
Adjusting to college also influences identity — a phenomenon Silver has termed Identity Disorientation. “When students head off to college, the familiar people are no longer there to reinforce the identity these students have created for themselves.” This can make students “disoriented and feel a loss of their sense of self,” contributing to symptoms of depression and anxiety.

Many of these college students do not seek mental health services. Referring again to the Fitzpatrick, et al., article (April-June, 2017):

…up to 75% of the college students that need them do not access clinical services. While the reasons for this are varied, the ubiquity of free or inexpensive mental health services on campuses suggests that service availability and cost are not primary barriers to care. Like non-college populations, stigma is considered the primary barrier to accessing psychological health services.

As described in this article, in their effort to overcome this fear of stigma Stanford researchers developed a virtual therapist, or conversational agent (often called a chatbot). The chatbot employs artificial intelligence and natural language processing to deliver cognitive behavior therapy (CBT) to college students self-identified as suffering from significant depression and/or anxiety.

Stanford's virtual therapist is named Woebot. Like many chatbots, Woebot uses Natural Language Programming to process student responses to questions posed by the virtual therapist, then guides the conversation to an appropriate node of a decision tree to provide suggested actions.

The Original Chatbot


Chatbot software was originally based on the "Eliza" virtual therapist that was developed back in the early 60s by Professor Joseph Weizenbaum at the Massachusetts Institute of Technology (Markoff, 3/23/2008). I studied "Eliza" in the late 90s and used it as a model for a virtual professor I developed when I worked at the University of Oregon. I was so excited to see that someone had finally recognized the potential of artificial intelligence to help people cope with life's challenges!

Dr. Weizenbaum's “Eliza” virtual therapist was initially designed to simply keep a conversation going between his chatbot and a human to see if the human could figure out they were talking to a computer and not a real person. However, Stanford's Woebot chatbot uses the scientific principles of cognitive behavior therapy to encourage its human "friends" to develop a positive mindset and overcome depression. Quoting again from the Woebot clinical trials report by Fitzpatrick, et al. (April-June, 2017):
  • "Psychoeducational content was adapted from self-help for CBT. Aside from CBT content, the bot was created to include the following therapeutic process-oriented features:
  • Empathic responses: The bot replied in an empathic way appropriate to the participants’ inputted mood. For example, in response to endorsed loneliness, it replied “I’m so sorry you’re feeling lonely. I guess we all feel a little lonely sometimes” or it showed excitement, “Yay, always good to hear that!”
  • Tailoring: Specific content is sent to individuals depending on mood state. For example, a participant indicating that they feel anxious is offered in-vivo assistance with the anxious event.
  • Goal setting: The conversational agent asked participants if they had a personal goal that they hoped to achieve over the 2-week period.
To engage the individual in daily monitoring, the bot sent one personalized message every day or every other day to initiate a conversation (ie, prompting). In addition, “emojis” and animated gifs with messages that provide positive reinforcement were used to encourage effort and completion of tasks.

A Chat with Woebot


Woebot is now freely available online (Woebot, n.d.). On the Woebot website, you can click on a link that connects you and Woebot to a private Facebook Messenger session that no one else can see. Then Woebot talks with you about how you are feeling and how you can keep a positive frame of mind using techniques from cognitive behavioral therapy. I've had talks with Woebot about those pesky "should" statements, discussions about self-defeating "all-or-nothing" viewpoints, the futility of trying to predict other people's reactions, and the importance of self-compassion. Sometimes the little bot even provides interesting short videos about behavioral research.

One that I found particularly interesting was Carol Dweck’s video about the problem of students who develop a fixed mindset when they are praised as "you're so smart" from a young age. I strongly recommend this excellent 10-minute video (Dweck, December, 2014).

After your initial session, Woebot then contacts you each day through Facebook Messenger and engages in a short friendly conversation. This can teach you how to identify your strengths, to mentally rework your own internal dialogue to develop a healthier opinion of yourself, and to recognize negative approaches in your relationships with others. If you wish to talk to Woebot about a specific problem, you can also initiate a conversation like you would with any of your friends on Facebook Messenger. Woebot is also available as a free smartphone app in the Apple or Google Play Stores.

Using Gamification to Combat Poor Adherence


In their article cited earlier, Fitzpatrick, et al., note that other psychologists have been experimenting with computerized CBT, but that motivating patients to continue interaction with computerized CBT tools has been challenging:

In recent years, there has been an explosion of interest and development of such services to either supplement existing mental health treatments or expand limited access to quality mental health services. This development is matched by great patient demand with about 70% showing interest in using mobile apps to self-monitor and self-manage their mental health. Internet interventions for anxiety and depression have empirical support with outcomes comparable to therapist-delivered cognitive behavioral therapy (CBT). Yet, despite demonstrated efficacy, they are characterized by relatively poor adoption and adherence.

To address these problems of adherence, Woebot's team of researchers adopted the "daily dose" model, since online learning studies have shown small doses of learning embedded in every day learning appears to be more effective than one lecture. They also introduced some game-like elements designed to the likelihood that people will come back the next day.

CBT for Seniors

I contacted the CEO of the Woebot project, Dr. Alison Darcy, and submitted a written interview to which she responded. In it I encouraged her to develop a Woebot to assist much older people with depression and loneliness. I pointed out that seniors' mental health needs differ significantly from those of college students, as the challenges of aging often involving chronic illnesses, deaths of loved ones, living alone, and feelings of irrelevance when no longer employed in the workplace.

I also pointed out that, although Medicare recognizes depression has a serious impact on quality of life and ensures that a senior's annual wellness visit includes questions about their emotional state, many seniors take friends or family members with them to the doctor. Thus, they may be embarrassed to admit to their physician that they are feeling depressed or even suicidal when their friends or family members are present—very much the same fear of stigma demonstrated by the college students. To make the problem even more difficult to address, many family physicians are not trained in dealing with mental health issues, and the best they may be able to do is refer the senior to a specialist. Appointments to visit such specialists are usually weeks away and often seniors on limited incomes cannot even afford the co-pay, a sad fact of life in the U.S. commercial health care model.

I also think the long-term caregivers may themselves need yet another type of Woebot, one that could help them to deal with their own feelings of frustration and even anger that may often crop up when dealing day-in and day-out with a patient or loved one with physical and emotional impairments.

CBT Delivery with Virtual Assistants

With the growing presence of voice-activated virtual assistants like Amazon's Alexa, I also expressed my support for porting Woebot to a voice-only interface to Darcy in my written interview with her. Many older adults are not as technology-savvy as college students and probably are not as comfortable on Facebook or a smartphone.

In their clinical analysis of their Woebot development project, Darcy and her fellow researchers apparently agreed with me in theory saying:

Theoretically, conversational interfaces may be better positioned than visually oriented mobile apps to deliver structured, manualized therapies because in addition to delivering therapeutic content, they can mirror therapeutic process. Conversational agents (such as Apple’s Siri or Amazon’s Alexa) may be a more natural medium through which individuals engage with technology. Humans respond and converse with nonhuman agents in ways that mirror emotional and social discourse dynamics when discussing behavioral health.

However, Darcy expressed reservations to me about eliminating the written aspects of therapy made possible by the messenger interface in Facebook or on a smartphone in my interview with her. Continuing to quote Darcy:

The core of what we do—the CBT skills that are triggered when someone is upset in the moment that they reach out to Woebot —is actually dependent on writing down negative automatic thoughts. This is true even in the therapist's office, because it seems to be central to externalizing the thoughts. That is, there is something in seeing your negative thoughts written down that allows you to process it in a different way, ultimately allowing it to be intervened upon (by rewriting).

I do hope she reconsiders, however. But for now, I think Woebot, even in its current iteration, could prove helpful to millions of people. I know I find confessing my deepest thoughts to a properly programmed computer application to be less troubling than revealing them to another human being, many of whom may have their own biases.

Summary and Final Remarks

The skyrocketing cost of higher education is adding to the mental toll that transition to higher education and adult life takes on modern college students. With studies that show one out of every four college students suffers from some form of mental illness, psychologists worldwide are now focused on providing mental health care to these young adults. But, the stigma that often accompanies mental health treatment remains an obstacle.

Clinical trials with computerized cognitive behavior therapy have demonstrated that CBT delivered anonymously in a computerized environment is as effective as person-to-person talk therapy in the relief of symptoms of depression and anxiety. Furthermore, because these therapy sessions are conducted without patient tracking, the fear of stigma can be eliminated. Tools, such as conversational agents like Woebot, in combination with gamification strategies, can be used to encourage students to adhere to a treatment program.

As artificially intelligent voice-activated interfaces become more widespread, computerized CBT may become part of students’ daily hygiene to help them to maintain the best outlook possible as they navigate higher education’s landscape.

References and Resources

Bickmore, T., Gruber, A., & Picard, R. (October, 2005). Establishing the computer-patient working alliance in automated health behavior change interventions. Patient Education Counseling. Abstract retrieved 4/19/2018 from https://www.researchgate.net/publication/7567340_Establishing_the_computer-patient_working_alliance_in_automated_health_behavior_change_interventions.

Burns, D. (1980). Feeling good: The new mood therapy. New York: Harper Collins.

Burns, D. (2006). When panic attacks. New York: Harmony.

Dweck, C. (December, 2014). The power of believing that you can improve. TED Talks. (Video, 10:20.) Retrieved 4/19/2018 from https://www.ted.com/speakers/carol_dweck.

Fitzpatrick, K.K., Darcy, A., & Vierhile, M. (April-June, 2017). Delivering cognitive behavior therapy to young adults with symptoms of depression and anxiety using a fully automated conversational agent (Woebot): A randomized controlled trial. JMIR Mental Health. Retrieved 4/19/2018 from http://mental.jmir.org/2017/2/e19/ DOI: 10.2196/mental.7785 PMID: 28588005 PMCID: 5478797.

Holmes, L. (1/14/2015). 19 statistics that prove mental illness is more prominent than you think. Wellness. Retrieved 4/19/2018 from https://www.huffingtonpost.com/2014/12/01/mental-illness-statistics_n_6193660.html.

Hunt, J., & Eisenberg, D. (January, 2010). Mental health problems and help-seeking behavior among college students. Journal of Adolescent Health.

Kerr, M. (3/29/2012). Depression in college students: Signs, causes, and statistics. Healthline. Retrieved 4/19/2018 from https://www.healthline.com/health/depression/college-students#1.

Kessler, R.C., et al. (July, 2007). Age of onset of mental disorders: a review of recent literature. Current Opinion in Psychiatry.

Markoff, J. (3/23/2008). Joseph Weizenbaum, famed programmer, is dead at 85. The New York Times. Retrieved 4/19/2018 from https://www.nytimes.com/2008/03/13/world/europe/13weizenbaum.html.

Tartakovsky, M. (7/17/2016). Depression and anxiety among college students. PsychCentral. Retrieved 4/19/2018 from https://psychcentral.com/lib/depression-and-anxiety-among-college-students/.

Towery, J. (2016). The anti-depressant book: A practical guide for teens and young adults to overcome depression and stay healthy. Palo Alto, CA: Jacob Towery.

Woebot (n.d.). Woebot. Retrieved 4/15/2018 from https://www.woebot.io/.

Zivin, K., et al. (10/1/2009). Persistence of mental health problems and needs in a college student population. Journal of Affective Disorders.

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Author

Mary Harrsch was the director of Networks and Management Information Systems at the University of Oregon's College of Education for 20 years. Previously, she had worked in the private sector as a technologist, journalist, photographer, and entrepreneur. She retired from the University in 2008 so she could focus on photography, ancient history research, and writing.

Now she travels the world photographing historical art and architecture and makes the images available for free use by teachers, researchers and students as well as others involved in educational publishing (including bloggers and Wikipedia). Her work has been used to illustrate online university courses including MIT's Open Courseware Initiative and educational programming broadcast on PBS, The History Channel and the Canadian Public Broadcasting System. Her still images have been used to illustrate educational texts in both the U.S. and internationally including Argentina and Venezuela. She has also published articles in a variety of national and international periodicals and produces short videos with historical themes.

Email: mharrsch@uoregon.edu

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