June 14, 2023

Several direct-to-consumer teletherapy platforms, like Betterhelp and Talkspace, have policies explicitly stating that they may use AI to support patient matching and improve the therapeutic encounter. But what does that actually look like? Does it simply involve parsing survey data to match clients with a therapist who has a similar identity or relevant cultural competencies? Or might it involve drawing on signals detected through a person’s choice of words, facial expressions, keystrokes, sleeping patterns, or other inferential smartphone data? Referred to as emotion AI, these technologies are most often deployed in areas like advertising and personnel testing, but mental health care practitioners (particularly online therapists) may find them useful as a means of providing additional, context specific information about their patients. Or at least that’s what the companies behind the tech would like us to think.

To explore how one therapist thinks about this category of technology, I talked with Kikelomo Ogunfowora, a clinical social worker and public health researcher who has been working remotely since 2020. Before the COVID-19 pandemic prompted therapists and their patients to co-exist in digital space, Ogunfowora’s first year of training and practicing as a therapist was in-person. She explains that technology didn’t dramatically change the way she provides care, underscoring the need to ask harder questions about the role it plays in therapeutic settings.

Iretiolu Akinrinade: When we talk about mental health care, it tends to be positioned as either entirely different or essentially the same as the ways we monitor, diagnose, and treat physical conditions. If it is viewed like a physical condition, there’s this assumption that more, and more accurate, information can help improve treatment outcomes. Which side do you come down on?

Kikelomo Ogunfowora: While depression and anxiety are acknowledged as medical conditions, they are primarily understood as social conditions, and people have a lot of ideas about what causes depression and anxiety and how you move through them. There are treatment approaches that don’t exist for other medical conditions. With something like Parkinsons, I suspect that most people would meet with a medical doctor to engage in treatment. For depression, someone might go to the gym, see a therapist, work to stop engaging in negative self talk. Essentially, treatment suggestions are influenced by how people conceptualize the causes of depression. That makes it more socially acceptable to engage a range of treatment options.

Akinrinade: How has the transition to telehealth informed your therapeutic practice?

Ogunfowora: Over time, I’ve learned to pay close attention to the non-verbal shifts that happen in a session, and then vocalize those changes to and with the client. That can be challenging when you’ve never shared physical space. But telehealth has many benefits, too. There’s a lot that can come from someone being in a space of their own choosing, that can shift the power balance in the relationship. I often question what the essential elements of therapy are, the essential elements of the therapeutic relationships, and if they change over time. These are practice and research questions that drive the work I do.

Akinrinade: If you were providing therapy on a platform that could detect a patient’s nonverbal cues, within your therapeutic encounter or in your patient’s other online spaces, would that information be interesting or valuable to you when it comes to how you deliver care?

Ogunfowora: I wouldn’t see myself using that sort of tool in my work. The difference between telehealth and in-person care is not about one mimicking the other — they’re just different. I don’t think one is necessarily better than the other. For some clients, in-person might be better because it’s a contained environment. At home there are space and privacy issues; for example, they might be overheard by others because of the space they share. But when it comes to a tool that can detect if a person is behaving in a way that indicates that they are experiencing depression or anxiety, I would be skeptical. For instance, there’s a DSM criteria for diagnosing anxiety, but that diagnosis doesn’t tell you much about what has happened to a person or why certain symptoms come up for them. For me, what is most valuable is finding out what a person’s story is, and what their understanding is of what has happened to them — that information is what impacts the treatment or intervention. Furthermore, a manualized diagnosis and treatment does not take into account how the therapeutic relationship affects treatment. As a therapist you change and adapt for each client and you become a different therapist with each client you see.

Akinrinade: That makes sense. Therapy is a space to tell the story of your life experience, and some of these digital tools may introduce a secondary narrator between the patient and therapist, in the form of data and its computations. How do you hold space for people to be able to name their own conditions or tell their own stories?

Ogunfowora: I always encourage clients to think of therapy as a way to tell their story on their terms, a method known as narrative therapy. Through telling your story in the context of our relationship, there is the opportunity to understand the meaning we ascribe to things that happen in our lives. The meaning you ascribe to what happened really does have an impact on how you process it. There’s also something really valuable and healing in being with someone else who hears that story and takes it seriously. That doesn’t mean that as a therapist I don’t challenge patients or offer observations, but I trust how they are telling their experience and then ask questions about it. I think people just want to be listened to, to be heard and be seen. And it is a powerful thing to be able to share your human presence with others.

I understand the patient-practitioner relationship as the foundation of therapy. Events have very different meanings if you trust that someone cares about you and offers treatment from a place of care. As a therapist, I’m not trying to change anyone. I just want to give people as many options as possible for how they can engage with their thoughts, emotions, and the world around them. Sometimes I’ll be working with someone and we’ll come to the conclusion that they do not want to change a behavior, but by going through the therapy process they have a better understanding of the history of this behavior, how it came to be, and how it affects them. Having the fluency to understand themselves is a big takeaway.