Fighting loneliness and anxiety: Can a chatbot provide additional support for your patients?

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Fighting loneliness and anxiety: Can a chatbot provide additional support for your patients?
In this installment of “Let’s Get Technical,” our panel of experts review three mental health chatbots: Woebot, Wysa, and Youper.
By Nicole Owings-Fonner, MA
August 2021
You’ve probably interacted with chatbots in your daily life, perhaps without realizing it. A chatbot is a conversational assistant that allows businesses to communicate with their audiences in a way that is both automatized and personalized. They are commonly used in customer service, answering frequently asked questions, acting in place of webforms, and guiding users through websites. You might have come across one on your bank’s website or while looking for assistance with a medical diagnosis, for example.
Chatbots have also been incorporated into some mental health apps providing 24/7 support that mimics conversations with a real person though texts and instant messages. They can guide users through how they are feeling, help users challenge negative thoughts, suggest tools and resources, and engage them in evidence-based therapy techniques including mood tracking and mindfulness. Of course, chatbots aren’t perfect. They do not always understand what the user is expressing and cannot replace professional help from a psychotherapist.
In this installment of “Let’s Get Technical,” our panel of experts review three mental health chatbots. For each app, we provide guidance on several background factors practitioners should consider when selecting mental health apps for their patients. Next, our panel of psychologists share their own ratings, reviews, and recommendations for how these chatbots can be incorporated into mental health care.
Woebot
★★★☆☆
Woebot: Your self-care expert
Woebot is a chat/text-based app developed to provide adult users with access to mental health support around the clock. Woebot uses machine learning to generate “predictable responses” using techniques from Cognitive Behavior Therapy (CBT), Dialectical Behavior Therapy (DBT), and Interpersonal Psychotherapy (IPT) theoretical approaches. Users are provided psychoeducation and self-guided interventions in multiple areas of mental health wellness, including anxiety and depression, substance abuse, postpartum depression, sleep concerns, the impacts of COVID-19, and relationship issues.
Woebot features three main navigation tools that the user can select to start: Topics, Tools, and Journal. The Topics section covers 10 concepts such as managing emotions, relationships, self-care, achieving goals, mindfulness; Tools covers several therapy tools including Challenge Negativity and Challenge Stress; and Journal consists of a mood tracker and a gratitude journal.
Woebot is available on iOS and Android and is currently free to all users.
Overall Review Ratings
Privacy/Security
4 ★★★★☆
Features an easy to understand, detailed privacy and security policies, and is HIPAA compliant. Policies describe how data is processed, shared, secured, and what rights users have to their data. Users do not need to set up an account to use the app though it is encouraged to allow for access on multiple devices. Anonymous usage tracking is conducted to perform analytics and improve the app.
Evidence base for the app
5 ★★★★★
Woebot has conducted several randomized control trials in collaboration with Stanford University and the National Institutes of Drug Abuse demonstrating efficacy of their platform using psychometrically validated efficacy measures, including PHQ-9 and GAD-7. Woebot continues to undergo frequent research trials as their services expand.
User feedback
5 ★★★★★
Around 15,000 overwhelmingly positive reviews averaging 4.7/5 stars. Users appreciate the daily check-ins, emotion monitoring, tools for adjusting negative thinking, and that it is free. The biggest complaints are that Woebot may not understand all of what a user is saying and that responses can sometimes feel repetitive.
Panelist ratings and comments — JoAnna Romero Cartaya, PhD
I recommend psychologists review Woebot’s content and see how it may match their approach to therapy and client populations, especially given its growing scope. Woebot is completely free and provides high-quality, tailored, brief interventions based in psychological research and a pleasant layout experience. While the app did genuinely make me smile and I found the interventions to be helpful, it was disappointing when the app did not understand what I was trying to communicate—a factor that would need to be discussed with clients to better set their expectations for using the app in conjunction with therapy. I do wish Woebot was more advanced in its cultural considerations and ability to respond to concerns from underrepresented/marginalized populations; however, I was heartened to learn that they have a committee dedicated to these concerns and are currently trying to expand the capabilities and effectiveness of Woebot.
—JoAnna Romero Cartaya, PhD 
Purpose
4 ★★★★☆
Woebot strives for all individuals to have access to mental health support at the right time with the right intervention. Woebot is warm, accepting, and uses humor/emojis/short videos to engage to users. Woebot was generally able to adapt to my responses and usually provide an appropriate intervention that was tailored to either CBT, IPT, or DBT with specific instructions and feedback.
Appropriateness of Content
5 ★★★★★
The content and interventions match the intended purpose of the app. The interventions target the issues the user identifies, adapt by reported symptoms and severity, and then a mini-lesson or activity begins. The app is based on CBT, IPT, and DBT and clearly follows the scope of these psychological theories.
Cultural Responsiveness
2 ★★☆☆☆
The app’s developers have more work to do in becoming culturally inclusive and including content that may reflect the experiences from marginalized groups and its interaction on mental health wellness. While Woebot was generally compassionate, responses did not target or understand the concern when words like racism, microaggression, or racial slur were entered in the chat.
Ease of Use
5 ★★★★★
Woebot’s overall layout is straightforward and simple to use. The initial open-ended questions make it easy to jump into the content. Clients report that it is easy to use and to form a relationship with Woebot. A user can choose the name that Woebot calls them and the times that Woebot will check in on symptoms.
Functionality
4 ★★★★☆
Woebot performs well. The app requires Wifi to function. There is also no option to export data or share responses outside of the Woebot app. As such, this may be a limiting factor for users or areas (especially rural areas) where access to stable internet access may be difficult.
Recommendations for use
I recommend this app for clients that have fairly good functioning but would like additional guidance or support in between sessions, especially if their goals match the types of interventions used in Woebot. I have recommended that college students use the app especially for anxiety and depressive symptoms with adjustment type concerns. While Woebot provides resources and support during moments of crisis (and also does a brief assessment) it may not be best for those clients who are experiencing significant depressive symptoms or significant mood instability.
Panelist ratings and comments — Charmain F. Jackman, PhD
Overall, I find that Woebot is a valuable tool that teaches and reinforces content that CBT and DBT mental health practitioners use in their sessions with patients. The app engages users in discussions about their emotional health and provides content that teaches skills and helps users to practice these skills. The interface is simple and easy to use. Patients who are comfortable texting could find great value in this tool. There is content specific to coping in a pandemic and with social isolation, which I think people would find extremely valuable. While texting is the main component, the app also connects to videos that I found very interesting. One downside is that the app is only available in English.
—Charmain F. Jackman, PhD
Purpose
4 ★★★★☆
Woebot was developed to give users access to mental health support at all hours of the day. It provides users with educational content and exercises that they can use to manage their stress, mood, and emotions between therapy sessions. If someone uses the app every day, Woebot could be an effective tool in helping cope with the challenges of daily life.
Appropriateness of Content
5 ★★★★★
The app provides accurate information about CBT, DBT, and IPT approaches and breaks down the skills to help patients understand the information. The content is provided in basic language and provides education on commonly discussed topics relevant to stress reduction and emotional well-being. I can see this being useful for high school students and above, and those who enjoy using texts as a form of communication.
Cultural Responsiveness
3 ★★★☆☆
Woebot claims that it is inclusive, however, it is only available in English. Individuals who are comfortable texting to communicate for extended periods of time will find Woebot appealing, while those who are not may quickly lose attention. It does have interesting videos, and humor and casual language add to Woebot’s personality.
Ease of Use
5 ★★★★★
Woebot is extremely easy to navigate. The interface is simple, clear and engaging. Once you choose from its three main navigation tools (Topic, Tool, or Journal), Woebot walks you through a series of questions to which you respond. You cannot change your answers, but you can start over if you do not want to continue with a particular content area.
Functionality
4 ★★★★☆
Woebot performs well though it is not available offline. The daily mood tracker allows the user to select the time of the day that they want to check-in and will start with that when the app is opened. However, it does not appear that you can export your data.
Recommendations for use
Woebot could be an effective tool for some patients who are using CBT, DBT, or IPT in their therapy sessions. It provides content that teaches CBT skills and gives patients opportunities to practice these skills between sessions. Clinicians can identify topics for the patient to do between sessions or patients can choose a topic based on what they are dealing with at a particular moment.
I especially like the mood tracker, which allows patients to track their emotions over time. For some patients this could be a helpful tool to obtain information about their moods over the course of a week or a month. For people, like me, who journal using pen and paper, the journal feature may not be as enticing.
I would recommend having an explicit conversation with your patient about crisis resources and how to use (or not) if they are experiencing a crisis. I also would not recommend using for youth younger than 16 years old as the content is not child friendly.
Wysa: Mental health support
Wysa’s mission is to make the “world more mentally resilient” by providing 24/7 mental health support and virtual coaching through an artificial intelligence (AI) chatbot, along with blended human support. The app was developed using cognitive behavior therapy (CBT), Dialectical Behavior Therapy (DBT), Motivational Interviewing (MI), and “micro-actions to help [users] build mental resilience skills.” While Wysa offers an assessment process, the app is not intended to diagnose, treat, or cure disorders and it does not give advice on “unrecognizable issues.”
Wysa features over 150 therapeutic exercises to address mental health (e.g., anxiety, trauma), well-being (e.g., sleep, loneliness), lifestyle (e.g., relationships, break-ups, conflict, grief), mindfulness and stress management, and activating strategies (e.g., productivity, focus, and energizers). For those who’d like additional support, subscriptions can be purchased for daily messaging support and a 30 minute live texting session every week with a Well-being Coach or Therapist.
Wysa is available on iOS and Android. Wysa’s free version offers one exercise per tool pack. The premium version provides access to all content for $49.99 per year or $7.99 per month or $99.99 for life. A 7-day free trial is available. Additionally, if you want to communicate via text sessions with a coach or therapist, they offer varying prices for four texting support sessions per month from $79.99–$99.99 a month or $144–$179.99 for three months.
Overall Review Ratings
Privacy/Security
4 ★★★★☆
Wysa features an up-to-date privacy policy that describes how user data is processed, shared, secured, and what rights users have to their data, including its deletion. Users do not need to set up an account and are encouraged to use an unidentifiable nickname and a pin. Accidentally submitted personal data is automatically redacted. Response to assessments is voluntary and users can opt to not report assessment scores that are anonymized and used for population-level research and statistical purposes.
Evidence base for the app
4 ★★★★☆
A peer-reviewed study of 129 real-world users found that users who engaged more with the Wysa app showed a higher reduction in depression symptoms compared with low engagement users. Wysa provides content that is consistent with evidence-based techniques using CBT, DBT, and behavior activation.
User feedback
4 ★★★★☆
Over 88,000 reviews in the United States averaging 4.8/5 stars. Most users are very pleased with this app though comments indicate Wysa asks users to provide ratings soon after installation. Complaints focus on cost for premium features and therapist support sessions, as well as instances of Wysa not understanding all of what a user is saying and repetitiveness or the limited nature of the chat responses.
Panelist ratings and comments — Mary O’Leary Wiley, PhD, ABPP
Although this technology was quite interesting, easy to use, and functioned well, I wouldn’t find it helpful for psychologists working directly with clients, unless the client needs a great deal of reassurance between sessions. There are other self-help resources available that are deeper and more reflective that can be used for homework, including podcasts, websites, online videos, and reading materials. Wysa can be a resource, however, for individuals who are unable to access in-person treatment.
— Mary O’Leary Wiley, PhD, ABPP
Purpose
4 ★★★★☆
Wysa’s goal is to provide inexpensive forms of contact through texting, which can be helpful to those who feel isolated or unable to understand what is going on in their lives. It also provides self-assessment instruments (for depression, anxiety, sleep disorders, etc.). Conversations with the online counselor were pleasant, supportive, and encouraging, but the format would not have allowed for any deep work.
Appropriateness of Content
3 ★★★☆☆
The questions asked lined up with assessment for standard problems such as depression, anxiety, worry, and offered instructions on relaxation, meditation, and breathing. The content is appropriate, but the question-and-answer format does not allow for any deep reflection or analysis on the part of the client. Responses to problem identification, such as “Good job,” were sometimes annoying.
Cultural Responsiveness
2 ★★☆☆☆
There is a module for LGBTQIA with cognitive behavioral strategies focused on self-compassion, building support, and visualizing confidence, but content doesn’t factor in homophobia or other difficulties in the environment and ways to approach them. There are no resources for BIPOC populations, coping with racism or xenophobia, or difficult issues related to sexism, disability concerns, or intersectional issues.
Ease of Use
4 ★★★★☆
There are many comprehensive resources and paths to follow in this app. Users are reminded that they can schedule an appointment with a text-based counselor on most pages. Some of the suggested activities may not be accessible to all, such as “Try sketching,” and may be hard for others, such as positive self-talk.
Functionality
The app worked seamlessly. No gaps or slowness.
Recommendations for use
Wysa could potentially be used with clients who are seeing a psychologist when looking for quick resources and suggestions, or for individuals who are unable to access in-person treatment and feel isolated or unable to understand what is going on in their lives. I might recommend it on rare occasions when I am seeing a client who needs a great deal of reassurance between sessions. It seems most appropriate for teens and young adults who aren’t already aware of tasks to avoid procrastination, such as making lists, or creating a quiet space for effective sleep patterns. The sleep sounds were excellent, and a nice change from texting. The online therapist I spoke with was very good; this resource could be used during times that the regular psychologist is away. However, the appointments need to be scheduled in advance. It is not for drop-in support from a live person.
Panelist ratings and comments — Charmain F. Jackman, PhD
Overall, I find that Wysa is a valuable tool that supports users on topics related to anxiety, stress, and general coping using CBT and DBT techniques. The app engages users in discussions about their emotional well-being and then tailors content based on the responses and choices the user selects.
While I like the interface and the addition of including research findings about the featured techniques and exercises, it is quite pricey. Additionally, there are fewer functions when compared to other apps that are currently available for free (e.g., Woebot) or have more free options. Wysa does go above by offering live text conversations (30 minutes per week) for paid users. This blended model makes it stand out, and also explains the higher cost.
Wysa is a high-quality product, but its high cost and limited functions lower my likelihood to recommend it.
— Charmain F. Jackman, PhD
Purpose
5 ★★★★★
Wysa’s mission is to make the “world more mentally resilient” by providing 24/7 mental health support and virtual coaching through an artificial intelligence (AI) chatbot, along with blended human support. The “library” of over 100 therapeutic exercises and support of Well-being Coaches and Therapists are highly likely to do just that.
Appropriateness of Content
5 ★★★★★
Wysa was developed by a team of psychologists, designers, developers, and incorporated feedback from over 500,000 users. Wysa delivers content that is consistent with CBT, DBT, and behavior activation and provides research citations that support the recommended strategies and exercises.
Cultural Responsiveness
3 ★★★☆☆
Wysa is designed for adults in more than 30 countries but is only available in English. It is not intended for users under 13 years of age. Even when interacting with the therapist or coach, Wysa utilizes text communication only. Therefore, it would be most effective with people who regularly engage in text communication.
Ease of Use
5 ★★★★★
Wysa’s interface is simple, yet modern, and it is easy to navigate. Each exercise provides the length of time it takes to run, so that you can budget your time accordingly. It also has a “Recently Used” folder and a “Journal” function that tracks the conversations you have with the character.
Functionality
4 ★★★★☆
The app functions well, although internet service is required to access it. For the cost of the premium version, I would expect more functions, such as a mood tracker, a given on most mental health apps. Data from previous conversations or exercises can be shared with the Wysa Coach or Therapist but cannot be downloaded or exported.
Recommendations for use
Wysa can be a great tool for practitioners who use CBT and DBT in their clinical practice to help clients with mild anxiety symptoms and common life stressors practice skills between sessions. Wysa is not a substitute for therapy or for assessing a mental health concern. It merely gives resources to navigate typical life stressors.
Given that the app is available 24 hours a day, my concern is that people might select the app when they are in a crisis versus calling an emergency number. An SOS button takes you to a section with options to engage in a grounding technique, to access hotline numbers, or to create a safety plan. Once the safety plan has been created, you can only access the U.S. based hotlines through the safety plan. If you recommend Wysa to clients, be sure to have an explicit conversation about what they should do if they are having a crisis.
Youper – Mental health
Youper (You + Super) is a chatbot app that seeks to expand mental health support for anxiety and depression and other conditions related to wellness (i.e., increasing productivity, stress reduction, building self-esteem, and increasing happiness) through AI technology utilizing cognitive behavioral therapy (CBT), acceptance and commitment therapy (ACT), and mindfulness.
Users begin with a self-assessment to rule out (or suggest the presence of) depression, borderline personality disorder, posttraumatic stress disorder, anxiety disorders, and others. Based on the user’s assessment and inputs, Youper offers text/chat guided brief psychoeducation and smart goal setting as well as tracking of progress and goals within the app. Users have the ability to share their open-ended responses and goals within social media, automatically formatted as a post appearing on the insights page after each lesson.
Youper is available on iOS and Android. While there are some free features, recent updates to the app require a full paid account for $89.99 per year in order to access useful content after a free 7-day trial.
Overall Review Ratings
Privacy/Security
3 ★★★☆☆
Youper’s privacy policy asserts that they do not collect or store “medical information or protected health information” and, therefore, do not need to be HIPAA compliant. Users are required to provide personal information and set up an account. Youper uses tracking to perform analytics, improve the app, and for research purposes. The language around user rights to request deletion or limitation of the processing of personal data is somewhat unclear.
Evidence base for the app
2 ★★☆☆☆
Currently, the only peer-reviewed scientific studies of Youper focus on the number of users and their engagement with the app, not on clinical effectiveness. Users are asked to share deidentified data “to improve mental health” though no mention is made of specific research project disclosure.
User feedback
4 ★★★★☆
Over 60,000 reviews averaging 4.5/5 stars, however, the bulk of these reviews came before a recent update and change from free access to paid subscription requirement. Current negative reviews are primarily from previous users citing displeasure with the navigation of the app, changes away from the conversational nature of the app, and the cost.
Panelist ratings and comments — JoAnna Romero Cartaya, PhD
Youper is beautifully done and well designed with easy-to-use features. It is more of a mental health wellness app than a treatment app as the content is more suited to those that do not have significant levels of mental health concerns. Given this, the screenings for borderline personality disorder, PTSD, and social anxiety are somewhat puzzling to me. Youper’s AI is a good start; however, it has a ways to go to fully be responsive to users’ comments, especially comments that have multicultural factors or associated trauma from racism/discrimination. The app’s responses did not seem culturally sensitive or able to distinguish this content from other experiences of anxiety/depression. I found the goal setting features and brainstorming of ideas of each lesson to be the most helpful components. Those features could be used as an adjunct to therapy. Given the price point of Youper, I would have expected more of the lesson content to expand as the user engages with the app.
—JoAnna Romero Cartaya, PhD
Purpose
3 ★★★☆☆
Youper states that it is not meant to diagnose or provide treatment, however, the app automatically begins tracking symptoms such as anxiety and depression and has screenings for Borderline Personality, Panic, Posttraumatic stress, and social anxiety. These areas of tracking appear inconsistent with the interventions used within the app itself.
Appropriateness of Content
4 ★★★★☆
Youper is appropriate for those who seek a guided self-help application, but it is not sufficient for more severe mental health conditions. Psychoeducation and exercises provide short, manageable interventions that are fairly basic and appear to be CBT-like in nature. I wish that their content went more in-depth with the mini-lesson or was able to provide more specific feedback to the user’s responses.
Cultural Responsiveness
2 ★★☆☆☆
The images provided on the app attempt to be diverse; however, there does not appear to be any specific content around cultural factors or the experiences of underrepresented and marginalized groups that a user could describe experiencing in the open chat boxes.
Ease of Use
5 ★★★★★
Youper is easy to navigate and engage with. Users can choose the type of content they would like to use and the lessons take 2 to 5 minutes to complete. The guided meditations also provide time amounts so users can plan how long they would like to engage in a meditation. Favorites are posted to a specific page making it easier for users to reengage with interventions or meditations they find to be the most beneficial.
Functionality
5 ★★★★★
The app works well and does not need internet connection to work after downloading; however, data cannot be backed up until it has an internet connection. Users can share their session summaries that post to the insights page; however, other information cannot be downloaded or exported.
Recommendations for use
Given that this app does not provide any cultural features other than images, I would refrain from using this app for clients who are experiencing racial marginalization or trauma. I also found it glaring to see my responses or private thoughts in a shareable image to post on social media. While these prepared posts are beautifully done, they may have painful or emotionally charged content that could trigger clients with trauma. This gives me pause when thinking about recommending the app to populations that may desire to post these types of images and thoughts. I may recommend the app for goal setting and tracking with the brief interventions for clients with minimal symptoms of depression or anxiety or adjustment to life concerns and are wanting to be more productive and motivated. This app is best for clients that are high functioning and may be in the early stages of therapy or using the app when therapy ends as a refresher. To really access the useful content within the app a user would need to have a full paid account, which is $89.99 per year after the 7 day trial, which to me is a significant cost for what the app is providing.
Panelist ratings and comments — Mary O’Leary Wiley, PhD, ABPP
Youper is quite easy to use with attractive photographs and a clear menu. Unfortunately, I don’t think it would add to an individual’s work with a psychologist given its self-help design and symptom/diagnosis focused approach. There are resources embedded into it that are good, and the app does make them easily available in one place. However, those resources can be accessed in other ways when working directly with a therapist. It could be helpful to individuals who have not yet worked with a therapist to assess their difficulties and concerns.
—Mary O’Leary Wiley, PhD, ABPP
Purpose
4 ★★★★☆
Youper aims to help people track their thoughts and feelings to lower anxiety, decrease depressive symptoms, and deal with other mood and sleep difficulties. Youper gives a self-care therapy exercise (e.g. talk through your challenges, listen to audio sessions) every day that is recommended for the individual with strategies to change thoughts and feelings.
Appropriateness of Content
4 ★★★★☆
Youper’s app team leader is a psychiatrist and the diagnostic and assessment tool approach are consistent with a psychiatry model where medication decisions are based on specific diagnoses and symptom monitoring. That said, the audio content is excellent and references the research that supports these exercises.
Cultural Responsiveness
1 ★☆☆☆☆
Youper has no resources that are tailored to different cultural groups, or groups that may deal with common struggles such as racial or ethnic groups or gender or sexual minorities. The assessment questions are symptoms focused and do not assess experiences that might put these symptoms into a cultural context.
Ease of Use
Youper is quite easy to use. The icons are attractive and the menu is clear.
Functionality
4 ★★★★☆
Youper performs well, loads easily, and the transitions are seamless. Internet is not required. Patients cannot download their data, nor can they print them out.
Recommendations for use
As a psychologist, I might recommend this app to clients who are focused on a diagnosis and are prone to be compliant with checklists and assignments. It could be also helpful to individuals who have not yet worked with a therapist to assess their difficulties and concerns. The audio content is excellent for those who will use it and includes such things as Beautiful Mind Meditation (7 minutes), Body Appreciation Meditation (5 minutes), and Going to Sleep on a Rainy Night (30 minutes). Another excellent resource is the Myers Briggs Type Indicator, which is embedded in the app, with good descriptions.
I would not recommend it for those who need to look beyond symptoms monitoring, to issues in their lives that are exacerbating their difficulties, including relationships, work settings, health practices, addictions, abusive relationships, etc.
Background Ratings Key
What are current user feedback/ratings?
1- Very negative reviews; 5- Very positive review
Psychologist Panel Review Ratings Key
(categories rated from 1–5, with 5 being the most positive score)
Purpose
What is the proposed intervention or what does it claim to do? Is it likely to do what it claims?
1-Highly unlikely; 5- Highly likely
Appropriateness of Content
Is the content appropriate? Does the content match the description and purpose? Were any clinical/psychology experts involved in the development of the material?
1- Very inappropriate; 5- Highly appropriate
Cultural Responsiveness
Did the app/software consider a variety/range of cultural factors (e.g., age, race, ethnicity, gender, gender identity, sexual orientation, ability levels) in the development? Is the app/software likely to appeal to people from different cultural backgrounds? Is it available in multiple languages?
1- Very unresponsive; 5- very responsive
Ease of Use