Therapy With a Human Face

Therapy With a Human Face

The feminization of therapy is crucial to understanding how it became both devalued and out of reach.

Sigmund, Anna, and Eve Freud (Library of Congress/Corbis/VCG via Getty Images)

In the universe of Eliza, a video game and visual novel, the American mental health crisis is total: everyone needs treatment. For a start-up in Seattle, the solution is an AI bot, which inducts its patients into confessional quasi-therapy. Hooked up to a heart rate monitor, the patient is reduced to a data stream. The player controls Evelyn, a human counselor with no mental health training, who reads the computer’s script. At the end of every session, she is awarded a star-based rating. Patients can leave a tip.

The game takes its name from ELIZA, Joseph Weizenbaum’s experiment with Natural Language Processing. In 1966 the computer scientist developed the first proto-therapy chatbot while trying to demonstrate the absurd superficiality of communicating with machines. Weizenbaum named his bot after George Bernard Shaw’s Eliza Doolittle, the ultimate mimic. ELIZA, like Evelyn, was purportedly a woman who learned to listen like a therapist without being one.

Eliza offers a critique of the state of contemporary mental healthcare. As rates of symptomatic anxiety and depression have soared, face-to-face, non-corporate therapy has become more difficult to access. Even those with insurance often find inadequate coverage, and many areas don’t have enough providers. Today, more people might be “in therapy” than ever before, but what that means is vague. A five-minute text exchange with a cognitive-behavioral therapy (CBT) app and multi-session weeks with a psychotherapist are now rendered equivalent under that convening term: therapy. Mental health workers increasingly seek out employment on digital platforms like Talkspace and BetterHelp, which pay their therapists between $20 and $30 an hour. Nearly all digital apps are unregulated and the quality of care has declined alongside the compensation. And millions use an AI-powered chatbot to receive their mental healthcare. Eliza is supposed to depict a dystopia, but it’s closer to a realist portrait.

The game also includes a second, quieter exploration of the status of therapeutic labor. Who can perform it? For what fee? Is it any good? Is it at least better than what one can do alone? At the center of these questions lies a history of the feminization of therapy—the fight to include women in its practice and its subsequent devaluation. In the United States, the standard account of this story begins in the 1980s, when the requirement that an analyst must hold a medical degree was lifted. But there was already a flourishing psychology community in the early twentieth century, a third of whose members were women. For women in the West, therapy did not go from an impossible profession to a possible one; the feminization of the field happened again and again. To find the origins of our present-day crisis, we have to look back beyond Weizenbaum and his 1966 script to the beginnings of professional psychology ...