Episode 45

Scaling Mental Health Care with AI

with Alison Darcy, P.h.D.

September 20, 2022

Alison Darcy, P.h.D.
Founder and President, Woebot Health

Alison is a clinical research psychologist and health tech visionary dedicated to creating smart, scalable and accessible mental healthcare solutions. Her work to explore how digital treatments can help solve human problems began more than 20 years ago, when she created one of the first online support groups for people with eating disorders. That work led to PhD level studies in psychology at University College Dublin and post-doctoral training at Stanford School of Medicine and with the American Psychiatric Association. At Stanford, Alison also worked with AI pioneer Andrew Ng to explore the intersection of AI and healthcare, leading his Health Innovation Lab in Computer Science. A frequent speaker on digital therapeutics design and development, barriers to care, and engagement, Alison has authored more than 40 publications and been awarded research grants and contracts from the NIH, the Davis Foundation and APA. She is also currently an Adjunct Faculty member in the Psychiatry and Behavioral Sciences Department of Stanford’s School of Medicine. Alison holds a PhD, an MLitt and a Bachelor of Arts degree in psychology from University College Dublin.


Everybody has mental health, and everyone has to deal with it.



[00:01:00] Tarun Kapoor, MD: Hi everyone. I’m Tarun Kapoor for here with Day Zero. And I’m very excited to introduce you all to Dr. Allison Darcy, who is our guest for today’s session. Without further ado, I’m gonna let Ali introduce herself. Ali, please. Welcome.

[00:01:16] Alison Darcy, P.h.D.: Thank you very much for having me. My name is Alison Darcy and I’m the founder and president of Woebot Health.

[00:01:21] Tarun Kapoor, MD: All right. So right off the bat, I think we need to talk a little bit Woebot Health. That’s an interesting name. So tell us a little bit about the company, what you do and what you’re doing today. And then we’ll explore how you got to where you are today.

[00:01:34] Alison Darcy, P.h.D.: Sure. Yeah. Woebot Health is a digital therapeutics company. We make digital behavioral health through relational technologies in particular. And our therapeutics right now are delivered by our relational agent who is called “Woebot,” which we’ll talk about how we got that name, but yeah we built a suite of products basically to support people who have symptoms of anxiety and depression. There is a solution for postpartum depression that we’re hoping to send through FDA clearance and also for adolescence as well.

[00:02:03] Tarun Kapoor, MD: So this is not something that you just came up with recently. This is something you’ve been thinking about and passionate about. Can you tell us about how this first percolated as an idea and when did this all start in your thought process?

[00:02:17] Alison Darcy, P.h.D.: There was a number of things came together. One of those was just the knowledge of what was happening outside of the lab and the ivory tower. The reality of the numbers of people suffering in the population, just going through the roof at a much faster pace than we had expected as a field. The knowledge that we don’t have enough resources to deal with everybody, and that actual fundamental architecture of therapy is not scalable. I started to really believe that our system around mental healthcare is not just not scalable, but it’s kind, flawed from a design perspective and that the architecture, the basic design of what a session looks like, could be traced back to some Freudian era, the era of the 1890s. But we have never really evolved beyond that in a meaningful sense. And I just thought for, in particular, young people and various subgroups, co-therapy is like just a bad design in lots of ways, but not the therapeutic process itself, but the architecture around it, the structure, the needing to go to a clinic, the limitation around it being, one to one interactions and things with another human. And then, of course, those things that keep it somewhat stigmatized, frankly. Really hard to find a practitioner, it takes a lot for somebody to reach out and get help.

[00:03:36] Tarun Kapoor, MD: It’s so fascinating. You brought up the Freudian piece, cause it never even dawned in my head, wait a minute, yeah, we’re doing something, quote the couch. Well, The only way to do the couch is to physically have a couch and maybe the fundamental problem is, and is this fair to say the fundamental assumption that you’re challenging is it doesn’t require a couch or it doesn’t require an office? Is that fair?

[00:03:58] Alison Darcy, P.h.D.: I think that there’s a role for the couch and there’s a role for the office. But there’s also a role for these other things. And I don’t know where along the line we became obsessed with the fact that there’s like the archetype of therapy is one thing and it is two people in a room around a couch, the proverbial couch. Actually, there are so many approaches that do better, or I think have the potential to be better implemented through a digital format and because of the nature of what they’re trying to do, and one cognitive behavioral therapy in my view is one of those therapies. And it basically, comes down to the model itself is based on enabling people to gather information that challenges a negative worldview that they might have of themselves, the world and the future. And I was recently rereading Beck’s original therapy manual that was published in 1979. And in it, Aaron Beck actually suggests that therapists do home visits so they can be by the side of their patient as they deal with their day to day struggles. Such that they can coach them through that opportunity to say, let’s challenge your thinking. Let’s challenge your thought process around what’s happening right now. And so they can replace it with something more balanced and objective. Well, there’s no therapist that’s really doing home visits. That’s very rare. But that’s the role of a Woebot. A Woebot is there as that person is living their life in that moment where they are faced with something that, honestly, is defeating or crushing them, or, making them feel really powerless. And can talk them through, okay what are you feeling now? So that’s the problem I went to solve. It was not, could I make a digital therapeutic that digitizes CBT? That was a solved problem. Lots of people had done that, but can you do it in a way that really engages people meaningfully at that key therapeutic moment?

[00:05:49] Tarun Kapoor, MD: I think you’ve just hit on another theme that, you know, as I’ve had an opportunity to do some interviews with other founders and co-founders, you hit on that is don’t just take the current process, put digital on it, and now it’s a… Right? That doesn’t solve, that doesn’t solve the problem. Understand the underlying problem, and you and your team spent a lot of time on this exact point. Not trying to just digitize an analog process, but actually creating a new architecture, I think is the term you use. Talk us through a little bit? Even the title Woebot, I asked you like, where did you come up with this name, Woebot? Cause it doesn’t quite click in my head, cause you know, we’ve heard of other happy terms out there.

[00:06:30] Alison Darcy, P.h.D.: I know that’s right.

[00:06:32] Tarun Kapoor, MD: Where did this Woebot concept?

[00:06:34] Alison Darcy, P.h.D.: Frankly, that’s all of us, we all have mental health and we all need to look after it. But when you’re really struggling with depression, the last thing you want to be told is to, just be happier, be a better version of yourself and all this stuff. And actually, the name for me was tongue in cheek. It’s a pollen. But it’s also about. Approaching the problem with a, just a touch of humor, like just a touch of we don’t have to be professional heavy. So ah, I’m not articulating this well, as you can tell, it was quite an instinctual name that I thought was funny. What I observed when working with people was that actually a bit of humor in your practice does help to move the work along because a lot of this work is, frankly, not fun, right? It’s not that entertaining or fun to explore your most negative belief systems about yourself. These are heavy things. And so a bit of humor allows us to move with that and go into that process a bit more readily, so that’s where the name came from.

[00:07:29] Tarun Kapoor, MD: The other thing that I think I’m hearing you talk about is, tell me if you disagree with this, is a lot of times it’s either or in digital, right? If digital is going to replace analog, is that you’re looking to blend those concepts. Right?

[00:07:44] Alison Darcy, P.h.D.: Oh, absolutely. Yeah, absolutely. There’s often a narrative around replacement and because Woebot is a conversational agent or a relational agent, it seems like you’re just trying to be a therapist. And then actually, that’s exactly not what we’re trying to be. Now, that doesn’t mean that Woebot, isn’t informed and guiding people through solid cognitive behavioral therapy principles, but Woebot is explicitly not a therapist. Woebot’s showing up as a peer as a person who is like by your side as an ally, truly an ally. And that is a different role because they’re there, in the middle of the night or what have you. And that’s why we also chose Woebot, like the very robotness of the name is intentional. The Woebot archetype look and feel all of that is intentional so that it is its own thing and never mistaken for being a human and never trying to be a human, because human connection is something very different, unique, and precious. And what Woebot does is a utilitarian role but it also is ensuring that the person understands that really there is no person there allowing them to, again, engage, allowing them to disclose, what might be something very dark for them and difficult. I think the beauty of it is when you come through a process, that person implicitly understands. This Woebot didn’t tell me anything I didn’t know about myself already. They just asked the right questions. I have the resources. I actually went through a process and I think that’s a win for me because I think the best of cognitive behavioral therapy is very self-directed.

[00:09:12] Tarun Kapoor, MD: So you formally founded Woebot. It’s been how long now?

[00:09:17] Alison Darcy, P.h.D.: It was five years. So yeah, I was 2017. I was working on the problem earlier. But I didn’t answer your actual, your previous question you asked, which I meant to get to, but I stopped the whole point about that process being distinct from a therapeutic process is that they actually sit side by side really complimentarily. So Woebot is this like really great tool that enables people to engage in some of the skills that their therapist is teaching them. And it just works so beautifully where we’ve had engagements where we’ve seen, therapists refer their patients to Woebot and they come back and say things like their patients come more ready, more engaged in therapy with them. So yeah, that was just to loop back and your question.

[00:09:59] Tarun Kapoor, MD: So the reason I brought up asked about it’s 2017, you clearly knew COVID was gonna happen. That’s why you set it up, oh my goodness. Can you help guide, the listeners out there? How have you had to pivot Woebot, do stuff different at Woebot, given now that, we knew about the mental health, but it is never exposed to this extent. What have you had to do differently with Woebot coming out of the pandemic?

[00:10:26] Alison Darcy, P.h.D.: What we saw was an acceleration of the infrastructure and the world around us, it was really intriguing within a few weeks. We no longer had to have a discussion about the merit of digital and, it was just implicitly understood and adopted. We think back on the ludicrousness of, clinicians not being reimbursed at the same level for a telemedicine appointment as a regular appointment, it seems archaic to us now. Because the time that they spend is exactly the same. Though, that was the reality back then. So I think we saw an acceleration of adoption and also the people’s conversation, just, the zeitgeist changed fundamentally. And I think there was just a global acceptance. I would say, as universal, as we’ve ever seen it, that everybody has mental health and everyone has to deal with it. It was very dramatic. For those of us who had been working in mental health for the longest time to suddenly find mental health on the topic of everybody’s, on top of mind. And, I think just was a very good thing, even though, obviously we don’t love the circumstances that got us there. So in many ways, actually what we had to do is keep our head down and keep building. And that’s what we did. We actually didn’t shift our pipeline. We stayed more resolute. And from that point on, it was head down, keep going in the knowledge that, yeah, what we do is meaningful and important.

[00:11:47] Tarun Kapoor, MD: And now the other end of that question, it would be the acceleration, the rapid adoption of digital I would say format architectures for healthcare. Now, lot more economic uncertainty in the world today. How are you having to pivot Woebot or are some lessons learned so far that you could share with the listeners, things that you need to think about, or you have to think about differently as there’s more economic headwinds that folks are running into.

[00:12:14] Alison Darcy, P.h.D.: Yeah. We’re very fortunate in the time that we raised relatively recently. And and we’ve always been frugal. We’ve always been lean. And I think now, you’re especially cared to be fiscally responsible, right? You just have to be very strategic around the resource allocation in the company and ensuring that we all do good work and don’t become comfortable. I think as a startup, you never really are just sitting back and breathing a sigh of relief and thinking, yeah, we made it. As a startup, by definition, you’re never at that point. And I think what’s happening, what we’ve seen as a result of the pandemic and probably as we move into a new economic climate, is the argument around cost and the infrastructure around healthcare spending may be shifting. It’s still shifting. I think that the sand is shifting under our feet. And we just have to be more discerning and even more strategic around demonstrating cost savings around what we do. You have to be realistic and think, there has to be an ROI. And of course we believe it, as people. But it is the challenge because things like preventative care or earlier intervention may not have that immediate ROI that lends itself very well to just, an easy commercial argument or a business case. But it just drives the creativity of the team, frankly. And I actually think alongside this economic shift is a genuine acceleration of people’s thinking around the fallout from negative mental health. So alongside the shifting macro is also an expansion of people’s understanding of where mental health negatively impacts the bottom line in all kinds of contexts. It’s not just mental health as this niche thing. People are realizing mental health as a role in all health. You can’t really disentangle the two. And so I think the world is really shifting.

[00:14:10] Tarun Kapoor, MD: So before it’s yeah, listen, I need to pay for this exact visit, but maybe now it’s I need to care for my employee population, cause I need to retain them. And that’s a different value point. Is that a fair statement?

[00:14:22] Alison Darcy, P.h.D.: Yeah, that’s right. I think that’s right. Honestly, I think there are additional arguments that we haven’t seen before that are very welcome in that people are saying, no, hang on a second. There has to be some equity and inclusion here. We can’t just have great access for one group and then the others are ignored. What about people in rural areas? So I think where the world is moving to more equitable. Access as an overriding principle, digital solutions have to become part of that.

[00:14:48] Tarun Kapoor, MD: So just before we close out, just a couple of thoughts wanted to explore with you. Being a founder is not easy. You’re a sole founder, right? A lot of times we have talked to co-founders. Can you maybe share a little bit what are some of the toughest things you had to go through or even your construct of how you get through the tough stuff? That keeps you going, it’s oh boy, because sometimes there isn’t always a shoulder to, yeah, to proverbially anything on. So, how do you pull it off?

[00:15:15] Alison Darcy, P.h.D.: You lean into the problem and you think this is not about me. This isn’t about me or the company like this thing needs to be solved. When you take yourself out of it, it’s a little bit easier to just keep going and, to calibrate to doing the right thing. As the company has grown, of course, I think what keeps me going now, it’s the problem in the context that is complex and juicy and the people that we have in the company around the table solving it. We have some incredibly brilliant and talented people at Woebot Health and I, can’t believe it. They’re so interesting as well. I am sitting here in Dublin and just when I think of the engineers that are here, one of them was an archeologist before, another one was a PhD in French literature. And then they’re all incredible musicians, like concert level musicians. And of course, when I think about that, I think yeah, they’re the builders and, of course, they come from interesting backgrounds because what we’re solving is so human and so plugged in to like creativity as well as great engineering and as well as great clinical theory and science.

[00:16:14] Tarun Kapoor, MD: I cannot think of a better way to land. Dr. Allison Darcy, on behalf of the team here at day zero, thank you so much for taking the time and sharing your insights with us.

[00:16:24] Alison Darcy, P.h.D.: Thank you so much for having me. It’s been really great.

[00:16:26] Tarun Kapoor, MD: Have a great one.

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