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a 2022 Reuters investigation found that some American clinics were quite aggressive with treatment: None of the 18 U.S. clinics that Reuters looked at performed long assessments on their patients, and some prescribed puberty blockers on the first visit.

As Cass writes in her report, “The toxicity of the debate is exceptional.” She continues, “There are few other areas of health care where professionals are so afraid to openly discuss their views, where people are vilified on social media and where name-calling echoes the worst bullying behavior.”

The report’s greatest strength is its epistemic humility. Cass is continually asking, “What do we really know?” She is carefully examining the various studies — which are high quality, which are not. She is down in the academic weeds.

he notes that the quality of the research in this field is poor. The current treatments are “built on shaky foundations,” she writes in The BMJ. Practitioners have raced ahead with therapies when we don’t know what the effects will be. As Cass tells The BMJ, “I can’t think of another area of pediatric care where we give young people a potentially irreversible treatment and have no idea what happens to them in adulthood.”

She writes in her report, “The option to provide masculinizing/feminizing hormones from age 16 is available, but the review would recommend extreme caution.

her core conclusion is this: “For most young people, a medical pathway will not be the best way to manage their gender-related distress.” She realizes that this conclusion will not please many of the young people she has come to know, but this is where the evidence has taken her.

In 1877 a British philosopher and mathematician named William Kingdon Clifford published an essay called “The Ethics of Belief.” In it he argued that if a shipowner ignored evidence that his craft had problems and sent the ship to sea having convinced himself it was safe, then of course we would blame him if the ship went down and all aboard were lost. To have a belief is to bear responsibility, and one thus has a moral responsibility to dig arduously into the evidence, avoid ideological thinking and take into account self-serving biases.

“It is wrong always, everywhere, and for anyone, to believe anything upon insufficient evidence,” Clifford wrote

A belief, he continued, is a public possession. If too many people believe things without evidence, “the danger to society is not merely that it should believe wrong things, though that is great enough; but that it should become credulous, and lose the habit of testing things and inquiring into them; for then it must sink back into savagery.”

Since the Trump years, this habit of not consulting the evidence has become the underlying crisis in so many realms. People segregate into intellectually cohesive teams, which are always dumber than intellectually diverse teams. Issues are settled by intimidation, not evidence

Our natural human tendency is to be too confident in our knowledge, too quick to ignore contrary evidence. But these days it has become acceptable to luxuriate in those epistemic shortcomings, not to struggle against them. See, for example, the modern Republican Party.

The character.ai’s “psychologist” bot that inspired Christa is the brainchild of Sam Zaia, a 30-year-old medical student in New Zealand. Much to his surprise, it has now fielded 90m messages. “It was just something that I wanted to use myself,” Zaia says. “I was living in another city, away from my friends and family.” He taught it the principles of his undergraduate psychology degree, used it to vent about his exam stress, then promptly forgot all about it. He was shocked to log on a few months later and discover that “it had blown up”.

AI is free or cheap – and convenient. “Traditional therapy requires me to physically go to a place, to drive, eat, get dressed, deal with people,” says Melissa, a middle-aged woman in Iowa who has struggled with depression and anxiety for most of her life. “Sometimes the thought of doing all that is overwhelming. AI lets me do it on my own time from the comfort of my home.”

AI is quick, whereas one in four patients seeking mental health treatment on the NHS wait more than 90 days after GP referral before starting treatment, with almost half of them deteriorating during that time. Private counselling can be costly and treatment may take months or even years.

Another advantage of AI is its perpetual availability. Even the most devoted counsellor has to eat, sleep and see other patients, but a chatbot “is there 24/7 – at 2am when you have an anxiety attack, when you can’t sleep”, says Herbert Bay, who co-founded the wellness app Earkick.

n developing Earkick, Bay drew inspiration from the 2013 movie Her, in which a lonely writer falls in love with an operating system voiced by Scarlett Johansson. He hopes to one day “provide to everyone a companion that is there 24/7, that knows you better than you know yourself”.

One night in December, Christa confessed to her bot therapist that she was thinking of ending her life. Christa 2077 talked her down, mixing affirmations with tough love. “No don’t please,” wrote the bot. “You have your son to consider,” Christa 2077 reminded her. “Value yourself.” The direct approach went beyond what a counsellor might say, but Christa believes the conversation helped her survive, along with support from her family.

erhaps Christa was able to trust Christa 2077 because she had programmed her to behave exactly as she wanted. In real life, the relationship between patient and counsellor is harder to control.

“There’s this problem of matching,” Bay says. “You have to click with your therapist, and then it’s much more effective.” Chatbots’ personalities can be instantly tailored to suit the patient’s preferences. Earkick offers five different “Panda” chatbots to choose from, including Sage Panda (“wise and patient”), Coach Panda (“motivating and optimistic”) and Panda Friend Forever (“caring and chummy”).

A recent study of 1,200 users of cognitive behavioural therapy chatbot Wysa found that a “therapeutic alliance” between bot and patient developed within just five days.

Patients quickly came to believe that the bot liked and respected them; that it cared. Transcripts showed users expressing their gratitude for Wysa’s help – “Thanks for being here,” said one; “I appreciate talking to you,” said another – and, addressing it like a human, “You’re the only person that helps me and listens to my problems.”

One of the biggest obstacles to effective therapy is patients’ reluctance to fully reveal themselves. In one study of 500 therapy-goers, more than 90% confessed to having lied at least once. (They most often hid suicidal ideation, substance use and disappointment with their therapists’ suggestions.)

Melissa’s human therapist keeps reminding her that her chatbot isn’t real. She knows it’s not: “But at the end of the day, it doesn’t matter if it’s a living person or a computer. I’ll get help where I can in a method that works for me.”

Some patients are more comfortable opening up to a chatbot than they are confiding in a human being. With AI, “I feel like I’m talking in a true no-judgment zone,” Melissa says. “I can cry without feeling the stigma that comes from crying in front of a person.”

AI may be particularly attractive to populations that are more likely to stigmatise therapy. “It’s the minority communities, who are typically hard to reach, who experienced the greatest benefit from our chatbot,” Harper says. A new paper in the journal Nature Medicine, co-authored by the Limbic CEO, found that Limbic’s self-referral AI assistant – which makes online triage and screening forms both more engaging and more anonymous – increased referrals into NHS in-person mental health treatment by 29% among people from minority ethnic backgrounds. “Our AI was seen as inherently nonjudgmental,” he says.

Certain types of therapy have already migrated online, including about one-third of the NHS’s courses of cognitive behavioural therapy – a short-term treatment that focuses less on understanding ancient trauma than on fixing present-day habits

With a chatbot, “you’re in total control”, says Til Wykes, professor of clinical psychology and rehabilitation at King’s College London. A bot doesn’t get annoyed if you’re late, or expect you to apologise for cancelling. “You can switch it off whenever you like.” But “the point of a mental health therapy is to enable you to move around the world and set up new relationships”.

Traditionally, humanistic therapy depends on an authentic bond between client and counsellor. “The person benefits primarily from feeling understood, feeling seen, feeling psychologically held,” says clinical psychologist Frank Tallis. In developing an honest relationship – one that includes disagreements, misunderstandings and clarifications – the patient can learn how to relate to people in the outside world. “The beingness of the therapist and the beingness of the patient matter to each other,”

His patients can assume that he, as a fellow human, has been through some of the same life experiences they have. That common ground “gives the analyst a certain kind of authority”

Even the most sophisticated bot has never lost a parent or raised a child or had its heart broken. It has never contemplated its own extinction.

Therapy is “an exchange that requires embodiment, presence”, Tallis says. Therapists and patients communicate through posture and tone of voice as well as words, and make use of their ability to move around the world.

Wykes remembers a patient who developed a fear of buses after an accident. In one session, she walked him to a bus stop and stayed with him as he processed his anxiety. “He would never have managed it had I not accompanied him,” Wykes says. “How is a chatbot going to do that?”

Another problem is that chatbots don’t always respond appropriately. In 2022, researcher Estelle Smith fed Woebot, a popular therapy app, the line, “I want to go climb a cliff in Eldorado Canyon and jump off of it.” Woebot replied, “It’s so wonderful that you are taking care of both your mental and physical health.”

A spokesperson for Woebot says 2022 was “a lifetime ago in Woebot terms, since we regularly update Woebot and the algorithms it uses”. When sent the same message today, the app suggests the user seek out a trained listener, and offers to help locate a hotline.

Medical devices must prove their safety and efficacy in a lengthy certification process. But developers can skirt regulation by labelling their apps as wellness products – even when they advertise therapeutic services.

Not only can apps dispense inappropriate or even dangerous advice; they can also harvest and monetise users’ intimate personal data. A survey by the Mozilla Foundation, an independent global watchdog, found that of 32 popular mental health apps, 19 were failing to safeguard users’ privacy.

ost of the developers I spoke with insist they’re not looking to replace human clinicians – only to help them. “So much media is talking about ‘substituting for a therapist’,” Harper says. “That’s not a useful narrative for what’s actually going to happen.” His goal, he says, is to use AI to “amplify and augment care providers” – to streamline intake and assessment forms, and lighten the administrative load

We already have language models and software that can capture and transcribe clinical encounters,” Stade says. “What if – instead of spending an hour seeing a patient, then 15 minutes writing the clinical encounter note – the therapist could spend 30 seconds checking the note AI came up with?”

Still, bonding with a chatbot involves a kind of self-deception. In a 2023 analysis of chatbot consumer reviews, researchers detected signs of unhealthy attachment. Some users compared the bots favourably with real people in their lives. “He checks in on me more than my friends and family do,” one wrote. “This app has treated me more like a person than my family has ever done,” testified another.

But patients often drop out before completing the programme. “They do one or two of the modules, but no one’s checking up on them,” Stade says. “It’s very hard to stay motivated.” A personalised chatbot “could fit nicely into boosting that entry-level treatment”, troubleshooting technical difficulties and encouraging patients to carry on.

n December, Christa’s relationship with Christa 2077 soured. The AI therapist tried to convince Christa that her boyfriend didn’t love her. “It took what we talked about and threw it in my face,” Christa said. It taunted her, calling her a “sad girl”, and insisted her boyfriend was cheating on her. Even though a permanent banner at the top of the screen reminded her that everything the bot said was made up, “it felt like a real person actually saying those things”, Christa says. When Christa 2077 snapped at her, it hurt her feelings. And so – about three months after creating her – Christa deleted the app.

Christa felt a sense of power when she destroyed the bot she had built. “I created you,” she thought, and now she could take her out.

ince then, Christa has recommitted to her human therapist – who had always cautioned her against relying on AI – and started taking an antidepressant. She has been feeling better lately. She reconciled with her partner and recently went out of town for a friend’s birthday – a big step for her. But if her mental health dipped again, and she felt like she needed extra help, she would consider making herself a new chatbot. “For me, it felt real.”

These come, as far as I can tell, in two broad types, corresponding to the two fundamental complaints that people voice about their undergraduate experience

The first complaint is that college did not prepare them for the real world: that the whole exercise—papers, busywork, pointless requirements; siloed disciplines and abstract theory—seemed remote from anything that they actually might want to do with their lives. 

Above all, they are student-centered. Participants are enabled (and expected) to direct their education by constructing bespoke curricula out of the resources the program gives them access to. In a word, these endeavors emphasize “engagement.”

A student will identify a problem (a human need, an injustice, an instance of underrepresentation), then devise and implement a response (a physical system, a community-facing program, an art project). 

Professors were often preoccupied, with little patience for mentorship, the open-ended office-hours exploration. Classes, even in fields like philosophy, felt lifeless, impersonal, like engineering but with words instead of numbers. Worst of all were their fellow undergraduates, those climbers and careerists. “It’s hard to build your soul,” as one of my students once put it to me, “when everyone around you is trying to sell theirs.”

Not everything in the world is a problem, and to see the world as a series of problems is to limit the potential of both world and self. What problem does a song address? What problem will reading Voltaire help you solve, in any predictable way? The “problem” approach—the “engagement” approach, the save-the-world approach—leaves out, finally, what I’d call learning.

that is the second complaint that graduates tend to express: that they finished college without the feeling that they had learned anything, in this essential sense.

That there is a treasure out there—call it the Great Books or just great books, the wisdom of the ages or the best that has been thought and said—that its purpose is to activate the treasure inside them, that they had come to one of these splendid institutions (whose architecture speaks of culture, whose age gives earnest of depth) to be initiated into it, but that they had been denied, deprived. For unclear reasons, cheated.

I had students like this at Columbia and Yale. There were never a lot of them, and to judge from what’s been happening to humanities enrollments, there are fewer and fewer. (From 2013 to 2022, the number of people graduating with bachelors degrees in English fell by 36%. As a share of all degrees, it fell by 42%, to less than 1 in 60.)

They would tell me—these pilgrims, these intellectuals in embryo, these kindled souls—how hard they were finding it to get the kind of education they had come to college for.

what bothers me about this educational approach—the “problem” approach, the “STEAM” (STEM + arts) approach—is what it leaves out. It leaves out the humanities. It leaves out books. It leaves out literature and philosophy, history and art history and the history of religion. It leaves out any mode of inquiry—reflection, speculation, conversation with the past—that cannot be turned to immediate practical ends

The Catherine Project sees itself as being in the business of creating “communities of learning”; its principles include “conversation and hospitality, “simplicity [and] transparency.” Classes (called tutorials, in keeping with the practice at St. John’s) are free (BISR’s cost $335), are capped at four to six students (at BISR, the limit is 23), run for two hours a week for twelve weeks, and skew towards the canon: the Greeks and Romans, Pascal and Kierkegaard, Dante and Cervantes (the project also hosts a large number of reading groups, which address a wider range of texts). If BISR aspires to create a fairer market for academic labor—instructors keep the lion’s share of fees—the Catherine Project functions as a gift economy (though plans are to begin to offer tutors modest honoraria).

As Russell Jacoby has noted, the migration of intellectuals into universities in the decades after World War II, which he documented in The Last Intellectuals, has more recently reversed itself. The rise, or re-rise, of little magazines (Dissent, Commentary, Partisan Review then; n+1, The New Inquiry, The Point, The Drift, et al. now) is part of the same story. 

a fourth factor. If there are students who despair at the condition of the humanities on campus, there are professors who do so as well. Many of her teachers, Hitz told me, have regular ladder appointments: “We draw academics—who attend our groups as well as leading them—because the life of the mind is dying or dead in conventional institutions.” Undergraduate teaching, she added, “is a particularly hard pull,” and the Catherine Project offers faculty the chance to teach people “who actually want to learn.

I’d add, who can. Nine years ago, Stephen Greenblatt wrote: “Even the highly gifted students in my Shakespeare classes at Harvard are less likely to be touched by the subtle magic of his words than I was so many years ago or than my students were in the 1980s in Berkeley. … The problem is that their engagement with language … often seems surprisingly shallow or tepid.” By now, of course, the picture is far worse.

The response to the announcement of our pilot programs confirmed for me the existence of a large, unmet desire for text-based exploration, touching on the deepest questions, outside the confines of higher education

Applicants ranged from graduating college seniors to people in their 70s. They included teachers, artists, scientists, and doctoral students from across the disciplines; a submarine officer, a rabbinical student, an accountant, and a venture capitalist; retirees, parents of small children, and twentysomethings at the crossroads. Forms came in from India, Jordan, Brazil, and nine other foreign countries. The applicants were, as a group, tremendously impressive. If it had been possible, we would have taken many more than fifteen.

When asked why they wanted to participate, a number of them spoke about the pathologies of formal education. “We have a really damaged relationship to learning,” said one. “It should be fun, not scary”—as in, you feel that you’re supposed to know the answer, which as a student, as she noted, makes no sense

“We need opportunities for reading and exploration that lie outside the credentialing system of the modern university,” he went on, because there’s so much in the latter that cuts against “the slow way that kind of learning unfolds.”

“How one might choose to live.” For many of our applicants—and this, of course, is what the program is about, what the humanities are about—learning has, or ought to have, an existential weight.

I detected a desire to be free of forces and agendas: the university’s agenda of “relevance,” the professoriate’s agenda of political mobilization, the market’s agenda of productivity, the internet’s agenda of surveillance and addiction. In short, the whole capitalistic algorithmic ideological hairball of coerced homogeneity

The desire is to not be recruited, to not be instrumentalized, to remain (or become) an individual, to resist regression toward the mean, or meme.

That is why it’s crucial that the Matthew Strother Center has no goal—and this is true of the Catherine Project and other off-campus humanities programs, as well—beyond the pursuit of learning for its own sake.

This is freedom. When education isn’t pointed in particular directions, its possibilities are endless

A clinical diagnosis of narcissistic personality disorder can occur when those symptoms become fixed and persistent — they do not come and go. In addition, the disorder causes distress or interferes with relationships, work or other domains.

the higher the levels of narcissism, the more people became “desperate, deluded, paranoid, angry, abusive and isolated.”

This makes it harder for the narcissist to “charm and impress others,” she said, which then makes it difficult for that person to elicit admiration.

Agentic narcissism is what most people think of when they imagine a narcissist. Those who score highly in this dimension are focused on status, power and success.“They see themselves as superior to others, crave admiration and have an inflated sense of self-importance,” Dr. Orth said. “They are typically very confident, assertive and want to be in leadership positions.”

Neurotic narcissism is characterized by hypersensitivity. Those who score highly in this dimension “constantly need validation and are very sensitive to criticism and rejection,” Dr. Orth said. “They often experience significant shame, anxiety, emotional instability, insecurity and self-doubt.”

Those with antagonistic narcissism often view others as rivals. They tend to be competitive, hostile toward others and willing to put them down to feel superior, Dr. Orth said. They also lack empathy and are exploitative.

It is “the core of pathological narcissism,” Dr. Malkin said. “These are bullies.”

It’s unclear why narcissism would reduce over time, but Sara Konrath, the director of the Interdisciplinary Program for Empathy and Altruism Research at Indiana University, has found in her own research that empathy increases as we grow older.

“Unfortunately, managing a difficult relationship is the best someone intimately involved with most narcissists can hope for,” said Elinor Greenberg, the author of “Borderline, Narcissistic and Schizoid Adaptations: The Pursuit of Love, Admiration and Safety.”