Comment by theothertimcook

> Therapy isn't supposed to scale. It's the relationship that heals.

My understanding is that modern evidence-based therapy is basically a checklist of "common sense" advice, a few filters to check if it's the right advice ("stop being lazy" vs "stop working yourself to death" are both good advice depending on context) and some tricks to get the patient to actually listen to the advice that everyone already gives them (e.g. making the patient think they thought of it). You can lead a horse to water, but a skilled therapist's job is to get it to actually drink.

As far as I can see, the main issue I see with a lot of LMMs would be that they're fine tuned to agree with people and most people who benefit from therapy are there because they have some terrible ideas that they want to double down on.

Yes, the human connection is one of the "tricks". And while a LLM could be useful for someone who actually wants to change, I suspect a lot of people will just find it too easy to "doctor shop" until they find a LLM that tells them their bad habits and lifestyle are totally valid. I think there's probably some good in LLMs but in general they'll probably just be like using TikTok or Twitter for therapy - the danger won't be the lack of human touch but that there's too much choice for people who make bad choices.

> A "relationship" with an LLM has an obvious, intrinsic, and fundamental problem.

What exactly do you mean? What do you think a therapist brings to the table an LLM cannot?

Empathy? I have been participating in exchanges with AI that felt a lot more empathetic than 90% of the people I interact with every day.

Let's be honest: a therapist is not a close friend - in fact, a good therapist knows how to keep a professional distance. Their performative friendliness is as fake as the AI's friendliness, and everyone recognises that when it's invoicing time.

To be blunt, AI never tells me that ‘our time is up for this week’ after an hour of me having an emotional breakdown on the couch. How’s that for empathy?

> It's the relationship that heals.

Ehhh. It’s the patent who does the healing. The therapist holds open the door. You’re the one who walks into the abyss.

I’ve had some amazing therapists, and I wouldn’t trade some of those sessions for anything. But it would be a lie to say you can’t also have useful therapy sessions with chatgpt. I’ve gotten value out of talking to it about some of my issues. It’s clearly nowhere near as good as my therapist. At least not yet. But she’s expensive and needs to be booked in advance. ChatGPT is right there. It’s free. And I can talk as long as I need to, and pause and resume the session whenever want.

One person I’ve spoken to says they trust chatgpt more than a human therapist because chatgpt won’t judge them for what they say. And they feel more comfortable telling chatgpt to change its approach than they would with a human therapist, because they feel anxious about bossing a therapist around. If its the relationship which heals, why can't a relationship with chatgpt heal just as well?

That was a very interesting read, it's funny because I have done and experienced (both sides) of what the LLM did here.

Don't get me wrong there are many phenomenal mental health workers, but it's a taxing role, and the ones that are exceptional posses skills that are far more valuable not dealing with broken people, not to mention the exposure to vicarious trauma.

I think maybe "therapy" is the problem and that open source, local models developed to walk people through therapeutic tools and exercises might be the scalable help that people need.

You only need to look at some of the wild stories on the chatgpt subreddit to start to wonder at it's potential, recently read two stories of posters who self treated ongoing physical conditions using llms (back pin and jaw clicking) only to have several commenters come out and explain it helped them too.

> Therapy isn't supposed to scale.

As I see it "therapy" is already a catch-all terms for many very different things. In my experience, sometimes "it's the relationship that heals", other times it's something else.

E.g. as I understand it, cognitive behavioral therapy up there in terms of evidence base. In my experience it's more of a "learn cognitive skills" modality than an "it's the relationship that heals" modality. (As compared with, say, psychodynamic therapy.)

For better or for worse, to me CBT feels like an approach that doesn't go particularly deep, but is in some cases effective anyway. And it's subject to some valid criticism for that: in some cases it just gives the patient more tools to bury issues more deeply; functionally patching symptoms rather than addressing an underlying issue. There's tension around this even within the world of "human" therapy.

One way or another, a lot of current therapeutic practice is an attempt to "get therapy to scale", with associated compromises. Human therapists are "good enough", not "perfect". We find approaches that tend to work, gather evidence that they work, create educational materials and train people up to produce more competent practitioners of those approaches, then throw them at the world. This process is subject to the same enshittification pressures and compromises that any attempts at scaling are. (The world of "influencer" and "life coach" nonsense even more so.)

I expect something akin to "ChatGPT therapy" to ultimately fit somewhere in this landscape. My hope is that it's somewhere between self-help books and human therapy. I do hope it doesn't completely steamroll the aspects of real therapy that are grounded in "it's the [human] relationship that heals". (And I do worry that it will.) I expect LLMs to remain a pretty poor replacement for this for a long time, even in a scenario where they are "better than human" at other cognitive tasks.

But I do think some therapy modalities (not just influencer and life coach nonsense) are a place where LLMs could fit in and make things better with "scale". Whatever it is, it won't be a drop-in replacement, I think if it goes this way we'll (have to) navigate new compromises and develop new therapy modalities for this niche that are relatively easy to "teach" to an LLM, while being effective and safe.

Personally, the main reason I think replacing human therapists with LLMs would be wildly irresponsible isn't "it's the relationship that heals", its an LLM's ability to remain grounded and e.g. "escalate" when appropriate. (Like recognizing signs of a suicidal client and behaving appropriately, e.g. pulling a human into the loop. I trust self-driving cars to drive more safely than humans, and pull over when they can't [after ~$1e11 of investment]. I have less trust for an LLM-driven therapist to "pull over" at the right time.)

To me that's a bigger sense in which "you shouldn't call it therapy" if you hot-swap an LLM in place of a human. In therapy, the person on the other end is a medical practitioner with an ethical code and responsibilities. If anything, I'm relying on them to wear that hat more than I'm relying on them to wear a "capable of human relationship" hat.

Youre right you can pretty much run that line backwards for scarcity/availability Shrink, Psych, Social, Counsellor.

I was shocked how many psychiatrists deal almost exclusively with treatment and titration of ADHD medication, some are 100% remote via zoom.

I've been involved with the publishing of psychology research, my faith in that system is low, see replication crisis comments, beyond that, working in/around mental health I hear of interactions where psychologists or MH social workers have "prescribed" bible study and alike so anecdotal evidence combined with my own experiences over the years.

Re: socioeconomic backgrounds, you said so yourself, many cannot afford to go route of clinical psych, increasingly the profession has become pretty exclusive and probably not for the better.

Agree regarding the snake oilers but you can't discount distrust and disenfranchisement of/from the establishment nd institutions.

'This way up' is already offering self-paced online CBT, I see LLMs as an extension of that, if only for the simple fact that a person can open a new tab and start the engagement without a referral, appointment, transport, cost, or even really any idea if how the process works.

Infact, I'm certain it is already happening based on reading the chatgpt subreddit, as for efficacy I don't think we'll ever really know, I know that I personally would be more comfortable being totally honest with a text box thank a living breathing human so who knows.i appreciate your insights though.

they don’t need to be from the same class, but without insurance traditional once a week therapy costs as much as rent, and society wide, insurance can’t actually reduce price

> They're giving clients specific services that that training prepared them to provide.

And what would that be?

And yet, studies show that journaling is super effective at helping to sort out your issues. Apparently in one study, journaling was rated as effective than 70% of counselling sessions by participants. I don’t need my journal to understand anything about my internal, subjective experience. That’s my job.

Talking to a friend can be great for your mental health if your friend keeps the attention on you, asks leading questions, and reflects back what you say from time to time. ChatGPT is great at that if you prompt it right. Not as good as a skilled therapist, but good therapists and expensive and in short supply. ChatGPT is way better than nothing.

I think a lot of it comes down to promoting though. I’m untrained, but I’ve both had amazing therapists and I’ve filled that role for years in many social groups. I know what I want chatgpt to ask me when we talk about this stuff. It’s pretty good at following directions. But I bet you’d have a way worse experience if you don’t know what you need.

Also, that friend has amnesia and you know for absolute certain that the friend doesn't actually care about you in the least.

Virology, immunology, and Oncology eradicated entire illnesses and reduced cancer mortality by double digits.

Psychology, nearly crashed the peer review system, now recognises excessive use of Xbox as a mental illness.

It is similar to "we got all these super useful and productive methods to workout (weight lifting, cardio, yoga, gymnastics, martial arts, etc.) yet people drink, smoke, consume sugar, sit all day, etc.

We cannot blame X or Y. "It takes a village". It requires "me" to get my ass off the couch, it requires a friend to ask we go for a hike, and so on.

We got many solutions and many problems. We have to pick the better activity (sit vs walk)(smoke vs not)(etc..)

Having said that, LLMs can help, but the issue with relying on an LLM (imho) is that it you take a wrong path (like Interstellar's TARS the X parameter is too damn high) you can be detailed, while a decent (certified doc) therapist will redirect you to see someone else.

>What if they're the same levels of mental health issues as before?

Maybe but this raises the question of how on Earth we'd ever know we were on the right track when it comes to mental health. With physical diseases it's pretty easy to show that overall public health systems in the developed world have been broadly successful over the last 100 years. Less people die young, dramatically less children die in infancy and survival rates for a lot of diseases are much improved. Obesity is clearly a major problem, but even allowing for that the average person is likely to live longer than their great-grandparents.

It seems inherently harder to know whether the mental health industry is achieving the same level of success. If we massively expand access to therapy and everyone is still anxious/miserable/etc at what point will we be able to say "Maybe this isn't working".

Psychology has succeeded in creating new disorders while fields like virology, immunology and oncology are eradicating and improving mortality rates.

It was these professions and their predecessors doing the padded cell confinement, labotomising and etc.