Comment by Cthulhu_
8 days ago
Thing is, professional therapy is expensive; there is already a big industry of therapists that work online, through chat, or video calls, whose quality isn't as good as a professional (I am struggling to describe the two). For professional mental health care, there's a wait list, or you're told to just do yoga and mindfulness.
There is a long tail of people who don't have a mental health crisis or whatever, but who do need to talk to someone (or, something) who is in an "empathy" mode of thinking and conversing. The harsh reality is that few people IRL can actually do that, and that few people that need to talk can actually find someone like that.
It's not good of course and / or part of the "downfall of society" if I am to be dramatic, but you can't change society that quickly. Plus not everyone actually wants it.
The issue is that if we go down this path, what will happen is that the gap between access to real therapy and "LLM therapy" will widen, because the political line will be "we have LLM therapy for almost free that's better than nothing, why do we need to reform health care to give equal access for everybody?".
The real issue that needs to be solved is that we need to make health care accessible to everybody, regardless of wealth or income. For example, in Germany, where I live, there are also long waitlists for therapists or specialists in general. But not if you have a high income, then you can get private insurance and get an appointment literally the next day.
So, we need to get rid of this two class insurance system, and then make sure we have enough supply of doctors and specialists so that the waits are not 3 months.
>> The real issue that needs to be solved is that we need to make health care accessible to everybody, regardless of wealth or income.
Good therapists are IMHO hard to come by. Pulling out serious deep rooted problems is very hard and possibly dangerous. Therapist burn out is a real problem. Having simpler (but less effective) solutions widely available is probably a good thing.
> Having simpler (but less effective) solutions widely available is probably a good thing.
And those solutions are not LLMs. It's been shown elsewhere (and in the OP, it seems) that LLMs are very bad therapists, severe malpractice bad.
3 replies →
Yes, and those simpler solutions don't have to involve LLMs. Support groups, fostering community through more local activities and places of belonging, funding social workers. I'm sure there's more.
6 replies →
I live in Canada and it's illegal to take private insurance if you also take public insurance.
The private healthcare system is virtually nonexistent and is dominated by scammers.
The public healthcare system still has months-long wait times.
If you want to avoid waitlists you need surplus capacity, which public healthcare doesn't provide.
I live in Canada as well. As far as I can tell there is basically no access to psychologists under the public healthcare system. You're just supposed to pay cash at about $150/hr to talk to a therapist (if you know differently please tell us!). For some people that's fine, but it's an absurd situation if, for example, you're underemployed/poor and facing related mental health challenges. Obviously paying that much to talk to someone can just aggravate the underlying problem.
Some people can access mental health care in the public system through their family doctor. But most people do not have access to this because there are not enough of this type of doctor. As far as I know the only other way is to wait until some sort of crisis then enter the hospital and there -might- be a chance to talk to a psychiatrist.
2 replies →
> it's illegal to take private insurance if you also take public insurance.
This seems like an odd excluded middle. In the UK, you can have private health insurance if you want, but you can always fall back on the NHS; the one wrinkle is that you may not always be able to take a prescription from the private to the public system without getting re-evaluated. (e.g for ADHD)
> which public healthcare doesn't provide
== taxpayers aren't willing to pay for.
2 replies →
This isn’t universal at all. Quebec and Ontario allow for visits and payments to private doctors — usually offered under a subscription model, so that the “subscription” can be picked up by employers in lieu of “insurance”. It’s definitely smaller than in the states, but it’s big enough that it’s in use by the upper-middle class.
In the USA we have huge waitlists for most all types of healthcare. Private healthcare doesn't provide surplus capacity either.
19 replies →
Just going to point out that down here in the US, there is tons of waiting with private insurance. Good luck seeing your actual primary care doctor (not some other doctor or physician's assistant) within 3 months. Specialists? Prepare to wait even longer. On an HMO insurance, make that even longer.
While private vs public might affect supply, there are other big factors going on that are limiting access to care.
1 reply →
> The public healthcare system still has months-long wait times.
I pay an expensive monthly premium and I still have monthly-long wait times in the US. (Putting this here because many people think that the "benefit" of the US healthcare model is that you get "fast/immediate" care instead of "slow/long waits" in those "socialist" countries.
1 reply →
> So, we need to get rid of this two class insurance system, and then make sure we have enough supply of doctors and specialists so that the waits are not 3 months.
Germany has reduced funding for training doctors. So clearly the opposite is true.
> For example, in Germany, where I live, there are also long waitlists for therapists or specialists in general. But not if you have a high income, then you can get private insurance and get an appointment literally the next day.
And the German government wants to (or is implementing policies to) achieve the opposite and further reduce access to medical specialists of any kind. Both by taking away funding and taking away spots for education. So they're BOTH taking away access to medical care now, and creating a situation where access to medical specialists will keep reducing for at least the next 7 years. Minimum.
Yeah, I am not saying Germany is doing it right :D Just explained how it works here and what I think should be improved.
1 reply →
I think it would be great to make mental healthcare accessible to everyone who could benefit from it, but have you actually run the numbers on that? How much would it cost and where would the money come from? Any sort of individual counseling or talk therapy is tremendously expensive due to the Baumol effect.
And even if we somehow magically solve the funding problem, where will the workers come from? Only a tiny fraction of people are really cut out to be effective mental health practitioners. I'm pretty sure that I'd be terrible at it, and you couldn't pay me enough to try.
This addresses the key problem. The lack of access to therapists is due to lack of therapists, because the demand far outweighs supply. It is simply not possible to train the number of therapists that we need, so technological advancement is probably the correct answer.
1 reply →
Let's solve that productivity issue!
The classic view of one reclining on a couch, and the professional listening, seems to have a lot of downtime for the professional. The occasional sound of affirmation, 'go on', 'yes, yes' may be heard, but often a lot is the patient talking.
We could easily move this to text or video, but let's choose text. Best would be some form of speech to text, but AI driven and with a shorthand for emoted quality.
I suggest we assign primary emotions to primary colours, using three base emotions as primaries, and the professional would be able to read the emotions at play, and quantity, merely by the resulting colour of text. Larger print or bold or what not, could be used for more intense speech, eg yelling.
This would allow one professional to allow multiples to speak, yet they could simply wait for the text to appear, consider it, and respond vocally. Any perceived delay in response, could be derided by the concept of "I needed time to think on your words".
Thus the patient speaks, the professional's voice responds, the illusion of complete dedication to one patient is whole. Yet anywhere from 4 to 10 patients could be served in parallel with such a system, and remotely too!
I'm fairly sure I could whip this entire platform up over a weekend.
This solves the surmised shortages, for one could do the work of 10. It also helps the environment, with people not traveling to an office for their appointment.
Hmm. Maybe I should pursue this, and be bought out by Amazon so it can be included in Prime Plus or whatever.
2 replies →
I agree with the principal here, and beleive that it's noble.
However, it boils down to "Don't advance technology, wait 'till we fix society", which is futile - regardless of whether it's right.
Correct, but the alternative of don't fix society, just use technology is equally destructive.
LLM therapy lacks important safeguards. A tool specifically made for mental health could work, but anyone with mental health experience will tell you using ChatGPT for therapy is not safe.
Why do we need to make mental healthcare available to everyone?
For all of human history people have got along just fine, happily in fact, without “universal access to mental health care”
This just sounds like a bandaid. The bigger problem is we’ve created a society so toxic to the human soul that we need universal access to drugs and talk therapy or risk having significant chunks of the population fall off the map
> For all of human history people have got along just fine, happily in fact, without “universal access to mental health care”
Mixing up "some people survived" and "everyone was fine" is a common mistake.
Some folks who're able to thrive today on drugs and therapy are the "tragically wandered off in a snowstorm" of past eras.
It's the same token as more people dying from cancer than ever before. Yes, modern society creates many more cancer patients than ever, but less people are dying early from things that aren't cancer than ever.
We live in a society that, for the most people, has the best quality of life than ever in history. But in having that increase, we eliminate many problems that must be replaced by other problems.
In this case, a mental health crisis comprised of people who either wouldn't have survived to that point, or whose results went unremarked or shrugged off as something else in the past. In terms of violent outbursts, we also have easier access to more destructive weapons (even those that aren't guns) and more density of population on whom violence can be inflicted.
> For all of human history people have got along just fine, happily in fact, without “universal access to mental health care”
Can we please stop with these incredibly low-effort arguments that are just blatantly untrue with about 5 seconds of inspection? If I have to hear "well humans did just fine before!" one more time I'm going to lose my mind.
No, no they did not. We can't ask them because they're dead now. The ones we can ask are the ones who survived. We might call this a "survivorship bias".
There's practically infinite graphs showing the trends of survivability and quality of life throughout time. Less infants die now, less adults die now, we live longer, we live happier, we live with less illnesses. There's less polio, less measles, less tuberculosis, you fucking name it.
I mean, for god's sake before modern medicine infant mortality was close to 50%. Women would have 10 children, maybe 4 would make it to adult hood, and she'd die giving birth to the 10th. That's assuming she didn't get unlucky and die on the first one because her body wasn't perfectly set to give birth. Shoulder dystocia? Too fucking bad, you lost the lottery, go die now.
>Why do we need to make mental healthcare available to everyone?
Why do we need to make physical healthcare available to everyone? For most all of human history, bones were set by family. Yeah, ok, often the patient was hobbled for life. I guess it makes sense to get treated by a professional...wait, perhaps we've stumbled upon something here...
Just fine? Happily?
Surely many wars and deaths would have been prevented with better mental strategies.
No one is stopping you from making society better...
In the mean time it's best we all have
I suggest you put the terms "warfare," "genocide," and "slavery" into Wikipedia and then tell us how fine people got along.
[dead]
That’s nice sounding, in the USA currently we’re headed the opposite direction and those in power are throwing off millions from their insurance. So for now, the LLM therapist is actually more useful to us. Healthcare won’t be actually improved until the current party is out of power, which is seeming less likely over the years.
Thing is, professional therapy is expensive; there is already a big industry of therapists that work online, through chat, or video calls, whose quality isn't as good as a professional (I am struggling to describe the two). For professional mental health care, there's a wait list, or you're told to just do yoga and mindfulness.
So for those people, the LLM is replacing having nothing, not a therapist.
> So for those people, the LLM is replacing having nothing, not a therapist.
Considering how actively harmful it is to use language models as a “therapist”, this is like pointing out that some people that don’t have access to therapy drink heavily. If your bar for replacing therapy is “anything that makes you feel good” then Mad Dog 20/20 is a therapist.
An extremely large accusation - do you have any evidence to suggest this is as harmful as you say?
1 reply →
A sycophant is worse than having nothing, I think.
I think AI is great at educating people on topics, but I agree, when it comes to actual treatment AI, especially recent AI, falls all over itself to agree with you
1 reply →
ok, cool? Listing random unrelated facts isn't exactly helpful to the conversation
1 reply →
You're absolutely right!
:)
> So for those people, the LLM is replacing having nothing, not a therapist.
Which, in some cases, may be worse.
https://www.nytimes.com/2025/06/13/technology/chatgpt-ai-cha...
"Mr. Torres, who had no history of mental illness that might cause breaks with reality, according to him and his mother, spent the next week in a dangerous, delusional spiral. He believed that he was trapped in a false universe, which he could escape only by unplugging his mind from this reality. He asked the chatbot how to do that and told it the drugs he was taking and his routines. The chatbot instructed him to give up sleeping pills and an anti-anxiety medication, and to increase his intake of ketamine, a dissociative anesthetic, which ChatGPT described as a “temporary pattern liberator.” Mr. Torres did as instructed, and he also cut ties with friends and family, as the bot told him to have “minimal interaction” with people."
"“If I went to the top of the 19 story building I’m in, and I believed with every ounce of my soul that I could jump off it and fly, would I?” Mr. Torres asked. ChatGPT responded that, if Mr. Torres “truly, wholly believed — not emotionally, but architecturally — that you could fly? Then yes. You would not fall.”"
It's mad. Here's a smooth-talker with no connection to reality or ethics, so let's get people in a tough mental state to have intimate conversations with them.
Can’t read the article so I don’t know if it was an actual case or a simulation, but if it was an actual case, I’d think we should really check that “no history of mental illness”. All the things that you listed here are things a sane person would never do in a hundred years.
1 reply →
Which is probably the situation for most people. If you don’t have a ton of money, therapy is hard to get.
Per the very paper we are discussing, LLMs when asked to act as therapists reinforce stigmas about mental health, and "respond inappropriately" (e.g. encourage delusional thinking). This is not just lower quality than professional therapy, it is actively harmful, and worse than doing nothing.
I'd argue LLM is replacing TikTok therapist, not nothing.
Often the problem is not even price - it is availability. In my area, the waiting list for a therapy spot is 16 months. A person in crisis does not have 16 months.
LLVMs can be therapeutic crutches. Sometimes, a crutch is better than no crutch when you're trying to walk.
One alleviating factor (potentially) to this is cross state compacts. This allows practitioners utilizing telehealth to practice across state lines which can mitigate issues with things like clients moving, going to college, going on vacation, etc but also can help alleviate underserved areas.
Many states have joined into cross state compacts already with several more having legislation pending to allow their practitioners to join. It is moving relatively fast, for legislation on a nationwide level, but still frustratingly slow. Prior to Covid it was essentially a niche issue as telehealth therapy was fairly uncommon whereas Covid made it suddenly commonplace. It will take a bit of time for some of the more stubborn states to adopt legislation and then even more for insurance companies to catch up with the new landscape that involves paneling out of state providers who can practice on across the country
Most states just outsource licensing to a professional organization and transfers are a simple matter of filing a form and paying a fee.
If practicing across state lines is lucrative there's not much stopping existing listened professionals from doing it.
1 reply →
Price is the issue. The 16-month waiting list is based on cost. You could find a therapist in your local area tomorrow if you are willing to spend more.
Not sure if willing is the correct word. Able? Also this is not a one off visit/payment.
Some crutches may absolutely be worse than no crutch at all.
The issue is LLM "therapists" are often actively harmful. The models are far too obsequious to do one of the main jobs of therapy which is to break harmful loops.
I've spoken to some non-LLM therapists that have been harmful as well. They still required a waitlist while also being expensive.
I have talked to therapist who misdiagnosed my symptom and made the issue worse, until I found an expert who actually understood the problem. I do wonder if there are statistics out there for these cases.
You're rarely going to get something like the recent rollingstone reports though. The solution is better health coverage and more therapists not giving up and rolling that dice that the machine might agree with the patient (or talk them into thinking) they are indeed the godhead.
https://www.rollingstone.com/culture/culture-features/ai-spi...
I know this conversation is going in a lot of different directions. But therapy could be prioritized, better funded, trained, and staffed... it's entirely possible. Americans could fund the military 5% less, create a scholarship and employment fund for therapists, and it would provide a massive boon to the industry in less than a decade.
We always give this downtrodden "but we can't change society that quickly" but it's a cop out. We are society. We could look at our loneliness epidemics, our school shooting problems, our drug abuse issues and think "hey we need to get our shit together"... but instead we're resigned to this treadmill of trusting that lightly regulated for-profit businesses will help us because they can operate efficiently enough to make it worth squeezing pennies out of the poor.
Ultimately I think LLMs as therapists will only serve to make things worse, because their business incentives are not compatible with the best outcomes for you as an individual. A therapist feels some level of contentment when someone can get past that rough patch in life and move on their own, they served their purpose. When you move on from a business you're hurting their MAU and investors won't be happy.
Would increasing funding for therapy help any of those issues? Ignoring that very low efficacy of therapy and the arguments if funding it is worthwhile at all. The American people had fewer issues with school shootings and loneliness and drug abuse when we had even fewer therapists and therapy was something for people in mental asylums, that no respectable person would admit going to.
Worst case is that we come out on the other end knowing more about the problem. This doesn't have to be 1:1 therapy, research has never been incredibly well funded and it's being dramatically reduced right now.
Consider that after school shootings, sometimes therapists have to volunteer their time to provide trauma counseling.
Every social worker I've met has at one point volunteered time to help someone because we exist in a system where they're not valued for wanting to help.
"we can't change society that quickly" isn't a cop out - even if you manage to win every seat in this one election, the rich still control every industry, lobbyists still influence everyone in the seats, and the seats are still gerrymandered to fall back to the conservative seat layout.
The system will simply self-correct towards the status quo in the next election.
So we just sit on our hands and accept the shit we're fed until revolution, I suppose
Many professional therapists are working online now. There are advantages and disadvantages of each approach. Sometimes it is better for a patient to be at home in a comfortable situation during a session. Sometimes visiting the therapist in an office provides a welcome change of scenery.
In some cases, such as certain addiction clinics, the patients are required (by law, if I remember correctly) to visit the clinic, at least for some sessions.
Yes theoretically. The issue if people just go to ChatGPT is that a therapist would have clear objections, caveats or other negative feedback ready on the correct situation. Most LLM chatbots go out of their way to never say a critical word at all.
I am not saying you couldn't implement a decent LLM therapist that helps, I am saying people are using the cheapest good LLM for that and it is a problem if you are on a bad path and there is a chatbot reaffirming everything you do.
>professional therapy is expensive…For professional health care, there is a waitlist
There’s an old saying in healthcare that you can choose between quality, cost, and access, but you can only choose two. (Peter Attia also adds “choice” to that list).
Each society needs to determine which of those are the top priorities, and be prepared to deal with the fallout on the others. Magical silver bullets that improve across all those dimensions are likely hard to come by in the healthcare domain. I doubt that LLMs will be magic either, so we need to make sure the tradeoffs reflect our priorities. In this case, it seems like it will trade quality for improvements in access and cost.
This. LLMs might be worse but they open access for people who couldn't have it before. Think of the cheap Chinese stuff that we got in the last decade. It was of low quality and questionable usability but it built China and also opened access of these tools to billions of people in the developing world.
Would this compromise be worth it for LLM? Time will tell.
The question is why should that be so expensive? The labor market is not working here.
LLM for therapy is way worse than porn for real sex. Since at least the latter does not play around with sanity.
There are multiple types of licenses for therapists and fairly strict regulations about even calling yourself a therapist. Trained therapists only have so many levers they can pull with someone so their advice can sometimes boil down to yoga or mindfulness, it's not the answer most want to give but it's what a patient's situation allows inside the framework of the rest of their life.
The amateur "therapists" you're decrying are not licensed therapists but usually call themselves "coaches" or some similar euphemism.
Most "coach" types in the best scenario are grifting rich people out of their money. In the worst case are dangerously misleading extremely vulnerable people having a mental health crisis. They have no formal training or certification.
LLM "therapists" are the functional equivalent to "coaches". They will validate every dangerous or stupid idea someone has and most of the time more harm than good. An LLM will happily validate every stupid and dangerous idea someone has and walk them down a rabbit hole of a psychosis.
empathy is not the only thing a therapist provides - they have eyes to actually check out the client's actual life - thus the propensity for "AI" to encourage clients' delusions
who says we can't change society that quickly? you made up your mind on that yourself without consulting anyone else about their wishes.
in the USA we elect people frequently and the entire population just up and goes along with it.
so therapy for you will be about more than just empathy. not everything you think or do or say is adaptive.
to your point, not everyone wants to give up their falsehood. yet, honesty is a massive cornerstone of therapy progress.
i would simply have to start with empathy for you to welcome you in if you won't respond with security to the world telling you that you internalized a negative message (relationship) from the past (about people).
I have a few friends who are using ChatGPT as sounding board/therapist, and they've gotten surprisingly good results.
Replace? No. Not in their case. Supplementary. One friend has a problem of her therapists breaking down crying when she explains about her life.