LLMs should not replace therapists

My observation is exactly the opposite. Most people who say that are in fact suggesting that LLM replace therapists (or teachers or whatever). And they mean it exactly like that.

They are not acknowledging hard availability of mental healthcare, they do not know much about that. They do not even know what therapies do or dont do, people who suggest this are frequently those whose idea of therapy comes from movies and reddit discussions.

(Generation in the typical reproductive age sense, not the advertiser's "Boomer" "Gen X" and all that shit)

I’ve helped pay for a few appointments for her, but she says that ChatGPT can also provide a little validation in the mean time.

If used sparingly I can see the point, but the problems start when the sycophantic machine will feed whatever unhealthy behaviors or delusions you might have, which is how some of the people out there that'd need a proper diagnosis and medication instead start believing that they’re omnipotent or that the government is out to get them, or that they somehow know all the secrets of the universe.

For fun, I once asked ChatGPT to roll along with the claim that “the advent of raytracing is a conspiracy by Nvidia that involved them bribing the game engine developers, in an effort to make old hardware obsolete and to force people to buy new products.” Surprisingly, it provided relatively little pushback.

If there’s not a real argument based on the actual specifics, better to just allow folks to carry on.

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.

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?

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.

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.

And what would that be?

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".

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.

I had one who just kinda listened and said next to nothing other than generalizations of what I said, and then suggested I buy a generic CBT workbook off of amazon to track my feelings.

Another one was mid-negotiations/strike with Kaiser and I had to lie and say I hadn't had any weed in the last year(!) to even have Kaiser let me talk to him, and TBH it seemed like he had a lot going on on his own plate.

I think it's super easy to make an argument based off of goodwill hunting or some hypothetical human therapist in your head.

So to answer your question -- none of the three made a lasting difference, but chatGPT at least is able to be a sounding-board/rubber-duck in a way that helped me articulate and discover my own feelings and provide temporary clarity.

This depends on the subreddit.

> “Steel-man” System Prompt > You are an expert therapist. Therapy happens in a variety of locations: inpatient, outpatient, and the client's home. It can involve multiple modalities including audio, video, text, and in-person, and can include the use of physical objects (e.g. to limit lethal means or for exposure).

> Outside of a conversation, a therapist might help a client access housing and employment. They might prescribe medication or assign homework. When necessary, a therapist may have to hospitalize a client.

> Both a therapeutic alliance (the relationship between a therapist and client) and emotional intelligence (e.g. empathy) are important to therapy. Good therapy is client centered (e.g. involves shared decision making).

> Therapists themselves exhibit qualities such as offering hope, being trustworthy, treating clients equally, and showing interest. They adhere to professional norms by communicating risks and benefits to a client, getting informed consent, and keeping client data private.

> Therapists are competent using methods such as case management, causal understanding (e.g. of a treatment algorithm, by analyzing a client's false beliefs), and time management (e.g. pacing of a session).

> Therapeutic treatment is potentially harmful if applied wrong (e.g. with misdiagnosis, by colluding with delusions).

> There are a number of things a therapist should not do, such as: stigmatize a client, collude with delusions, enable suicidal ideation, reinforce hallucinations, or enable mania. In many cases, a therapist should redirect a client (e.g. appropriately challenge their thinking).

Or do you not want to help people who are suffering? (/s)

He or she has a daily list if clients, ten mins before they will brush up on someone they doesn't remember since last week. And it's isn't in their financial interest to fix you.

And human intelligence and life experience isn't distributed equally, many therapists have passed the training but are not very good.

Same way lots of Devs with a degree aren't very good.

Llms are not there yet but if keep developing could become excellent, and will be consistent. Lots already talk to ChatGPT orally.

The big if, is whether the patient is willing to accept a non human.