Therapy chatbots?

The BBC has recently been highlighting therapy and how it can help people. In one article, they examined the rising popularity of chatbots and Large Language Models (LLMs) such as ChatGPT as digital therapists. But there are some nuances that are worth highlighting...

The BBC has been highlighting therapy

Therapy is not just for mental health issues

In the UK, when you mention therapy, most people immediately think of mental health issues such as anxiety and depression, and talking therapies offered by the NHS which focus mainly on Cognitive Behavioural Therapy (CBT), which scientific studies have shown can be effective at treating diagnoses of anxiety and depression.

But there's a key distinction here - in this context, anxiety and depression are medical diagnoses. (You don't necessarily have to have received a diagnosis - medicine defines a group termed as "sub-clinical" who are people experiencing symptoms of anxiety and/or depression, but who don't yet meet the diagnostic threshold. In effect, these people are on the slippery slope, and many, if left un-supported, will progress to medically diagnosable anxiety or depression.)

But when you hear people talking about working with their therapist in the US - where having a therapist is much more prevalent and carries much less stigma - it is typically understood that they are seeking to address things in their lives and/or personalities that hold them back in some way - relationship difficulties, long-standing impacts of trauma, procrastination, self-sabotage, self-medicating with illicit drugs, feeling 'stuck' in life. None of these are medical conditions - though many if left un-addressed may begin to manifest as mental health conditions such as anxiety or depression. And working with a therapist can help to unpack, bring to the fore and gain insight and perspective on these things in a way that helps people live better lives and flourish.

Does digital therapy work?

So when looking at the question of digital therapy chatbots, it's helpful to keep in mind the distinction between therapy for mental health issues and therapy for life issues.

When considering therapy for mental health issues - in effect treating a medical condition - the potential for harm is higher, and the therapy chatbot needs to be held to a higher standard in terms of what therapeutic modality, such as CBT, it is delivering, how well it conforms to the modality, whether it is measurably effective, and whether it causes or allows people to come to harm. The gold standard for answering these questions are rigorous controlled clinical trials, similar to those that a pharmaceutical has to go through to be prescribed by a doctor.

And there is quite a lot of work going on in this space, with the research results being published in high quality peer-reviewed journals, unsurprisingly focused mainly on digitally delivering CBT.

But if you look at social media you can find a growing number of people talking about using LLMs such as ChatGPT as their therapist. Some are dealing with diagnosed or sub-clinical mental health conditions, but many are struggling with 'life issues'. And there is very little scientific research being done to look at this latter group. But anecdotally, people claim to experience significant life improvements, attributing the success to their ability to be more open with the algorithm than they might feel comfortable being with another person, and often simply because they're able to access these LLMs at little-to-no cost, at times that suit them, when they may not be able to find or afford a human therapist.

What are the risks?

The sudden unfettered access to these digital therapist LLMs has, unsurprisingly, given rise to horror stories. It's easy to see that someone suffering with symptoms of a mental health condition who might be prone to, or already having thoughts of, self-harm or suicide is exposed to significant risk when they're able to chat with an algorithm that sounds like it has insight, and has been trained to be often effusively supportive and empathetic, but which has flimsy safeguard, if any, and has not been put under the microscope in a clinical trial. There are documented instances of users expressing suicidal ideation, either directly or indirectly, and receiving responses that are affirmatory and even encouraging the user to follow through.

The other risk that is being insufficiently discussed is the data that users are generating. Particularly when the chatbot is free, the companies behind these systems are usually harvesting the things the user says to train the next generation of their technology, or even to sell to companies such as advertisers. As mentioned earlier, one of the things that users find attractive about these digital therapists is the feeling that it's private and there is no human listener silently judging them. As a result they feel comfortable sharing personal details that they might hesitate to on social media, for instance. It's not difficult to see how this kind of data, previously inaccessible to the worlds richest and most powerful tech companies, might be of value.

The value of a human therapist

The last thing to say is that there is a fluidity to therapy. Often someone may initially seek help due to something seemingly benign like procrastination, but through working with an experienced therapist they uncover the root of this behaviour in, for example, difficult and unprocessed early life experiences. It's not uncommon for this kind of work to be somewhat destabilising for the individual - which is part of the therapeutic journey - but requires the oversight and input of an experienced professional to hold a safe space in which the client can have the wobbles they need to have, and keep an eye that these aren't spiralling to a damaging place.

There is often value in being able to air, sort out and gain perspective on our thoughts, and this is a place that current therapy chatbots can help, but the true work of therapy requires skill, insight and experience from the therapist, and this is not yet something that is being addressed by therapy chatbots.

Finding a therapist with the right combination of skill, insight and experience can be difficult and is often reduced to trial-and-error - another reason why many people are turning to the chatbots.

We've written previously about steps you can take to make finding the right therapist a bit less like shooting in the dark. But we think the best way to find a highly experience therapist is to be hand-matched to one by a highly experienced therapist.

If you're interested in meeting with an expert therapist, you can book an initial assessment here.