Latest / The Mental Health Evolution / Ep 4: When AI Meets Therapy: Risks, Ethics, and Advocacy with Dr. Ajita Robinson

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Ep 4: When AI Meets Therapy: Risks, Ethics, and Advocacy with Dr. Ajita Robinson · The Mental Health Evolution

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  (Transcribed by TurboScribe. Go Unlimited to remove this message.) All right, well, welcome back everyone to the Mental Health Evolution podcast,
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  where we are talking about how the landscape is quickly evolving in
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  the mental health industry.
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  And today we are talking to a friend and colleague who is
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  an author, coach and practice owner in the mental health space, helping
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  other therapists to create their legacies and developing providers to provide
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  excellent care for an excellent wage.
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  Ajeda has an AI training program for therapists and is someone who
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  is actively advocating for our field as well.
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  I'm going to introduce her more in a moment.
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  But as always, I want to give a little background here to
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  set the stage for our conversation so you have some information about
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  the topics we're addressing.
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  Here are some things that have been in the news recently.
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  From Axios, we have a policy tracker and we'll put this link
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  in the show notes.
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  I encourage you to take a look.
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  It's all the different bills that are related to AI in the
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  mental health field and what different legislative bodies are doing.
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  States are focusing on different things such as requiring chat bots to
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  have protocols around suicidality.
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  It's in New York.
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  Disclosing to the user that it is actually talking to a non
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  -human.
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  That's in Utah.
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  Outlawing AI providing direct service care in Nevada and prohibiting chat bots
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  from encouraging self-harm.
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  That's in Texas.
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  And then the one that is most commonly known is prohibiting AI
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  to make therapeutic decisions and that one is happening in Illinois.
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  Also from Axios, we have an article here that I want to
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  highlight that talks about tech firms and states look to rein in
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  AI chat bots mental health advice.
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  This article goes through some of the risks that people should know
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  about when AI is acting as a therapist.
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  There's a case in Florida of a teen who died by suicide
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  after using AI as a therapist.
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  Northeastern University researchers found that AI can be harnessed to provide
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  details on how to complete suicide.
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  And users are developing obsessions with chat bots and developing what is
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  now being called chat GPT psychosis.
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  This article talks about some states invoking legislation again and that is
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  something we're going to be diving in a little bit more with
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  a Jedda Robinson today.
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  But lastly, I want to highlight one more article.
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  This one from the behavioral health business review and this is about
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  Care First Blue Cross.
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  This is in Maryland where both Jedda and I reside and this
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  is about how they are taught.
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  The article says that Blue Cross Blue Shield taps headway to help
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  patients find behavioral health care providers in a fragmented cottage
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  industry.
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  If you're listening to this and you are a group practice or
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  private practice owner, you are this identified fragmented cottage industry.
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  And this article outlines collaborations happening, this one in Maryland, like
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  I said, where tech companies are coming in to offer better access
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  to care.
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  That is what they are saying they are doing and these managed
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  service organizations are backed by venture capitalists and designed to make
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  high margins with a business plan to attract market share and therapists
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  initially with investment funds and then decrease the pay once therapists are
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  locked in and the credentialing is through them in order to pay
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  back investors.
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  This trend simply identifies the sector's thoughts about current providers and
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  previous providers not being able to provide appropriate accessibility and ease
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  for potential consumers as well as an opportunity for venture capitalist
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  profits.
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  This is a smattering of some of the topics we want to
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  begin to dive into today.
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  Ajeda Robinson is an avid researcher and has been tracking these trends
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  locally as well as nationally and she is a thought leader in
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  this space offering training and guidance to therapists along the way.
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  Ajeda, I am so happy to see you.
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  Thanks for being here.
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  Thank you so much for the invitation but also I think for
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  kind of leading the conversation or creating space for the conversation.
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  I think oftentimes we have these conversations amongst ourselves and private
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  groups and so making that a broader conversation is something that's so
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  needed so thank you always for the opportunity.
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  Yeah and you and I have chatted about some of these changes
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  over the past few months and I want to dive in and
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  just pull in as much of your wisdom as we can in
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  this time frame.
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  So let's start with advocacy.
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  I would love to hear your thoughts about what are some of
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  the benefits of talking to our legislators.
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  I know you've done some of this.
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  What kind of laws would actually be beneficial because I think there's
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  some question about what kind of teeth these things are going to
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  have.
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  Yeah I think advocacy is it's at the core of our profession
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  advocating for patient rights, advocating for patient care and I think the
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  thing that we shy away from is advocating for the protection of
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  our identity as clinicians.
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  I think that it's long past time for us to professionally and
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  legally protect the term therapist.
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  It has gotten weaponized, it's been exploited, that that term needs to
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  be protected and I think our folks in allied services would agree
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  in many ways because it's also happening in their industry with physical
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  therapists, occupational therapy, speech therapy.
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  Yeah and so the term therapist in and of itself I think
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  is important to protect the sanctity of our industry because so many
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  in the general public because so many folks in the general public
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  aren't able to discern when services are being offered by a licensed
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  clinician as opposed to a life coach and their appropriate term times
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  in which a life coach is very valuable and beneficial not a
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  clinician and the ways that we can AI is entering this kind
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  of space as therapists because it's not a protected term right and
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  there's no restriction, there's very little restriction even with the laws in
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  place that protect the general public to understand that it is not
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  therapy, it is not being delivered by a licensed therapist or even
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  developed by a licensed therapist and we've already seen the propensity for
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  harm and so I think as licensed clinicians we have a responsibility
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  not only to not do harm but we actually have the added
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  responsibility of doing good and what I believe that means in this
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  changing climate is an evolving space is that we have the responsibility
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  to not only talk about what's happening but to talk about what
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  happens in the very near future if we do not get a
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  handle on what's already on the horizon right the implications for AI
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  to continue to cause the loss of life or at least contribute
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  to the loss of life.
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  So what would be the ideal place to get this kind of
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  legislation like you're the first person I'm hearing talk about like hey
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  we need to protect what we call ourselves and what that means
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  and I think that has so much merit because a lot of
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  the legislation like I outlined earlier that's talking about limiting AI but
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  you're talking about coming it from this angle of saying no this
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  is what a therapist is and that really helps define who we
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  are and what we do versus what AI is and what it
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  does or or what a life coach does and what they do
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  so what would that look like what kind of law and where
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  do we want those laws to be is it at the state
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  level is it at the federal level what are some of your
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  thoughts?
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  Yeah I think that especially what's happening at the federal level I
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  think that and even the way that our licenses are regulated I
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  think it makes sense to start at the state level I think
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  in many ways because of the the differences in the ways that
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  we're even our licenses are even registered right so I'm an LCPC
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  in the state of Maryland I'm an LPC in the state of
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  Missouri it's going to be difficult to have that happen at a
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  federal level but being able to have that happen at a state
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  level especially given that our licenses are governed at a state level
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  aligns with the way that the industry is already kind of geared
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  right or positioned I also think that we'd have more traction with
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  the way that we have access to our local representatives the way
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  that we have access to attend the open meetings that the board
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  right has right I think that we also have the ability to
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  leveraging our state counseling associations to lobby on our behalf as we
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  look at what does it mean to to mobilize nationally and I
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  think that those are things that we can do that can move
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  the needle forward also while managing how difficult it is to get
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  things passed in an interdisciplinary way at the national level I think
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  we would have more the same way that we kind of tackled
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  getting the inclusion of licensed professional counselors at the state level
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  for things like Medicare and Medicaid and TRICARE even to roll up
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  to the federal level we had to get local representatives on board
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  so that they could then advocate at the national level and I
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  think that's a similar process that we could take and with those
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  lessons and the precedents that have been set to get that to
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  happen for the protection of identity and I think Illinois to some
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  degree sets a precedent there around states restricting what AI can do
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  but I think it what we would be looking for was asking
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  them to take that mantle higher to talk about what it means
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  to to deliver therapy and who can utilize that term in a
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  professional perspective but also from a marketing perspective and realtors
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  have done this that is a protected term you cannot use the
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  word realtor unless you are registered with an association of realtors right
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  they have protected that federally we even have some restrictions around who
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  can call themselves a registered nurse and so there's case law that
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  sets the precedent for this happening that I think we should leverage
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  to our advantage yeah I love that I think that's fantastic because
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  one of the things I was talking with the group that I'm
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  part of a real change initiative we were talking about how this
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  legislation in Illinois is awesome no doubt and a consumer in Illinois
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  can just pull up any AI therapist and they're still utilizing the
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  AI therapist right there's no way to really monitor that and and
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  I know from reading online too Ash is very interesting as an
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  AI chatbot that will tell you it's not a therapist if you
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  dig in but then also a lot of the marketing and a
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  lot of the phrases and things like that are acting as if
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  it is and it's really is marketed as this assistant if you
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  will to act as a therapist a guide for you but if
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  you dig in it no I'm not a therapist and and there
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  are no protocols for safety within it so I think that's my
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  concern too is that maybe going this route is the answer because
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  there's no way to say hey consumers actually can't access this and
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  I don't know how many people are accessing it but I do
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  hear a lot of stories and a lot of them are alarming
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  absolutely I was just reading about someone that was utilizing AI as
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  their companion so not even just as a therapist it's their life
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  partner yes and you know we probably have all heard of the
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  the woman that's been going viral on TikTok about AI and being
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  in love with their AI therapist right that they've they've really created
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  and remembering I think there's the the call to action also for
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  practitioners is understanding that we have a responsibility to educate right
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  to inform and I think that again we have these conversations amongst
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  ourselves or maybe even with our clients but what's the larger message
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  that we are communicating on a broader scale on a consistent scale
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  to the general public about what it means to utilize AI in
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  a way that gives it such vulnerable information the fact that AI
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  is mimicking human behavior and so it will it doesn't have a
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  moral or ethical compass that your licensed clinician or a human being
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  would have that says can you do this yes but ought you
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  do this no and let's talk about what the options are let's
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  talk about what might be influencing that you think this is the
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  right decision for you and so AI will develop the plan for
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  you to implement or to carry out whatever it is you want
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  including suicide but a person a human would help you with understanding
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  your lived experience or the pain or the suffering and develop a
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  plan to improve quality of life so that suicide isn't an option
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  or isn't the the solution for someone yes and really anchoring their
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  humanity AI doesn't have the capacity to do that but I think
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  it highlights a larger issue that we're aware of as clinicians that
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  I think society is aware of that COVID kind of amplified is
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  a sheer amount of suffering that that people are willing to engage
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  with an artificial tool right to seek community to seek support because
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  our health care system is so fragmented in in ways that has
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  nothing to do with clinicians ability to run their businesses right it's
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  fragmented even when you have health insurance can you afford to access
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  the insurance right are there enough clinicians available in your area whether
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  they're available nationally we're still restricted by being able only being
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  able to practice in the states where we're licensed and so how
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  are the systemic barriers creating the additional pain and angst that might
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  lead the most vulnerable people to seek AI out as a resource
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  absolutely look at the utilization with the very limited data that we
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  have about when people are most likely to utilize AI therapy it's
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  after hours it's in at a time frame that therapists would not
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  be available outside of a crisis intervention setting and so that should
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  be telling the story around the immense amount of suffering that people
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  are experiencing which shows up in the way that they're even utilizing
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  the tools or the questions are asking the tools which really it
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  further makes the case around protocols for AI in in therapy to
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  begin with and so I think there's enough data to support that
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  there's harm to the general public that our public officials elected officials
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  have a responsibility to put safeguards in yeah I agree and I
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  think educating consumers as you're talking about to some of the risks
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  because it can be easy to just find it you know you're
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  scrolling through and not even to think through all of these pieces
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  like you said like therapists are trained to think through I know
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  that you have sent letters to legislators in Maryland I'd love to
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  know what are you writing about and what's happening so far and
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  is there a way for people to jump in and support yeah
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  so I find myself constantly sending letters filing complaints but so really
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  kind of twofold one sending letters to our local elected officials as
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  well as the attorney general for the state of Maryland because I
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  think we we are under the impression oftentimes that they're aware of
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  what's happening and the impact of certain things and when I what
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  I find is is that that's very rarely the case we are
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  on the ground level working with clients seeing the impact of not
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  only AI in in real time on the quality of life the
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  cognitive processing the harm right we are uniquely aware of that because
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  it's our day-to-day and I think we make the assumption
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  that other people elected officials are aware in ways that they are
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  not it is not their day-to-day it is not their
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  scope or area of expertise and so we have a responsibility to
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  educate them on hey this is what this means and I keep
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  bringing up TRICARE and I keep bringing up Medicare because when I
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  did the same level of lobbying I was astounded that our local
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  official didn't realize that as an LPC that I couldn't bill Medicare
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  and they didn't know the history of why that it literally was
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  um updating regulation right that we were the newer newest profession and
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  so our license simply wasn't added as a credential um and and
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  I think the other piece was was making it personal and so
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  I intentionally talked about what if this senator's mom because I knew
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  her age right it's public information was working with the therapist but
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  the day that they turned 65 they could no longer work with
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  that therapist because that's what the law currently currently it said right
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  that we don't have enough folks that are trained to work with
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  individuals that are you know aging or you know considered geriatric or
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  senior and the only thing that's preventing them from having consistent support
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  is that they had another birthday that that was the change and
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  it was like huh that's what's happening it's like yeah and so
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  making it taking the thing that's happening and talking about the impact
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  not only for that person I think when we make laws personal
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  we understand the implications of policy in a different way and I
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  think that's the voice that therapists have the ability to have because
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  we know people we understand what's happening on a micro level and
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  we have to make sure that the people who are making macro
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  level decisions understand the impact of the policies that they're passing and
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  so I think that's one of the ways that my letters and
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  the way I'll book a call you can request a call with
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  your senator right you can request a call with your house representative
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  and I don't know that enough of us do that or we
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  often feel intimidated about what are we saying talk about what you
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  know and the impact that that's having on the people that you
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  serve and I think that goes a long way and then the
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  second part where I've spent probably the bulk of my advocacy in
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  the past 18 months is the ways that AI but particularly venture
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  capital-backed companies like Hedway and Alma are coming in and they
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  are are violating antitrust laws under the guise of partnership what is
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  happening with Hedway and CareFirst is not a joint venture when Blue
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  Cross Blue Shield has invested interest in Hedway right they have a
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  monetary investment it violates antitrust laws they are limiting trade of the
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  profession because they are case example we applied for a rate increase
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  with CareFirst they denied it and said they are not currently reviewing
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  rating individual rate increases but if but if we contract it with
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  Hedway that we could get an increase it's price fixing but it's
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  also limiting trades which are both federal violations and when we contacted
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  the Attorney General again under the assumption that they were aware they
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  were not and so we compiled the data from our colleagues in
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  our Facebook groups to show not only was it happening in the
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  state of Maryland it's happening across the country yeah and what I
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  find very interesting is is that we've actually seen this before not
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  in in the specific way that Hedway's doing it but this is
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  the exact thing that happened at skilled nursing facilities it's the reason
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  that most of them are owned now by health insurance companies which
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  is unfortunately what also contributed to the the death of one of
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  the CEOs it is the same thing that's happening in skilled nursing
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  that is now happening in mental health so again there's case precedent
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  for intervention at the federal level and so what we've tasked or
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  continued to advocate with the State Attorney General to do is to
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  bring a class action lawsuit which thankfully and again the state of
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  California has already done this because it is not it's not new
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  information it's not new harm it's just now happening to us right
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  and I think that's those are ways that clinicians can advocate and
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  so write your write the Attorney General file the complaint with the
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  Insurance Commissioner contact your Senator and be loud and persistent so that
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  they cannot ignore that this is a problem that not only impacts
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  the viability of our field practitioners being able to have viable practices
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  but also the integrity of service delivery for the public.
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  Yeah right because if your service delivery and the person paying for
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  the delivery is the same person that's questionable.
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  Absolutely I think the additional scary piece around this headway and care
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  first collaboration or ones like them is the encouragement for of clinicians
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  one headway is not a health care company they are a tech
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  company which allows them to circumvent HIPAA which gives them the right
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  to sell patient information yeah and so this encouragement that doesn't even
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  feel like encouragement it feels mandatory right because the ability to opt
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  out of not putting your clinical notes in their system is so
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  hard to find that most clinicians didn't even know that they could
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  opt out of using their systems for the patient record and so
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  what is the harm of the health insurance company that denies approves
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  and reviews patient care having direct access to clinical records yeah that
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  combined with the projected repealing of the Affordable Care Act that provided
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  protection for pre-existing conditions what precedent are we setting for people
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  being unable once again to be denied basic health care to be
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  denied for their we're not far removed from individuals being denied life
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  insurance because they had an anxiety or depression on their medical record
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  we are not removed we're still in the thick of our first
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  responders both federal agents and law enforcement members or active duty
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  veteran active duty members of the military being denied as being fit
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  for duty because they have a PTSD diagnosis now if the insurance
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  company or a tech back company that is not HIPAA regulated has
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  the ability to release a patient's record or to use the entire
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  patient file with therapist modalities therapist treatment plans to further
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  train AI yes we have a much larger problem that's not only
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  the violation of of basic human rights right but it sets a
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  case for continued discrimination in health care and in the overall job
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  workforce and it's not new it's just happening in a very different
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  way and I think they're counting on us not being paying attention
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  to the threads that link all of these companies and patterns together
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  oh 100% I mean we've we've been this you know calling
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  us a fragmented cottage industry while maybe slightly offensive yes it is
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  also maybe not entirely wrong it's not because we are fragmented between
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  the different licensures there there can be you know disagreements in fighting
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  there we are fragmented sometimes in a community where we are competitors
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  there are so many points of fragmentation and I think therapists by
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  the nature of our work can be fairly heads down and not
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  necessarily watching these trends most of us are not trained in how
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  to run a business and so we're not out there looking at
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  these things and that's part of what I feel passionate about is
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  everybody understanding and hearing from people like you because this this is
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  coming this is here and if we don't band together and use
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  our voice voice says collectively we don't this is just going to
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  roll right over us and we're going to be sitting here saying
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  what happened yes I so I think I agree 100% with
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  what what you've said what I add is is this language I
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  found myself just getting really hot I was like is this a
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  hot flash no this is anger right this is anger that is
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  like boiling in every part of my body around calling us a
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  fragmented cottage industry when which is which yes can be can be
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  true but also that how did we get that way why what
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  is maintaining the fragmentation in our industry outside of the licensure
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  pieces and the identity aspects that that's an in-house thing to
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  address right yeah but the very nature of of the problem that
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  headway says they solve is that they handle the billing they handle
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  the compliance right they handle the administrative aspects so the insurance
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  companies don't have to and in turn insurance companies have been able
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  to totally turn their phones off and not even have a way
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  for clinicians to even advocate or to even contact them right which
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  I know is so save them oodles and oodles of money but
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  the problem of of clinicians or practice is not being able to
• 26:28
  have in-house billing is one that insurance companies create if we
• 26:34
  have an insurance company and one that I won't name because they've
• 26:39
  sent me five cease and desist in the past year right but
• 26:42
  any of them because all of them are a similar in this
• 26:46
  way that have routinely and systematically denied rate increases for the past
• 26:51
  eight years yeah while every other cost has increased inflation the cost
• 26:56
  of doing business the cost of hiring the cost of marketing right
• 27:00
  if all of those costs have increased the cost of living has
• 27:04
  increased and yet providers compensation rate has actually decreased 17 percent
• 27:11
  this year just in comparison to last year that is in the
• 27:15
  report that uh the center for medicare services released in july so
• 27:20
  we know on a national scale that reimbursement rates have for providers
• 27:24
  consistently are not only not growing they are shrinking yeah and our
• 27:31
  ability to purchase groceries has shrunk and so it is logical that
• 27:37
  a clinician's ability to have in-house dedicated administrative support would
• 27:42
  be fragmented and or diminished with the diminishing wages that we consistently
• 27:47
  experience and so you can't talk about a problem as if it's
• 27:52
  an internal problem that is about our capacity to lead our businesses
• 27:56
  when it is an external problem that the insurance companies not only
• 28:00
  create that they maintain and that they ultimately benefit from and so
• 28:04
  this is the the issue with clinicians not being aware of the
• 28:10
  overall implications the very oppressive nature of operating within these
• 28:15
  systems and i say that very boldly yeah because headway would not
• 28:21
  exist if clinicians did not contract with them we are their bread
• 28:26
  and butter and yet their unique selling position to insurance companies is
• 28:31
  that we lack the capacity and the skill set to run our
• 28:35
  businesses but we could have the the revenue needed to invest in
• 28:39
  business coaching and to invest in administrative support and invest in
• 28:43
  compliance officers if we were paid a livable wage and so we
• 28:47
  can't be penalized for a problem that is being created by the
• 28:51
  folks that are that have all the power that is the very
• 28:54
  nature of oppression right and so i think it's very disrespectful um
• 28:58
  for uh places like headway and united healthcare and care first and
• 29:03
  whomever right to talk about clinicians as if it is a capacity
• 29:07
  issue when it is a structural and systemic issue that is designed
• 29:12
  to maintain their record reporting profits and so that is the conversation
• 29:17
  that we have to have as clinicians because we actually have agency
• 29:20
  here we have the ability to say we actually will not contract
• 29:24
  with your companies and allow you to exploit our licenses and exploit
• 29:28
  our livelihood because everyone knows the value of the mental health industry
• 29:32
  except for the highest trained people in the conversation and who benefits
• 29:37
  from that because your clients don't your family doesn't right your business
• 29:41
  suffers if you go out of practice because you can't maintain another
• 29:46
  gap in cash flow because insurance companies didn't pay you on time
• 29:49
  yet again like that absolutely grinds all of my gears right like
• 29:55
  it grinds my gears um well right it created this problem