When AI Meets Therapy: Risks, Ethics, and Advocacy with Dr. Ajita Robinson

welcome to Mental Health Evolution, a podcast about what's changing in mental health and why it matters. I'm your host, Rachel Harrison, inviting you into honest conversations with people from all perspectives in the field. Clinicians, tech founders, investors, insurance companies and all the folks in between. Let's explore what's working, what's not, and what's next.

Well, welcome back everyone to the Mental Health Evolution podcast where we are talking about how the landscape is quickly evolving in the mental health industry. And today we are talking to a friend and colleague who is an author, coach and practice owner in the mental health space, helping other therapists to create their legacies and developing providers to provide excellent care for an excellent wage. Ageta has an AI training program for therapists and is someone who is actively advocating for our field as well. I'm going to introduce her more in a moment, but as always I want to give a little background here to set the stage for our conversation so you have some information about the topics we're addressing. Here are some things that have been in the news recently. From Axios, we have a policy tracker and we'll put this link in the show notes. I encourage you to take a look. It's all the different bills that are related to AI in the mental health field and what different legislative bodies are doing. States are focusing on different things such as requiring chatbots to have protocols around suicidality. It's in New York. Disclosing to the user that it is actually talking to a non human. That's in Utah. Outlawing AI providing direct service care in Nevada and prohibiting chatbots from encouraging self harm. That's in Texas. And then the one that is most commonly known is prohibiting AI to make therapeutic decisions and that one is happening in Illinois. Also from Axios, we have an article here that I want to highlight that talks about tech firms and states look to rein in AI Chatbots mental health advice this article goes through some of the risks that people should know about when when AI is acting as a therapist. There's a case in Florida of a teen who died by suicide after using AI as a therapist. Northeastern University researchers found that AI can be harnessed to provide details on how to complete suicide and users are developing obsessions with chatbots and developing what is now being called ChatGpt psychosis. This article talks about some states invoking legislation again and that is something we're going to be diving in a little bit more with Ajeta Robinson today But lastly, I want to highlight one more article, this one from the Behavioral Health Business Review and this is about Care First Blue Cross. This is in Maryland where both Ajeta and I reside and the article says that Blue Cross Blue Shield taps headway to help patients find behavioral healthcare providers in a fragmented cottage industry. If you're listening to this and you are a group practice or private practice owner, you are this identified fragmented cottage industry. And this article outlines collaborations happening this one in Maryland like I said, where tech companies are coming in to offer better access to care. That is what they are saying they are doing. And these managed service organizations are by venture capitalists and designed to make high margins with a business plan to attract market share and therapist initially with investment funds and then decrease the pay once therapists are locked in and the credentialing is through them in order to pay back investors. This trend simply identifies the sector's thoughts about current and previous providers not being able to provide appropriate accessibility and ease for potential consumers, well as an opportunity for venture capitalist products. This is a smattering of some of the topics we want to begin to dive into today. Ejeta Robinson is an avid researcher and has been tracking these trends locally as well as nationally, and she is a thought leader in this space, offering training and guidance to therapists along the way. Ejeta, I am so happy to see you. Thanks for being here.

Thank you so much for the invitation, but also I think for kind of leading the conversation or creating space for the conversation. I think oftentimes we have these conversations amongst ourselves in private groups and so making that a broader conversation is something that's so needed. So thank you always for the opportunity.

And you and I have chatted about some of these changes over the past few months and I want to dive in and just pull in as much of your wisdom as we can in this timeframe. So let's start with advocacy. I would love to hear your thoughts about what are some of the benefits of talking to our legislators. I know you've done some of this. What kind of laws would actually be beneficial? Because I think there's some question about what kind of teeth these things are going to have.

Yeah, I think advocacy is the core of our profession. Advocating for patient rights, advocating for patient care. And I think the thing that we shy away from is advocating for the protection of our identity as clinicians. I think that it's long past time for us to professionally and legally protect the term therapist. It has gotten weaponized, it's been exploited. That term needs to be protected. And I think our folks in allied services would agree in many ways because it's also happening in their industry with physical therapists, occupational therapy, speech therapy. So the term therapist in and of itself, I think is important to protect the sanctity of our industry because so many folks in the general public aren't able to discern when services are being offered by a licensed clinician as opposed to a life coach and their appropriate term, times in which a life coach is very valuable and beneficial, not a clinician. And the ways that we can. AI is entering this kind of space as therapists because it's not a protected term. Right. And there's no restriction. There's very little restriction even with the laws in place that protect the general public to understand that it is not therapy, it is not being delivered by a licensed therapist or even developed by a licensed therapist. And we've already seen the propensity for harm. And so I think as licensed clinicians, we have a responsibility not only to not do harm, but, but we actually have the added responsibility of doing good. And what I believe that means in this changing climate is an evolving space, is that we have the responsibility to not only talk about what's happening, but to talk about what happens in the very near future if we do not get a handle on what's already on the horizon. Right. The implications for AI to continue to cause the loss of life or at least contribute to the loss of life.

So what would be the ideal place to get this kind of legislation? Like, you're the first person I'm hearing talk about, like, hey, we need to protect what we call ourselves and what that means. And I, I think that has so much merit because a lot of the legislation like I outlined earlier, that's talking about limiting AI, but you're talking about coming at from this angle of saying, no, this is what a therapist is. And that really helps define who we are and what we versus what AI is and what it does or what a life coach does and what they do. So what would that look like? What kind of law and where do we want those laws to be? Is it at the state level? Is it at the federal level? What are some of your thoughts?

Yeah, I think that especially what's happening at the federal level, I think that. And even the way that our licenses are regulated, I think it makes sense to start at the state level. I think in many ways, because of the. The differences in the ways that we're even our licenses are even registered. Right. So I'm an LCPC the state of Maryland. I'm an LPC in the state of Missouri. It's going to be difficult to have that happen at a federal level, but being able to have that happen at a state level, especially given that our licenses are governed at a state level, aligns with the way that the industry is already kind of geared right. Or positioned. I also think that we'd have more traction with the way that we have access to our local representatives, the way that we have access to attend the open meetings that the board. Right. Has. Right. I think, think that we also have the ability of leveraging our state counseling associations to lobby on our behalf as we look at what does it mean to. To mobilize nationally. And I think that those are things that we can do that can move the needle forward also while managing how difficult it is to get things passed in an interdisciplinary way at the national level. I think we would have more the same way that we kind of tackled getting the inclusion of licensed professional counselors at the state level for things like Medicare and Medicaid and TRIC there even to roll up to the federal level. We had to get local representatives on board so that they could then advocate at the national level. And I think that's a similar process that we could take and with those lessons and the precedents that have been set to get that to happen for the protection of identity. And I think Illinois to some degree sets a precedent there around states restricting what AI can do. But I think what we would be looking for was asking them to take that mantle higher, to talk about what it means to. To deliver therapy and who can utilize that term in a professional perspective, but also from a marketing perspective. And Realtors have done this. That is a protected term. You cannot use the word realtor unless you are registered with an association of Realtors. Right. They have protected that federally. We even have some restrictions around who can call themselves a registered nurse. And so there's case law that sets the precedent for this happening that I think we should leverage to our advantage.

Yeah, I love that. I think that's fantastic. Because one of the things I was talking with the group that I'm part of a real change initiative. We were talking about how this legislation in Illinois is awesome, no doubt. And a consumer in Illinois can just pull up any AI therapist and they're still utilizing the AI therapist. Right. There's no way to really monitor that. And I know from reading online too, Ash is very interesting as an AI chatbot that will tell you it's not a therapist if you dig in. But then also a lot of the marketing and a lot of the phrases and things like that are acting as if it is. And it's really is marketed as this assistant, if you will, to act as a therapist, a guide for you. But if you dig in it. No, I'm not a therapist. And there are no protocols for safety within it. So I think that's my concern too, is that maybe going this route is the answer. Because there's no way to say, hey, consumers actually can't access this. And I don't know how many people are accessing it, but I do hear a lot of stories and a lot of them are alarming.

Absolutely. I was just reading about someone that was utilizing AI as their companion. So not even just as a therapist, it's their life partner.

Yes.

And, you know, we probably have all heard of the. The woman that's been going viral on TikTok about AI and being in love with their AI therapist. Right. That they've, they've really created and remembering. I think there's the call to action also for practitioners is understanding that we have a responsibility to educate. Right. To inform. And I think that again, we have these conversations amongst ourselves or maybe even with our clients, but what's the larger message that we are communicating on a broader scale, on a consistent scale to the general public about what it means to utilize AI in a way that gives it such vulnerable information? The fact that AI is mimicking human behavior, and so it doesn't have a moral or ethical compass that your licensed clinician or a human being would have that says, can you do this? Yes. But ought you do this? No. And let's talk about what the options are. Let's talk about what might be influencing that. You think this is the right decision for you. And so AI will develop the plan for you to implement or to carry out whatever it is you want, including suicide. But a person, a human, would help you with understanding your lived experience or the pain or the suffering, and develop a plan to improve quality of life so that suicide isn't an option or isn't the. The solution for someone and really anchoring their humanity. AI doesn't have the capacity to do that, but I think it highlights a larger issue that we're aware of as clinicians that I think society is aware of. That Covid kind of amplified is the sheer amount of suffering that, that people are willing to engage with an artificial tool. Right. To seek community, to seek support. Because our health care system is so fragmented in ways that has nothing to do with clinicians ability to run their businesses. Right. It's fragmented. Even when you have health insurance, can you afford to access the insurance? Right. Are there enough clinicians available in your area? Whether they're available nationally, we're still restricted by being able, only being able to practice in the states where we're licensed. And so how are the systemic barriers creating the additional pain and angst that might lead the most vulnerable people to seek AI out as a resource?

Absolutely.

We look at the utilization with the very limited data that we have about when people are most likely to utilize AI therapy. It's after hours, it's in at a timeframe that therapists wake up, would not be available outside of a crisis intervention setting. And so that should be telling the story around the immense amount of suffering that people are experiencing, which shows up in the way that they're even utilizing the tools or the questions they're asking the tools, which really further makes the case around protocols for AI and therapy to begin with. And so I think there's enough data to support that there's harm to the general public that our public officials, elected officials, have a responsibility to put safeguards in.

I agree. And I think educating consumers, as you're talking about, to some of the risks, because it can be easy to just find it, you know, you're scrolling through and not even to think through all of these pieces like you said, like therapists are trained to think through. I know that you have sent letters to legislators in Maryland. I'd love to know what are you writing about and what's happening so far and is there a way for people to jump in and support.

Yeah, so I find myself constantly sending letters, filing complaints, but so really kind of twofold. One, sending letters to our local elected officials as well as the attorney general for the state of Maryland. Because I think we, we are under the impression oftentimes that they're aware of what's happening and the impact of certain things. And what I find is that that's very rarely the case. We are on the ground level working with clients, seeing the impact of not only AI in real time on the quality of life, the cognitive processing, the harm. Right. We are uniquely aware of that because it's our day to day. And I think we make the assumption that other people, elected officials, are aware in ways that they are not. It is not their day to day, it is not their scope or area of expertise. And so we have a responsibility to educate them on, hey, this is what this means. And I keep bringing up tricare And I keep bringing up, up Medicare because when I did the same level of lobbying, I was astounded that our local official didn't realize that as an LPC that I couldn't bill Medicare. And they didn't know the history of why, that it literally was updating regulation. Right. That we were the newer, newest profession. And so our license simply wasn't added as a credential. And I think the other piece was, was making it personal. And so I intentionally talked about what if this senator's mom, because I knew her age, right. It's public information, was working with the therapist. But the day that they turned 65, they could no longer work with that therapist because that's what the law currently, currently had said, right? That we don't have enough folks that are trained to work with individuals that are, you know, aging or you know, considered geriatric or senior. And the only thing that's preventing them from having consistent support is that they had another birthday. That that was the change. And it was like, huh, that's what's happening. It's like, yeah. And so making it, taking a thing that's happening and talking not only for that person. I think when we make laws personal, we understand the implications of policy in a different way. And I think that's the voice that they have the ability to have because we know people, we understand what's happening on a micro level and we have to make sure that the people who are making macro level decisions understand the impact of the policies that they're passing. And so I think that's one of the ways that my letters and the way I'll book a call. You can request a call with your senator, right? You can request a call with your House representative. And I don't know that enough of us do that or we often feel intimidated about what are we saying. Talk about what you know and the impact that that's having on the people that you serve. And I think that goes a long way. And then the second part, where I've spent probably the bulk of my advocacy in the past 18 months is the ways that AI, but particularly venture capital backed companies like Headway and Alma are coming in and they are violating antitrust laws under the guise of partnerships. What is happening with Headway and CareFirst is not a joint venture. When Blue Cross Blue Shield has an invested interest in Headway, right. They have a monetary investment. It violates antitrust laws. They are limiting trade of the profession because they are case example, we applied for a rate increase with Care first they denied it and said they are not currently reviewing individual rate increases. But if, but if we contract it with headway, that we could get an increase. It's price fixing, but it's also limiting trades, which are both federal violations. And when we contacted the Attorney General, again under the assumption that they were aware, they were not. And so we compiled the data from our colleagues in our Facebook groups to show not only was it happening in the state of Maryland, it's happening across the country.

Yeah.

And what I find very interesting is, is that we've actually seen this before. Not in, in the specific way that Headway's doing it, but this is the exact thing that happened in skilled nursing facilities. It's the reason that most of them are, are owned now by health insurance companies, which is unfortunately what also contributed to the death of one of the CEOs. It is the same thing that's happening in skilled nursing that is now happening in mental health. So again, there's case precedent for intervention at the federal level. And so what we've tasked or continued to advocate with the state Attorney general to do is to bring a class action lawsuit, which thankfully and again, the state of California has already done this because it's not new information, it's not new harm, it's just now happening to us. Right. And I think that's, those are ways that clinicians can advocate. And so write your, write the Attorney General, file the complaint with the insurance commissioner, contact your senator and be loud and persistent so that they cannot ignore that this is a problem that not only impacts the viability of our field practitioners being able to have viable practices, but also the integrity of service delivery for the public.

Right. Because if your service delivery and the person paying for the delivery is the same person, that's questionable.

Absolutely. I think the additional scary piece around this Headway and Care first collaboration or ones like them is the encouragement for of clinicians. One, Headway is not a healthcare company. They are a tech company which allows them to circumvent hipaa, which gives them the right to sell patient information. And so this encouragement, that doesn't even feel like encouragement, it feels mandatory. Right. Because the ability to opt out of not putting your clinical notes in their system is so hard to find that most clinicians didn't even know that they could opt out of using their systems for the patient record. And so what is the harm of the health insurance company that denies, approves and reviews patient care having direct access to, to clinical records? That combined with the projected repealing of the affordable Care act that provided protection for pre existing conditions. What precedent are we setting for people being unable once again to be denied basic health care, to be denied for their. We, we're not far removed from individuals being denied life insurance because they had of anxiety or depression on their medical record. We are not removed. We're still in the thick of our first responders, both federal agents and law enforcement members or active duty members of the military being denied as being fit for duty because they have a PTSD diagnosis. Now, if the insurance company or a tech back company that is not HIPAA regulated has the ability to release a patient's record or to use the entire patient file with therapist modalities, therapist treatment plans to further train AI, we have a much larger problem. That's not only the violation of basic human rights. Right. But it sets a case for continued discrimination in healthcare and in the overall job workforce. And it's not new, it's just happening in a very different way. And I think they're counting on us not being paying attention to the threads that link all of these companies and patterns together.

Oh, 100%. I mean we've, we've been this, you know, calling us a fragmented cottage, while maybe slightly offensive.

Yes.

It is also maybe not entirely wrong. It's not because we are fragmented between the different licensures. There, there can be, you know, disagreements, infighting there. We are fragmented sometimes in a community where we are competitors, there are so many points of fragmentation and I think therapists by the nature of our work can be fairly heads down and not necessarily watching these trends. Most of us are not trained in how to run a business and so we're not out there looking at these things. And that's part of what I feel passionate about. Is everybody understanding and hearing from people like you. Because this is coming, this is here. And if we don't band together and use our voice, voice says collectively this is just going to roll right over us and we're going to be sitting here saying what happened.

So I think I agree 100% with what you've said. What I'd add is this language. I found myself just getting really hot. I was like, is this a hot flash? No, this is anger, right? This is anger that is like boiling in every part of my body around calling us a fragmented cottage industry. Yes, can be true. But also how did we get that way? What is maintaining the fragmentation in our industry outside of the licensure pieces and the identity aspects that that's an in house thing to address, right? Y the, the Very nature of, of the problem that Headway says they solve is that they handle the billing, they handle the compliance.

Right.

They handle the administrative aspects so the insurance companies don't have to. And in turn insurance companies have been able to totally turn their phones off and not even have a way for clinicians to even advocate or to even contact them. Right. Which I know has a whole nother oodles and oodles of money. But the problem of, of of clinicians or practices not being able to have in house billing is companies create. If we have an insurance company and one that I won't name because they've sent me five cease and desist in the past year. Right. But any of them, because all of them are a similar in this way that have routinely and systematically denied rate increases for the past eight years.

Yeah.

While every other cost has increased. Inflation, the cost of doing business, the cost of hiring, the cost of marketing. Right. If all of those costs have increased, the cost of living has increased. And yet providers compensation rate has actually decreased 17% this year just in comparison to last year. That is in the report that the center for Medicare Services released in July. So we know on a national scale that reimbursement rates have for providers consistently are not only not growing, they are shrinking. Yeah. Our ability to purchase groceries has shrunk. And so it is logical that a clinician's ability to have in house dedicated administrative support would be fragmented and or diminished with the diminishing wages that we consistently experience. And so you can't talk about a problem as if it's an internal problem that is about our capacity to lead our businesses when it is a external problem that the insurance companies not only create, that they maintain and that they ultimately benefit from from. And so this is the issue with clinicians not being aware of the overall implications, the very oppressive nature of operating within these systems. And I say that very boldly.

Yeah.

Because headway would not exist if clinicians did not contract with them. We are their bread and butter. And yet their unique selling position to insurance companies is that we lack the capacity and the skillset to run our businesses. And but we could have the revenue needed to invest in business coaching and to invest in administrative support and invest in compliance officers if we were paid a livable wage. And so we can't be penalized for a problem that is being created by the folks that have all the power. That is the very nature of oppression. Right. And so I think it's very disrespectful for places like Headway and United Healthcare and Care first and whomever. Right. To talk about clinicians as if it is a capacity issue when it is a structural and systemic issue that is designed to maintain their record reporting profits. And so that is the conversation that we have to have as clinicians because we actually have agency here. We have the ability to say we actually will not contract with your companies and allow you to exploit our licenses and exploit our livelihood. Because everyone knows the value of the mental health industry except for the highest trained part, people in the conversation. And who benefits from that because your clients don't. Your family doesn't. Right. Your business suffers if you go out of practice because you can't maintain another gap in cash flow because insurance companies didn't pay you on time. Yet again, like that absolutely grinds all of my gears. Like it grinds my gears. It created this problem.

It's creating the problem and then creating the solution. Correct. And they are financially benefiting from both

and gaslighting us in the process. It's wonderfully manipulative. Right? Yes.

I feel like we could go on and on about this ageta we are about at the end of time. But if you had just one thing, I'd like to ask this from the perspective of providers and then also from the perspective of consumers, those hoping to get therapy, what would be the one thing you would tell people to do next? If nothing else?

I think that I would tell people to go local. I think that when we're in a space where we're not sure who we can trust. Go local. Right. There's someone in your, your community that knows a clinician. There's someone in your community that can be a trusted resource because there's a lot of information. We're in an information age where we're saturated with information and discernment is low. Right. Because misinformation is high. Marketing campaigns are everywhere and it can be hard to determine what's actually true and real. And the thing that we've always been able to rely on are the people that we can know and trust. And so I think that in the age of information being readily available, I think we have to go back to relying on relationships and relying on people that already have our best interests at heart that we can trust while we filter through new dynamics. And so I think that that's also a call to access to clinicians to be. We've all kind of gone virtual and, you know, in our computers. And I think the best part of what we do is relating to people and being with people. And so I think that's also a call to action to be more present in our community and be visible. The helpers and healers should always have a flag that identifies them. It is well past the time that we waive it. And so for folks looking for support, there are people waving their flags and so connect with them.

Thank you so much for being here and sharing your perspective on these trends, friends, everything that's going on and what's important for us to know. All of Ajetta's contact information will be in the show notes so that you can connect with her on social. You can learn from her with her training programs. Definitely check her out. She's got a lot to offer. Next time, join us again. We're going to take a look from another view at changes in the mental health industry. Bye for now.