#145 What is Therapy & How Do We Measure It? with Megan Cornish

The rapid rise of AI chat presenting as therapists has spurred a reaction to differentiate what AI can do versus the work of a licensed therapist.

This is causing many people to look more closely at the question:

What Is Therapy?

In today’s discussion, we’ll both look back at how therapy has been understood historically and look forward to cutting-edge research like “interpersonal neural synchrony,” which is being studied across therapy professions and perhaps paving the way for a unified definition of therapy and its biological mechanisms. Understanding therapy in a neurobiological way will also help us understand why therapy is so often measured by triangulating multiple outcome measures.

We are joined in the course by Megan Cornish, LICSW, and we hope it will inspire you to consider the remarkable power of therapeutic relationships (that we are just at the beginning of understanding.) 

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Transcript

SPEAKER_00 0:00

We've entered a new frontier where AI chatbots are being marketed as actual therapists. And right now, tech companies across the globe are seeking ways to replace parts of therapy with AI tools. And all of this disruption is pushing people to look closer at two fundamental questions. What exactly is therapy? And how do we use technology to improve therapy without accidentally replacing what makes it work in the first place? In today's discussion, we'll both look back at how therapy has been understood historically and look forward to cutting-edge research like interpersonal neural synchrony, which is being studied across therapy professions and perhaps provides this unifying understanding of therapy. We are joined in today's episode by Megan Cornish, L-I-C SW. And we hope this discussion will inspire you to consider the remarkable power of therapeutic relationships, that we are really just at the beginning of understanding. So let's dive in. Welcome to the OT Potential Podcast. I'm your host, Sarah Lyon, OTRL, and I wanted to let you know that this podcast may qualify as continuing education for you. You are probably listening to this podcast on a free podcast platform. But to gain CEU credit, you will need to be a member of the OT Potential Club, our OT Continuing Education platform. You can go to OTpotential.com to learn more. Okay, here we go. As I mentioned at the top, our guest today is Megan Cornish, L-I-C-SW. Megan holds a master's degree of social work from the University of Washington and is a licensed clinical social worker with years of frontline experience in clinical mental health. But today, Megan operates as a prominent mental health writer and a true clinical futurist. She is the creator of the Substack newsletter Incomes and Outcomes. Megan is focused on understanding exactly how our systems got to where they are today and how we actually build a practical way out through human connection, real world skills, and community action. So without further ado, let's patch Megan into our live studio. Megan, welcome to OT Potential. It's so great to have you. Thank you so much for having me. I'm really excited to be here and have this very interesting conversation. I am so thankful that we are going into this next level on this conversation. You and I had an episode a couple months ago where we talked about the ethics of AI as therapists. And we talked about kind of like some of the regulatory barriers that using AI as therapy that they're going to face and um kind of looking at it against our ethical frameworks that we currently have. And of course, there's all kinds of red flags and barriers. But that really, that conversation made me think, I think even deeper about therapy. Um, and like beneath all the regulations and the red tape, to really look at the heart of it and be like, what can AI do? What can't AI do? And then you get at the heart of this question of what exactly even is therapy? What is happening during a therapy session? And when I looked initially online, like answer at these questions, I was very dissatisfied initially. I think a lot of the definitions of therapy that we've been relying on are outdated, um, aren't helpful anymore. But then as I went like the next layer deeper to look at the research that's going on about therapy sessions, about what we're learning, about what's happening with the human connection, I'm actually super excited. I'm super stoked. I think there's new ways we can be talking about therapy that really uh reaffirm what we've known all along. So I'm so excited to get to those things today. I just want to start though, uh, turn it over to you and ask why does this discussion feel important to you right now?

SPEAKER_01 4:23

Well, you know, you just talked about how you got online to look on definitions of therapy and they all felt outdated. And I think that makes sense because up until, you know, 10 years ago, the idea that a computer would ever even be able to make a good attempt at mimicking therapy was ridiculous. You didn't have to stipulate that it was a human because who else could do it? Like nothing else could do it than a human. So now that we actually have computers that can mimic human relationships, you know, in a passable way, it makes sense that it's time to start talking more specifically about what is unique about a human therapist and whether or not the therapy that happens in a session uh is more than just the sum of its parts. Like if a if a if a comp if a robot can say all the exact words the therapist is going to say, is there more that happens in the room with a human therapist versus just what the human therapist says?

SPEAKER_00 5:21

I get nervous looking at the landscape too, because on one hand, I see these health tech companies that are investing millions into the space, hoping to make billions, which one of the only pathways to do that is to replace human salaries. So we have this like huge, powerful force coming into the space. And then over here we have therapists, and we just tend to be like, we don't know what therapy is, we don't know why it works, and it can feel to me like we're going to get steamrolled. Do you have that sense? How do you think about that landscape?

SPEAKER_01 6:02

Um, how do I think about that landscape? Well, yes, they've definitely got the um, they've got the backing. I I want therapists to have a little more faith in what we do. Something I I often tell therapists is I don't really know any therapist who wouldn't want to work themselves out of a job. If it was proven beyond the shadow of a doubt that therapy was more effective when conducted by a robot and more people could access it and more people would be helping be healthier, then I think that most of us would be like, okay, I guess I'll find another job if that is truly a better option. But I don't think it is. I don't think any of us believe that it is. So while we're in the middle of proving out that it's not better, we just have to have a little bit of faith in the value of what we do and not have um such an anxious presence in the space because therapists have sat in sessions, you've seen amazing things happen with your clients because of the power of your relationship with them. Um so, like, have a little bit more faith in what that is and what that looks like, um, and just wait for that to prove itself out is kind of how I feel about it.

SPEAKER_00 7:08

I mentioned this in our previous episode too, but I look at social media and how we've given so much of our social lives to these platforms. And there are parts of our social lives that were replaced, like information gathering. I know about babies that were born quicker, I know things are happened, but I think we all see and feel what is being lost when so our social interactions are reduced to the platform. And that's my big fear for therapy is giving too much to platforms and all these unintended consequences, and we lose parts of healing, parts of um the therapeutic process that we were just undervaluing. Do you agree with that?

SPEAKER_01 8:06

Yeah, well, and I think it's I think about the parts of the therapeutic relationship that are unique to that can only happen with a human and the level of delusion it would take for a person to give that to a robot. And I think that would be really unhealthy. So even if you could get people deluded enough in thinking that robots or AI have this consciousness, this embodied sense of being in the room of like empathy and understanding. And even if we can make it as effective, it wouldn't be healthy because it wouldn't be based on reality. And furthermore, it would separate people from other humans, which, you know, like you're saying, we have a lot of information. What we're not locking is information, what we're locking is connection and relationship that will help us translate that information into something useful.

SPEAKER_00 8:55

We're going to talk a little bit during this conversation about like what we're learning about what happens during the relationships. We we don't understand all the level, all the layers of healing. We don't understand all the layers of connection. But I'm also like, we can't undersell ourselves because we understand a lot of the things that are going on. We can measure a lot of them. Um, I think we need to be vocal about those things. But one way I want to set up this conversation is to talk about the importance of defining therapy together between OT, PT, mental health therapists, you're um a clinical social worker, I'm an OT. Uh traditionally, we've been in totally different silos. Like we don't even talk to each other. Um, I think that's why there's not a unified definition of therapy, because like literally no one thinks outside their silo. Like if you Google therapy right now, psychology today is like therapy is uh psychotherapy. Like like people are just so narrowed. But as we have this big outside force that is honestly looking at all of us, it's looking at like, how do I replace mental health? How do I replace PT? How do I replace OT and SLP? Why is it important for us to like step back a little bit and think about defining therapy together and what the common threads are between all of us?

SPEAKER_01 10:25

Yeah, I would I would say a few months ago when you approached me to do our little conversation about AI and ethics, I was kind of that was the first time I've been like, wow, like why haven't we had more conversations across these aisles of therapy? And it and what you said is true is because we've never really had a common, like, I don't want to even call it an enemy, but we've never had something so starkly different from us in the space that it shows us how how similar we truly are. And I think that making sure that we reserve the the idea of therapy and this relationship that uh translates into healing um for humans for so many reasons, but just because of what it can be distorted into if it's if it's taken away from human relationships. Yeah.

SPEAKER_00 11:14

Yeah, it's almost like well, one, we need the power of the numbers uh to be talking about what therapy is. We need to be pooling our research. Honestly, we're researching a lot of the same things with maybe slightly different language. Like in OT, we tried we tend to use like therapeutic use of self versus therapeutic alliance, but it's really the same concept, very similar. Um, and the more we can like pool that research and those energies to understand the human connection that's happening, yeah, I think the better for all of us.

SPEAKER_01 11:52

Also, the the laws that exist to to protect our individual practices and our titles are already being used effectively to protect uh the industry from AI coming in. For example, I think that it was New York who was using physician title protection um as a way to basically prevent a AI uh character from saying that it was a psychiatrist. So I know in what in where I'm licensed in Washington State, social workers fought for title protection for years and years. And now the idea that it could be used to protect from having as an AI bot call itself a social worker is really interesting. And it's going to be super helpful anytime any one of our organizations or our our professional organizations or our uh professions uses those laws for title protection against uh a non-human entity.

SPEAKER_00 12:45

Yeah. Yeah, at the end of the day, all of the professions I just mentioned, we are licensed by our state. We really do have a similar framework in how we function. Lots of times our payment pathways are a little different, which I think that's really the driver of why we feel different. But from like a legal standpoint, we are very similar buckets. And that's what a lot of these battles are going to come down to is um, I guess, legal battles. Can AI chat call itself an OT? Can it call itself a general therapist? Um, what's protected and what's misleading the public?

SPEAKER_01 13:26

Yeah. Well, and I think a step further than that too is we all have licensing boards and codes of ethics. And there are no such thing for AI companies claiming to be therapists right now. So I think that that is also something worth worth standing by in this conversation, which is that you don't get to call yourself a therapist if you don't have a degree, if you don't have a code of ethics and a licensing board that you're held accountable to.

SPEAKER_00 13:51

Yeah, when you look at us in that way, you're like, oh, we are really similar. Like we went to a similar school that was accredited in this way, we're licensed in this way, we have these standards of practice that we all follow. In prep for this conversation, um I wanted to talk a little bit about the history of therapy. Like, neither of us are historians, but my one like uh little exploration that I went down was I'm really interested in just like the etymology of words, like when the word first came about, what were they probably trying to go for? Um, I did not know off the top of my head what therapy meant, but as I was looking at it, uh what I learned is it looks like it comes from the Greek word therapon, which is roughly translated to companion in service. Um maybe you could add in like companion in service of healing, like there's like a medical uh health component to it. Yeah. I love that definition when we're thinking of like looking at like what is therapy, like as it was originally understood, it was with someone and someone's like in service of the other. One, what does that make you think about? And two, any like history of therapy nuggets that come to mind when you're thinking about how we think of therapy, what's helpful, helpful background to think about. Yeah.

SPEAKER_01 15:28

Well, you know, obviously I'm from a I'm from a mental health background. Um, I actually last month had a conversation with uh Professor Andrew Skull, who is the the leading scholar on mental health history. So he he studies a lot of site psychiatry, especially. But you know, I just also finished reading his book and therapy in the mental health term is only 200, less than 200 years old. But I really think that's because in the past 200 years, we've really, like we've talked about, taken relationship out of our lives, and so we need it so desperately that now it's become a whole profession, profession to support people in the in the absence of other other places for it. Um, and I, you know, there was you're talking about the Greek word, like there's some very early usages of it where that word came about because they discovered that having like a relationship helped with the healing. Um, that like having a relationship with professional would also like assist people to heal more. And I I just love that idea that there is an attempt to make medicine its own thing that could stand on its own and just treat the body or just treat the mind. But we were reminded that we're not just bodies and we're not just minds, that we're that there's something more to us, and that that is an aspect of healing that can only be tapped in via like a human person in a relationship with someone, like they're throwing you, throwing you a line to pull you through. So I just love that idea that even at the beginning of figuring out medicine as a way to treat the body or the mind, we are constantly reminded that that's not all there is to us. There's a lot more to us, and that you cannot extract one from the other, that we're all just bound up so tightly, um, as like body, mind, and soul, or whatever you want to call it. There's just so much to us that there are aspects of our healing that can only be tapped by a relationship with a with an actual human who's present with you.

SPEAKER_00 17:28

Yeah, it's interesting to put it in that timeline to think of therapy just being around 200 years old. And I would say all the rehab therapies, OTPT, SLP, we all came about about the same time, about a hundred years ago, with uh similar, like for OTs, it was like, oh, if instead of having people lay in bed for weeks, what if we help them occupy their times with things that were meaningful? And that worked because there was a person and physical therapy similar. Like, what if we help people get moving and going? Um, but all at very difficult times in their lives. Like we really got called in in like World War I where there were um lots of veterans coming home, and the healing process was so hard. It was like you really needed someone to do it with you. And that's still like how part of how I define therapy today. Like, there's so many health challenges where you don't need to call in the power of a relationship. Like you can just Google and be like, okay, I'll wait all for two weeks, I'll rest, and I have that information and that's enough. But we're as therapists, we're in the business of like something is so hard. You have it helps to call in the power, power of a relationship.

SPEAKER_01 18:44

Like Yeah, where it's like the healing is a two-person job or a three-person job.

SPEAKER_00 18:50

Yes.

SPEAKER_01 18:50

Yep. You know, not and not just like the mental, like, I have to figure out how to do this, but also the emotional, like, there's gonna be days where I'm gonna think this is pointless and I'm gonna need someone else to come in and I'm gonna need to just do what they tell me and trust that they see something I don't see when I'm feeling hopeless about my own healing.

SPEAKER_00 19:09

I always think I'm the best example of that too, where I'm like, I have all the information or the different times I've needed therapy, I'm like, I have all the information of what needs to be done, but I still cannot do it on my own. Like if I try to do these hard things, like vision therapy or pelvic floor therapy, like even though I know what needs to be done without the power of someone else in the room, like I just can't do it.

SPEAKER_01 19:38

Um yeah, well, and you know, it's an important part, especially for mental health therapists, to uh to be in their own therapy, as at least once, but hopefully as often as they need it. Because it there's such a huge difference between knowing like technically what what the accurate information is and like seeing how it applies to you and its truth in like your particular circumstances. So yeah, it's not really something you can self-apply even if it's the information is fed to you in a very uh sentient manner on a computer screen.

SPEAKER_00 20:15

So that's kind of our brief look at the history, which big picture makes me be like, okay, therapy is not that old. It's okay that we're experiencing this new fluctuation. It's not like like we're only 100 or 200 years into this. So it's natural that we're at this point where we're like reassessing. Um and uh almost gives like a I want to say like a looseness, like, okay, like we're still early in this. Where is this gonna go? One of the things that I was most excited about thinking about this episode was I finally took the time to look at the research of around what I now know is called interpersonal synchrony. And I had known for a while, somehow in the back of my brain, like in the back of my mind, like when two people are in a conversation, there is a sink that can be seen, like at the brainwave level. And I just think about that a lot because I'm a podcast host and I'm like, I can tell when the sync happens when um I'm talking to someone. And the sync happens um like in our relationships through our days, it's not specific to therapy, but it it seems like it especially happens at to a heightened degree a lot of times in therapy. And I read multiple papers about this, but I want to call out the uh this paper that came out in 2025. It's called A Systematic Review of Hyperscanning for Clinical Encounters. Which I would never pick up if I was thinking, what is therapy? To me, this isn't a great title, but I think it does a really great job of uh giving a little background of what we're learning about interpersonal synchrony and hyperscanning is how we measure this sync that is happening. I'm going to walk through the paper just a little bit and then get your feedback on it. What I learned is there's interpersonal synchrony is like this umbrella term. And then there's kind of three categories of it. One is behavioral synchrony. So when we're in a conversation, we're doing it now, our body language is starting to mirror each other. Like we're both nodding. You might lean in at the same time. Like you can visibly see a sink of two people as that's happening. Um, the second thing which is happening internally, which we can also measure, is this physiological synchrony. Um, our heart rates might start to sink up, our breath might start to sink up. Um, something called our skin conductance starts to sync up, with which is another thing that they can measure. I've never called that psychological synchrony. In OT, we just call that co-regulation. Um, and uh that's just another thing we can study that can happen during therapy. And then the third is neural synchrony. And that's what I alluded to at the beginning is as you're talking, your brain waves start to sync with each other. And they can see that by um wearing the special cap or EEGs, or they've literally done it where they put two people in uh fMRI machines at the same time, and then they like record them talking to each other. And even in that setting, people start to sync with each other. So those are the different parts of uh synchrony that are happening, and we're starting to study it more in therapy, and we're seeing that it's connected to therapeutic alliance, which makes a ton of sense. Like if you're syncing, you're feeling more connected. And we already know that therapeutic alliance is the strongest predictor of therapy outcomes. Like, yes, and that's in mental health, that's in OT, PT. Um, I was telling you beforehand, I'm like, I think it even happens in like pharmacology. Like, if you believe in your medical, if you feel bonded to your doctor or pharmacist and you believe in your medications, you're going to have better outcomes. Like it is powerful. Um, I'm this is me just hypothesizing. We know this sink is happening. My hypothesis is this sink is creating the conditions for change. Like that's part of what makes therapy so powerful, is it puts us in this like physiological state where we're ready to like do hard things, we're in a safe, trusting place, and change can happen. So, all that research, I don't know, just makes me think about therapy differently. Um, makes me think about it on one that's just like a very human connected thing that we're just beginning to see what's happening when two people connect. Um, and we're just starting to understand the power of what's going on.

SPEAKER_01 25:33

It kind of makes me laugh a little bit because, you know, scientists are figuring this out, and now they're putting these fancy names to it, but like anyone who's ever had a deep friendship with someone, and the second, you know, you can go 10 years, and the second you see them, you're you're you know, we call it back on the same wavelength. I don't know if we use that phrase. Like we we have this relational sense that these things are true, and it's you know, it's nice to have the science for it too, but it I think it's also a really good reminder that there's so much that's happening that we know to be true that we just don't have the words for yet, or we don't have that data to back it up yet, and that doesn't necessarily mean that it's not legitimate. So, and I think that's also an important thing as we're continuing because you know, my fear with this research is it's gonna become the new metric by which AI companies are gonna start trying to see if they can get their AI to elicit these kind of brain waves from the users, and you know, the the pathway that that's going to lead us down, and just remembering that there's even if we don't always have the exact scientific language around something, doesn't mean that it's completely that it's not legitimate. So, like the value of the human and um in the midst of that, eventually, if we don't objectively believe that a human has something to offer that a AI doesn't have, then what's to stop us from ending up in the matrix? You know, what's to stop us from not having any human friends? So I think that this co-relation I co co-regulation idea that's so essential in therapy is just like one aspect of what makes a human relationship so valuable, but it's not the whole nine yards. And to remember that there's there's a lot more under the hood that we it might be decades or centuries before we fully understand. So yeah, I don't I just don't want to see, you know, this become the new flag word that then AI is going to try and like, you know, imitate, as if this is like if they can do this thing, then they'll be as good as human relationships, if that makes sense.

SPEAKER_00 27:42

I've already seen the study on like uh the therapeutic alliance with a chatbot. And if I'm I'll I'll have to double check this, but I think people felt like they had a therapeutic alliance with their chat bots. So I totally agree on as we learn more things, the fear is always that we over-index towards single things and we're not taking in or we're not acknowledging that there's probably more going on and we're we're probably missing stuff if we're over-indexing towards one thing. Yeah.

SPEAKER_01 28:17

Or we we mistake that this is the value itself and not a symptom of the value, if that makes sense. Yeah. Like this is this is one of the things that happens when a helpful like um interpersonal relationship is occurring, and it is not itself the value of that interpersonal relationship, if that makes sense. Sorry to get so et so philosophical about it, but I've just seen some some AI companies doing some crazy things with brain scanners, even trying to trying to show that they're as good as a person. And so remembering that we're hedging on humanity all the way throughout, no matter even if the brain scans show that there's you know co-regulation occurring eventually.

SPEAKER_00 28:59

Yeah, I'm like, I can see the two sides of the coin where I'm like one we don't want to over-index towards the few things that we know and think that if um AI can do it, it can do all that a human connection can do. But at the same time, I don't want us to undersell that we don't know anything about what's happening in here. Absolutely. We actually know a lot. And right now, I actually think we tend to like understate what we know. Like, even though we don't know everything about human connection, we're learning a whole lot about the multifaceted nature of it. And I think as therapists, we should be like excited and proud and see a lot of this as really helpful, like, and be like AI companies, you want to prove that you have well, you just fundamentally cannot have an interpersonal neural sink. Like, yeah, you fundamentally cannot have that. You could create the feeling in someone that they're having a therapeutic alliance, but you don't have a brain, so you fundamentally cannot sync with another brain the way a human can, right?

SPEAKER_01 30:16

Right?

SPEAKER_00 30:17

Well, and I think like by definition, you can't do that, yeah.

SPEAKER_01 30:21

To which I think they would say, well, why does it matter if we can get the same outcomes? And I, you know, which is why I think it's important for us to say to a certain extent, yes, we can we can talk about outcomes, but we have to look wider than just these specific therapeutic outcomes, also to the health of the whole person. Like if it's good for you therapeutically, but if it's deteriorating your health in other areas, then is it good? No, it's not good, it's bad. So I think that's you know, it's such a deep philosophical question. I was reading an article that AI companies are hiding all are hiring all these philosophers to have these conversations. So I'm like, yes, let's have let's also be having this conversation amongst ourselves as well about what our value is, even as they try to bring up science and research up to date with us.

SPEAKER_00 31:05

That was actually my next question. When I look very high-level at therapy research, like we understand, like I said, like therapeutic alliance is one of the biggest predictors of your outcomes. We're starting to be able to measure like this interpersonal neural sink that is happening. But at the end of the day, like the mechanisms behind a lot of our inf like interventions, we still don't fully understand them. Probably because healing like sits at the intersection of so many mechanisms in our bodies. Like we just don't fully understand, yeah. I mean, we don't understand consciousness fully. So how are so then it makes it hard to like fully understand the mechanisms of therapy? And so, how do we you were starting to say this, but I just want to like hit it explicitly. Like, how do we stay like confident in therapy, um, in our value, and even like in defining therapy when we also know there's all this ambiguity?

SPEAKER_01 32:24

Well, I you know, I feel like all I have to do is to think about back on those experiences that I've had in in sessions with clients, the ones that, you know, that have become flashball moments for me in my career. And I have no doubt. So even if those things haven't don't yet have their technical science names yet, I believe that they will. Um, and that they'll that they'll bear out eventually on the page. But also I think about who who I want to be sitting across from in those moments when I need to heal or when I am struggling with things, and I have no doubt in my mind that a human is is who I want to be there. I was talking with someone who is trying to figure out what's the best way to compare human therapists to AI. And I said, one of the things you have to remember, and I was mentioning this earlier, is uh that if you have a human therapist with whom you have a relationship and you have an off day and you don't feel like showing up, if you like and trust your therapist, if you respect them in their time, then you will still show up out of your sense of your relationship and obligation to them as another human being. And AI doesn't AI doesn't exist when I'm not talking to it. It's not gonna, it's not gonna have its feelings hurt. It's not gonna, I never hurt it, which is not always a good thing. Sometimes we do the things we need to do out of obligation, and some people would even call that love for other humans. That sense of other people having existence and agency and needs and their own thoughts and feelings and opinions outside of us actually forces us to behave in ways that are good for them and for us. And a lot of a lot of things in healthcare are very hard, and that's what therapy has discovered that if you if you bring in this element of relationship or love, you know, whatever, however you define that, but a sense of obligation to another human, that it can helps provide the scaffolding for a healing process that's not going to happen on its own.

SPEAKER_00 34:22

Yeah, I think that I mean, across therapies, like we all got into this work because of the caring relationship that happens. Like we all decided to dedicate our careers to this work, like with that core belief that that is something unique and special and needed. And even even thinking about love, I'm like, we know a lot of things about love, like what it does to us, our neuro neurobiology, like it's going nuts when there's love involved, but we still don't fully understand it. I actually think that's kind of a good comparison for therapy. Like, there's a lot we understand about what's going on, but we still don't fully understand it. Yes, exactly. But we know it's important, and I agree with that, just like fundamental question. Like, you have something really hard going on. I'm always like, you wake up from a stroke, and do you want a person sitting there? And right now we are actively designing the healthcare of the future. Yeah. And we have the opportunity right now to start making those choices. And as therapists, we can't be passive when we see important things being threatened. I think we've been way too passive for too many years, as we've seen too many like human connection threatened at so many levels. I think we've been way too passive. And I hope what's happening now is kind of a wake-up call to be like, we are almost like protectors of human connection. Like that. We didn't sign up to be the protectors of that. We signed up for individual sessions where that like we've all signed up to work with individuals, and we're our generation is being like thrust into this role of protectors of human connection.

SPEAKER_01 36:37

Yes.

SPEAKER_00 36:38

Is that accurate? That sounds very I hadn't thought about that, and it sounds very grand. And am I going to regret saying that? What do you think of that?

SPEAKER_01 36:46

I um I don't think we're gonna need to be. I really think that we're the research is going to bear out the importance of the human relationship in so many aspects of healthcare. So that's why I really don't think we should be so anxious, and it's easy to get carried away in the philosophical, like angsty existential questions of like, is my is my profession I've decayed dedicated my whole life to even going to exist in 10 years. I don't think it's something that we need to make the argument for as strongly because I really I have told faith it's going to the research is going to show that while there are helpful aspects of having computers and AI, that when it comes down to it, humans are still going to be the best form of providing therapy. I was just reading an article about AI jobs, and a lot of people are like Ford just rehired a bunch of their um top engineers. They had laid off like thousands of them. They rehired them because they they said it turns out that AI is not good at these like niche, complicated knowledge applications. And it's because large language models are their uh prediction machines, they're not actually experts. So not only not only is the human relationship an important part of it, it's also the fact that we are experts. So those two things in combination, I think, are going to win out. And if you're starting to lose faith in whether or not your job is important, I think all you have to do is look at your caseload and and ask whether you matter to those to those people or whether they'd be better served by chat GBT or whatever, you know, hop onto these chat bots that are saying that they can replace you and have a conversation and then hop back on and see what they remember about you and and tell me whether you'd rather do that than sit with a qualified therapist. I and I'm just not that worried.

SPEAKER_00 38:42

Yeah, the research that we already have is amazing. I'm just like, I want to lift up our researchers to keep going. Absolutely. Yeah, no, they're keep up the good work, let us know how we can be supportive.

SPEAKER_01 38:57

Yes, absolutely. Absolutely.

SPEAKER_00 39:00

I uh want to create a whole additional podcast around this next little topic. So I just want to touch on it briefly because I'm like, we're kind of getting in above our heads. But when you talk about what is therapy, one of the questions that is a natural follow-up is, well, then how do we measure it? I think my personal belief is in, or just when I hear people talking, we tend to over-index towards like, we don't really know what's happening, so we can't fully capture it, we can't really measure it, which I'm like on some level, yes, kind of like love, like um, but on another level, I'm like, we have hundreds of measures that are can be very specific to your very to your condition. And they're awesome. Like, usually, especially when you think of patient-reported outcome measures, like I just think we tend to undersell those. Like, even though we have all these great sleep devices where you can track all different kinds of your sleep and get all these biometrics on it, still the best way, the best measure of your sleep is your self-report. Because even those different metrics are still limited. They're still just getting a snapshot of the picture. Um, I'm actually really thankful for trackers because I'm like, oh, that's giving such a big chunk of the population the opportunity to experience, like, oh, this number said I was 100%, but I didn't sleep great. Or I did sleep great and it said it was 75. Like, I'm hoping people are looking at those trackers and starting to be like, oh, the best measure of my sleep is still actually my report. And that's what we use a lot of in therapy. And I hope those can get elevated more and appreciated more. Sorry, this is like such a long lead up to the question. When I tend to like uh group our outcome measures for us in like the rehab therapies, I tend to think of patient goals. That's like our main, that's our North Star. Then we have like whole person health measures, um, like a lifestyle medicine um metric. I think those are great to take in every session. And then we have a lot of condition-specific measures we can draw from, which are both uh can be patient reported or objective measures. And then in this world of payers, we also ideally are uh tracking cost effectiveness. Yeah. That's how I tend to think about measuring therapy. I think we know a lot. I think there's a lot more to learn. Um, what am I missing there?

SPEAKER_01 42:00

And I know this is a huge conversation, but it is well, and I think one of this is one of the areas that while we're all therapists, the different uh professions uh differ because this is one of the most wicked problems in mental health therapy right now is our lack of good outcome measurements and our lack of agreement over what may the basically the outcomes we're using were created by marketers in you know the 90s. We're still using that. That's what the PhQ9 is, and again, seven that measures depression and anxiety. Furthermore, we kind of agree in general that those aren't necessarily the best measurements of what a good life is. You can still have some of those symptoms, even enough symptoms to trigger your depression score or your anxiety score, and still be relatively satisfied with your life overall. So, you know, I think that it's our air, our neighborhood of therapy is still trying to figure out that that particular little snarl. And payers really want it to be neat and tidy, which is why they continue to use those outcome measures that were like, well, those are not really the best ones. But, anyways, that's a whole conversation.

SPEAKER_00 43:17

Yeah, we still have to do a lot of just like what I call triangulating, like collect multiple data points and like try to find like is healing happening in this process? Because healing is so multifaceted and we can't measure all the things that are happening. It still seems like we're best to collect those multiple data points and try to weave together a picture.

SPEAKER_01 43:44

Absolutely.

SPEAKER_00 43:45

And when anything to rely on what the patient is saying.

SPEAKER_01 43:48

Yes, what the patient's saying, or you know. Yeah, there's some times where the patient in mental health may not have but may not have the ability to self report, and so then you have. You know, the the family or the caretakers and stuff like that. So and there's measures for that. Measures for that, exactly right. So many measures.

SPEAKER_00 44:13

I want to circle back to what I mentioned at the beginning and um dissatisfying definitions of therapy. Like as we're getting deeper into this conversation, I'm starting to piece together like things I would like in a therapy definition. Um, but I want to say explicitly what we think are bad definitions of therapy. I want to say the one that like spurred me to even create this episode, and that is the top Google results. Psychology Today, right now, uh describes therapy as like an impartial listener who gives guidance. And I'm like, that's describing a chatbot. That is not describing human connection. I think we have to be so cautious. Or, you know, your dog do away. Yes, or your dog. Yes. Yeah. Do you agree with that as being very problematic and other red flags you would think of and just unhelpful ways to describe therapy?

SPEAKER_01 45:23

At the beginning of the whole AI therapy conversation, or rather, right before it all came up, we were talking a lot in mental health about coaches and the role of mental health coaches. Um, and a lot of therapists didn't like the idea that coaches could help with practical skills, which I was always kind of fine with. For example, I I knew of a a therapist, a very popular marriage counselor, who hired coaches who were in the process of becoming therapists who would work on communication skills with the couples he was working with. So they'd have an hour session with him, and then they'd have an hour session just practicing talking about their issues with the coach hopping in to like be like, well, you know, now this is the next step, the skill building exercise. So I think that reducing therapy to just a set of teaching skills also is a poor definition of it. If it's something that someone can learn from a book, then it's probably not therapy. Not to say it's not an aspect of therapy, having a human presence who is very educated and knows when that will be the most helpful in that moment absolutely can be a part of therapy, but you can't reduce it just to you know going to a therapist to get skills. That's that's one I don't like very much. That and I don't think we need to gatekeep it. If if tech can support people in practicing skills taught by their therapist, go for it. That would be wonderful. Um, as long as the therapist's relationship is still essential.

SPEAKER_00 46:59

We're not impartial, we're like fully connected with our patients. Uh we're not just delivering information, even though that happens. Yes. We're not just teaching skills, even though that happens. Yes. So if it's not that, if your friend asks you what therapy is, what do you say after this conversation today and kind of piecing stuff together?

SPEAKER_01 47:29

I won't hold this to you forever, but I think therapy is bringing in the power of a human relationship. Specifically a relationship with an expert to pull you through parts of healing that are too hard to do on your own. Fully agree. Yeah.

SPEAKER_00 47:50

Hard stop. Yeah. We're we're going to write that down and put that on the internet.

SPEAKER_01 47:57

Yes, because just the reason why it has to be a professional is because a human relationship is powerful and not always powerful in positive ways. So if you have someone that you're giving that level of trust to who uses that power in harmful ways, you can go the opposite direction. You can do damage. Um, so that's why we are so careful about safeguarding those relationships with codes of ethics and licensing boards and degrees, because we know that that with great power comes great responsibility.

SPEAKER_00 48:32

I love that definition of therapy. I mean, we're doing it on the this on the fly, so I won't hold us to any of this. But if that's what we describe therapy as, where off the top of your head do you see the most value in like AI tool supports? Like I'm seeing some chatting in the comments about AI chats supporting um some of our like neurodivergent populations and like some good things about it and some worrisome if we're landing on like this is what therapy is, where do we want the supports from these new tools? Like the new tools are coming. They are also powerful. We don't want to undersell them either. If it was up to Megan, where would you channel that energy of these new tools?

SPEAKER_01 49:31

If it's, I feel like if it's something that you could trust Google to do given enough time, they can have it. You know, one of the one of the best uses right now for me is I used to spend so much time looking for emails in my inbox. If I I'd be like, I'm finding something from like last year, and I would spend and now AI finds it for me. You know, if it's it is very good at finding research for me, it's very good at like referencing things. And I kind of think of it as like a faster Google, but there are certain things that I would never Google. You know, I'm not gonna go to Google for a friendship. I'm not like I might talk to Google about what I think my doctor would say when I'm like wondering, but I'm still gonna talk to my doctor because they're the expert. So I think that if it's something that can be safely relegated to Google, then AI can have it. If it's not something that can be relegated to Google, then it needs to stay with a professional.

SPEAKER_00 50:36

I don't know. What do you think about that? And something I would say yes, like this feeling of trust. I would also say something where we want the decision maker to have a lot of context. And our like bodies and minds are still the best machines ever at like taking in context. Like we're like right now, I'm taking in like all these visual cues about you. If I was sitting with you, I'd be taking in all these sensory cues about you. I can know if you're in a relationship, you like learn a lot about the person, and that's one of the powers of relationships is taking in all this context about the person. And our AI chats as they exist now, absolutely aren't doing that.

SPEAKER_01 51:28

Yeah. Even if they had the sensory input to do that, they wouldn't have the context to understand it because that kind of information doesn't exist on the internet, and that's their brain. They're just trained on the internet. You know, the internet doesn't provide you with the amount of data that comes with walking down a street, and you know, it only there's only words on the internet, and there's some videos and pictures, but like it's not it's not like a five senses like embodied experience that you would need, and that's why they're starting, you know, people are saying that large language models are not gonna hit average general AGI is average general intelligence intelligence, right? AGI is like the equivalent of a human brain. They're saying that the model of AI we're using now is not gonna get there because you have to be in a human in a body to have that level of um intersensory experience like you're describing.

SPEAKER_00 52:21

Yeah. Yeah, and to not undersell ourselves on that and to appreciate the power of that. I always think of a hand therapist I had on who was like, I've never had a textbook client. And I'm like, hand therapy is totally where you should have textbook clients because it's such a, in my mind, straightforward. But to be like, every patient that we work with is so complex. And the protocol should tell me that I'm doing this today, and I can tell from the second they walk into the door that like the mood is not right for this one thing. I'm shifting to meet them where they are and to not undersell the complexity of like all the things that you're doing as a therapist. Yeah, we are already so close to the end of our time. One, thank you for having this conversation because it's so big and so hard. We've touched on a lot of things, there's more like threads. I'm like, we just touched that thread and we're going to keep going on that in the podcast. But to wrap us up, what's what do you want to leave people on? What's the thoughts you want in people's head as they're like weighing this heavy what is therapy? What's our future?

SPEAKER_01 53:42

Yeah, I think I I think what I said earlier about having some faith in the value, and that if you lose faith looking at your client list or looking at your clients in the base, um, you don't have nobody's asking individual therapists to prove the value of their profession in a huge existential way right now. Um that's going to come that's gonna all play out on its own. But remembering why you got into the field and the impact that you're having on your clients right now, you know, that's that shouldn't be proof for now to to glue you up as the other proof comes out.

SPEAKER_00 54:25

Yeah, this has really helped me think about the power of therapy and define it in new ways, to the point where I'm I'm almost like, oh, good thing these AI chats are trying to do this because this is like forcing me to dig a little deeper into understanding what we're doing. Megan, I just want to thank you for this conversation for the time today for being willing to have this uh really expansive and important conversation. I just so appreciate your time today and waiting into all of this with us. Yeah, absolutely.

SPEAKER_01 55:02

I love I love thinking on these levels. I think it's super important and definitely timely for therapists. So thanks for leaving it.

SPEAKER_00 55:14

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