PPRNet Clinical summary: Can ChatGPT Deliver CBT Like a Human Therapist?

Cognitive-behavioural therapy (CBT) is the most researched psychotherapy, deemed to be an evidence-based treatment for depression and anxiety disorders. CBT targets cognitive distortions, maladaptive behaviours, and distressing emotions. It often involves cognitive restructuring and behaviour modification delivered by trained therapists who guide patients through structured exercises. Because of the shortage of mental health professionals worldwide, artificial intelligence (AI) may be an alternative means of increasing access to CBT. These AI tools may save costs and may provide immediately accessible support, potentially preventing mental health crises. Early research has demonstrated the effectiveness of AI in reducing depression and anxiety symptoms. Some argue that the lack of emotional intelligence of AI systems poses limitations in simulating empathy necessary for a successful therapeutic relationship. In this study, Acevedo and colleagues compared a single AI implementation using ChatGPT with a human therapist delivering text-based CBT. Both the human therapist and ChatGPT interacted with a simulated standardized patient, so that the issues and behaviours of the patient were equivalent. The researchers conducted a survey of 75 mental health professionals who provided psychotherapy in their practice. Survey respondents were asked to rate therapy transcripts of the human therapist and the ChatGPT therapist with the standardized patient. Participants then completed a validated measure of fidelity to CBT (how well and accurately the therapists provided CBT) to compare ChatGPT to the human CBT therapist. Survey respondents also provided open-ended feedback. The researchers then tallied up the percentage of survey respondents who rated the human or AI as “excelling” at a particular CBT behaviour or task. The human therapist was rated as better than ChatGPT at eliciting client feedback (29% rated the human therapist as “excelling” vs only 9% who rated ChatGPT as “excelling”), using guided imagery (24% vs 12%), focusing on key cognitions (31% vs 21%), applying CBT techniques (43% vs 16%), incorporating homework (35% vs 13%), and integrating homework into the therapy (21% vs 3%). The human therapist was rated slightly better than ChatGPT in understanding the patients’ internal reality (36% vs 21%) and displaying warmth (36% vs 21%). The authors then thematically coded the feedback from participants, who were unaware whether they were reading a transcript of a human therapist or ChatGPT. The responses suggested that although the ChatGPT therapist demonstrated some empathy, it felt generic and “sounded like an AI program”. Some respondents also felt that the ChatGPT sessions were more like lectures rather than being patient-focused. They described the AI therapy as impersonal and not tailored to patients’ individual needs.

Practice Implications 

The human therapist consistently outperformed the AI in key CBT domains, as well as in empathy, warmth, and patient-focused care. At this stage of development, AI can deliver structured therapy using CBT principles, but is currently unable to replicate the nuanced empathy and therapeutic relationship that a human therapist can provide. Ethical issues with AI-delivered psychotherapy persist, including concerns over data privacy, clinical accountability, responsiveness to crises, and the potential for providing questionable or even dangerous advice.

Acevedo, S., Aneja, E., Opler, D.J., Valera, P., & Jarmon, E. (2025). Evaluating the efficacy of ChatGPT-3.5 versus human text-based cognitive-behavioral therapy: A comparative pilot study. American Journal of Psychotherapy. Advance online publication. https://doi.org/10.1176/appi.psychotherapy.20240070.