Online therapy apps promise a therapist anytime, anywhere — but at what cost?

Close-up of professional psychologist making notes in card while talking to patient online on laptop at office (Big Stock Image).

This story is from The Pulse, a weekly health and science podcast.

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If you listen to basically any podcast you’ve probably heard of them: BetterHelp, Talkspace and others.

Online subscription therapy platforms exploded during and after the coronavirus pandemic.

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There’s no shortage of comedians, YouTubers, athletes, and actors singing the praises of these online subscription therapy apps, but therapists themselves — the very people that make these platforms possible — very often tell a different story.

Like the rest of us, Pennsylvania counselor Amy Kemp heard about BetterHelp on one of her favorite podcasts. The concept appealed to her at first.

“Of course, therapy being more accessible sounds like a great thing. I actually was kind of supportive of it at that point in thinking that it was a way for people to access care,” Kemp said.

But when she looked into it online, she found horror stories on Facebook groups and forums. Users and therapists complaining about low quality therapy and poor business practices.

“One other story that came up in one … was somebody was notified that their therapist had died and that they basically just got refunded that week and told another therapist will be in touch with you shortly,” she said.

It was so corporate it was off-putting. Like, “sorry your therapist expired, we’ll replace them.” The more Kemp looked into online subscription therapy the stranger it seemed. The further it got from the traditional therapy she was used to.

“When I started seeing people can text you and call you and try to message you day and night — that’s not how therapy works,” she said.

It’s a common selling point with online subscription therapy that a therapist is going to be available whenever you need them.

Which Kemp argues is kind of the opposite of what therapy is supposed to do: You’re supposed to get well enough to deal with your issues on your own — without having to rely on a clinician.

“You need that space to be able to say, ‘Okay, I can start to trust myself again in this issue, in my depression, in my anxiety, in my grief,” she said. “And not create this dependency, this need for this other person.”

But, Kemp says what really tipped a lot of therapists against these apps were privacy issues. The way some of these apps can track user behavior across all kinds of different platforms.

“There’s no reason that Facebook needs to know every time somebody logs in to just say, ‘hey, I need some support around something.’ It just doesn’t even make sense,” she said. “I mean, it’s completely unethical.”

Therapy is a practice built on confidentiality and privacy, the things we tell our therapists we tell no one else. So this type of thing was completely alien to a lot of therapists.

“I’ve seen that somebody can see when you’re on the app or when you’re available, but not really available because you’re just checking something. It’s very intrusive and really, really disturbing,” Kemp said.

But despite all of these concerns, many therapists work for online, on-demand services like BetterHelp. I spoke with one. We’re calling her Cassandra because she’s worried about getting sued for talking about her experience working for BetterHelp.

She’d been a therapist for about a decade but a sudden health problem a couple of years back meant she could no longer work in an office. Then a colleague reached out to her about an opportunity.

“He said, ‘hey, [you] have your independent license. You can work from home. I work for BetterHelp right now. And, you know, maybe that would be a good option for you,’” she said. “So, we talked about it. I didn’t know this at the time, but BetterHelp offers therapists like $2-300 to recruit other therapists. So it wasn’t coming from like the kindness of his heart or anything.”

Cassandra didn’t bite, instead she looked on job boards, searching for remote therapist positions, and there seemed to be a ton.

“One company was called Gotham. There was another one called Guideline,” she said. “And I didn’t know that these were all linked to BetterHelp. I had no idea.” she said.

They had different names, but one goal, farm therapists out to BetterHelp.

She finally found a remote job that seemed like a good fit, and it wasn’t BetterHelp, she thought.

“He told me, actually, once we had a phone call. That’s the thing. We had emails back and forth, and he never said anything in the emails [about BetterHelp] until I had a phone call with this guy,” she said.

Yep, another BetterHelp recruiter.

Cassandra was surrounded. She thought, oh well, her friend did BetterHelp, she didn’t have any other options. So she went for it.

She did a two week onboarding, sent in her licenses. She filled out her qualifications, what types of issues she treats, things like substance abuse, trauma and mood disorders, then the app would find clients, and refer them to her. There was even an option to accelerate her referrals.

“So I said, okay, I guess the faster I build up my caseload, the better for me, I guess. So I turned on the accelerator,” she said. “I was getting referrals left and right from people that I would never treat. I got a referral from someone in Puerto Rico who was struggling with pedophilia issues that I was like, ‘whoa, whoa, whoa. I’m not touching that. I don’t have the training.’”

It was an early red flag, but she persisted. Even after turning away clients with issues way outside her practice, Cassandra soon had an unwieldy case load.

“I believe I had like 30, 32 [clients]. I would get messages all hours of the day and BetterHelp does this thing where if you don’t respond within 24 hours and you leave a few unresponded, they actually suspend your account,” she said. “So, I had to respond within 24 hours. So, I would be done with one client and then I’d be on the app, responding to messages, just responding, responding, responding like sending out worksheets, doing all this other stuff because if I didn’t — I would get penalized for it.”

It got so bad she says she’d be juggling clients while cooking dinner.

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This was not at all what she had been told by the recruiter — who had promised her that if she worked 30 hours a week, at their hourly rates, she’d make about $100,000 a year.

“Which to me is like, ‘oh, wow, that’s awesome.’ But here’s the catch that I did not know until I started working for BetterHelp. This is the trick: For you to get to 30 hours a week, you would have to see about 40 to 45 clients,” she said. “That is an impossible case load if you’re trying to be a good therapist.”

Cassandra says the problem here is the way BetterHelp reimburses therapists for their time.

“Each session is 45 minutes long. So, let’s say you see about 10 clients, that’s 450 minutes. But you divide that by 60 and that’s how you get paid,” she said. “That’s why you’d have to see about 40 clients just to reach that 30 hours.”

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Traditional insurance reimbursement works differently, it’s typically 53 minutes of therapy, plus 7 minutes of note taking and paperwork. That’s an hour of therapy.

That note taking by the way, is a big deal in the traditional therapy world, but Cassandra says it wasn’t even an afterthought here.

“You’re not required to do notes, which is kind of shady. If you don’t do your clinical notes, first of all, you’re not documenting the client’s progress. You’re not documenting what they’re working on. You’re not documenting your clinical intervention,” she said. “I mean, therapy isn’t just like talking to someone, you know, you’re working through a lot of really difficult mental health issues.”

Cassandra is a bit of a stickler, she did her notes anyway. And, if clients needed more than the 45 minutes, she stayed on the line. But she didn’t get paid for any of this, for doing what she felt she had to, to do a good job.

“Oh, I felt so trapped,” she said. “I wanted out.”

She felt trapped because she had all of these clients all of a sudden, and she felt responsible for them.

“One of the biggest principles of the ethical code is you cannot abandon a client,” she said. “So what that means is, you know, you’ve been working with someone for like a few months and then all of a sudden you drop them, that’s wrong. You’re causing them damage, you’re causing them harm.”

In the end, she told her clients: Listen, in a few months I’m going to be leaving. I don’t think this is a good company. I’ll help you prepare to find a new therapist or you can see me remotely. But I can’t stay with BetterHelp.

“I think clients don’t understand the pressure that BetterHelp puts on the therapists,” she said.

The pay, the way it’s all structured, Cassandra thinks it incentivizes bad therapy and bad therapists. She had a partner she could rely on for income shortfalls, but she knows other therapists don’t have that, especially newbies starting out.

“I know that there are some crappy therapists out there. I’m not saying there isn’t. I know there are some people that do very unethical things,” she said. “But BetterHelp the way it’s designed, the way their pay structure is, the pressure that they put on you, it puts you in a position to maybe do things that are unethical if you really need the money.”

Online therapy boom

I wanted to get a handle on the big picture: Is this just one disgruntled employee? Is the chatter on message boards just sour grapes — therapists upset about a disruption to their field?

I reached out to BetterHelp for comment. In fairness to them, there was plenty of online criticism to go around, including a lengthy open letter from therapists bemoaning the practices of a big competitor: Talkspace.

Neither agreed to go on the record for an interview.

So, I reached out to lots of professional psychological organizations and researchers, people I thought would have their eye on this type of thing, and I got nowhere.

Nobody could speak with any real authority about how these subscription teletherapy services work, or how they treat therapists. That is until I spoke to psychologist Ben Miller.

“One of the issues that I think you surface is the lack of transparency in what actually is happening on some of these platforms,” he said.

These are private companies, and Miller says they can be pretty opaque — operating in a new and likely under-regulated world.

Miller, though, has some insight into them from his last job, chairing a philanthropic foundation that supports mental health access.

“I routinely, weekly sometimes, would get hit up by somebody who had a new app that they thought was going to change the world,” he said.

He doesn’t name names, but he tells me a lot of Silicon Valley types came into his office hoping to raise capital for their telemental health app.

He says early on, a lot of mental health apps were just that, apps, that is, they weren’t connected to an actual therapist. They were about behavior prompts: your phone would tell you to take deep breaths, journal, or make an inventory of triggers — and you would do the therapy work on your own.

The only problem is data showed that users abandoned these apps pretty quickly, many after just one try.

“What [start ups] realized is because of that retention issue they needed to have that relational element baked in — so they started creating networks of therapists,” he said.
They needed actual people, human therapists involved in order to make sure the users kept using the service. The foundational part of talk therapy is the therapeutic relationship, it’s two humans forming a bond where they trust each other and get vulnerable.

This all created a bit of a rush on therapists — these apps suddenly needed a lot of flesh and blood professionals to function.

I was reminded of how Cassandra, the former BetterHelp therapist, saw recruiters for the service everywhere she turned. Miller says hiring is very competitive.

“Remember, there are only a certain number of clinicians out there,” he said. “We have a workforce crisis in this country as it relates to individuals that deliver mental health and substance use services that existed prior to COVID.”

And Miller says the pandemic got a lot of people used to telemedicine, including telemental health.

“There’s never going to be enough clinicians, just remember that. I mean, one of the fundamental policy issues that I still work on is that states or even the federal government, they want to have more clinicians and we’re never going to have enough,” he said. “So, the supply side simply cannot ever create enough clinicians to meet the community demand.”

It can take roughly a decade of schooling and licensing, and interning to become a therapist and it’s expensive.

“And I do think it’s something that a lot of these companies probably didn’t factor into their business model when they were initially conceptualizing their asks,” Miller said.
By their “asks;” he’s talking about the way the services promise a therapist available whenever you need them via text, email, or video chat. They were asking the same limited pool of therapists to treat more people and to do it more often.

It’s a problem of basic arithmetic.

The more successful any subscription therapy app becomes, the more customers they get, the more demand they create for therapy that can still only be met by a fixed number of actual therapists.

Miller tells me it’s a perfect recipe for burnout, and for low quality therapy.

He says these subscription services mean well. He even says they eliminate a lot of needless inefficiencies, allowing therapists to treat people across state lines and across the country. They’re trying to do something that helps society and if they make a buck along the way that’s fine.

He even calls them “our entrepreneurial friends.”

Miller says the goal of democratizing access to mental health care is a noble one, but he has a different idea of how to get there.

He says there’s no way to magically make more therapists, but that we can train more people in how to use parts of the therapist toolbox.

“So, there is nothing magical about a cognitive behavioral intervention, nothing magical about it. It’s grounded in the science. We know what the recipe is,” he said. “So, teaching other individuals and helping them see how they can deliver effective interventions to one another is how you disrupt this backlog of never having enough.”

Lay people in our communities could learn how to do this, being essentially deputized into mental health care. Miller calls this kind of thing community initiated care.

“It’s care in community by community for community. It’s care that we give barbers, who you probably have a more profound relationship with, than many other people in your life,” he said. “It’s making sure that the barista that serves you coffee every other day can recognize signs and symptoms when there’s an issue in your life.”

Miller says this model has worked overseas where a lay person in a town or village is trained in the basics of some kind of therapy and they become the access point for their friends, neighbors, and family.

“Imagine walking to downtown Philly and you see one of your brothers that you hang out with on the weekend and they’re sitting on a bench and you’ve just had a really bad day, and you sit down and they help you through that,” he said. “To me, that’s the future of mental health. I mean, that’s where we got to go.”

Miller’s got some new venture cooking at the moment that he hopes will make that happen.

He won’t tell me much as he’s not ready to launch, but if he’s successful he could disrupt the disruptors, returning therapy closer to home in the process.

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