Why affordable online therapy apps for therapists might suck
This was not at all what the recruiter had told her – who had promised her that if she worked 30 hours a week, on her hourly wages, she would make about $100,000 a year.
And it’s like, ‘Oh, wow, that’s cool. But here’s the thing I didn’t know until I started working at BetterHelp. Here’s the trick: To get to 30 hours a week, you have to see about 40 to 45 clients,” she said. “That’s an impossible caseload if you’re trying to be a good therapist.”
The problem here, Cassandra says, is the way BetterHelp compensates therapists for their time.
The duration of each session is 45 minutes. Let’s say you saw 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 have to see about 40 clients just to get to that 30 hour.”
Paying off traditional insurance works differently, it usually takes 53 minutes of treatment, plus 7 minutes of taking notes and paperwork. This is an hour of therapy.
This observation, by the way, is a huge problem in the world of conventional therapy, but Cassandra says it wasn’t an afterthought here.
“You’re not required to make notes, which is kind of a shadow. If you don’t make your own clinical notes, first 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. What, you know, you’re working through a lot of really tough mental health issues.”
Cassandra is a bit prickly, she wrote her notes anyway. And if customers need more than 45 minutes, she stays on the line. But she was not paid for any of this, for doing what she felt she had to do, to do a good job.
“Oh, I felt so trapped,” she said. “I wanted out.”
She felt trapped because she suddenly had all these clients, and she felt responsible for them.
“One of the biggest tenets of the moral law is that you can never give up on a customer,” she said. “What that means is, you know, you’ve been working with someone for a few months and then all of a sudden you leave, that’s wrong. You’re causing them harm, and you’re causing them harm.”
In the end, she said to her clients: Listen, I’m leaving in a few months. I don’t think this is a good company. I will 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 BetterHelp is putting on therapists,” she said.
The pay, in the way it is fully regulated, Cassandra believes motivates bad therapy and bad therapists. She had a partner she could count on for lack of income, but she knew other healers didn’t have that, especially beginners.
“I know there are some bad therapists out there. I’m not saying there aren’t. I know there are some people who do very unethical things,” she said. “But BetterHelp the way it’s designed, the way their pay structure, the pressure they put on you, puts you in a position to possibly do unethical things if you really need the money.”
Online therapy boom
I wanted to understand the big picture: Is this just one disgruntled employee? Is the chatter on message boards just sour grapes – therapists upset about a disruption in their field?
I’ve reached out to BetterHelp for comment. In fairness to them, there has been plenty of criticism online, including a lengthy open letter from therapists bemoaning the practices of a major competitor: Talkspace.
Neither of them agreed to sign up for an interview.
So, I reached out to several professional psychological organizations and researchers, who I thought would have their eye on this sort of thing, and got nowhere.
No one can talk to any real authority about how these teletherapy services work, or how they treat therapists. That was until I spoke with psychologist Ben Miller.
“One of the issues that I think you’re bubbling up is the lack of transparency as to what’s really going on on some of these platforms,” he said.
These are private companies, and Miller says they can be very opaque — operating in a new and potentially unregulated world.
Despite this, Miller has some thoughts on them from his last job, where he headed up a charity that supports access to mental health services.
“Routinely, sometimes weekly, I get hit on by someone who has a new app that they think is going to change the world,” he said.
He didn’t name names, but he did tell me that a lot of Silicon Valley types had come to his office hoping to raise capital for their telehealth app.
Early on, he says, a lot of the mental health apps were just apps, meaning they weren’t associated with an actual therapist. It was about behavioral prompts: Your phone would tell you to take deep breaths, journal, or take a trigger inventory—and you’d do the therapy yourself.
The only problem is that data has shown that users abandon these apps very quickly, many of them after just one try.
“what [start ups] They realized it was because of the retention problem that they needed to have that relational component — so they started creating networks of therapists,” he said.
They needed real people and human handlers in order to make sure users could continue to use the service. The essential part of talk therapy is the therapeutic relationship, where two people form a bond where they trust each other and become vulnerable.
All of this created a bit of a rush for healers — these apps suddenly needed a lot of flesh-and-blood specialists to function.
I was reminded of how Cassandra, a former BetterHelp therapist, saw recruits for the service everywhere I turned. Recruitment is very competitive, Miller says.
“Remember, there are only a certain number of doctors out there,” he said. “We have a workforce crisis in this country as it relates to individuals providing mental health and substance abuse services that existed before COVID.”
And the pandemic has caused many people to use telemedicine, including telehealth, Miller says.
“There won’t be enough doctors, just remember that. I mean, one of the underlying policy issues I’m still working on is that the states or even the federal government, they want to have more doctors and we’re never going to have enough for them,” he said. “Therefore, the supply side simply cannot create enough doctors to meet society’s demand.”
It can take nearly a decade of study, licensing, and training to become a therapist, and it’s expensive.
“I think it’s something that a lot of these companies may not have considered in their business model when they were initially conceptualizing their applications,” Miller said.
by “asking”; It speaks to the way the services are a therapist who is available whenever you need them via text, email, or video chat. They would ask the same limited group of therapists to treat more people and do it more often.
It’s a basic math problem.
The more successful any combination therapy application becomes, the more clients it gets, and the more demand they have for treatment that can still only be met by a fixed number of actual therapists.
It’s the perfect recipe for fatigue and low-quality therapy, Miller told me.
He says these subscription services mean well. He even says they eliminate a lot of unnecessary shortcomings, allowing therapists to treat people across state lines and across the country. They’re trying to do something that helps the community and if they win along the way that’s fine.
He even calls them our “entrepreneur friends.”
The goal of democratizing access to mental health care is a noble goal, Miller says, but he has a different idea of how to access it.
He says there’s no magic way to make more therapists, but we can train more people how to use parts of the therapist’s toolkit.
“So, there is nothing magical about a cognitive behavioral intervention, nothing magical about it. It’s rooted in the science. We know what the prescription is,” he said. “So teaching other individuals and helping them figure out how they can offer effective interventions to each other is how Disrupt this buildup of not having enough.”
Ordinary people in our communities can learn to do this, as they are primarily mandated in mental health care. Miller calls this kind of community-initiated thing nurturing.
“It’s a nurturing in the community by the community of the community. It’s important to give to the barbers, with whom you probably have a much deeper relationship, than to many other people in your life,” he said. “It’s making sure that the barista who serves you coffee every day can recognize the signs and symptoms when there’s a problem in your life.”
Miller says this model has worked abroad where an ordinary person in a town or village is trained in the basics of a type of therapy and becomes a point of access for their friends, neighbors and family.
“Imagine you’re walking into 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 had a really bad day, and you sit down and they help you through it,” he said. “For me, this is the future of mental health. I mean, this is where we have to go.”
Miller’s got some new ventures into cooking at the moment he’s hoping to make it happen.
He won’t tell me much because he’s not ready to go, but if he works, he can deactivate the triggers, recreating therapy closer to home in the process.