There is a chap called Eric who has taken to emailing me regularly, enthusiastically offering me the chance to earn up to ‘$136K’ a year by providing therapy from the comfort of my own home, along with a ‘substantial bonus’ when I take on my first client. He’s so convinced his offer can benefit me that he’s even got his friends involved – this week Will and Chelsea also emailed me with the same offer, ending their emails with ‘I am a real person’ and a smiley face. I have to admire their persistence as they show no signs of being deterred by my complete lack of response to their emails.
If you work in private practice, the chances are you have your own ‘Will’ who messages you, and recognise the marketing approach of BetterHelp, the high-profile and controversial US therapy platform that has now expanded into the UK. Co-founded by technology entrepreneur Alon Matas in 2013, it was acquired for $3.5 million by telemedicine company Teledoc Inc in 2015, and now claims to be the ‘world’s largest counseling [sic] service’, offering clients ‘unlimited access’ to therapists for a monthly subscription fee that it says is less than the average ‘in office’ therapy session. Its extensive social media-based marketing campaign has involved Instagram influencers and celebrity endorsements.
Thanks to developments in digital technology, BetterHelp is just one of a growing number of platforms that aim to offer ‘instant access’ to video, telephone and text-based therapy – a concept pioneered by Talkspace in New York in 2012. As well as these big players, who have the benefit of major financial investment – and the burden of achieving returns for shareholders – we are also seeing smaller-scale, home-grown versions entering the market, which are often more likely to be clinician led.
In theory, such online therapy platforms should be a win-win for practitioners and clients, offering a hassle-free way for therapists to reach new clients and get paid, while also removing many of the barriers that stop clients accessing help when they need it. Although, like EAP work, the session rate paid to therapists is often lower than the average fee charged in private practice, many therapists regard working for a therapy platform as a convenient way to top up their income. But, in our willingness to be open and responsive to new ways of working – and with our need to make a living – are we in danger of colluding with what some say are profit-driven initiatives that underpay therapists and give clients an unsatisfactory impression of what therapy involves?
Controversy
Put ‘counselling UK’ or ‘therapist UK’ into a search engine and BetterHelp’s advertisement currently comes up top. But put ‘BetterHelp’ into the search bar of a therapist networking group on social media and you’ll find a number of posts from disgruntled therapists who have tried and left the platform.
Janine Hayter is an experienced BACP registered private practitioner who responded to a direct email approach from BetterHelp earlier this year. Within four months, she had stopped taking on new clients for the platform after what she describes as an ‘uncomfortable’ experience. ‘In private practice, I offer a free 15-minute consultation before accepting a client for a full assessment. With BetterHelp, you have to accept clients on the basis of minimum information. If you take on a client and realise during the first session that you are not a good fit for each other, you can’t refer on – the work can only be terminated by the client, so you’re working with clients whether you want to or not, which to me felt really uncomfortable and unprofessional,’ she says.
She also had concerns about the ‘unlimited’ messaging that clients are promised as part of their subscription. ‘I’d get messages from a client saying they’d just had an argument with their boyfriend and what should they do, or they woke up feeling anxious,’ she says. ‘But having instant answers isn’t what therapy is about and my feeling is that it could develop a dependency. It’s up to the therapist when they respond to messages, but you’ve constantly got “red flag” notifications that your “account actions are overdue” – some people might be able to ignore that but it sent my stress levels through the roof.’
However, not every therapist has had a negative experience. BACP registered therapist Katie Rose, who has set up a Facebook group for UK therapists working for BetterHelp to share tips, says you can make it work for you: ‘Yes, clients can message you at any time of day, but you don’t need to respond at any time of day. I respond during my normal working hours. The system does pester you if you don’t respond within 24 hours but you’re not expected to respond immediately or at the weekends,’ she says. ‘Plus, you do get paid for messaging so for me, there is an incentive to respond.’
The lucrative joining bonus was also a draw for Rose: ‘Initially it was $2,000 [since reduced to $1,000], and that made up for the lower hourly rate. Supplemented with the bonus, it gave me at least three or four months to find out whether I like the platform and decide what I want to do about it.’
She thinks of working for BetterHelp as like ‘the analogy of the golf balls and pebbles and sand in a jar. For me BetterHelp is the sand that fills in the gaps when I’m not doing private practice or EAP work. If I earn £25 for a slot that would otherwise be empty, it’s better than not earning at all in those gaps – I have a mortgage and bills to pay.’
What is causing controversy is that BetterHelp’s payment scheme seems to incentivise therapists to take on as many clients as they can handle and work all hours. The first five hours are paid at a base rate of $30 (around £25) an hour, but as sessions are 45 minutes long, that works out at around £18 per client session. That rate goes up in $5 increments for every additional five hours of therapy delivered. Working 27 hours in a week could in theory earn you $1,100 (around £915) but you will need to deliver 36 client sessions to achieve that, which, for many therapists, will come at the cost of both their own self-care and the quality of work.
Appeal
Despite the lower fees, working for a platform still appeals to many practitioners because it eliminates two of the most onerous aspects of private practice – marketing/attracting clients, and ensuring they pay. Counsellor and coach Ruth Juster joined the UK-based platform Augmentive after retraining in therapy and moving to Dundee following a career in business in London. ‘What I love about Augmentive is that they take care of every activity that I don’t particularly like doing, like the self-promotion and the invoicing. Joining the platform offered me a way to set up in private practice without having to create a website or pay for a directory subscription. Although I now live in Dundee, the Augmentive platform means I reach mainly London-based clients with a business background,’ she says. ‘I also find it helpful that I never have to chase payments – the client can’t enter a session until payment is made. I feel it also protects the relationship as it’s the site asking for the money and not me, which just feels better. They take the price of a coffee off each session fee [practitioners set their own fees and Augmentive takes 15% of the first client session and 5% of subsequent sessions] and for me, it’s well worth it.’
Reaching clients outside his location was also part of the appeal of joining a platform for Ralf Bidder, a therapist working for the UK start-up platform Spill. ‘I have a small private practice in a rural part of the north-west of England, and I am also a bank counsellor for a hospice charity. I wanted to extend my private work beyond my local area and joining a platform seemed to offer that opportunity,’ he says. Unlike other platforms, Spill is only available to employees working for companies that have subscribed to the platform. Unlike most EAP providers, however, employees book their own therapy directly through the platform. ‘I wanted to see what it would be like working with younger clients – most are in their 20s and 30s, whereas the clients I work with in both my hospice and my private practice work tend to be older,’ says Bidder. ‘It’s been great experience for me to work with a different generation. Part of Spill’s offering is also single-session therapy, and I was curious to experience that – you have to focus a session on what is coming up strongest for the client at the moment, and also give more structure to the sessions than I would normally do.’ For Bidder, working for Spill also offers the opportunity to work in his first language of German, as it has contracts with many international companies.
Spill was founded in 2017 by Yorkshire-based entrepreneur Calvin Benton, who grew up with a counsellor mum and clinical psychologist dad. Fees are set at £35 a session, higher than many platforms and EAP providers, although still lower than most therapists charge in private practice. The draw for Bidder is that the platform collects client fees and pays promptly: ‘The finding clients and collecting fees is all done for me and that is a big benefit, especially as the pay is prompt,’ he says. ‘For me, it’s an easy way to fill in gaps in my working day – you can set your own hours. I also like that supervision is included, and there is a platform for the therapists to connect with each other and share knowledge and support. You don’t have autonomy over clients but, out of around 150 I have seen so far, I would say there was only one I felt I could not connect with.’
For therapist Justin Lee Slaughter, meanwhile, joining UK-based HarleyTherapy.com, one of the longest-established platforms, brought him online work throughout the lockdowns that was ‘very consistent and very sustained’. And the benefits extended beyond a reliable supply of client referrals: ‘My previous work was all in person, and they also offered a degree of support as I transitioned to online work – I could go to them with questions, and it was a person replying and not an autobot. I also set my own fees – I regard the commission the platform takes as payment for their marketing and the support they provide,’ he says.
Therapists also set their own fees on Welldoing.org, another start-up, and no commission is taken, but they do pay a subscription to the platform (monthly or annual), which offers an invoicing and direct payment system for clients. ‘The payment system ensures that the fee is taken before the session,’ says founder Louise Chunn. ‘Many therapists put all of their clients through it, even if the original contact didn’t come through us, as it takes away the worry and bother.’
Profit driven
Both HarleyTherapy.com and Augmentive were co-founded by clinicians. However, many therapy platforms are business initiatives, and our willingness as a profession to work on their terms is a source of frustration for Sharon McCormick, founder of the Midlands- based EAP provider The Listening Centre. ‘We are sleepwalking into a situation where we are allowing big companies to exploit us, instead of taking the initiative ourselves and starting our own businesses,’ she says.
‘Therapists on the whole say they are driven by meaningful work rather than making money but that shouldn’t mean we end up making money for other people. I set up The Listening Centre with no business background, learning as it grew, and our unique selling point is offering fair rates of pay and benefits to therapists while delivering a first-class service to local organisations – it takes work but it can be done.’
But, as Dr Sheri Jacobson found out, setting up a digital-based therapy platform takes a lot of investment. She says she was driven to set up HarleyTherapy.com in 2017 after setting up a successful high-end physical practice, Harley Therapy; she wanted to find a way to offer more affordable sessions. ‘I think the biggest surprise was how much we underestimated the requirements of the technology, and how much it takes to run it, essentially,’ she says. ‘We had looked at various different ways that just didn’t work but then the whole zeitgeist of platforms was coming about, such as Airbnb, and I was very inspired to use technology to make therapy more accessible and affordable. I had to find a technical co-founder because my background is clinical with a bit of business – I’m not a coder or a programming engineer.’
Even small initiatives need funding to survive and grow, and investors seek a return on their investment. For some platforms, profit comes from clients’ data as well as from therapy sessions. According to a recent investigation by the not-for-profit research foundation Mozilla, many mental health apps and platforms ‘fail spectacularly’ when it comes to privacy and security. The organisation reviewed 32 of the top mental health and prayer apps, giving 26 a ‘privacy not included’ warning label, indicating strong concerns over how data were being managed.
As I discovered when I went through BetterHelp’s client inquiry process, being matched with a therapist involves agreeing to BetterHelp sharing with ‘third parties’ your sensitive personal information, which includes your racial or ethnic origin, religious or philosophical beliefs and data concerning your health, sex life or sexual orientation, and transferring your personal information outside the EU or the UK.
The selling and sharing of user information have been described as a ‘data harvesting bonanza’ by Jen Caltrider, lead researcher at Mozilla. ‘Taking a broad, general look at these mental health apps, we were quite shocked at how poorly they seem to actually care about privacy,’ she says. ‘We live in the data economy, but everybody shouldn’t be participating at the same level and mental health apps should absolutely be better. Privacy laws do protect some of the data these platforms collect but there’s a very grey, murky area that we found where these privacy laws end and the data economy begins.’
Caltrider compares the sharing of data relating to our mental health as the equivalent of ‘putting up a sign outside your house that says, “Hey, I’m depressed, I have a drinking problem and I’m meeting with my therapist from six to seven.” We don’t put that on the outside of our house, for obvious reasons. Yet when you hand this sort of data over to a company, that becomes something they can treat as a business asset and use, share or even sell to target you online with ads.’
NHS
Health-based technologies tend to originate from one of two camps, says Dr Lloyd Humphreys, MD of the Organisation for the Review of Health and Care Apps (ORCHA), which assesses and accredits digital health technologies in the UK: ‘You may get a clinician or a therapist coming up with a great idea because they can see an unmet need within their practice, but they don’t have the technology credentials, so they may fall foul of things like data and privacy, because they’re not familiar with that world. Or, on the other side, you have a technologist who thinks there’s an unmet need but hasn’t been in the system to actually identify whether it is or not. So both sides of that fence have unique challenges, and the magic really happens when you bring those two worlds together and that’s where you can see some really great technologies come about.’
The issue of the standard of mental health technologies goes beyond private practice. As NHS mental health services increasingly deliver the ‘first step’ of mental health treatment for patients via apps, it’s not a leap of faith to assume they may also outsource the ‘therapist step’ of their service to a therapy platform. Says Humphreys, ‘As a clinical psychologist by training, I think advances in technology offer a real opportunity. Of course, there are concerns around privacy and security. But we shouldn’t ever consider that it’s a binary choice between technology or traditional care – technology-enabled care can augment, complement and enhance what we do as professionals in this space. Technology in the form of self-help apps, for instance, can be used to free up therapists to deal with clients who are in need of their highly trained skills. We are in the unfortunate position of having a paucity of therapists and growing waiting lists, and technology can help address some of this burden on the system, providing greater capacity.’
Client access
The increased demand for mental health support is also the main reason that therapy platforms are seen as a viable business venture – even people outside the profession are aware of how hard it can be to find a therapist. In the UK, clients who search for a therapist on one of the main directories are likely to get a significant number of profiles and then have to undertake the laborious process of contacting practitioners one by one to enquire about availability.
‘It is disappointing, but my experience, and the experience of many others, is that you don’t even get a reply from a lot of the emails you send to therapists in private practice,’ says Louise Chunn, who set up the therapy platform Welldoing.org in 2014 after her own experience of therapy. ‘I went on a counselling directory and the search function brought up around 500 therapists within five miles of where I was living, and I just had no idea how to choose. I kind of stumbled into seeing someone and I did wonder if I was seeing the right kind of therapist. It’s one of the reasons why, at Welldoing, one of the services we offer clients is a curated search to match them with an appropriate therapist.’
Even accessing help through an EAP programme isn’t straightforward. Counselling psychologist Sam Spedder, Clinical Director at Spill, says the platform’s unique offer is that it removes barriers and gives autonomy and privacy for employees in seeking help. ‘They don’t have to apply to HR for counselling – they just click on the platform, which can be linked to the company’s Slack or Teams platforms, select a counsellor from the list of profiles and set up a session. Companies buy a number of sessions and can opt to allow single sessions for employees or up to six sessions. They can see how many sessions have been used, but not which employees are using them.’
Augmentive offers a ‘hand matching’ service for clients – where necessary – by co-founder Sarah Norman, a qualified and experienced therapist. ‘Some clients choose their own practitioner using the AI-driven search tool on the site, but they also have the option of having a conversation with me, and I recommend the right person.’ Sarah’s son Kit Norman is the other co-founder, and the team also includes Alina Ivan, a former researcher at the Institute of Psychiatry, Psychology and Neuroscience at King’s College London. ‘We named it Augmentive because we see the platform as augmenting therapists’ practice with the best technology and human service,’ says Sarah.
As well as therapists, clients can use Augmentive to book holistic practitioners such as nutritionists, breathwork practitioners and personal trainers. ‘It allows our practitioners to cross-refer where necessary. We’re increasingly aware of the importance of working holistically. Take the connection between gut health and mental health for instance,’ Sarah says. Kit Norman adds, ‘I was inspired by a friend at university who was struggling with his mental health despite seeing a counsellor, but when he also started seeing a personal trainer and focusing on nutrition, things really started to change.’
Jacobson agrees that the therapy platforms wouldn’t exist if therapy was easier to access. ‘I have been asked by friends in the past to recommend a therapist and, if it was not appropriate for them to come to a therapist at my clinic, I would do my own search in their geographical region, or for the specific issue that they or their child was needing help with. And what I have found is that it is very hard to sift through the practitioners and to get insight into their reputation. Another challenge was that often neither fees nor availability were displayed. It doesn’t surprise me that people can be easily discouraged in persisting in finding a therapist.’
Consumerist
The new therapy platforms take a consumerist approach to therapy – it’s all about the client getting what they need fast, in a way that suits them. Jacobson describes HarleyTherapy.com’s rating system for therapists – they earn ‘badges’ on their profiles such as ‘clients stay longer with this therapist than average’ and ‘this therapist confirms their appointments quickly’ and ‘8 out of 10 clients return’ – as the opposite of a ‘Deliveroo’ approach. ‘Unlike platforms like Deliveroo where restaurants can pay for top placement, we don’t charge therapists to be in our “recommended” list because we wanted to create a platform that offers clients transparency,’ says Jacobson.
HarleyTherapy.com takes the full fee of the first session, and 12% of subsequent sessions. Therapists set their own session fee, and clients pay an admin fee on top of that, for which they get a ‘satisfaction guarantee’ – if they aren’t happy with their first choice of therapist, the platform offers them another session with a different therapist, free of charge. ‘We want to give clients a sense of being looked after – if there is a difficulty getting started, or the therapist doesn’t turn up, there’s some accountability: there is a third party able to intervene; they can contact us and say, I’m not happy with the way my therapist is dealing with me,’ Jacobson says. ‘While we don’t get involved in serious clinical issues, we try to independently mediate where appropriate. We feel that it takes a great effort to sign up for therapy and give it a try, and people can be easily discouraged if that connection isn’t a suitable one or a good fit at the beginning.’
Despite this ‘treat the client like a consumer’ approach, even Jacobson worries about therapy becoming ‘commoditised’ by subscription models such as BetterHelp, which charges clients £60 per week every four weeks unless the account is cancelled, in return for a weekly live session and 24/7 text, audio and video messaging. ‘The more players there are, the more choice there is for anyone to find psychological support, and that’s great, we’re really up for that,’ says Jacobson. ‘But packaging therapy in terms of a monthly subscription that includes unlimited texts per day, it’s not real therapy, in our view. We’re trying to be reflective because we want to take signals from what clients are asking for and what other professionals are doing. But, in my view, we short-change clients if they subscribe to a monthly service that is more expensive than just paying for therapy, on the basis of promised “24/7” asynchronous chat – that’s not therapy.’
Online therapy specialist and trainer Pip Weitz has concerns about the numbers of therapists who sign up to work online through therapy platforms with no specialist online therapy training. ‘I know many therapists have taken the initiative to have online training, but it shocks me that few of the therapy platforms specify this as a requirement,’ she says. ‘I think what we’re going to start to see in the next 18 months will be complaints coming through that involve online work and a lack of training and a lack of standards. As an online supervisor, I hear some terrible stories and it seems that, with platforms, there just isn’t any triaging, and it’s often an AI programme that matches clients to therapists, not a clinician. I have had to say to a therapist not so long ago, who was working for a platform, “You are working beyond your competence with this client.” I think the problem stems from lack of understanding about what therapy is all about. I have been in a situation where I was asked to come on board as a consultant to a start-up – getting business people with no clinical background to understand why things have to be done in a certain way or why some things can’t be done was like pushing water uphill. In the end, ethically I felt I could no longer carry on consulting for them and left. The bottom line is many are driven by making money, not helping clients.’
Scalable therapy
Psychotherapist Aaron Balick was an early pioneer of therapy platforms with the Stillpoint Spaces initiative set up in 2015, but he wound down the platform after concluding that therapy isn’t scalable in the same way as other businesses. ‘We were a small organisation who knew all the counsellors we were working with, but once we started to scale up and attract more therapists to our platform, it became harder to vet them for quality, particularly those working internationally. For example, how can you vet a therapist from Slovenia or somewhere in South America when you are unfamiliar with their standards of training and qualifications? We became aware that we couldn’t maintain the same high-standard care and oversight and we didn’t feel comfortable facilitating therapy when we couldn’t guarantee the quality of our therapists.
‘As soon as you go to scale, there’s this inverse thing that happens in that you automatically have a reduction in how closely you can oversee what’s happening. Some say that providing something is better than nothing, but I’m not entirely sure that’s true because there can be bad practice and people can get into trouble. I’m not commenting on any specific services, but in our experience, the more we grew, the less able we were to spend time getting to know our clinicians. In the end, we didn’t feel confident scaling a service that is fundamentally a very sensitive and intimate affair. Speaking just from our experience, I’d say that we were therapists first, having a go at innovation, and in the tech sense we didn’t really succeed. On the other hand, there are those who are great at innovation but know little about therapy – ideally mental health innovations should be arrived at in close conversation between both.’
But it could be argued that the seismic change in how we do therapy that was triggered by the COVID pandemic was long overdue. Platforms such as BetterHelp are ‘disrupters’ to therapy, says Katie Rose, ‘in the same way as Uber was disruptive to the London black cab market, Airbnb was disruptive to the hotel market and Amazon was disruptive to the high street. There are problems with these models and they are contentious in many ways, but being disruptive doesn’t mean a model is intrinsically wrong. In the end, people use and rely on Uber, Airbnb and Amazon because they offer them a service they need.’
Change happens in every profession whether or not it is wanted and liked, and the uncomfortable reality is that therapy platforms exist because of a problem that we as a profession have so far not managed to address – the barriers facing many people in getting the support they need. Time will tell whether these platforms provide a viable and enduring solution and bring benefits in terms of better meeting clients’ expectations and a better experience of therapy.