Teletherapy can really help, and really hurt

The US has a therapist shortage. Even if you can find one, good luck snagging an appointment with a therapist who is affordable or covered by your insurance. That’s where online therapy platforms like BetterHelp come in. Even if you’re not a user, you’ve almost certainly heard of them. For years, BetterHelp blanketed the online world with advertisements and enlisted an army of podcasters, influencers, and creators to produce sponsored content that promotes their service as a solution. According to podcast analytics firm Magellan AI, BetterHelp spent an estimated $24.6 million on podcast ads in the first quarter of 2024, more than any other company in the audio space. These ads, sometimes personal and direct to camera, sometimes funny, and always earnest, have turned BetterHelp into probably the most recognizable sponsor of stuff people listen to on the internet. (Disclosure: BetterHelp advertises on several Vox Media podcasts.) But the efficiency behind BetterHelp’s infinite expansion, it seems, can come at a cost to patients, as about 800,000 current or former clients are learning this week. In 2023, the FTC said that BetterHelp shared the sensitive data it collected on its users with advertisers, seemingly without their consent, or with provisions in place to limit how that data was then used. According to the AP, BetterHelp has said it was simply adhering to practices that were “standard for the industry.” BetterHelp and the FTC eventually reached a settlement, and now anyone who signed up for BetterHelp between August 1, 2017, and December 31, 2020, is being notified of their eligibility for a refund. In a recent statement, BetterHelp said that the settlement was “not an admission of wrongdoing,” and clarified that the company did not share the “private information” of its members, such as their names or clinical data from sessions, with third parties. There’s a lesson here about combining the optimization and efficiency tactics of any tech startup in order to provide something as vital and as sensitive as mental health care to people who may be in crisis. When these strategies intersect with a field that requires expertise and treats people in vulnerable moments, something’s almost bound to go awry. If you’ve been paying attention to the race to optimize therapy with technology, this is a lesson you’ve seen taught before. Mental health care goes remote The start of the Covid-19 pandemic in 2020 caused an abrupt shift in therapy access. Regulations and insurance policies restricting the feasibility of teletherapy were loosened. Some therapists and patients found that meeting online worked better for them. As Brian Resnick wrote for Vox at the time, the onset of the pandemic was a “much-needed kick forward into the 21st century” for mental health care. For those seeking therapy, though, the new ease of finding virtual care meant sorting through waves of targeted ads on social media from companies that might not prioritize the quality of care over growing their businesses. Cerebral, founded in early 2020, enticed patients with easy, subscription-based access to virtual psychiatric treatment, including prescriptions for medication treating ADHD. But mental health professionals and patients raised worrying questions about the quality of that treatment. Underpaid providers were, according to Bloomberg, pressured to meet the expectations of patients who signed up for the service after seeing ads on social media promising quick and seamless access to medications. These concerns led to investigations. The New York attorney general’s office fined Cerebral $740,000 over its “burdensome” cancellation policies and for manipulating online reviews. Cerebral, like BetterHelp, also recently settled with the FTC, which has accused the company of disclosing sensitive user data for advertising purposes, misleading customers over its cancellation policies, and of violating the Opioid Addiction Recovery Fraud Prevention Act. As a result of the settlement, Cerebral has agreed to pay more than $7 million. The experience of being a patient through services like these will vary. Plenty of people who sign up for teletherapy through services like BetterHelp will have their needs met. I currently use a telehealth service provided by my insurance that matched me with a local practitioner in order to access medication, and I’m happy with it. But during a more acute mental health crisis in 2021, I signed up for another teletherapy and medication platform that I’d seen advertised. While it was indeed easy for me to gain access to treatments for my anxiety, I ended up dropping my practitioner, and the service, months later after she missed an emergency appointment I’d made, and then spent the majority of the make-up appointment venting to me about a personal crisis in her life. When things go wrong Mistakes happen, but when services in something as vital as mental health go wrong, people get hurt. I still think a lot about a 2022 story in the Wall Street Journal, which detailed what this can look like. Caleb Hill, a young adult who had been kicked out of his family home after coming out as gay, signed up for BetterHelp, requesting a therapist who specializes in LGBTQ+ issues. He was instead matched with a therapist whose private practice offers Christian counseling, and who told Hill that “either you sacrifice your family or you sacrifice being gay,” Hill told the paper. A former BetterHelp employee told the Journal that part of the issue was how the company’s focus on growth leads to a minimal training and oversight process for their therapists: “I felt they were treated like Uber drivers,” Sonya Bruner, BetterHelp’s first clinical director and later a consultant to the company, told the Journal. “There are a lot of good counselors on there,” she said, “but you also find counselors who aren’t, who do the minimum. They don’t get paid a lot, so they’ll phone it in.” I’ve thought a lot about the roles that technology can and can’t play in increasing access to mental health care like therapy. I’ve tried whenever possible to keep an open mind. I can see, for example, that there’s a pretty compelling argument to be made that, deployed ethically, chatbots and other implementations of AI can help improve patient access and results when seeking mental health care. Even at their best, though, these tools and services are basically patches in an expensive system that creates its own barriers to care. And when technological solutions to mental health access do go wrong, the cost is steep: private, sensitive data is sacrificed to feed growth. And people, often in vulnerable situations, get hurt.