After a crowd stampede killed 10 people at Travis Scott’s AstroWorld performance last November in Houston, the rapper announced he’d be partnering with BetterHelp, an app-based mental health company, to offer concert attendees one free month of therapy.
The announcement sparked immediate backlash: Scott was accused of profiting off the tragedy through his partnership with the company (something the company denied), and many people rightfully pointed out that a free month of therapy was a drop in the bucket of what was needed for people to heal after the disastrous event.
Though no monetary partnership between Scott and BetterHelp existed, it was nonetheless part of a PR strategy employed by BetterHelp and its therapy-app competitors like Talkspace to promote their services through partnerships with influencers, celebrities, and groups as far flung as the NYPD and a lingerie company.
Therapy apps have proliferated in recent years, promising to democratize mental healthcare by offering a more convenient and affordable alternative to traditional talk therapy. These promises come at a crucial time. Since the beginning of the pandemic, rates of depression and anxiety have skyrocketed and so has the use of therapy apps — which makes sense given that people have struggled to find a traditional therapist as demand outpaces supply. But the service offered by these apps is very different from the traditional concept of therapy: Much of the communication between users and therapists is done over text or in live chats instead of face-to-face meetings. The therapy-app companies also don’t hire their own therapists, but rely on overworked contracted therapists.
Talk therapy is just the latest industry to be disrupted by the Silicon Valley playbook. For years, tech companies have taken advantage of the lack of anti-monopoly regulation in the US and a lack of government support for public infrastructure in order to take over industries and drive wages down in an attempt to reap massive profits (often unsuccessfully). From Grubhub to Uber to Amazon, Silicon Valley entrepreneurs have presented themselves as innovators, modernizing stale industries and filling gaps in ineffective systems.
But in reality, these companies rely more on monopolization than true innovation. These tech companies frequently operate at a loss while they pressure enough people into their ecosystem, at which point they can jack up prices and cut costs.
We can see the same thing happening now with therapy apps: BetterHelp, Talkspace, and other therapy apps not only aim to take advantage of a dearth of public-health infrastructure to grow their products, they aim to fundamentally change the economics of mental healthcare so that they can siphon money not only from patients, but therapists as well. What these apps innovated was not therapy mediated by technology, but therapy stripped down to a bare-bones version of itself, with less quality, less overhead, and less pay for its practitioners.
The Uber model
Since the outset, Uber, Lyft, and other ride-hailing apps presented themselves as radical technological breakthroughs. But beneath the shiny technological veneer is a much darker reality. Uber and its competitors did not simply innovate their way to dominance, they broke down traditional labor forces, skirted laws, and lobbied lawmakers so that they became nearly the only game in town. Uber now controls 70% of the rideshare market, and ride-hailing apps now account for over 80% of the taxi market in New York City.
On the road to dominance, these apps also caused chaos for the workers on which they depend. In New York City, taxi drivers’ earnings fell 44% between 2013 and 2019, and many Uber and Lyft drivers can barely afford housing, food, and other basic necessities.
Once Uber destroyed the old labor market and created a new one with lower pay and worse working conditions, it monopolized the market, giving people fewer options for getting around by eating into public-transit budgets and then forcing people to pay more for the only options left.
This destruction-to-monopolization system, employed by Uber and countless other tech companies, is now standard practice in the tech industry.
The Ubers of mental health
BetterHelp, Talkspace, and its competitors are using the same playbook to break down the current mental health system. The apps present themselves as technological innovations — never before could people so easily access a therapist! But of course, this isn’t true. As the University of California Berkeley professor Hannah Zeavin writes in her book, “The Distance Cure: A History of Teletherapy,” therapy has been done by phone, mail, and other forms of not-in-person correspondence since Sigmund Freud’s time. What’s different about these therapy apps is that their goal is to make a profit. Their priority isn’t helping people get better, but constantly roping in new customers with a stripped-down version of therapy.
Just as Uber and Lyft have raised prices while they continue to underpay their workers, therapy apps charge high fees to give substandard service and wages. BetterHelp can cost up to $360 a month, which may be cheaper than some therapists, but is more expensive than therapy covered by the government or private insurance — which can be free on some insurance plans, or partially reimbursed. And despite the fees, the apps pay contracted mental healthcare workers less per hour than traditional therapy models. The companies have attempted to maintain as much opacity around their pay structure as possible, but therapists told New York Magazine that they were making somewhere between $20 and $30 an hour, far below the rates of traditional therapists (the average salary for therapists and psychologists in 2020 was just over $89,000 a year, according to the Bureau of Labor Statistics).
The apps charge this much and pay this little only to offer substandard service — therapists told New York Magazine that the hybrid structure of talk and text that can take place at any time, not during a defined weekly session, does not benefit patients and goes against most of their therapeutic training. Other users have reported mediocre care, like therapists offering one-word responses. Research on the effectiveness of app-based therapy is still limited, but even BetterHelp says in its own FAQ that it might not be a good replacement for traditional therapy. As one psychologist put it, “There is simply no replacement for sitting in the same room as someone and having your pain witnessed and validated.”
What, then, is the purpose of these apps if not to provide better care or easier access? They simply exist to make money, and will do so by any means necessary. Many therapy apps have been accused of using questionable data-sharing practices, which is particularly worrying since the apps deal with sensitive mental health information; and, similar to how Uber and Lyft skirted some laws in order to operate, Talkspace has offered to cover legal expenses for therapists who operate in states in which they aren’t licensed.
An innovative dead end
Talkspace, BetterHelp, Uber, and other tech companies exist partially because there is a need for disruption in the fields in which they operate.
Uber has been so successful not only because of its business strategy, but because it filled a vacuum in the United States and other countries where public transportation is severely lacking. Many people do not have a choice except to use Uber in places where subway and bus systems don’t exist or have been systemically underfunded for decades.
The mental healthcare system is also in need of change — it’s expensive, bureaucratic, fragmented, confusing, and exclusionary. Many people cannot afford therapy, and insurance often is not required to cover it. Wait lists for psychologists or psychiatrists can be months long.
While Silicon Valley companies aim to fill the gaps in these problematic systems, they are often unsuccessful.
In the case of Uber, recent studies suggest it increases traffic congestion. And workers begin to realize that their tenuous employment (which is not legally employment at all) is not worth it and protest or simply quit. Meanwhile, it’s unclear whether ride-sharing companies are even profitable, despite their raised prices and market monopolization. And while Uber attempts to fill in where public transit fails, it remains unaffordable for many.
We can see the same thing happening with the therapy apps: By using the gig-economy approach to labor, these apps take advantage of working therapists trying to earn extra money or help more patients in their spare time by paying them far less than they are worth. Like Uber, it’s a stopgap solution for workers who aren’t paid enough at their day jobs — and the lack of public services like transportation and healthcare in the US — and lets the companies off the hook from providing their workers the security of full-time employment with benefits. And like Uber, it’s already not going well: Talkspace went public last year, and its stock has already plummeted to nearly a tenth of its original value; it’s now facing a shareholder lawsuit.
If the companies are barely profitable with labor laws bent in their favor, and while underpaying their workers and giving customers substandard service, it’s unclear how they can be sustainable if forced to pay fair wages and provide adequate services to their customers.
This is the darker side of the Silicon Valley model: Companies disrupt industries, but often do not create a sustainable alternative in their place. And even as these businesses struggle, they cause massive change in the industries in which they operate, hurting customers and providers in the process.
It’s too early to tell how disruptive apps like BetterHelp and Talkspace will be in the mental health industry, but if the history of other Silicon Valley tech companies is any guide, then many people — workers and patients — could get hurt along the way.