The Failed Promise of Online Mental Health Treatment

Heavy advertising and other strategies from Silicon Valley’s playbook boost providers’ growth but not the quality of care.

The Wall Street Journal

Here are some excerpts by Ken Pope, PhD:

Remote treatment of mental-health problems surged in the pandemic, as in-person treatment became difficult while pandemic-driven isolation increased anxiety and depression.

Digital mental-health companies plunged in, promising to provide millions with access to high-quality care by video, phone, and messaging.

Many of the businesses, however, put a premium on growth. Investor-backed, they deployed classic Silicon Valley tactics such as spending heavily on advertising and expansion while often using contractors instead of employees to control costs. A strategy designed for mundane businesses such as food delivery, the formula can be badly suited to the sensitive activity of treating mental-health problems.

After Caleb Hill told his parents he was gay, he was kicked out of the house. He had been taught, growing up in a conservative Christian household in Tennessee, that his attraction to men was a grave sin.

Feeling isolated and depressed a few months later, Mr. Hill, then 22, thought therapy might help. He had heard podcast ads for BetterHelp, a company that provides therapy remotely and promises “a personalized therapist match that is tailored to your preferences and needs.”

His biggest concern was he missed his family. The therapist he was given, he says, recommended he try to stop being gay so he could go back to them. “He said if I chose to go back to who I was and deny those feelings, he could get me where I needed to be,” Mr. Hill said.

Mr. Hill had requested an LGBTQ+ therapist, a screenshot of his intake form shows.

BetterHelp gave him one who didn’t specialize in LGBTQ+ issues, according to the provider’s profile on its website, and whose personal website says he practices Christian counseling.

“He said either you sacrifice your family or you sacrifice being gay,” said Mr. Hill. “I needed someone to tell me I was gay and that was OK. I got the exact opposite.”

BetterHelp declined to comment on Mr. Hill’s experience, citing patient confidentiality. The therapist wouldn’t discuss him either, citing the same reason.

Other clients of digital mental health companies described to The Wall Street Journal how they were badly matched or encountered unprofessional therapists.

Some, like Mr. Hill, also told of being gay and being assigned to therapists who were unsympathetic.

Telehealth technology was used for 36% of outpatient visits for mental-health and substance-abuse treatment in the March-through-August stretch of 2021, a jump from essentially zero before the pandemic, according to research from Kaiser Family Foundation.

Sensing opportunity, investors last year poured $4.8 billion into startups offering digital mental-health services, according to Rock Health, a research and investment firm. Some of the companies provide therapy, some prescribe psychiatric drugs, and some do both.

The companies say that their advertising helps to break the stigma associated with seeking mental-health treatment. And those that lean on nurse practitioners instead of physicians to prescribe medication can lower the price of care and expand the number of available providers. Many patients say the care they have received from the companies is good and also is unavailable elsewhere.

Cerebral Inc. was a star in the field. It raised hundreds of millions of dollars, signed Olympic gymnast Simone Biles as a spokeswoman and by two years after its launch was valued at close to $5 billion.

Its heavy social-media advertising and brief appointments with clinical contractors sparked trouble when the company began prescribing drugs that are prone to abuse.

The Wall Street Journal reported how Cerebral executives pitched its investors on the superior profitability of prescribing stimulants such as Adderall, which can benefit people with attention deficit hyperactivity disorder but are sought by others for the buzz they provide.

The reporting showed how some Cerebral clinicians felt pressured to prescribe the drugs.

Cerebral now faces two federal investigations, has been told by Walmart Inc. and CVS Health Corp. that they will no longer fill its prescriptions for controlled substances and has been dropped from insurance networks Optum and Aetna. It has laid off hundreds, fired its CEO, and stopped prescribing stimulants.

Another digital mental-health provider, Done Global Inc., faces a Justice Department investigation after the Journal reported that some of its clinicians, too, felt pressured to prescribe stimulants to treat ADHD.

Done, run by a former Facebook product manager with no medical training, also advertises heavily on social media. Done’s clinicians continue to prescribe stimulants, sometimes after appointments as short as 10 minutes, the Journal has reported. Walmart and CVS have said they won’t fill its prescriptions for the drugs.

Cerebral and Done have said that they don’t pressure clinicians and that they provide an essential service.

Neither company answered questions for this article.

Workit Health Inc. was a hot startup treating opioid addiction via telehealth, ranking among the leaders in capital raised. Its clinicians prescribe Suboxone, an aid to controlling cravings. Workit’s social-media ads show boxes of the medication.

Addiction experts say that while Suboxone can be crucial for opiate addicts to help hold addiction at bay, so is counseling that helps them develop new habits and gives them other tools to beat the addiction.

Workit advertises support to help with recovery. In some states it has hundreds or thousands of clients but just a handful of counselors, according to people familiar with the figures.

In Florida, it recently had a few thousand clients and no counselors licensed there, the people said, as its last one departed in September.

Some former Workit counselors said they couldn’t provide quality support because of the number of clients they were responsible for. They said they felt the company was more focused on expanding than on the quality of its care.

“They’re building a Suboxone vending machine,” said Dorothy Moore, who was a Workit nurse practitioner for four years and managed clinicians across several states for the company before she left in February.

“When you put venture capital money into this mixture, it really pushes people to take risks,” Ms. Moore said.

“It’s one thing to be a disruptive innovator, but there’s a reason medicine is encumbered by so many regulations—we’re dealing with people’s lives.”

Suboxone is an opioid and if taken in large quantities or combined with alcohol or sedatives it can stop a patient’s breathing, she said.

A spokeswoman for Workit said the company aims to provide “low threshold” access to medication that reduces the risk of overdose deaths.

She said Workit provides patients with therapeutic self-directed courses and support groups. If they require support the company can’t provide, it refers them to others, she said.

Alex Paone signed up with Talkspace Inc., which provides both therapy and medication via telehealth, to work through anxiety related to family and relationship issues. Offering sessions via video, Talkspace was easy to sign up for and accepted his insurance.

His Talkspace therapist quickly struck him as unprofessional. During their first session, he said, the therapist was switching between rooms in her house before ending up on a couch with a kitchen in the background. There was someone walking behind her during parts of the session, he recalled.

She did the second session from the passenger seat of a car, Mr. Paone said. Part way through, they stopped for gas.

“I could hear the driver get out of the car,” Mr. Paone said. “I could see the gas pumps.”

What upset him, he said, was that the therapist seemed distracted: “It doesn’t seem like she’s in a place where she can listen to me intently.”

The therapist, Kristine Hoestermann, said she’d had to move in temporarily with her mother, with whom she shared an office. She said she wears headphones so no one can hear what clients are saying.

Ms. Hoestermann said she was at Talkspace for only a few months, leaving because pay was low and she felt she had to see too many patients too frequently to keep up. “I couldn’t be the kind of provider I wanted to be,” she said.

Mr. Paone said he declined Talkspace’s offer of another therapist after she left. “I think I was just so turned off by that first experience, I kind of gave up on it,” he said.

The company and Ms. Hoestermann declined to comment on Mr. Paone, citing confidentiality rules.

Another former Talkspace therapist, Liz Kelly, said poor client experiences happened in part because increased demand during the pandemic meant it lowered the bar for hiring and training.

The pandemic brought a rush of clients. As the company struggled to hire enough therapists, there was a push to hire more quickly, Ms. Kelly said.

Training is important because digital mental-health care requires writing, technical and other skills that aren’t used in traditional face-to-face therapy, said Ms. Kelly and others in the industry.

Before Ms. Kelly left, she sent a memo to a supervisor outlining her concerns, including that some of its therapists weren’t qualified and that low pay would make it hard to retain good ones.

One of her tasks had been to interview new therapists. She wrote that some she reviewed lacked clinical skills and technology competence and were hired over her objections.

Talkspace “grew too quickly, and in growing so quickly they sacrificed quality,” Ms. Kelly said.

Talkspace’s chief medical officer, Varun Choudhary, said in a written statement that the company has the most rigorous hiring, credentialing and training process in the industry.

“Over the past several years as the need for mental-healthcare services has surged, we have worked diligently to keep up with demand. We are continually looking for ways to improve service and provide members a high level of care,” he said. Talkspace said it offers competitive pay rates.

Since Talkspace’s 2021 public-offering pitch, with singer Demi Lovato and swimmer Michael Phelps as spokespeople, the company’s business of offering therapy and psychiatric drugs directly to consumers has shrunk. Another business selling its services to companies to offer as an employee benefit has grown, but not enough to make up the difference.

The stock is down steeply since its debut, and its co-founders left last year.

BetterHelp, the company that Mr. Hill in Tennessee says made a bad match when he sought therapy, is one of the U.S.’s largest providers of therapy. It has about $1 billion a year of revenue, it said.

BetterHelp says it has 29,900 therapists and that it has served more than three million clients. The therapists are independent contractors, paid by the hour, instead of employees.

The company simplifies its business by not taking insurance. Customers pay about $300 a month for four sessions plus messaging with a therapist.

A summer 2022 roster of BetterHelp’s staff showed that its thousands of contract therapists were overseen by a clinical operations staff of just five people. The marketing team numbered 25.

Marketing isn’t BetterHelp’s biggest team, but it’s where the company invests the most money, said Erin Devine, previously a product manager at the company. “BetterHelp just wants therapists to do the therapy themselves,” she said.

“The pressure to grow is sometimes antithetical to delivering customer value,” she said, while adding that she felt BetterHelp grew at a responsible pace so it could continue improving the quality of its care.

BetterHelp’s ad budget runs to hundreds of millions of dollars a year. It spent $64 million on podcast advertising through the first 10 months of 2022, research firm Magellan AI estimates, making it the largest podcast advertiser.

BetterHelp’s growth focus is also evident in its quick therapist onboarding process. Interviews of prospective therapists are short and are conducted by nonclinical workers. Training is minimal.

“I felt they were treated like Uber drivers,” said Sonya Bruner, who was BetterHelp’s first clinical director and later a consultant to the company. Ms. Bruner now runs a small therapy website that started in Singapore but hopes to come to the U.S.

Ms. Bruner said therapists’ pay was so low that to get an acceptable income meant taking on more clients.

“There are a lot of good counselors on there,” Ms. Bruner 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.”

BetterHelp has signed up influencers on YouTube and other social media, in addition to celebrity promoters such as Justin Bieber and Ariane Grande. They weren’t paid but received free therapy for their fans or workers, said the spokeswoman.

Besides the BetterHelp.com website, the company owns teencounseling.com targeting teens, ReGain for couples therapy, faithfulcounseling.com for those seeking Christian-based therapy, pridecounseling.com for the queer community, and others.

Algorithms collect information from new clients and match them to therapists. Sometimes a good match isn’t available. Many therapists listed on BetterHelp’s site aren’t accepting new clients, and some have left the platform, said people familiar with the service. Availability is also limited by the states where therapists are licensed.

Mr. Hill, the gay client from Tennessee, said the therapist BetterHelp assigned him asked if he had ever been physically affectionate with a man. Mr. Hill said he hadn’t.

“He said, ‘Good.’ He said if I did want to go back to my family, I should think hard about being physical with a man, because it would be a lot harder after that,” Mr. Hill said.

Mr. Hill said he believed that Mr. Lambert was deploying a technique known as conversion therapy, which seeks to change a person’s orientation from gay to straight.

Mr. Lambert didn’t respond to a message asking whether he favors such therapy.

Conversion therapy is a technique that the American Counseling Association, a professional group, says on its website “does not work, can cause harm, and violates our Code of Ethics. It is an attempt to treat something that is not a mental illness.”

BetterHelp has a blog post that opposes conversion therapy, calling it dangerous.

After his session with Mr. Lambert, Mr. Hill wrote the therapist an email saying he couldn’t go back to his old life. “I finally opened the door of the prison I built up inside, and the thought of going back kills me,” he wrote, according to a copy reviewed by the Journal. “Will kill me if I lock myself inside again.”

He quit BetterHelp after sending the note.