BetterHelp or BetterNot? Ensuring Mental Health Tech Innovation is Psychologically Sound.
Updated: Aug 23
In the rapidly evolving landscape of digital mental health services, BetterHelp has emerged as one of the most prominent players; and in a world where social media is the go to place for mental health information (or misinformation as it often happens), adverts for BetterHelp are never far behind. Where traditional talking therapies have been slow to innovate in order to meet modern challenges, increase accessibility, and meet diverse client needs, tech innovators have stepped into the breech - bringing with them controversy and criticism. But can you get tech innovation that is psychologically sound?
The Reddest of Red Lines: Confidentiality
If there's one thing you don't want to get wrong in providing a mental health service, it's protecting people's privacy. One of the most significant controversies surrounding BetterHelp involves its handling of user data. In March 2023, the US Federal Trade Commission (FTC) revealed that BetterHelp had shared confidential information from its intake questionnaires with major advertising platforms, including Facebook, Snapchat, Criteo, and Pinterest. This breach of trust was particularly alarming given BetterHelp’s assurances that such information would be “kept strictly private” and “never shared, sold, or disclosed to anyone.” The FTC’s proposed settlement included $7.8 million in partial refunds to affected customers.
The information was acquired via BetterHelp’s intake questionnaire which requires that they hand over sensitive information through “unavoidable prompts.” Despite BetterHelp's promise that: “Rest assured – any information provided in this questionnaire will stay private between you and your counselor.” The FTC suggested that a truthful statement would have been:
“Rest assured – we plan to share your information with major advertising platforms, including Facebook, Snapchat, Criteo, and Pinterest."
The FTC goes on to report that since its founding, more than two million people have signed up for BetterHelp and that nearly that number of email addresses have been shared with advertisers alongside information that 1.5 million of those people had disclosed having had therapy in the past. Using private information like this to drive recruitment is just one example of how marketing the drive to create growth are often run in counter-purpose to ethical practice in the talking therapies.
Whose Needs Are Prioritised? Shareholders, Clients, or Therapists?
BetterHelp is owned by Teledoc Health Inc., a multi-national publicly owned and traded company. Having run a cottage industry sized therapy company myself (Stillpoint), I know what the challenges are in scaling a service as individuated as psychotherapy. In fact, one of the reasons it folded was that I was unable to accept the compromises that came in scaling - namely the ability to adequately vet clinicians and maintain reasonable quality control. There was also the inherent problems that come with responsible marketing and recruitment of clinicians and clients. I came to the conclusion that I wasn't able to scale and ensure quality at the same time. That doesn't mean someone else couldn't, but the challenges are gargantuan. These challenges include quality clinicians, client care, a psychologically sound platform, and ethical marketing.
Quality of Clinicians, Ethics and Professional Practice:
Verifying qualifications of mental health professionals is a minefield - in the UK alone there are several registering bodies. each of which have different requirements for professional membership (and many with complex tiers of membership). As soon as you go international, the complexity becomes dizzying. Furthermore, a qualification is by no means a measure of quality - it simply means that an individual has met the criteria for their registering bodies. According to research conducted by Maastricht University BetterHelp does not provide therapy itself, it connects a "licensed" practitioner with a user.
According to the Maastricht study, "Initially, the company's terms of services stated that the company could not guarantee a professional therapist. It only connects the user with a therapist, who, in theory, should be licensed to be included in BetterHelp's network. This, however, cannot be promised by the platform. Another problem is that it is not easy to authenticate that the person on the other side of your web-based communication is really a trained therapist. This responsibility was, in the original terms of services, shifted by BetterHelp to the user itself."
Client Concerns:
While BetterHealth promotes itself as making it easier for potential clients, it appears that it may not be providing the essential structures that would be required for client care. Users have reported encountering unprofessional or under-qualified therapists, raising doubts about the platform’s vetting processes. Those seeking therapy are often confused by the myriad of labels and qualifications (e.g. psychotherapist, psychologist, counsellor and UKCP, BACP, NCP, BPS, etc) and may assume that BetterHelp has done this for them. In truth, there appears to be little transparency around what qualifies as a license and the responsibility is, as outlined in the terms and conditions, thrown back on the user.
As we've already discussed, licences in themselves do not ensure professionalism. Complaints by users include therapists being late to sessions, missing appointments, or even promoting their own books during therapy sessions. Others have complained about difficulties claiming refunds and other complicated issues with billing that have left them with a bad taste in their mouths. Naturally, any of these issues could equally arise in smaller organisations or with therapists in private practice. However in that context clients can usually bring up issues directly with their therapist (which is ideally contained in a trusting relationship) and not through a middleman.
While I'm sure that many of the clinicians working as BetterHelp counsellors are properly licensed, well intentioned, and offer a quality service, at such large numbers it would be extremely difficult to ensure adequate oversight and quality control. Furthermore, the way the service is set up may indeed make it more difficult for their counsellors to maintain the kind of ethical and professional practice they would otherwise.
Counsellor Concerns:
In her blog, Anna Kim (LCSW) writes about BetterHelp's aggressive recruitment techniques which she has referred to as "harassment." She notes that:
they are, first and foremost, a tech company. They are mining and using data about their customers, therapists, and consumer habits to make money, and this is, in my opinion, impossible to square with the ethics of being a mental health provider.
While many therapists recognise this from their own experience, there can still be a strong attraction to the service for those struggling to find work and get clients, such as newly qualified therapists or those who are moonlighting around other work to make ends meet. Kim notes that:
Like any system, those who work within it are, for the most part, disenfranchised participants. At a societal level, we don’t value therapists, and so they’re unable to find sustainable workplaces.
Many clinicians have raised concerns about the platform’s model of practice which may tie practitioners into ways of practicing they don't agree with. This includes things like the fee structure, high turnover of clients (who can change their therapist whenever they want), and the pressure to take on more clients than one can handle - all variables that may make one feel undervalued and lead to burnout, which obviously affects the quality of care.
Fees per session start quite low when compared to those in private practice and they rise with the more clients a therapist takes on. There are also cash incentives for meeting certain thresholds, like taking on 40 hours within the first month. While all therapists working privately will be incentivised by the income they earn from the amount of sessions they provide, the inclusion of a bonus structure is more akin to selling widgets than treating people for mental health concerns. At the end of the day who does scaling users benefit most? The shareholders.
Flexibility, Convenience, And Accessibility Are Great - But Are They Always Psychologically Sound?
One of the reasons that services like BetterHelp are growing at such an exponential rate is due to the fact that the talking therapies have been slow to change and meet the challenges of our post-Covid world. Many therapists continue to work exactly as they had in the 1950s - once a week for fifty minute sessions. And while many have moved their practices online, they still operate on generally the same model.
This model is difficult for many contemporary clients to accommodate. They generally require more flexibility and convenience in the way they engage in therapy. And while the professional field needs to acknowledge this and shift to better meet clients where they are - some of those traditions are there for good reason, and shouldn't be discarded willy-nilly in the name of convenience.
One of these traditions is the regularity of a time and place for therapy that creates a special kind of relationship that builds trust and consistency. The trust enables the pair to work through any potential conflicts that arise between them, which is ultimately therapeutic because working through interpersonal complexity is a transferable skill. Even the time between sessions, which can cause clients anxiety at times, helps them build up a client's independent coping skills and learn to manage anxiety themselves.
With BetterHelp, the basic structural elements of the service go against decades of tried and tested practice that diminish the capacity of their therapists to properly address the mental health needs of their users.
For example, clinicians are trained and required to work within their competencies, and refer out when they meet with clients whose needs are outside them. With BetterHelp you cannot remove a client from your caseload once you've taken them on. That means that if you've identified that they might be better off with someone else, moving them on is not so easy (possible, it appears from the linked article, but not at all ideal).
Contrastingly, clients can drop a therapist and find a new one very easily. While in theory this is good because it empowers users to seek out what's right for them, for me it smells a bit too much like Tinder - where you can just "swipe left" or ghost a counsellor who isn't seen as perfectly meeting your needs.
No doubt that a good match with a therapist is super important, as is client autonomy. I'm just not convinced that BetterHelp's is the best solution to this problem. There are further things to criticise about the model too. There is a heavy reliance on brief, text-based interactions, which may not be suitable for addressing complex mental health issues. The lack of face-to-face interaction can limit the depth of the therapeutic relationship, which is crucial for effective therapy.
Perhaps one of the more pernicious elements lies behind something that at first appears like a perk - I mean - who doesn't want flexibility from their therapy? But can you have too much of a good thing? If you have an anxiety disorder or suffer from codependency, is 24/7 access to a therapist really the best way forward?
As I've mentioned elsewhere, relying on a technological companion that's always there may have some sinister consequences. In this case there are consequences for both therapist and client. Clients may get what they think they need (rather than what might be the most useful therapeutic intervention) while therapists might feel pressure to meet those needs in order to keep their client from fleeing quickly to someone who will (whether that's the right clinical decision or not). A high client load and messages coming at all hours cannot be good for the clients, or the work/life balance of the therapist.
The tricky thing here is that at base the source for all these innovations are actually good things! We want to increase accessibility, reduce the obstacles to getting help for users, increase flexibility, and use tech to help us do all those things.
The trouble is that tech developers are trained to solve pain points in platforms, not to think clinically about the psychological consequences of removing them.
Mental Health, Brought To You By Instagram
The TikTokification of mental health has been a double-edged sword. While TikTok and Instagram have greatly contributed to the destigmatisation of mental illness, they have also elevated influencers into "experts" who tend to over-simplify complex ideas as well as contribute to misinformation. The biggest influencers also stand to make a great deal of money from their areas of influence - and these days mental health is a big earner.
BetterHelp ads are ubiquitous across social media and across podcasts. It is being promoted by mega-stars like Tim Ferris and Andrew Huberman as well as trusted networks like National Public Radio (NPR) in the United States where BetterHelp is a sponsor. The platform also partners numerous social media influencers and YouTubers to promote its services. These partnerships usually include affiliate links that that provide a kickback to the influencer for each sign-up. While this strategy has undoubtedly increased BetterHelp’s visibility, it has also raised ethical concerns.
Critics argue that the use of influencers to promote mental health services can be problematic, as it may prioritise profit over genuine care. Influencers, who may not have any expertise in mental health, can sometimes present therapy as a quick fix, potentially misleading their audience about the complexities of mental health treatment. Additionally, the financial incentives tied to affiliate links can create conflicts of interest, where the primary goal becomes generating sign-ups rather than ensuring the quality of care.
It strikes me that many people promoting BetterHelp may not be aware that the service might be problematic. Tim Ferris, for example, has talked openly about his own psychotherapy, and how helpful it has been for him. I can't say for certain, but I somehow doubt he met his therapist on BetterHelp. He may be extolling the benefits of a more traditional therapeutic approach while directing people to one that's quite different. Each new signup, however, will directly benefit the platform and the affiliate with a new customer. So who's winning?
Can We Get Mental Health Tech Innovation That'sPsychologically Sound?
"Move fast and break things" didn't work out so well for Facebook: it's not going to do any better for mental health. I did not write this piece to beat up BetterHelp, but I struggle to find a better example of how tech innovation in the mental health space pans out without adequate psychological oversight (or indeed if the oversight was provided but over-ruled by more profit driving factors). There is little doubt that the traditional way that the talking therapies have been delivered has been slow to change in the face of a changing world. We have left a vacuum that developers were quick to fill.
The way forward is more conversations between clinicians and developers. Tech may offer some really new and exciting ways to make a difference in people's lives - but it must do so responsibly and ethically. Those conversations may not be easy - but the alternative is much worse. That is a world in which mental health tech becomes unhinged from its psychological roots and traditional psychotherapy remains as it was, but only for the privileged few. Alternatively, we can find a world where we innovate responsibly - and create a technology that's psychologically sound and fit for human flourishing.
I recently spoke to GQ's Sam Parker for this wonderful article on the value of longer-term face-to-face therapy as contrasted to what you might be missing out on with BetterHelp:
