Psychology

While the pandemic proved online mental healthcare has its place, the rise of subscription therapy apps is intensifying concerns about the quality of care that is being dispensed. By Ahona Guha.

The therapy app trap

The Better Help phone app.

Credit: Ella Katz

The pandemic brought several sweeping changes to the way mental healthcare is practised in Australia – most notably, the normalisation of digital therapy via video. Before this, most psychologists – including myself — baulked at using online platforms. We weren’t sure about the privacy provisions, or whether a lack of non-verbal cues meant that we would miss relevant clinical information. All these worries were overwhelmed almost instantly in 2020 as we realised that we, and our clients, would need to either adapt or simply be unable to engage in mental health treatment for years.

Digital mental healthcare is now here to stay. It has allowed increased access, with most private practitioners able to treat people across Australia, rendering distance meaningless. Various platforms have sprung up connecting psychologists with clients, as have other digital forms of mental health support that are used as an adjunct to specialised treatment, such as mindfulness apps.

And the Australian mental healthcare space is headed for yet another transformation, with the advent of therapy subscription apps. The most well-known of these is BetterHelp. This app has dominated the American market for years now and is ubiquitous, with prolific social media ads and influencers spruiking its services. BetterHelp is now positioning itself to enter the Australian market and has been aggressively advertising to clinicians.

It is led by technology entrepreneurs, not by clinicians, and is a significant departure from usual therapeutic practice. The app’s model is subscription-based, where clients pay a set amount – say, $90-120 a week – to access a weekly 30 or 45-minute session with a therapist. They are also able to message their therapist anytime between sessions and are advised that therapists will usually log in twice a day to respond to messages.

Traditionally, therapy clients pay only for sessions they book and attend. The frequency of these sessions is negotiated, and the intensity of therapy that is provided is based on need and stage of treatment. Most traditional therapy services do not offer regular between-session contact, except in specific instances such as client crises.

While this between-session contact is positioned as a benefit of the BetterHealth model, in practice it may be the opposite.

BetterHealth claims to be like traditional therapy – the home page describes it as “The World’s Largest Therapy Service” – but also indicates that it isn’t. Buried in the fine print are the caveats: “while the service may have similar benefits, it’s not capable of substituting for traditional face-to-face therapy in every case. Please note that your therapist won’t be able to make any official diagnosis, to fulfill any court order or prescribe medication”.

For most trained psychologists, making diagnoses where applicable is a core part of determining treatment needs and the type of therapy to be used. The non-specific “depression and anxiety” noted on most referral letters are usually symptoms, not diagnoses, and these symptoms might be reflective of a vast array of underlying mental health disorders.

There are a few pertinent questions to consider in relation to therapy subscription apps. First – do they work? To date, there has been only one study assessing the effectiveness of BetterHelp intervention, conducted by a team at the University of California. This study looked at reduction in depression symptoms and showed that counselling provided via BetterHelp significantly reduced depressive symptoms. However, unlike most studies in the therapy field, this one did not use a comparison group receiving treatment-as-usual, which is usually the real test of any therapeutic intervention. Moreover, the sample group self-selected into the study. Those who benefited from the intervention were possibly more likely to opt into the study, artificially skewing its results towards the positive.

Apart from this study, BetterHelp says testimonials prove client satisfaction with their services. Psychologists in Australia are banned from using testimonials by the Australian Health Practitioner Regulation Agency, so it’ll be interesting to observe how BetterHelp manages this. While the app suggests its services work as well as traditional services, this has not been tested. One study focusing on one type of mental health disorder does not make a solid evidence base.

It’s possible a lower-intensity intervention such as this will benefit those with less acute mental health disorders, but there does not appear to be any form of clinically led triage screening clients. BetterHelp does not provide any insight into its process in matching clients with therapists.

Another question is whether there are benefits to this form of therapy subscription over traditional therapy models. While the $90 fee per week may seem cheap for a regular half-hour session, this is not much cheaper than the average out-of-pocket cost for a 50 minute session, after Medicare rebates, with a trained clinical psychologist.

Most therapy interventions require this longer time to cover the necessary ground. And while the capacity to message a therapist between sessions may be attractive, there are no proven clinical benefits to doing so. Being able to contact a therapist in this way increases dependence and makes it less likely that the client will use their skills, rely on other social supports or be able to tolerate temporary emotional distress. Therapy is not “1800-Phone a Friend”, and allowing immediate access to therapists in this manner changes the very definition of what therapy is.

An arguable benefit of therapy apps may be increased access for those who live regionally, but telehealth platforms facilitating traditional fee-for-service therapy already provide this.

The third important question concerns data privacy and care coordination. These are paramount. BetterHelp was fined in the US for harvesting and selling sensitive health data to advertisers, despite assuring customers it maintained their privacy. If there are similar problems in the Australian market, individual consumers will have limited recourse to pursue reparation from a company based overseas. It’s also unclear who owns and can access therapy notes – and if these are even recorded.

There is no mandatory regulation of online therapy services in Australia, and companies such as BetterHelp are positioning themselves to act in this gap. Clinicians in Australia are bound by an exhaustive set of record-keeping and data privacy laws and can usually only share information if relevant for healthcare provision, such as with a GP, as an essential component of ensuring good wrap- around care for those with mental illnesses. BetterHelp does not facilitate any information sharing with a client’s health practitioners – indeed, users can remain anonymous – which might leave people very vulnerable in crisis situations.

Finally, what of the person who is providing the therapy? The therapist themself is central to the provision of mental healthcare. BetterHelp is opaque about pay, providing only a yearly salary range based on how many hours a week one wants to work.

It appears the rate is about US$30 an hour initially, rising to US$45 if the therapist works 30 or more hours a week. For most therapists, this is unsustainable and will very rapidly lead to burnout.

As we engage with this new digital frontier in healthcare, it’s important to look past the glossy marketing and promises and focus on the hard questions around whether a service delivers what it promises. Is its model evidence-based, and what protection and benefits does such a platform offer clients and providers alike? On all these fronts, subscription-based therapy models remain dubious.

All views are Dr Guha’s own.

This article was first published in the print edition of The Saturday Paper on August 10, 2024 as "There’s no app for that".

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