Therapy by App: A Clinical Psychologist Tries BetterHelp

“Get help, you deserve to be happy!”

Ads for the for-profit therapy company BetterHelp are everywhere: on television, public radio, podcasts, social media, and in magazines. It’s not surprising for a company that reportedly spent over $100 million on advertising in 2023, making it the country’s projected leading sponsor of podcasts. The messages are appealing, boasting more than 30,000 therapists available by text, phone, chat, or video at an affordable price. They assure us that therapy is nothing to be ashamed of, a comfortable place for growth and wellness. BetterHelp and its competitors suggest they are the answer to a pressing societal mental health crisis.

Indeed, even before the pandemic, studies showed steadily rising distress due to depression and anxiety among adults, teens, and children, including an alarming rise in suicide rates. Mounting despair is evident too in the increasing number of deaths from opiate overdoses. The enforced isolation and withdrawal from ordinary life during the pandemic only made matters worse. As a result, people are seeking mental health care at unprecedented rates, leaving many professionals too full to accept new patients, and creating an opening for new platforms. During the pandemic, online treatment, once a rarity among conventional therapists, became acceptable, creating additional legitimacy for online therapy companies.

As a doctoral-level clinical psychologist with 35 years of experience as a clinician, professor, and supervisor of therapists, I was naturally curious about these platforms. I decided to turn my professional eye on BetterHelp, the largest and most prominent of these services, seeking my own psychotherapy with the company, applying and getting hired as a therapist, and interviewing BetterHelp clinicians. I read the online materials provided to guide both patients and therapists, reviewed ratings by patients, and canvassed other experienced professionals about the implications such services created for an already struggling American mental health system.

I came away with serious concerns about BetterHelp’s ability to provide quality, secure treatment and, perhaps more troubling, its potential to destabilize the therapy profession. But I also came to see that unresolved tensions in the science and practice of psychotherapy have left an opening for services like BetterHelp to exploit. Since there are few agreed-upon standards for what adequate psychotherapy entails, venture capital-funded companies focused on the bottom line do not have to invest in providing high-quality and effective state of the art treatment, since there is no consensus on what that really is.

Therapy at BetterHelp

To better understand BetterHelp’s approach, I decided to become a patient. I presented for therapy with genuine problems: overeating in the evenings after dinner and procrastination in completing paperwork and writing projects. I acknowledged to the therapists that I too worked as a therapist, but I did not reveal I was also gathering information to write about the platform.

After the initial intake process—a 30-question survey seeking demographic details and information about depression and anxiety symptoms, which probably helps BetterHelp screen out the patients the platform says it isn’t suited for, such as those who are suicidal, seeking medication, or don’t have the kind of problems it treats—I was quickly matched a therapist who was available within a day or two. I was given a free first week as part of a promotion, and then charged $85 a week, which includes one in person weekly meeting of at least 30 minutes and the ability to text between sessions. (Text therapy, which I did not take advantage of, is controversial because of a lack of data regarding its effectiveness.)

One advantage of BetterHelp is that because the service does not bill insurance, there is no need for clinicians to provide a diagnosis and target therapy to fit the “medical necessity” requirements imposed by third-party payers. Without insurance, patients can choose to be seen for whatever they want, and therapists don’t need to shoehorn them into a diagnostic category, which can be stigmatizing.

The first therapist I consulted, a gray-haired woman I’ll call Margaret, seemed ill at ease and unsure how to proceed from the outset. Like all three therapists I ultimately consulted, she held a master’s degree in social work. When I mentioned the problem with night eating, I saw a worried expression come across her face, and she mentioned that she struggled with the same problem. Margaret later revealed that she had Type 2 Diabetes, struggled with controlling her blood sugar, and had attended support groups to get better control. Patients often find such a level of self-disclosure about the therapist’s problems burdensome and distracting, and I immediately felt less confidence in her ability to help.

Without much assessment, she offered solutions that were absurd, and didn’t seem specifically suited for me, a middle-aged man. For instance, she talked of running a group for delinquent adolescents many years ago and rewarding them with a gumball for every 15 minutes they went without misbehaving. Translating that to a method for my problem, she suggested I monitor the night eating and “give yourself a star,” as a reward. She then suggested going to bed early to avoid eating. As the session came to a close, she still seemed at a loss and said she would try to come up with other techniques to address the problem in the next session.

After this disappointing session, I decided to see if I could find a more skillful helper. BetterHelp makes it easy to switch therapists if you are dissatisfied, without needing to inform the therapist you plan to make the change.

It took a day or two to be matched with my second therapist, who I’ll call Julie. In contrast to Margaret, Julie, a woman with straight brown hair who appeared to be in her late 30s, presented as understanding and confident from the start. As I explained my problem with overeating, she immediately jumped in with potential solutions. The ideas were practical and made some sense, but I felt she bombarded me with them. It was as if Julie was throwing out a bunch of tips from her therapy tricks bag and hoping that some might stick. And while they seemed like plausible solutions, she didn’t investigate my experience in detail enough to know if they would be appropriate. For instance, she thought I might be “stuffing” unpleasant emotions by eating, which was possible, but said the feelings might derive from the stress I experienced as a therapist from “giving away my time all day” and that it is important to set boundaries, because “clients would go on for two hours if you let them.” Was I really stressed by “giving away” my time all day? She never asked, and I actually wasn’t. Instead, I got the message that she felt that her clients (including me) were a burden, that we were wasting her time—and that maybe she was the one who struggled to set boundaries.

Though I had some reservations, the initial session was promising enough to schedule another a week later. Julie continued to offer a string of suggestions in her breezy manner, often with a bit of a know-it-all tone, making confident assumptions about what things must be like for me based on the few details I had communicated. She introduced some techniques from cognitive behavioral therapy (CBT), an approach that focuses on helping patients identify irrational thoughts and assumptions and assembling evidence against them. To address what she said were my negative thoughts, she suggested making a list of negative expectations and searching for evidence of whether they were “real”—perhaps she meant true—or “helpful,” as opposed to irrational.

It seemed more like she was telling me about CBT than doing it with me. Traditional CBT begins with a detailed assessment, thorough history taking, and clear articulation of goals for change. Then, through a process of Socratic questioning, the therapist helps patients identify irrational thoughts and asks questions to guide them to decide for themselves if there is evidence for their beliefs. It is important in CBT that patients come to their own conclusions about their thoughts. Julie’s approach was more lecturing than questioning. I wondered why she didn’t elicit a list of thoughts in the session, as is typical in CBT; instead, she said she’d send me a worksheet to fill out on my own. I later discovered that therapists are paid more when patients complete worksheets. After this disappointing session, it was time to try another therapist.

My last therapist I’ll call Steve. A bearded man in his early 40s, he disclosed that he worked during the day as a social worker with emotionally disturbed children. Steve was the best of the three therapists I saw. After I told him I had recently stopped working with another BetterHelp therapist, he encouraged me to bring up any questions and to tell him if I thought he was off base. “I’m an open guy,” he said.

Steve asked more questions and worked harder to understand me than the first two therapists. He checked in with me several times to see if I felt he understood me correctly. He adhered to the CBT approach more faithfully than Julie, attempting to identify unhelpful or irrational thoughts, but he appeared to believe identifying a thought was enough to weaken its hold on me. He didn’t do much to develop evidence that that the thought was irrational, an important part of traditional CBT. And too often he retreated to superficial, self-help maxims—“there is no such thing as perfect”—a “look on the bright side” attitude that trivialized my concerns.

These three experiences were disappointing. I found the first two ineffective, and though the third was better, he was still not someone I’d imagine continuing with if I was seeking treatment. These were short samples of treatment and perhaps things might have developed in positive directions if I’d continued. Still, as part of my training and for personal growth, I’ve had my own therapy with highly trained therapists, mostly using a psychoanalytic approach, and benefitted from their efforts to patiently get to know me. This was conspicuously absent from the BetterHelp sessions.

I suspect BetterHelp therapists feel pressure to help quickly—in order keep up their caseload and avoid being ghosted on a platform where patients are encouraged to provide a star rating for each session—so they respond hastily without listening well. Retaining clients is essential, since pay is determined by the amount of interaction with a client and therapists are encouraged to add more and more time to earn better compensation: working under 10 hours a week pays just $30 per hour, while 35 hours and above pays $70. The structure and set up of the platform may make therapists jittery, pressing them into achieving quick results and using superficial interventions.

Is BetterHelp Effective?

Clinical data on the effectiveness of BetterHelp treatment is scant. BetterHelp’s website referred to one published study of 318 patients, most of whom primarily used text messages to communicate with their therapists. Results after three months of treatment showed clinically significant improvement on a measure of depression. But the researchers said the study was preliminary and suggested the need for further research.  The results were limited by the lack of a control group—a group of patients who did not receive the treatment—which would help assess whether improvement was due to the therapy or some other factor, such as the passage of time.  And all participants in the research were volunteers, so there is no way of knowing how different such individuals are from those who did not choose to participate. The research also is compromised by conflicts of interest: one of the four co-authors currently is employed by the company; another is a former consultant. From a scientific perspective, a single methodologically flawed study establishes little. Formal studies on other platforms are similarly preliminary and unconclusive.

Of course, BetterHelp’s website paints a positive picture of the service’s effectiveness, with pages of positive reviews from patients. The Apple App Store compiles almost 100,000 reviews with an average rating of 4.8 out of 5. Independent rating sites, like the Better Business Bureau and Trust Pilot, show mostly positive reviews. However, it doesn’t take much experience to know the limitations of such reviews, as anyone knows who has purchased a highly rated product that turns out to be disappointing.

Without systematic data, it’s hard to know how common the egregious practices some BetterHelp users have complained about might be. On TikTok, the hashtag “BetterHelp is a scam” has been viewed by 5.3 million people. On that platform and in news reports, complaints range from descriptions of the annoying—therapists who don’t show up or arrive late—to  destructive experiences. One man claimed, in a Wall Street Journal article, that he sought a gay-affirming therapist, but was matched with one who told him he needed to change his sexual orientation and reconcile with the family that had kicked him out for being gay.

Bruce Wampold, one of the country’s leading psychotherapy researchers and an emeritus professor of counseling at the University of Wisconsin, appreciates that services like BetterHelp may make therapy available to more people, but he is concerned that there is no good evidence about how well it works. He doesn’t object to the service only offering online treatment, as he recently completed an analysis that showed no significant differences, on average, between in-person and online video treatment.

“For me, it’s quality control,” Wampold said. “Is anybody really monitoring the outcomes and the quality of the therapists who are participating? I don’t see any evidence that quality is a factor in their business model.” And he said he’s heard “horrendous stories” about BetterHelp therapists, such as one who said his life was worse than the patients and another therapist who couldn’t remember the patient from one session to the next.

Wampold said research has shown there are, unfortunately, ineffective therapists in many settings. “Is [BetterHelp] worse than other systems of care?” Wampold asked. “We don’t really know.” But he and many other professionals are concerned based on what they know of the service. “There’s minimal screening of the therapist, there’s very little quality data that’s collected,” Wampold said. “And the remuneration is quite low. So, you put those together, and it creates skepticism. I’m sure that there are some therapists on all of these platforms who are quite effective. How do you find out?”

This is a general problem in the field: therapists do not routinely gather objective data on their outcomes. But some factors seem to contribute to effectiveness, such as working in a group practice or clinic where there is close contact with colleagues. There is no data on the reasons for this, but Wampold suspects that clinics provide an environment that values improvement, and therapists who work in them have some idea what their colleagues in the same location are doing. Therapists for BetterHelp are on their own. The site does provide a discussion board and webinars for therapists to discuss clinical issues, but it is unclear whether the kind of support and consultation that occurs in a clinic or group practice setting would occur on a discussion board with strangers.

Becoming a BetterHelp Therapist

In addition to getting a taste of the patient experience, I was interested in what it’s like to be a BetterHelp therapist and applied in order to observe their hiring process. Becoming a BetterHelp therapist was concerningly easy. It involved submitting a copy of my mental health license, providing information on the kind of patients I’d be willing to see, and creating a profile describing my background and approach to treatment that patients would see upon being matched with me. Once approved, I was invited to a 15-minute interview with a woman who did not work as a therapist. Its main purpose, she told me, was to provide information about the platform and the next steps in the hiring process. Early on in the interview it became clear that I had already passed the screening without any discussion of my experience or clinical competence.

The interviewer said I could start seeing patients once I completed a background check by a third-party service and completed a quiz I would receive shortly by email. The quiz included six easy multiple choice questions about psychotherapy, followed by a prompt to write a response to a female patient’s initial written request for therapy. The interviewer said no one she screened had ever failed it. The background check was completed quickly.

Now “hired,” I was given access to the aforementioned discussion board where therapists posted about clinical conundrums, seeking support and consultation. And I began getting emails each week telling me how many potential patients I missed by not making myself available to start seeing people. (I did not proceed to see patients on the site.)

BetterHelp states that it employs only fully licensed professionals in a number of mental health fields (counseling, social work, psychology) who have, at minimum, a master’s degree. The company’s website says conflicting things about the required level of experience to qualify.  In some places, it says it requires a minimum of three years of experience and in others it states 2000 supervised hours (about a year of full-time work). Therapists are hired as independent contractors who are paid by the hour and are not technically employees.

Critics have contended that the company does minimal screening for therapists because they do not take legal or ethical responsibility for the therapists’ work; BetterHelp’s terms of service clearly state that the company should not be considered the “provider” of the services and that “the Contractor provides Provider Services at his/her sole and entire risk.”

The poor screening is not the only problem with the BetterHelp workforce. Therapists I spoke to who work there described a challenging environment. Joe Grachowski, a doctoral level psychologist, joined BetterHelp at the beginning of the pandemic when his in-person work in a prison psychiatric unit in Ohio felt dangerous and he was in a position to take early retirement. The service appealed to him because he could work completely from home without having to take on the burden of starting his own practice. But from the outset, he became uncomfortable with the working conditions. Patients weren’t screened well and some were inappropriate for online therapy, struggling with severe psychopathology that required intensive in-person or hospital treatment. He thought the compensation system was confusing. And he was uncomfortable with the subscription model where customers are charged a monthly amount no matter how many sessions they have and, like Netflix or other such services, charges continue until you explicitly cancel, which he said seems like a “rip off.” (On the BetterHelp Facebook page, a large number of customers complain of trouble getting refunds.) Furthermore, some of the patients he was matched with were explicitly seeking a therapist with different demographics; he had recently been assigned a woman seeking a female African American therapist.

After a year and a half at BetterHelp, Grachowski said he was attempting to open his own practice that would compensate him better. Not only are the BetterHelp per-session rates low, Grachowski said, the payment doesn’t cover the time he spends arranging referrals for people who aren’t appropriate for online therapy, or who can no longer afford BetterHelp and need to find a low-fee agency. Still, despite the added work, he said it was hard to leave the site completely because their advertising ensures there are always new patients he can see to maintain a busy caseload.

Some therapists who work at BetterHelp full-time described tremendous pressure to put in long hours to earn a reasonable living and access benefits. For instance, a woman I’ll call Betty, a counselor in a state in the Great Plains, has worked for BetterHelp for three years. She declined to be identified because she did not want her negative comments to affect her employment. Because of the need to put in enough hours to achieve the higher payrate, she said she had to take on a large caseload.  Reflecting on the number of hours she needs to squeeze ink she said, “I have indeed reached the burnout point.”

Betty said she liked the flexibility of the site and had meaningful experiences working with some of her patients but felt disrespected by the company. Offering patients the option to change therapists at any time led her to feel disposable. “The company tells a potential client that if they don’t like us, they can throw us away and ask for someone else,” she said. “It comes across as if they are telling the clients that we are dispensable and unimportant.”

BetterHelp puts on town hall meetings for therapists where they urge therapists to take care of themselves and that the company values them, but those messages are inconsistent with the working conditions. “The payment schedule rewards people who are willing to sell their soul,” she said. “It almost feels like a production facility.”

Betty also found the service’s texting component stressful: Therapists are required to text patients every three days and respond to text messages sent by patients within 24 hours—48 hours on weekends. If this doesn’t occur, therapists get a threatening email message from the company. Betty said therapists are aware the company can punish them if they run afoul of expectations by shutting off access to new referrals. She also said the company misleads patients by saying they can text their therapists 24 hours a day, but do not explain to patients that therapists do not respond immediately.

Some, though, have had a better experience, like Michelle Sherman, who works part-time as a school social worker in Michigan and joined BetterHelp during the pandemic in order to add some individual therapy hours. It was easy to start working with patients without having to be credentialed by insurance companies, setting up a billing system, or finding the appropriate telehealth software. She has been impressed with how easy it is to use the platform and liked the idea that video might make therapy more accessible for those who were not comfortable meeting in person, especially during the pandemic.

At first, she found doing therapy by text challenging, but realized some people might be more at ease texting for a while before they were ready to be seen on video. Sherman said she’s aware that working just 5 to 10 hours puts her on the low end of the pay scale, but that’s okay since she has a full-time job. Still, she, too, is now in the process of setting up an independent practice where she can accept insurance and receive better compensation.

BetterHelp does offer its therapists some perks: They get free membership to the service, which allows therapists to receive their own therapy for free; free access to more than 390 continuing education courses, which therapists would otherwise need to pay for out of pocket to meet licensing requirements; and a $650 monthly stipend to cover health insurance. The insurance benefit, however, is only available to therapists who “continuously” work 30 hours per week for two months. Betty said she valued this benefit, but found it hard to maintain enough hours to qualify, especially after the company changed its payment scheme so it no longer counted words patients wrote on worksheets.

If patients do not show up or cancel at the last minute, the time reserved for the session is not reimbursed the first time, and only 15 minutes is credited for subsequent missed sessions. With late cancellations, it’s usually not possible to fill the time. (In private practice, therapists often charge for no shows or late cancellations.) When she took some time off recently, Betty said her hours dipped and she could not receive the health benefit again until she put in another two months of 30-hour work weeks. It often is difficult to meet the minimum for benefits because at times the company does not provide enough new referrals, she said.

Wampold, the psychotherapy researcher, said he believed BetterHelp’s business model is designed to induce therapists to work as many hours as possible, which likely detracts from the quality of care. He was also concerned the individualized nature of the service could make it harder for therapist to succeed: “It’s already isolating enough to do therapy. We go into a room and or on video, and you do this confidentially. You really need support, help, consultation, peer consultation; these things are all important.”

Controversies

Some therapists lost confidence in the site when the company was sanctioned by the Federal Trade Commission in March due to its privacy practices. The company agreed to refund $7.8 million to consumers after the FTC documented that it routinely released personal information to other websites. The FTC said the company promised to keep information private, but shared customers’ information, such as email addresses, with Facebook and other social media sites to help them sites identify similar consumers who could be targeted by BetterHelp ads. The proposed FTC settlement prohibited the company from releasing such information.

In a response posted on its website, BetterHelp denied wrongdoing, claiming that it was behaving consistently with industry practices. It said the company had recently been credentialed by HITRUST, a company the monitors privacy compliance, and is the “gold standard” for certifying protection of sensitive information.

BetterHelp has been the center of other controversies related to manipulative and deceptive business practices. In August of 2022, the company ended its association with the therapy marketing site Caredash in response to an outcry from mental health professionals. Caredash had posted profiles of thousands of therapists to their own site without permission. When potential patients clicked on these therapists, a message popped up stating this clinician was unavailable and suggested a BetterHelp therapist instead, a particularly insidious form of bait and switch.

Two of the largest organizations representing therapists, the American Psychological Association and the National Association of Social Workers, took legal action. After BetterHelp severed its relationship with Caredash, the latter site shut down.

Practices like this have led critics to contend that the service is driven more by growth and profit motives than providing mental health services. Todd Essig, a psychoanalyst and an advisor to the Psychotherapy Action Network, a group advocating for quality psychotherapy, argues that clinicians who work for services like BetterHelp are put in an ethical quandary: their professional codes of conduct require them to put the needs of their patients first, but when working with for-profit telehealth services, they must comply with policies and practices that prioritize the company’s interests.

“It’s essentially a fraudulent business model,” Essig said in an interview. “They market themselves in a manner similar to what, for example, a hospital would do. But unlike a hospital, which has to obey the canons of medical ethics, and is subject to lawsuits, licensing boards, and loss of accreditation, and full range of disciplinary measures, BetterHelp and Talkspace [another online for-profit therapy provider] are companies. They obey business ethics, but present themselves as providers of health care.”

Ben Miller, a clinical psychologist in Tennessee, spent six years reviewing proposals for the Well Being Trust, a foundation that funded promising mental health interventions, often digital. He said BetterHelp’s for-profit model was consistent with the venture capital approach evident in many of the proposals he saw. “There’s a mantra in this world that is dangerous, and it’s profit at all costs,” he said. “There’s nothing wrong with profit. But when you don’t consider the quality, or the patient experience, or the outcomes, or the true unintended consequences, then I feel like we’re bordering on irresponsible behavior, and people will get hurt.”

I submitted a list of questions to BetterHelp regarding the concerns about compensation, hiring, research backing and the FTC complaint. A spokesman for the company said it would not be able to address my specific questions and provided a brief statement contending the company had provided “affordable therapy” to more than four million people and helped reduce the stigma of mental health treatment. The statement listed the professional and licensure requirements for therapists, noting they were all in “good standing” with their licensing boards. It also provided a link to the company’s response to the FTC complaint denying wrongdoing.

Chaos in the Therapy World Provides an Opening

Despite its missteps, BetterHelp has become a significant provider of mental health care in America. This would not have been possible if the science of psychotherapy was not plagued by contention and confusion over what exactly psychotherapy is and what makes it effective.

Studies suggest there are more than 500 distinct forms of psychotherapy. Originally, there was one form of therapy: Sigmund Freud’s psychoanalysis, an insight-oriented form of treatment that emerged at the end of the 19^th century. While updated contemporary forms of this therapy, often termed psychodynamic, are still popular and supported by research, new forms of treatment have multiplied. Many of them emerge when charismatic individuals put forth an idea that challenges existing approaches and create new brands. New therapies are often referred to by initials—e.g., CBT for Cognitive Behavioral Therapy—resulting in a confusing alphabet soup of treatment approaches: ACT, CAT, CFT, DBT, EFT, IFS, ERP, EMDR, MBCT, MBSR, MBT, MI, PCT, PE, REBT, TFP.

Attempts by researchers to establish the most effective approaches to treatment have been controversial, leading to what Wampold, the therapy researcher, has called The Great Psychotherapy Debate and others refer to as the Therapy Wars. On one side are academics who conduct randomized controlled trials (RCTs), the same approach pharmaceutical companies use to establish whether drugs are effective. But critics contend that treatments provided in research settings are artificial. Standardized therapies employed in these studies are far different from what is offered in usual clinical practice, where patients do not have one clear cut diagnosis, as do patients in clinical trials. Therapists in these trials follow manuals to ensure all patients get the same treatment, but this also does not reflect therapy as usually practiced.

Such studies have established that some treatments, often based on CBT, show effectiveness with particular disorders and are “empirically supported.” But since researchers don’t have the funds or time to follow patients for very long, the treatments are short—eight to 16 weeks, typically—and there is often insufficient data to know if gains from therapy persist for more than a few months or a year or two.

Another set of studies has identified a set of “common factors” that appear to be present in all successful treatments. Such factors include providing empathic understanding, agreeing on treatment goals, facilitating exposure to feared experiences, and increased understanding of thoughts, feelings, and behaviors. But only recently have there been efforts to train therapists in these factors specifically. And in general, most therapists do no systematic monitoring of their effectiveness. Some studies show therapists who don’t study their own outcomes may stagnate, so those who are more experienced are not more effective.

Jon Allen, a psychologist at the Menninger Clinic, described the contemporary scene in an article for Psychiatric News in August of 2021:

We psychotherapists have no grounds for complacency; our field is in disarray and rife with conflict. We have hundreds of brands of psychotherapy tailored to myriad psychiatric symptoms and disorders. Scientists and clinicians wrangle. Researchers struggle to demonstrate consistent differences in effectiveness among methods of therapy while the overriding contribution of the quality of the patient-therapist relationship has been affirmed for decades. Correspondingly, individual differences among therapists contribute as much or more to treatment outcomes as do differences in their methods.

In such an environment, it is reasonable to wonder if the word psychotherapy even has a shared meaning these days. Marvin Goldfried, a clinical psychologist and professor of psychology at Stony Brook University, has written that the lack of consensus means psychotherapy should be considered an “infant” science, despite its more than 100-year history as a professional field. For at least 40 years, leaders in the field have been calling for unification, but new brands still appear, and proponents of existing theories continue to promote their own approaches, often fiercely.

Referencing another arena in which sectarianism and polarization persists, Goldfried wrote recently, “To achieve meaningful consensus, we will need to learn how to work across the aisle rather than compete against one another.” Goldfried suggests the field could unite around a set of common principles, but most training programs still teach the same common brands of therapy they always have and ignore or minimize approaches that don’t fit with their preferred theories.

BetterHelp’s workforce is composed of practitioners with a license in a therapeutic profession—such as social work, counseling, or psychology— who have a limited amount of post-degree experience. In a different therapeutic landscape, therapists might be expected to demonstrate competence in the core principles of therapy, and professional organizations could set expectations that therapy platforms maintain standards that make it possible to achieve those expectations. One common principle supported by decades or research is the importance of therapists promoting a sound, collaborative relationship with their patients. At places like BetterHelp, where underpaid clinicians are pressured to work long hours, without adequate support, it is unlikely that clinicians can regularly create such connections.

Instead, BetterHelp can advertise that it provides therapy, though there is no credible evidence that what patients on average receive is effective, or if therapists can even work competently under its stringent work requirements. If companies like BetterHelp continue to take over the marketplace, psychotherapy will become a frenzied, low-paying profession, which will discourage talented individuals from entering the field and burn out the ones who do.

The pandemic made online therapy in a variety of settings more acceptable and available than ever. But with the future of the profession involving rapid expansion of corporate providers like BetterHelp, it’s unlikely our country’s mental health crisis will improve any time soon.