UberTherapy and the Enshittification of our Relational Lives: Part 1 of our Interview with Elizabeth Cotton

Elizabeth Cotton is Associate Professor of Responsible Business at the University of Leicester and the founder of Surviving Work, which carries out socially engaged research on mental health and work. She has worked with health teams and trade unions, practiced as a psychotherapist in the NHS, and now runs the Digital Therapy Project, a group of UK and US researchers studying the future of therapy from both sides of the relationship.

In her new book, UberTherapy: The New Business of Mental Health, she explores the effects of reorganizing mental health care around the logic of the app store. Therapy is now something you can scroll through on your phone, match with in seconds, and rate like a ride share. Platforms promise frictionless access and personalized care. What is harder to see is how this new “mental health marketplace” is reshaping what therapy is, how it feels, and who it is really built to serve.

UberTherapy is part political economy, part insider account of therapy work, part literary exploration of what it actually feels like to bring our most distressed selves to the mental health app ecosystem.

In the first part of our conversation, we discuss how Cotton’s path through psychoanalysis, labor organizing, and sociology shaped Uber Therapy, and how shame and anger get intensified when platforms frame therapy as an easy consumer service.

The transcript below has been edited for length and clarity. Listen to the audio of the interview here.

Justin Karter: I really want to get into the details about what’s happening in the digitalization of therapy. But part of what makes this book so illuminating and unique is that you can speak to this issue from many vantage points. You’re a professor of responsible business, a labor organizer, an activist, a sociologist, a therapist, and a patient. Maybe the best place for us to start, to situate our readers, is with you.

Can you briefly situate yourself for our readers? Who are you? How do your various experiences make this particular book possible?

Elizabeth Cotton: Well, I’m quite old. I’m ancient, in fact, so I have a lot of experience in working life and experience in psychotherapy. It means lots of different things to me. I’m going to tell you some personal things about me, about what really has formed my character, my interests, and my politics.

I now live back in the place where I was born, in rural Britain, in the countryside, in the Cotswolds. When I was growing up, it was a really depressed and poor bit of the world. Now it’s like the Florida of the UK, and we have Beyoncé living here. It was not like this when I was a child.

I’m an identical twin, and that really shaped me as a person, both in a great way, I think, in that, from a very early age, I had somebody who really understood me and who really saw me, which is an incredible privilege for a young person to have. But we were also quite weird and quite smart young girls. We used to wear dressing up to school. At a very early stage, we were bullied, and we were considered quite strange.

In the 1970s, when I was growing up, being an intelligent, vocal young person—a girl—was a dangerous thing. My sister and I always had a very political sense of discrimination, of fairness, and also being a bit outside, being a bit strange, and not quite normal.

Then I ran away to London to study philosophy, well before the term employability came into existence, before you had to even think about what you were actually going to do to earn money. But I was a very troubled teenager, and I, through various therapies, I ended up at the Anna Freud Centre in London, which was very early—I was 19—and introduced to five times a week psychoanalysis. I was at a real crisis in my life and it was a complete culture shock. Can you imagine going from pretty much zero to five times a week psychoanalysis?

I tried to stay with it, but found it very difficult. I ran away. I got my grant check. In those days, you got a grant to go to university. I went to America, and I went to—again, a very long story—but I went to Canterbury Shaker Village in New England and looked after the last Shaker, Sister Ethel. I lived on this museum, Canterbury Shaker Village, and I was obsessed with collective organization and how do people live and how do people make sense of their environment, and also equality, because, of course, the Shakers were about equality between men and women.

It really started a long-term love affair with the States, with America. Although, of course, the anti-Americanism is very high now and always was, in a way. My parents were antiques dealers. When we were nine, we came to America for six weeks, and we travelled across California and New York, visiting antiques dealers. We met such exciting people, and it was a real introduction to how cool America is, how brilliant American stuff is, and the expansive landscape, both intellectually and also politically and geographically.

I’ve always had a long-term love of America. My sister now lives in Los Angeles, where she’s lived for many decades, writing about art. Again, this has always been a very politicized environment and world that we live in. We’re in a state of political catastrophe, but it has always been like this.

In many cases, my experience of living back in the place where I was born in rural Britain is pretty much like the 1970s, because misogyny and inequalities and discrimination haven’t shifted to a great degree, which is an extraordinary sadness for someone who has been a political activist their whole adult life.

I have a love affair with psychoanalysis. My dad did a PhD in his forties with Bruno Bettelheim, who wrote The Uses of Enchantment and did a Freudian analysis of children’s books. We always had Freud’s books in the house, and they were always on that shelf with the books about sex and Margaret Atwood. I always felt that Freud was an exciting thinker, and I’ve maintained my love of psychoanalytic writing because it’s brave stuff and it’s dangerous stuff.

I then moved on to working—again, another long story—but in my late twenties, I became head of education and organizing for the Miners International, for a Global Union Federation. I travelled all over the world, running organizing projects and campaigns. It was the initial days of cyber campaigning, so using technology to campaign and build solidaristic relationships.

I also spent a lot of time in the former Soviet Union. It was always a bizarre thing that my friends used to laugh about. I used to come up with funny stories about vodka for breakfast in Belarus. It was quite funny, in a way, because it was a really unusual experience. In the European Union, there used to be a lot of money to pay young people, including young activists, to go into the former Soviet Union just to find out what was going on, because no one had really had any in-depth contact. We didn’t know this environment. Of course, in the energy sector, the multinational companies were really important and really moving.

It turns out, again, that things come full circle, that the experience of working in Romania and Moldova and Azerbaijan in those years has incredible resonance for the political environment that we’re in now around authoritarianism and fascism. Even though it was a strange, big love job, and it was always quite difficult for me to integrate that into coming back to the UK, I think about it every day. I think about those experiences.

Then, like most activists, I got completely burnt out after a decade and had a complete emotional and psychological collapse. Like a lot of people who need a lot of therapy, I thought, “Oh, I know, I’ll come back, and I’ll be a therapist.” I went into training at the Tavistock in that kind of naive, stupid, but well-meaning way that a lot of people enter into training to be a therapist. Of course, I ended up in psychoanalysis and did that, not because I wanted to become a psychoanalyst anymore, but because I really needed it.

In the UK, having psychoanalysis is a rare and weird thing to do. It’s not available. It costs a lot of money. It was one of those things I didn’t really talk about in my working life. I worked unwaged in the NHS for a number of years as a psychotherapist, but I also became a part-time academic and started writing about mental health and work.

Then, in 2011, I was put in a compulsory redundancy pool for the first time in my life. It caused another collapse because I’d been representing workers for decades. Then, having to represent myself was—I just couldn’t do it. I just didn’t have the capacity. I was really disoriented about that.

I started writing as Surviving Work, which led to blogs and publications, but also developing a model around surviving work through trades union education methods. Then that led me into a series of research projects around therapeutic labor and around the future of therapy.

I then found a home as a sociologist, which, in a higher education environment that isn’t massively fond of critical thinking, feels like quite a delicate place to exist. But it’s definitely the place where I exist because it welcomes interdisciplinarity. It welcomes people with a practitioner background like mine.

There are huge snobberies, of course, in higher education and in the therapy world. Someone like me with lived experience can be seriously undervalued within these systems. But sociology does try. It tries to be inclusive in its interdisciplinary approach and mix of backgrounds, so it’s a place I feel quite comfortable in.

This ultimately led to Uber Therapy—this is a book that I feel as if I’ve written my whole life becauselike psychoanalysis, it tries to create the links between these apparently diverse and disconnected things.

I appreciate my organizing background because I’m also highly aware that no one reads academic stuff. It’s very readable. How many people will read your academic journal articles, which is kind of heartbreaking. But also, you’ve got to make it short and cheap and fun because you have a very limited time to hold people’s attention. I write in quite a provocative way, quite a journalistic way. It is an academic book. I think it’s important to underpin it with actual facts.

But the book is intended to seduce you into thinking about something that’s incredibly hard to think about, both in terms of the content of it—I mean, the sheer violence and thuggery that is involved in digital therapy—but also in terms of the attack on thinking that’s taking place across all of these domains now.

The book is very much, for me, an activist book because it’s an encouragement to engage with something that you’d really rather walk on by.

 

Karter: What a story. I kind of hope the next book is a psychobiography or a memoir. But really, all of these roles really do come through in UberTherapy. You’re able to write from an activist perspective, a journalistic perspective, a literary perspective, a sociological perspective, a business perspective.

But I want to narrow in on the lived experience piece. You illuminate the dark business networks and the interests behind them, but you also document, in a really provocative and literary way, what it feels like to encounter these apps with the parts of us that are traumatized, or the parts of us that we bring to long-term psychotherapy. You do this through introducing a character that you name Hair-n-Teeth. It’s such an evocative name as well.

I wonder if you could introduce Hair-n-Teeth to us and tell us about them: what it was like for you to write about this part of yourself, and what it was like, as a researcher, to bring this part of you forward through these different therapy apps.

Cotton: The first chapter of the book is called “Angerland.” I start this book with an orientation that a lot of us are feeling disoriented and angry in this digital environment, which is really my kickoff point. It’s a genuine book in the sense that I didn’t know what the punchline was going to be until I got to the end. One thing I didn’t know was how much this book was going to be about anger and how much it was going to be about shame.

Because shame is such a difficult word to say, and it doesn’t come up much in conversation because it’s so shameful to talk about shame. The thing that I kept coming back to in my research and experiences of using digital technologies in a therapeutic way was around what it feels like, and the potential algorithmic harms, which are considerably undermeasured and underestimated.

For someone like me, who has experienced distress and trauma and who’s very vulnerable to feeling deep triggering experiences of shame on a daily basis, I call it in the book an algorithmic invitation to self-harm. That’s the potential: we’re not talking about shopping for shoes here. We’re talking about, hopefully, showing the parts of ourselves that we are ashamed to show to another person. And that’s where the danger comes in. The potential harm comes in.

Hair-n-Teeth—I mean, I’m still nervous about talking about it. I can write about it, but talking about it is quite hard, because it’s such an unusual thing to do. It’s a vehicle to present an argument rather than sort of a testimonial or my story.

You don’t need to know my—thank you for asking about my story—but you don’t need to know who I am exactly. What I’m feeling when I’m using these technologies, I think most people feel, actually. I think a lot of people feel it and, for whatever reason, can’t relate to another person.

I feel that a lot of the technologies are presented in the e-commerce sector, online: it all works, everybody looks happy, everyone looks better than me. If it works for them, then it should work for me. And then when it doesn’t, there’s an individualization of an industrial problem. It becomes “I’m the problem,” rather than “maybe these technologies just aren’t good enough,” or “maybe they’re not appropriate for me.”

Hair-n-Teeth is a fast-tracked way to bring in a survivor’s perspective in an inclusive way, asking: what’s the worst that could happen to someone like me? What would it feel like? And how would I know if it’s not right for me? And it’s on that really grounded “this is what happens to my body when I’m put in this situation.”

It’s also a feminist perspective as well, because it’s still radical to talk about your experience and your feelings and push through the shame of that, and to say how much something hurts and how unfair something is and how that makes you feel, which is constantly being evaded in the AI debates.

As academics, we have a professional veneer. Some of us choose to take a more objective, less subjective stance, but actually, it misses the visceral quality of this. Our emotions are in our bodies, so we do have to talk about bodies in the way that we have to talk about sex, and we have to talk about money. These are incredibly hard things to talk about. But when we focus on what’s happening in our bodies right now when I use this technology, we come closer to the truth, I think, about what these technologies mean.

I also think that it’s a good contrast to the sort of advertising side of the business model, but also the black-and-white thinking that exists in the algorithm, in algorithmic thinking that’s part of this digital architecture: tick boxes, yes-no questionnaires, standardized models. They force you into boxes in a way that Hair-n-Teeth pulls you out again and says, “No, this is it. This is the experience. My experience cannot be reflected in your online questionnaire.”

Again, I think it’s really important to remind people that we might be measuring the wrong things, which we’ll come to a bit later in this interview, around datafication and performance data, that there is often an evasion of the harms and the real issues around the use of digital technologies.

I also think that Hair-n-Teeth is a trade union perspective as well as a feminist perspective, or a survivor perspective, in that it really prioritizes some practical stuff around: how does this harm you in your everyday life? What does this do to you? What does it stop you from doing? What’s the worst it can do to you?

In my work and in the book, I talk a lot about this idea of AI mental health and safety. Trades unions vary—it might sound a bit boring—but increasingly, absolutely life-saving health and safety is a really important framework to understand how would you use these tools, because actually we can’t get away from digitalization and AI technologies. They’re here. They’re here to stay. We have to understand them, but we also have to learn how to use them safely.

Just from a sort of experiential pedagogy, I come from that background of trade union education, which says: let’s analyze your experience, let’s pull out the risks, and let’s try and introduce some principles and practices of health and safety. That’s the palatable part of Hair-n-Teeth, which is to say, okay, so how am I going to make this hurt less? How can I be healthier and safer in the environment I find myself in?

 

Karter: You can feel that in the book, the way that Hair-n-Teeth is on the line. For our listeners who haven’t read the book yet, you introduce Hair-n-Teeth to a number of different types of digital therapeutics. You talked just now about the way that shame gets brought up in these interactions, particularly if you feel like, “It’s not working for me, it’s working for other people,” and now the industrial problem gets individualized.

I wonder if you could share one of the stories from the book about encountering one of the styles of AI therapeutics or digital therapeutics, and what it felt like to interact with it as Hair-n-Teeth.

Cotton: Oh gosh—that’s funny. That’s quite a difficult question for me to answer because, particularly where I was using online therapy platforms, I was dealing with real human being therapists. I had a lot of supervision and therapy of my own, where I had to think about the ethical parameters of that, as somebody who wasn’t using these services just as a service user.

I think the thing that came up in my interactions with actual human beings within these digital systems was how incredibly difficult it was for me to reach that person, and to see that person as a potential ally, through all of the architecture: missed calls, cameras not working, and only having six sessions. I mean, it seems almost remarkable to me.

I’m not wishing to denigrate the women. They were women whom I interacted with through digital therapy. I thought they were great and did what they could. But actually, the hoops you have to jump through just to get to the point of being in a safe space—I never even got off the starting blocks.

I know I’m unusual because I have a memory of five times a week psychoanalysis, so that’s not going to be replicated in the digital sphere. But I’m quite good at being able to establish a rapport with somebody and get a sense of whether I like them or trust them, but I found that almost impossible. I felt disoriented the whole time. That pushed me back into my most paranoid, hostile, reactive self, as Hair-n-Teeth, who is also quite angry.

I found myself being apoplectic with rage. I found myself checking my credit card to see if this wasn’t financial fraud because all of these systems require you to give so much financial and personal information. You’re suddenly left hanging before you even get to have contact with somebody.

The story of my experience really is quite grim from the get-go. I mean, it gets slightly more funny when I’m involved in a chatbot. I start off with the premise: I’m having too good a time in my sex life. I’m just too good at sex. I’m far too attractive. Which I assume is a problem that has never come up, really—or at least very rarely—comes up in therapy.

But I found that, in a way, what troubled me most was that the system did everything it could to prevent me from feeling as if I had a safe, caring, empathic interaction. I didn’t once even hit upon that. It felt like hostile terrain for me.

 

Karter:  It’s like reaching and reaching and trying to see: is this a real—can I get to a real person? Can I get to a real connection? And finding all these sorts of evasions and obstacles.

Cotton: Yeah. And I felt really miserable. I felt really ashamed. I felt really anxious. It made me much more anxious.

I think the thing about Hair-n-Teeth is that it represents a part of me that I had to work very hard to sit alongside in therapy. I sit alongside it. I don’t like it. I feel as if I’m an absolute newbie to self-worth. Self-confidence and self-worth have come late to me in life, and I felt all of that work being eroded by the same old traumatic PTSD issues coming up. They were really triggered in this process.

It made me really angry, because for me, the north star of therapy is: I can show myself as I really am to another person. That’s so powerful, isn’t it? It’s so rare. And that took me a lifetime to feel safe enough to show myself.

And I found myself really hurtling backwards. It felt really, just incredibly sad for me that if that was your first experience of therapy, what would that feel like? What would that tell you about yourself?

It was such a huge fight for me to get a basic level of self-acceptance. It makes me angry that somebody would be thrown off course by something that really didn’t work.

 

Karter: You mentioned that the individual therapists working in these systems might have been doing what they could, but that the system, as it’s come to exist, really prevented an actual connection or safety from being formed that would allow for these experiences of self-revelation.

Maybe we zoom out here to include the sociological piece. Can you walk us through how these systems have come to be? How austerity and neoliberalism have really set the stage for venture capital to enter the therapy space and begin what you call these processes of extraction and enshittification, which I think does some evocative work of explaining what it feels like.

Cotton: Now you’ve said it. I talk a lot in the book about shit. We could spend the next half an hour talking about shit if you wanted to.

Karter: How did digital therapy get so shitty and enshitified?

Cotton: It’s a bold claim, but I do also accept the theory of enshittification around digitalization and platformization.

Let me introduce Uberization, or Uber Therapy, to you. This is a book that offers an industrial relations perspective, first and foremost. That’s what’s distinct about the book: it’s talking about the profession and the practice of therapy from an industrial perspective, which is quite unusual in and of itself. The process that exists in every sector and is only now really visible in the professions is Uberization.

The book is looking at the business models. There are multiple business models. They’re fluid, and they’re changing all the time in terms of working out how to extract stuff from us: data, money, information. It’s looking at the business models coming out of digitalization and platformization, so the emergence of these platforms.

I’ll come back to the multiple meanings of the term “platforms.” But it includes datafication, the huge extraction and value of data that has emerged, and appification, how we do things through our mobile phones and through apps, and what that means for therapists and for the consumers of therapy. It’s in the words there: we’re now talking about consumers of therapy. Therapy becomes a sector of e-commerce. You can buy it business-to-business or business-to-consumer.

In industrial terms, we’re at this very exciting moment of regulation, management, and understanding of platforms. That’s a big industry in its own right. Internationally and nationally, we’re all trying to figure out how to regulate digital companies and the platformization of work and the gig economy. There’s a huge body of work going on around automation, surveillance, datafication, bias, and inequalities in datafication, and so regulation.

We’re in a world now where we’re obsessed with the Uberization process from many different perspectives. What’s quite new is that we’re not just talking about Amazon workers or Uber drivers. We’re talking about the professions, which have quietly been Uberized over the last ten years. We’re about five to ten years behind the US here in the UK in the platformization of therapy, but we’re clearly heading in your direction.

And one of the things I notice about lots of professions, lawyers, journalists, academics, writers, is the denial that exists around what’s happening. So if you’re in private practice as a psychoanalyst, you may not genuinely think that Uber Therapy has anything to do with you. The big take-home from the book is: oh yes, it is. It is now. This is your world. You have no choice but to understand it and prepare yourself for what is happening within your profession.

The line of argument in Uber Therapy is, firstly, that Uberization is taking place in a profession near you. So it is. We’ve seen the rapid emergence of manualized and digitalized models of therapy. We’re seeing increased use of AI technologies, whether or not they’re visible. It’s almost impossible to imagine a process within therapy now that doesn’t somehow touch on AI technologies: automation, datafication, performance management, how we assess recovery, our own performance, and how we justify that to insurance companies. And this is right across the public and private systems.

The question I ask in the book is: Is this model sold as a convenient fact of life? It is what it is. This is where the business is heading. But what’s the cost of that?

Included in the book is some information about the Digital Therapy Project, which I run with Linda Michaels from Psychotherapy Action Network (PsiAN), who I think you’re going to be interviewing soon, who is literally one of my heroes, famously sued by Talkspace for $40 million for asking if this is therapy.

It’s a complex and interesting story, the American setting. I’ve learned more from her co-edited book about future generations than from any other book. When I talk to UK therapists, I just say, “Read Linda’s book.” If you want to know what’s happening, it’s there. They’ve done the work. If they can tell you exactly what’s happening, don’t ignore it.

We conducted a survey of 500 UK and 500 US therapists about their experiences with digital therapy. It was incredibly hard to ask a question correctly because of issues with AI literacy and people’s awareness of the technologies they already use. We asked, “Do you work for an online therapy platform?” and in the UK, it flatlined. People didn’t even understand what we were talking about. Even if they were working for BetterHelp, they still weren’t quite sure of the terminology.

We’re in the very early stages of understanding which technologies we’re already using. But the take home from that survey, which will be published I hope this year, is that everybody understands the convenience of it, but at what cost?

One of the key conveniences is that, in the UK, a session with BetterHelp costs around £40 to £45. The rate is set so it’s cheap enough that you don’t have to spend the day on the phone with your private medical insurance company, both for you and your therapist. That’s the business model. It’s not very sophisticated.

But the cost to the therapist is the lack of transparency about what somebody pays and what you get paid, the sort of pyramid scales of pricing. And certainly in the UK, it has introduced an industry standard of around £40 an hour, about half of what it was before COVID. This is traditional industrial relations stuff. You’ve got a company like Amazon, you’re going to depress wages by 50% at some point. Then, around the corner is dynamic pricing: different scales and tiers of workers and pay scales that are algorithmically determined, and no one can challenge. The cost of that is very heavily financial for the therapist. This is not a sustainable form of work for therapists.

And the other cost is around the depth of therapy. How deep can you go? How much of a relationship can you form? I love open comment boxes on surveys with therapists because you get some dynamite in there. Therapists are very good at two sentences, really going for the jugular. One respondent introduced this phrase to us: defenses against thinking.

One of the big theses around the book is that this business model introduces, on multiple layers, a defense against thinking. It’s an attack on thinking. You don’t understand the system. You don’t see it. You don’t know where it’s taking you. You don’t know how much you’re paying. You don’t know how much somebody is receiving. It disorients you, stops you thinking, and certainly stops you thinking critically about it.

I also argue it’s a defense against dependency. That’s another attack on depth work. How could you become dependent upon someone who’s working in a system that is fundamentally unreliable and unsustainable for both of you?

In the book, I use the phrase therapeutic Tinder. I don’t use any actual company names other than Tinder, but somehow that got through the lawyers. No one’s told me to stop using it, so I use it. It’s a provocation about what it means to be in this sector of e-commerce: being able to swipe, being able to choose from a smorgasbord of therapists. If you don’t like them, move on.

In the early days of online therapy platforms, that was literally part of their advertising: “No need to become dependent on a therapist. If you don’t like them, we’ll find you another one.” I looked back at the adverts from five years ago, and you don’t see them anymore. Now it’s all green pages and healthy sustainability imagery. But in the early days, they’d literally say: this is cheap, this is fast, you don’t have to be dependent. The business model was much clearer then, if you kept your eyes open.

I also talk about therapy as a model of retail therapy. What does it mean to buy, to swipe, to rank, and rate? And the shaming and blaming involved in that, both of the client who isn’t able to get what they want, and then keeps spending money to make themselves feel better. It becomes this argument, which I think is very visible in the states of bad therapy, about being a bad patient and being a bad therapist. Again, it individualizes a problem about a business model.

I don’t advise therapists to do this, but if you go onto Reddit and look at bad therapy, you’ll see lots of therapists being named. It’s a very easy skip and a hop because BetterHelp doesn’t actually employ anybody. These are self-employed workers. It’s like ranking and rating your Uber driver. It’s a place to do a dump-and-run.

Coming back to shit, there is an enshittification, there is a degradation, of the work of the therapist and also what the consumer has a right to consume, has a right to demand. And although I find it funny, in a puerile way, it’s important: the degradation, the shittiness of this situation gets projected into the individuals involved on both sides of the therapeutic relationship. That should be a call to arms.

We’re being had here. It’s an evasion of business responsibilities, of corporate responsibilities. We’re seeing this around the regulation of chatbots, around young people’s mental health, around emerging cases of suicide and negligence, and issues around safeguarding. This will come, and it will be lived out in court.

In the book, I call it “Sabor a Mierda.” We’ve got this sense in us that something’s a bit off about this. I invite people to use Hair-n-Teeth to follow their gut feeling that this isn’t quite right as a way to determine what is harmful and what is not. These legal cases will live out. The United States leads the way, but the United Kingdom is following right behind you. We have to preempt this: develop a critical sense of what’s shit and what isn’t, and what’s right for us and what isn’t, and use that to be more discerning about where we place ourselves in this landscape.

 

Karter: It strikes me that in the book you talk about at least two ways in which the enshittification rolls downhill, right? There’s the business sense that these are individual consumers and individual practitioners who are 1099 workers or independent contractors. So if you have a bad experience, it’s a bad therapist who you can either fire and pick somebody new, or they can be made marginal by the algorithm in some way, so they match less frequently or something like that.

But there’s also the psychological, psychoanalytic interpretation that you offer of the way that shit gets projected because of the business system, and that allows us to avoid rupture and repair work in therapy. I’m wondering, could you say more about the psychological shit that’s getting thrown around because of the model, and then in the way that it frames and does not frame the therapy relationship?

Cotton: It projects the problem into the individual, both in terms of where the blame is and where the resolution is. It completely disempowers the individual to be able to do anything about it. And as a trade unionist, I’d say there’s also an individualizing issue here: it stops us thinking about it collectively.

That’s one of the challenging things about going onto Reddit or chat rooms and seeing the bad-therapy debates. You’re forced to go on social media to do the shaming, blaming, and naming, and to have a conversation about it.

If we’re going to have a conversation about this, if we’re going to resolve this, we have to do it collectively. We can’t just leave it to who shouts the loudest, who says the meanest stuff, and who takes the legal cases, because it’s extremely hard to be in court. That’s a whole story in and of itself.

It leaves you with nowhere to go and leads to further withdrawal from other people.

Another thesis of the book is that we have to relearn, come back into contact with, and re-experience that other people are not a waste of time.

I don’t have a magic silver bullet for that, but I don’t see how, as an individual, I can think my way out of this. This isn’t about clever stuff. It’s not about me being better or me being tougher or more resilient. It’s not those things. It’s about creating a safe environment where we collectively can put pressure, do some pushback.

These companies are enormous and will exist for as long as they choose. But within the therapeutic profession, within our professional bodies, within our networks, within progressive networks like PsiAN, we have a job to do: become literate in this, understand it, not be defended about the landscape we’re now working in, and start to develop principles and practices that could form the basis of regulation. We have to engage with it collectively.

I think the same is true for consumers as well. In many ways, consumers will have more traction in this business model, and probably more fun and more success in helping to redesign the sector, reorganize the sector, and play around with who the key actors are in that sector.

I don’t have a simple response to it. We can come back to this idea in chapter six: what real therapy and much better help would look like. But I frame it as intentionality within the book because I don’t have a how-to guide, and I’m aware that people are really tired, burnt out, and frightened at the moment.

In many ways, finding spaces where you can say what you think and what is on your mind is rare and precious. If you find that space, stay in that space. If you find yourself in an allegedly therapeutic space that does not allow you to say what’s on your mind, then leave it.

People often ask me, ” What can I tell my kid, what can I tell my teenager, and I’m just like: Look, if it feels like someone’s telling you to shut up, go, leave. That cannot possibly be a good thing. It’s on that very simple, intuitive level that we have to navigate this, daily.

 

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You can read Part 2 of our interview here (available 2/18/26): https://www.madinamerica.com/2026/02/ubertherapy-and-the-enshittification-of-our-relational-lives-part-2-of-our-interview-with-elizabeth-cotton_part2/

 

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