The Fight for the Soul of Psychotherapy: An Interview with Linda Michaels

Linda Michaels is a psychologist in private practice in Chicago and a co-founder of the Psychotherapy Action Network (PsiAN).

She trained at the Illinois School of Professional Psychology and completed the Psychoanalytic Psychotherapy program at the Chicago Psychoanalytic Institute. She is also a Consulting Editor at Psychoanalytic Inquiry and Clinical Associate Faculty at the Chicago Center for Psychoanalysis. She is currently a Fellow at the Lauder Institute Global MBA program. Before becoming a clinician, she worked in marketing, innovation, and management consulting, including work with organizations in the U.S. and Latin America.

In this conversation, we trace her path from market research to psychotherapy and then to organizing. We talk about what clients say they want from therapy and how training, insurance, and digital platforms have reshaped the conditions under which psychotherapy is practiced and accessed.

We also discuss her writing and research, including PsiAN’s national survey work on public attitudes toward therapy (“Going Beneath the Surface: What People Want from Therapy”) and a follow-up paper published in 2025 (“The Therapy World Has Changed: Where are We Now?”). We talk about her 2025 article in The American Psychoanalyst, “Corporations in the Consulting Room: What do we stand for, and what stands in our way?” and her edited volume, Advancing Psychotherapy for the Next Generation: Humanizing Mental Health Policy and Practice.

Linda also recounts some of the advocacy work she’s done and the adversity PsiAN has faced, including being sued by a major therapy platform, as well as how institutional alliances across our professional organizations are reshaping the contemporary mental health marketplace.

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

Justin Karter: To get us started, can you tell us a little bit about the Psychotherapy Action Network? What is the Network trying to change in the public consciousness about psychotherapy?

Michaels: We really want to make psychotherapy more accessible, more understandable, more real, to take away the myths and the mystique.

When we looked at the public narratives and understanding of therapy, compared to what we knew as psychotherapists, there were so many disconnects. The messages people are exposed to, whether from insurance companies, the media, movies, online ads, apps, world-famous spokespeople, or even academia and researchers, were just oversimplified. People really deserve to know, and to be able to access and afford, the right kind of care they individually need.

Even though stigma around therapy and mental health problems has been declining for some time, which is such good news, much of what people are exposed to still is not really the full story about therapy. More people are open to talking about therapy and going to therapy. Celebrities and athletes talk about it. It is obviously a huge topic on social media, and we have these TikTok therapists “giving advice” all over the place. But the sad irony is that a lot of what we are exposed to is really self-help tips or tools that have been repackaged or repositioned as therapy, and people deserve better.

People need help, and they deserve to understand what is available to them, what is really out there, and how they can find the help they need.

Karter: What would you say is the picture, the brief sketch of what therapy is that the public is getting? What is the idea of therapy that’s being promoted?

Michaels: I think the idea of therapy that is being promoted goes something like this: therapy should be brief and super fast. It should mainly focus on reducing and managing symptoms. That could include trouble sleeping, changes in your appetite, or low mood. It should just eliminate those symptoms, and then you are done.

One form of therapy, cognitive behavioral therapy, is held up as the “gold” standard.

When it comes to treatment more broadly, beyond therapy, I would say the message, even from pharmaceutical companies, is that you have to buy these newer medications. They are way, way better than the older stuff we used to sell.

I would also say that new forms of treatment, and I am doing air quotes here, everyone, like text therapy and AI therapy, are treated as totally legitimate. Things like coaching, self-help tips, or tools are presented as equivalent to therapy. In a nutshell, that is the picture, the message that is out there and reinforced in many different forms.

Each of those points is not substantiated by the evidence, does not align with what people actually want, and does not really match what I think a whole lot of therapists are actually doing day-to-day in their offices, regardless of how they would describe their own approach.

Karter: It is a striking picture of what it means to be human. It is mechanistic, as if we are a bundle of thoughts and motivations that sometimes go a little haywire, preventing us from working, being productive, or functioning efficiently, and as if some exchange of language with another human being or a bot can iron out the defect and get us back on our way. That seems to be the underlying assumption of that model. As a seasoned therapist, what screams out to you when you hear that? What is missing from that picture?

Michaels: Our humanity.

Understanding ourselves is an age-old question. Poets and philosophers have wrestled with it for centuries, and everyone is curious about themselves to some extent. All the complexity and confusion, the vulnerability, even the shame, everything that makes us human, including our hopes and dreams for transformation and growth, is missing from this picture. It is a picture that is more easily packaged, more easily sold, and easier to make money from. Unfortunately, people are missing out because therapy and what it can offer are incredibly powerful.

Its healing potential lies in helping people heal from some of life’s worst wounds, and that takes time, work, and effort. It is not a quick fix. I wish it were, but it is not. I think people understand that intuitively. That certainly came out in our market research.

But that is a hard message to package and sell if you are a corporation trying to meet a quarterly earnings target. There are a lot of competing interests here. At the end of the day, what gets lost is the human in all of us.

Karter: You are uniquely positioned to speak to corporate logic from the perspective of a psychotherapist because of your own background. Can you share a little bit about your life before you entered the psychotherapy field, and how that has informed your response to these changes?

Michaels: It has been very useful. It is interesting to think about what came before psychotherapy, because before I entered psychotherapy, I was in business, but before I was in business, I was raised in a family shaped by psychiatry and psychoanalysis.

My father was a psychiatrist who practiced for many decades and only recently retired. My mother is an artist. That was a huge part of my upbringing, and I always thought I would follow in my father’s footsteps and go into psychiatry or psychology. But I got waylaid. I was confused, did not really know what I wanted, and had questions about who I was, like many young people. So I delayed answering those questions and went into the business world after college because it seemed interesting.

I worked in business for a while. I worked in Latin America and in Spanish with many different companies and cultures, studied in an international business program, and did a lot of market research. I was always trying to understand what makes people tick, which I really loved.

Of course, that work was in the service of giving corporations information they could use to sell more products or services. But the part that interested me most was the human connection, interviewing people and talking with them about their lives.

Through my own therapy, my work with an analyst to whom I owe a great deal, and a growing understanding of my career choices and what I had been avoiding through them, I found my way back. At the end of the day, I wanted to help people, not help companies make more money. So I began a psychology program at the young age of 39.

Karter: Then you reenter a field that was already familiar to you from childhood. What did you find? What had changed, or was changing? And what led to the founding of PsiAN?

Michaels: I remember sitting around the kitchen table listening to my dad talk about these new kinds of insurance plans that were being introduced, and how worried he was. He did not think they were a good idea.

At the time, he was talking about HMOs. They were brand new, and I did not really understand all the ins and outs of it. But the larger point is that for a long time, really for decades, there has been a tension between wanting to help people and the pressures of profitability, with insurance companies wanting something very different.

As for the beginning of the Psychotherapy Action Network, in 2017 we were very concerned that an entire family of therapies was being marginalized. These were therapies that really value and center the humanity and individuality of each person. Each person comes with their own identities, background, and culture. They are not a symptom. They are not a diagnosis. As you were saying earlier, these depth therapies are highly effective, evidence-based, and have been very helpful for many people.

There is also some evidence that they have particularly long-lasting results, which, of course, is what everyone wants at the end of the day. But these therapies take time. They take effort. In that way, they run against many of the short-term, profit-focused pressures we were talking about earlier.

They are also somewhat out of step with the current cultural zeitgeist, which wants a quick fix and something concrete or quantitative to measure. Many therapists felt misunderstood and marginalized. At the same time, we saw many people who were still struggling. The therapies and products being offered to them were not improving mental health outcomes, and suffering was still increasing. We thought something was really wrong with this picture.

The Psychotherapy Action Network was the brainchild of Nancy Burke and emerged out of a hastily organized conference in Chicago. It was very different from most psychology conferences. It was multidisciplinary. It included therapists, researchers, professors, one of our state senators, and a former lobbyist from the insurance industry who could speak to how that industry really operates. Bob Whitaker was, in fact, one of our keynote speakers. It brought many of the tensions and issues of the day into sharp focus.

I was also very angry. I saw a great deal of injustice and a great deal that could have been done to help people who were suffering, and it was not being done in the name of corporate profits.

I think we gave therapists a voice, a way to come together and feel some collective power. For the most part, therapists work independently and alone in their offices, one-on-one. Through PsiAN, many felt a sense of confidence and power for the first time in a long time. Since then, we have done a great deal.

We now have almost 7,000 members. More than 90 organizations have joined us. We established a formal board and an advisory board, among other things. I think we have done important work in standing up for our field and for the kinds of care people really deserve.

Karter: It is worth saying that there is a need for this organization because other professional organizations were not advocating for this form of therapy, which you call therapies of depth and relationship.

You also pointed out that there is a great deal of research evidence for these therapies of depth and relationship. Part of the public discourse, I think, is that you have these science-backed, short-term, manualized therapies that may be a little directive, not as warm and fuzzy, but will get the job done because they are empirical in some way. Then you have other nice-to-have therapies that may seem more meandering or less scientific. Could you push back on that narrative and tell us what the evidence is for these therapies of depth and relationship?

Michaels: There is a great deal of evidence for them. There are many forms of evidence and many kinds of research studies one can conduct, from an in-depth case report on a single person to randomized controlled trials comparing groups receiving different treatments.

The cognitive-behavioral family of therapies got on the research bandwagon early. They said, we really need to study what we are doing as a scientific endeavor, and we are going to do research, document it, and build an evidence base. That is a good thing. We should be studying these treatments and verifying whether they work, how they work, and why they work.

Because they got an early start, cognitive and behavioral therapies came to claim the mantle of being evidence-based. But that is a shallow account of the larger story. Even though there are more studies on cognitive behavioral therapy, there are also many studies on depth therapies. What matters is not just the number of studies, but the quality of the evidence and what it actually tells us.

If we look only at randomized controlled trials, which some researchers regard as the strongest form of evidence, though even that is debatable, both camps have substantial support. CBT has more than 1,000 randomized controlled trials, and psychodynamic therapies have more than 400. There is certainly a difference in those numbers, but both are substantial.

Having more studies does not mean the evidence is better or higher quality. It just means there is more of it. It does not tell us anything by itself about the results or about effectiveness for people, which is what we should care most about.

Because the cognitive and behavioral therapies got a head start in building a research base, they became more closely associated, both in academia and in the public mind, with the label “evidence-based therapy.” But at this point, all of these therapies are evidence-based. It would be better to accept that and move on to more important questions, because people are still suffering.

Karter: You made the point that therapies of depth and relationship do not fit the zeitgeist as well. They do not fit the logic of the quick fix. They do not fit the logic of maximizing efficiency. They also do not fit the image of the individual as fully agentic, solely responsible for every decision, and disconnected from others and culture.

It may be that part of what makes these therapies effective is that they create a space outside that logic, which can itself be damaging to live within all the time.

But I wonder if you could talk about what you see as the ingredients of good therapy. What is it about these approaches, and even about some of the shorter-term manualized approaches, that actually helps shift something for people or make change possible?

Michaels: We honed in on depth, insight, and relationship because we believed these were the core elements across many different therapies, across many schools, and families of treatment. These were the ingredients that seemed most important. And yes, I think your point is a very true one. Part of what makes them so important may be that they offer people a space outside many of the ways our culture is currently organized.

When we talk about depth, which I think is so useful to people, we are talking about going beneath surface-level thoughts, feelings, and behaviors, which often get labeled as symptoms, in order to understand what is underneath them, what is driving them, and why this is happening for this particular person in this particular moment of their life. It is not just about the what. It is about the why.

Insight, or self-reflection, is another key part of effective therapy. It helps people recognize patterns they may not have been aware of until they sit down with a therapist and begin to see the links. They may realize, for example, that something feels familiar from childhood, or that the same dynamic keeps showing up in each job or relationship. Therapy helps people become aware of those patterns and, importantly, of their own role in them.

It is not just that things are happening to them. It is also that they are participating in patterns they may not yet understand. Once life begins to come into view in that way, it becomes more a matter of choice. People can begin to make different choices when they understand what they are doing.

All of this happens in the context of the relationship. The relationship with the therapist is where people can ideally feel that they will not be judged or shamed for what they want to talk about.

A supportive, empathic, helpful relationship can guide someone through difficult self-reflection and self-questioning. That is what can help repair past wounds and traumas and lay the foundation for more satisfying relationships, both with other people and, perhaps most importantly, with oneself. Those are the key ingredients across many different forms of therapy.

In our market research studies, when we asked people what they wanted from therapy, they told us, in so many words, depth, insight, and relationship.

Karter: You have now conducted and published two large surveys for the Psychotherapy Action Network. Could you tell us a little about the 2021 and 2025 studies, what you found, and what people are looking for in therapy?

Michaels: Drawing on my market research background, I worked with my friend and colleague Santiago Delboy, who had a remarkably similar career path. He also came out of consulting and market research and is now a psychotherapist. We looked at the therapy landscape and saw a great deal of misunderstanding. We wanted to understand what people actually want, what they believe therapy is, and how to close the gap between public perception and what therapy can really offer. We knew how to approach that question: through market research, and deep market research in particular.

In our 2021 study, we began with a qualitative phase, conducting one-on-one interviews with 46 people from around the country. These open-ended interviews allowed people to speak freely. There was an interview guide, of course, but the goal was to talk openly and generate hypotheses that we could later test quantitatively.

We then moved to a quantitative phase and hired a research firm to conduct it so that we could ensure an unbiased sample. We wanted a sample of more than 1,500 people from across the country that would be representative of the U.S. population. We weighted the respondents by age, gender, income, geographic region, and racial-ethnic identification so that the sample would reflect the country as a whole.

We asked all kinds of questions. Where do mental health problems come from? What helps? What do people want from therapy?

What we found was striking. People said they wanted depth. They wanted to get to the root. They wanted more self-awareness and more self-understanding. They understood that the problems they were dealing with had taken time to form and take shape in their lives, and they knew it would take time to understand and unwind them and then figure out how to move forward.

Symptom relief was not nearly enough for most people. It was a good starting point, but they wanted more.

When we asked whether they would prefer something shorter that focused mainly on symptom relief, or a therapy that would help with symptoms and also get to the root, even if it took longer, 90 percent said, sign me up for the therapy that will help me get to the root. That was their primary interest.

Karter: Then you did a follow-up study. What changed? What led you to do it again so quickly?

Michaels: It was because of the pandemic.

During the pandemic, of course, there was an explosion of telehealth. Everyone went online. We wanted to know whether people’s attitudes had changed, and we also wanted to ask more questions about how therapy was being delivered, online versus in person. AI was beginning to emerge, along with chatbots, apps, BetterHelp, Talkspace, and other technological developments. There was a great deal of new terrain to study.

What we found in the post-pandemic period was that people still wanted the same things. They still wanted depth. They still understood that therapy is about the relationship.

We also wanted to explore more carefully what people meant by “getting to the root.” What did that phrase actually mean to them? We found that it meant making connections between past and present, connecting the dots in their lives, understanding where certain tendencies or influences were coming from, and seeing what was driving repeating patterns.

We also found that, despite the pandemic and the expansion of teletherapy, people still really wanted to meet in person. They wanted to meet face-to-face and have that relationship with their therapist.

They were also very concerned about privacy. As more and more of therapy moves online and into digital formats, where data can be recorded, transcribed, and captured, people are increasingly concerned about what happens to that information and about their privacy.

Karter: It strikes me that while people’s wants have not changed, the barriers to accessing what they want have probably multiplied since the pandemic.

Before the pandemic, there was already a familiar set of obstacles. Training systems were producing and prioritizing researchers, and research that fit more cleanly with manualized approaches to therapy. The people training future therapists were more likely to practice or promote certain short-term therapies, which meant fewer therapists were being trained in the depth-and-relationship model you are describing.

Professional bodies like the APA were pushing to make psychology into a hard science and involving insurance companies in clinical training guidelines. Insurance companies themselves were restricting what therapists could do, how long they could see patients, and how they had to justify treatment. And of course, there was the biomedical model coming in through the DSM.

So there were already many barriers making this form of therapy less accessible, and they had been growing for some time. There is a literature on all of this, and you cover it in detail in your book, Advancing Psychotherapy for the Next Generation.

But then, during the pandemic, something happened. All of a sudden, there was an infusion of new ways of thinking about therapy, driven by new business models that seemed to pull the public further away from therapies of depth and relationship. Could you talk about what happened during the pandemic, what these new barriers are, and what new systems are making it harder and harder to find therapies of depth and relationship?

Michaels: You just summarized everything that’s been going on in the field for so long.

More recently, though, a few things have shifted. During the pandemic, and even more so afterward, there was a major move online. That brought with it a flood of apps, new options, and new kinds of companies looking at the field and seeing an opportunity to make money.

Our research showed that people are really struggling financially. In our second study, conducted after the pandemic, we asked people about the main stressors in their lives. The top issue was difficulty making ends meet. This was not about cutting back on luxuries. People were struggling at the level of basic financial survival, and that added tremendous stress to their lives.

At the same time, there were the old supply-and-demand dynamics. For a long time, stigma had been decreasing, and more people were becoming open to the idea of therapy. Demand had been building steadily. The pandemic accelerated that even further, since so many people were openly talking about stress, anxiety, and depression.

The supply of therapists remained relatively fixed, however. We are not training nearly enough new therapists to meet the growing demand. When you have that kind of imbalance, it draws in people who see a business opportunity. If insurance companies, state governments, and the federal government are all going to pay for treatment, then there is money to be made.

So we suddenly had a whole new set of entrants into the field: private equity, Silicon Valley, venture capital, and technology companies. These were people who had never previously shown any interest in mental health. They began launching apps, introducing new products, and pushing treatment online. They were applying the same business models they had used in other industries, even though here we are talking about trauma, addiction, abuse, and people’s lives.

Even the shift to online therapy, or teletherapy, was framed as if it would be the great equalizer. The promise was that it would finally bring therapy to rural communities, marginalized communities, and under-resourced people who could not travel to a therapist’s office or afford the usual model of care. It was supposed to greatly expand access.

But the pandemic gave us a chance to study that assumption. What we found was that the people who could already afford therapy before the pandemic were largely the same people getting therapy during and after it. They simply gained another option. They could now choose whether to meet online or go into the therapist’s office. It became a matter of convenience. It did not significantly expand access for marginalized, under-resourced, or rural communities.

That is the tragic part. We really need to think much more seriously about how to solve the access problem, because simply moving everything online is not going to do it.

Karter: It is a little like hijacking or co-opting the language of social justice around access in order to convince the field to degrade what it offers in certain ways. We are told that we need text-based therapy, or these lower-paid, short-term models, so that more people can access help. That makes it hard to say, in the middle of that argument, “hey, we are destroying the very thing we are supposedly trying to make more accessible.” It does seem as if the field has been caught in that vice.

Michaels: When these new companies, the technology firms and venture capital investors, talk about access, how are they measuring it? They are looking at the number of app downloads. They are looking at “engagement,” which is really just a euphemism for how long someone uses the app or product. And of course, these products are specifically designed to keep people online and keep them using the platform.

But that is not actual engagement with another human being. It is not a connection or a relationship. It is simply a measure of how long someone has used the product and, by extension, how many ads they have been exposed to.

So yes, they are co-opting the language of access. But what they are really talking about is something superficial and not especially meaningful. It may be good for the companies’ bottom lines, but it is not good for anyone’s mental health.

Karter: In your piece in The American Psychoanalyst last year, you laid out the disconnect between the animating values of the companies coming into this space to offer “mental health care” and the animating values of therapies of depth and relationship. Can you draw that distinction for us? How are these things fundamentally misaligned?

Michaels: If we think about the technology companies, venture capital firms, and private equity groups that are launching new mental health products left and right these days, and we think about their values and mission statements, I am sure everyone has heard some version of the “disrupt, move fast, and break things” approach. Bigger is better. The goal is massive numbers of downloads, as if that tells us anything, and “optimizing the user experience.” What does that mean? It means making it easy to click buttons, easy to download, and measuring everything in terms of customers. We have five-star customer ratings. That tells us absolutely nothing about the quality of the service, privacy, or healing. It just tells us whether the app is functional.

These companies are really focused on hoovering up data, the client’s data and the therapist’s data, and using it for advertising, product development, and customer retention. Privacy and confidentiality, which are the bedrock of therapy, are not really on their radar. Respecting another person’s subjectivity and privacy is not the point. The point is how much data they can gather so they can train their models and advertise to you.

Their goals are also fundamentally financial. Usually, within five to seven years, they want to sell their investments, get out, and move on. They are not in it for the long term. Therapists are. A therapist is there for the long term or the short term, whatever is needed, whatever the person needs.

Depth therapists, in particular, are looking at each person as a complex individual who may have disparate, contradictory, or conflicting parts of themselves. Everyone comes with their own history, and that history matters. In that sense, these are two completely different worlds coming together.

Unfortunately, the corporate world has far more money and far greater access to resources, and that can easily lead to monopolization. BetterHelp, for example, spent $100 million on podcast advertising a few years ago. You would hear those ads at the beginning, middle, and end of a podcast.

Insurance companies spend $20 billion a year lobbying Congress. These numbers are astronomical and completely beyond anything therapists could hope to match. In terms of power and messaging, there is simply no comparison.

Karter: It is a bit of a David and Goliath story: the Psychotherapy Action Network versus Silicon Valley and the insurance companies aligned around this new model. You threw your rocks, and you got hit with the club too.

Can you tell us what happened in 2019, when you began questioning whether some of these products were even therapy at all, and what the response revealed?

Michaels: It really was a David and Goliath story. Ironically, it began with an advertisement. In 2018, people started asking whether a Talkspace ad campaign was somehow connected to the Psychotherapy Action Network. We looked into it and realized this company was promoting a texting-based model of “therapy” that raised serious concerns for us about privacy, confidentiality, and whether it should even be considered therapy in any meaningful sense.

We also learned that the American Psychological Association was accepting Talkspace advertising in its journals and at its conferences. That struck us as deeply troubling. So we wrote to the APA laying out our concerns. Shortly afterward, Talkspace responded with legal threats. We defended our right to raise those concerns, and to the APA’s credit, it ended its advertising relationship with the company.

A year later, however, Talkspace entered into an arrangement with United Behavioral Health, which meant that people seeking therapy through United could now be directed toward this product. We were even more concerned, not only because of the privacy issues, but because there was still no real evidence base showing that this form of texting was a safe or effective treatment. So we wrote to the APA again.

The same day we sent that letter, we heard from Talkspace’s lawyers. Soon after, they sued us for defamation and libel, seeking $40 million in damages. They sued not only the Psychotherapy Action Network, but the three co-founders personally. It was terrifying.

Eventually, Arnold & Porter agreed to defend us on First Amendment grounds. In the course of that case, we learned something revealing: Talkspace was furious not simply because we had criticized them, but because our earlier letters had led the APA to cancel a partnership agreement with the company. That also explained how their lawyers had gotten hold of our letter so quickly. There were much closer ties there than we had realized.

In the end, the case was dismissed, and Talkspace did not refile. But the episode revealed just how much corporate influence had already entered the field, including through institutions that are supposed to represent and protect psychologists. That, to me, was one of the most disturbing parts of the whole story.

Karter: In sending those letters, you may have unknowingly prevented these ads from appearing in the journals and on the website of the largest professional organization in psychology. You may also have helped stop an organization ostensibly devoted to defending psychotherapy from effectively selling out the profession to this new model.

Michaels: It was a very sad state of affairs. It showed us that even though we talk about healing, helping people, and educating the next generation of therapists, a great deal of what is happening at the highest levels of the field is really about business, and about a slippery slope of decisions and compromises in which doing the right thing gets sacrificed to money and power.

Karter: Score one for the little guy there, but the avalanche of new digital products has not stopped, and we continue to be buried under it. The Psychotherapy Action Network has not been pulling punches. Even after being sued, you have stayed in the fight.

I have been following much of the work you have been doing to highlight the problems with these new products. Could you talk about what you see as the biggest encroachments on the psychotherapy space, and the things that people, including therapists like myself, may not realize about the systems we have been drawn into since the pandemic?

Michaels: One of the things I am most concerned about these days is a new kind of middleman called a practice management company. These companies are marketed to therapists, and when therapists sign up, their clients are pulled into the system as well. This is a relatively new trend, and probably around 80,000 therapists around the country have signed up with them.

These are middlemen inserted between the therapist and the insurance company. They say they will handle billing, marketing, and the electronic health record. They present themselves as a platform. But over time, the platform in the middle gains more power and takes more from both sides. That is what we are seeing now in the mental health landscape with these practice management companies.

Therapists who sign up with them give up a good deal of independence. They become contractors to these companies, in something like an Uber model. The company takes a percentage of each therapy session fee from the insurer and passes the rest on to the therapist. The pitch is that they will do all the administrative work, pay therapists reliably, and help them earn more than they would on their own because the company has more negotiating power with insurance companies.

We wanted to test those claims, so we did research with therapists, some who use these platforms and some who do not. About half said they were making more money. The other half said they were making the same or less. Many therapists did not understand how much they were being paid, how much the platform kept, or how the arrangement actually worked. That should not be a mystery.

There are also major concerns about patient privacy and data privacy, because these are technology companies, and technology companies live off data. One of these firms is currently being sued in a class action for sharing data directly with Google, which is also a major investor in the company. So we are talking about direct access to highly sensitive patient information, potentially being used for advertising purposes.

What I think surprises many therapists is who owns these platforms. They are backed by technology companies, venture capital, private equity, and insurance companies. The same insurance companies that therapists often experience as the bane of their existence are major investors in these platforms, and many therapists do not know that. In our research, when we asked whether therapists would continue using a platform if they knew an insurance company was a major investor or owner, 85 percent said no.

There are other warning signs too. Terms change after therapists sign up. Documentation requirements shift. Companies reach out directly to clients and collect information themselves, building their own databases of patient data.

And ultimately, many of these companies are trying to move toward a new payment model in which therapists are no longer paid by the session or by the hour, but in lump sums. This is now called value-based payment, but it is really a rebranded version of capitation. It sounds nicer, but it shifts more risk onto the individual therapist.

We have published a research report and guides on our website to help therapists navigate all of this. But this is the Orwellian Brave New World we’re dealing with.

Karter: As someone in private practice, and as someone who has long worked in this critical mental health space, the appeal was exactly what you described. Fighting with insurance companies over every payment and having to justify what I do in the language of standardized, manualized care really encroaches on the therapy itself. I have to document in very specific ways just to make sure the client can use their insurance, and I can be reimbursed.

And if you are fighting that battle all the time, it also takes away from your ability to actually see patients. So when something comes along and says, “You can submit a minimal note, and we’ll do the fighting for you,” that is obviously appealing.

Private practitioners are all negotiating individually with insurance companies, and the insurers know they have the upper hand because they do not care if any one of us leaves the panel. But if we were organized, maybe we could ask for more and begin to shift some of these conditions. That was the promise.

Then, to find out, through your work, that they are not fighting the insurance companies but are, in many cases, the insurance companies, is an incredible betrayal. We are being pulled into a system where, ultimately, the insurers will get what they want, which is to say: this is how much we can afford to spend per patient, now you figure it out. That is likely to shorten and radically change therapy in all kinds of ways. It is remarkable to realize how many of us have been led astray by these companies.

Michaels: I think if these companies really disclosed who they were up front and said, “We’re backed by insurance companies. Do you, as a therapist, want to become a contractor to an entity owned by the insurance industry?” a lot of people would have said, I need to think about that.

But as you said, it sounds like a useful tool and a good way to run a practice. Therapists are usually not business people. We are trying to help people, not get buried in administrative work. So when something comes along that seems to help with that, of course people are appreciative. I do think many early-career therapists now assume this is just how you start a practice. They are not aware of all the details or of the shifting ground underneath them.

What I would much rather see is a legislative solution for all therapists, not a private platform that helps only the people who sign up and become dependent on it. The real problem is the insurance industry. At the end of the day, we have to call it what it is: insurance companies discriminate against mental health. Therapists are paid less than other clinicians, burdened with extra paperwork, and forced to justify treatment in ways other providers often are not. It is just not right.

So it is understandable that many therapists move toward self-pay, even though that makes care more expensive and less accessible. But that is not a therapist problem. It is an insurance industry problem, and it calls for legislative and regulatory action.

The last thing I want to say is that the burdens of this whole system get projected onto the individual therapist and the patient. Therapists feel bad for participating in these platforms, even when they were not given full and transparent information. Clients think, “I’m using this app, I’m not getting better, what is wrong with me?” But the problem is not them. It is the system. It is the corporate entities in the middle. The problem gets displaced from its real source: the company.

Karter: Before we sign off, is there anything else you want to say, or anything coming up from the Psychotherapy Action Network that you would like people to know about?

Michaels: Everything we have talked about today is something we have tried to take action on through petitions, books, articles, letters to policymakers, and guides for therapists, so I would encourage people to take a look at our work.

We are also about to launch a new public-facing campaign. We have done a great deal for therapists, but this will be our first effort to speak directly to the public. As we said at the start of this conversation, we want to help demystify therapy. We also want to respond to one of the public’s biggest concerns, which is affordability.

So we have built a database of low-cost clinics around the country that offer care aligned with the principles of depth and relationship. I think it is the first directory of its kind. The care is affordable, and it reflects the kind of therapy people in our research said they want.

We are going to make that directory available through a public campaign so people know it exists and can use it if it seems helpful. I hope people will keep an eye out for it, share it, and give us feedback. Ideally, it will help fill some of these gaps and connect people with the kind of care they are actually looking for.

 

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