Brace yourself
Another mental health week. Behavioural jazz hands. Brace yourself.
I’m spending this mental health week writing UberTherapy about the business models and labour processes of the on-demand therapy sector. The book’s soundtrack turned out to be mainly Miley Cyrus but now that I’m at the point of going public I’m questioning the wisdom of going deep into pop to keep my spirits up over the last year. Given that you can be blacklisted for a tweet in the current academic freedom climate I have the sinking feeling that that too much positivity courtesy of Doctor (work it out) could end my career.
Actual thoughts about the new business of mental health, how very dare you.
One of the things that only became apparent to me late in the process of writing UberTherapy is how attrition is built in by design. That people not accessing support is a key component to the financial model that is emerging. How else to explain the sector wide reliance on the gamification of performance data to provide a return on investment (ROI). Whether its through losing people on hold in a therapy call centre or claiming recovery-minus-diagnosis based on attendance of two sessions the system is designed to evade complex problems rather than get stuck into them.
The games started in 2008 with the creation of the NHS’s Increased Access to Psychological Therapies (IAPT) programme – rebranded in 2023 to NHS Talking Therapies at precisely the point at which people are wondering if it’s not. Where we normalized the language of short term solution focused cognitive behavioural therapy (CBT) minus clinical diagnosis. Manualized it, used standardized self-reported questionnaires to lay claims to 50% recovery of clients when in reality at least 40% don’t make it to session two. By the time digital providers turned up, the scene was set for the fantastic claims of tens of thousands of therapists helping millions of customers to recover despite the emerging actual experience of anyone trying to get help online.
The gaming goes up a gear when you look at the more doubtful published results of digital therapy around access and inclusivity. Claims of 100s of percentage increases in access to care by hard to reach constituencies via AI-enabled chatbots charged with establishing a ‘judgement free’ framework. Lack of consciousness considered a good thing in unpacking the human condition.
Couldn’t make it up? Well we just did.
Probably the place where we see most clearly how UberTherapy is founded on a business model of attrition is business to business (B2B) platforms – in the UK related to the massive growth in employee assistance programmes (EAPs).
EAPs rely on a ‘cost-saving’ short term solution focused model of therapy where the ROI is based on a calculation of getting people back into work. The evidence base is wheeled out, despite consistent and continuous concerns about the grounds for claiming such high engagement and recovery. In the UK industry insiders used to estimate that only 1% of workers would access their EAP, potentially going up to 4% during Covid.
But me saying that based on interviews and talking to therapists over the last decade is of no use to you because the real data is not collected. It is attrition by design but if EAPs are actually measuring it, which is not hard to imagine given that there will be an algorithm for that, this information is protected by commercial interests. Academics don’t have access to commercial data nor can they get critical research published in the high ranking journals they need to protect their own research excellence metric scores. We go round and round reliant on anonymous and brave people and their trading standards lawyers to speak up for us to be able to think about what is happening to the therapy business.
Where’s my data for this? Locked up in an encrypted file in an executive account.
Psychoanalytic theory is full of literature that understands the attack on thinking that can take place in the consulting room. The dynamic processes of denial and projection are enlisted to disorientate and block actual thought. The threat of being misquoted combined with demands of an evidence base, state sponsored gaslighting and performative cultures of fear there’s not much in it for us to say what’s on our minds. This is important for us to understand that part of what happens in the growth of on-demand therapy is the intentional attack on our thinking about it. It is by this not-thinking and a ‘could-be-worse’ defense that we become complicit in our reaching the logical conclusion of unregulated platformization.
A few weeks ago I met Max Bazerman (Bazerman, 2023) who came to talk to a bunch of my students about complicity and ethical leadership. With the sweetness and humility of someone who has really thought about something on a deep level he spoke about pushing back unethical leadership by focusing on our own complicity in the systems that we engage with. Can’t crush actual evil but can do a lot to set regulatory parameters around organizational and financial models by not relying on the ‘la-la-la-I-can’t-hear-you’ survival strategy that many people in the therapy sector have relied on. It’s not because Max is a professor at Harvard Business School that I learned something from him, it was because he gently asked that throughout his talk we keep in mind where our complicity lies. And then proceeded to tell us about how he got caught up in a case of academic fraud in a paper he co-authored, by not paying attention to the data collection and the people he worked with. I don’t know this but I guess he had a lot of therapy to help him along his journey of self-reflection and to know the difference it makes when someone speaks openly with experience of working through their own complicity.
It is for this reason that we need to think about how bad it could get for us working in and consuming UberTherapy and to understand our complicity in that. This is not to take a pop at any platform therapist trying to earn money, to deny the benefits of teletherapy nor to deny that some platforms are better than others. Rather to help us navigate with some precision this new terrain in a way that’s likely to understand the platformization of therapy enough to protect both the therapist and the new consumers of therapy.
Whatever you do, do not cheer yourself up this week and instead listen to File on Four’s Investigating Employee Assistance Programmes on 12th March BBC Radio 4.