We’re not in Kansas anymore
I want to tell you a story about an online therapy platform TextSpace. Last week, despite a history of legal action in the USA taken by the Federal Trade Commission and repeated consumer data breaches they announced the formation of a new state wide service for teenagers, let’s call it TeenTextSpace.
Teens experiencing distress can message a ‘therapist’ any time through an app plus have one 30 minute virtual session each month. Therapy for all, no need to wait, on demand 24/7, actual words and emojis.
The therapy unicorn that is being offered here has a compelling business case. No more waiting lists, no more diagnosis or complex co-morbidity just consumers consuming therapy on an app. No obligation to concede the facts of life –that we are not as it happens wizards with all seeing powers but dependent on actual people in real life since nothing of the deep and meaningful ever comes simply on demand.
When patients became clients somewhere around 2008 when the IAPT juggernaut rolled into town it was worrying enough, but suddenly courtesy of the uberisation of therapy we are now just consumers and entrepreneurs on the attention market, trading bad reviews and magic solutions.
We could talk generally but let’s talk specifically about the emerging on-demand therapy business. In my writing I use no names because once we enter the Therapeutic Wild West we have to be careful about anti-trust laws and navigating monopoly capitalism. And the consequences of saying that out loud, from anti-trust litigation to blacklisting, represents the new occupational risk for therapists. Hence the no-naming policy of my book UberTherapy and why I never get invited to dinner parties.
This American story of neoliberal economics and comparative employment relations gets little traction here in the UK which is an own goal if you’re interested in therapy on either side of the consumption model. So I want to tell you a story, based on an interview between an American Woman, Dorothy, and a British Woman, called Lion. A story about a group of progressive psychotherapists founded by Dorothy who were sued in 2018 by TextSpace for $40million for asking a simple question.
Dorothy: It’s a funny story beginning in 2018. There was the very first advertisement that came out from TextSpace that featured an Olympic runner Micky Peeps. It was a beautiful ad. It was compelling. It was visually gorgeous. It was emotional. And he's in the middle of an empty track and he says, you know, I've had these mental health problems and I got help and I want therapy for all.
Somebody wrote to me on a therapists’ listserve what a beautiful ad from my organisation - and we're like, what are you talking about? They thought it just seemed like a public service announcement for therapy by my organisation. And so that got us interested in looking into TextSpace because when they say therapy for all, what do they mean?
And Micky Peeps had spoken publicly before he had some substance abuse problems, and that he went to intensive inpatient treatment. He did not use an app on his phone. I mean, he went to the other far extreme of this intensive inpatient programme and we said, wait a minute, this is how is he advertising for this company? What's going on?
So we wrote a letter to The Therapy Association that regulates therapy and outlined all of our concerns to find out that TTA was accepting advertising revenue from TextSpace and then it started to get dark. We got two letters back, one of them was a cease and desist letter from TextSpace’s lawyers and the second from the TTA who said they’d terminated their ‘partnership’ which nobody had ever heard of with TextSpace. Our lawyers sent back a 10 page letter to TextSpace and outlined all the reasons why we were allowed to have free speech and say our opinions and then that was the end of that. A couple of months later at TTA’s annual meeting the sponsors on the name tags was MuchBetterHelp – easy come, easy go.
Fast forward a year, 2019 and there’s a large class action lawsuit against one of the big health insurers here that they lost just at the time they enter into talks with TextSpace. This was a huge victory for us in that this insurer had been found letting its finance department - not its clinical team - make clinical decisions about treatment coverage.
But the same insurance company is partnered with one of these therapy apps and so if you want mental healthcare, you go online and look on your insurance company plan and see, OK, what are my mental healthcare options? The first thing that pops up is download TextSpace.
So we wrote a second letter of concern to TTA and within a day, we got a cease and desist letter from TextSpace lawyers and within three weeks they filed a lawsuit against us as an organisation and us as the three American Women founders for defamation, libel and $40 million in punitive damages for using the word ‘fraud’ in the letter. Our lawyers just resigned. We're like ohh ****. And we started calling literally just Googling and calling lawyers all over the country who specialised in First Amendment free speech issues.
TextSpace filed the lawsuit in Kansas precisely because it’s the only place in the whole US where you cannot immediately say that's frivolous and the case gets thrown out. All you have to do is prove to the judge that there’s a link to Kansas, which turned out to be a property owned by one of our co-founders bought for her son who was working in Kansas. They investigated us and this was the link they found. I mean, it was just ridiculous. To bring out these legal arguments, sue us in a jurisdiction that is totally unwarranted for $40 million, completely mind blowing and if we didn't get this pro bono lawyer sympathising with us and getting the case thrown out it would have been awful. I mean, it's still awful.
Lion: So how has this gone down in history in your world?
Dorothy: So for a long time, actually, we didn't talk about it at all. We were terrified. We were traumatised. There was a lot of animosity frankly with the TTA. We kept trying to talk to them, try to change the narrative around evidence based CBT, you know the script. Recently we’ve been more collaborative about the future of therapy but it’s been incredibly painful and stressful. I had to keep doing my day job while all of this was going on. And to be there and to help my patients while I had an extremely terrifying personal experience going on. It's very, very lonely, because the very first thing the lawyers tell you when you get sued is don't talk to anyone. It's a lot to bear.
Lion: It amazes me these companies have come so far and so fast when they're offering us nothing.
Dorothy: Yeah, but it works for the investors. I mean that's what it is. And the same thing with Uber, I mean that it's the same thing. You know, there was an industry that was just functional and had lots of independent small one person, businesses essentially cab drivers or therapists, whatever, and a whole bunch of money that investors want to invest somewhere and build a company, make money, sell the company and move on. So I think from that perspective, it works for them. But I will say, I think it's a David vs. Goliath story because TextSpace went public after this and their stock price was like $11.00 or so a share and now they're trading for less than a dollar connected to the selling of data by online therapy platforms investigated by the Federal Trade Commission that oversees advertising. Advertising is ubiquitous, all over the radio and inundated online and lots of celebrity spokespeople. Athletes and celebrities advertising just like any other consumer product. Lots of awareness subsequently about consumer rights and legal responsibilities.
Lion: There’s a two tier system that’s emerging in a different way here in the UK – often the opening gambit from journalists here that “we’ve spoken to people whose therapists are rubbish”. I have a view politically why we’re demeaning therapists but in the UK its certainly true that in the profession there’s huge snobbery and avoidance of talking about what’s happening outside private practice. Easy to look away or look down on other people in the platform therapy sector, denigrating the therapist and not seeing it as a systemic problem.
Dorothy: When in reality if you work for an App you’re on McDonalds wages. Literally. They also then have to take on humongous caseloads of clients in order to be able to make a decent amount of money, so that is why then I think you get so many stories of my therapist ghosted me and didn't show up for the session or didn't remember who I was. Some of these therapists, in order to make money they have caseloads of 60-70-80 clients. I think it's easy and lazy to blame the therapist.
Lion: But you see we have this long tradition of evidence based policy in the UK and yet the whole evidence of recovery has been corrupted. Numbers of patients seen and that kind of gaming and performance data because there's a whole industry of research that provides the evidence that the policymakers want to see. And in the meantime, keep us busy biting chunks out of each other blaming the therapist.
Dorothy: Well, that’s the story of Therapy.
Far from the fantasy of the great men and Cassandras of tech saving us all from the Big Data Daddy in the sky, the reality of what we’re dealing with in the future of therapy is monopoly capitalism. Big digital multinationals, hoovering up the data and uberizing the professions, slipping through regulatory loop holes on the back of political corruption. As therapists become just clickworkers, quickly and invisibly as their professional bodies and institutions implode from neglect and lack of governance we all fail to organize against what happens next.
As we are all silenced by the attack on freedom of speech and academic freedoms. As we allow yet another inquiry into governance failures and corruption not to change a thing.
Much of my 2023 was spent not-writing-my-book instead talking to journalists about digital therapy as the AI interest exploded and topics like mental health and worker rights that used to clear a room, raised genuine public curiosity about the black box of therapy. One of these conversations was with a team producing a documentary for Channel 4 about an online therapy platform, let’s call it MuchBetterHelp. A team of young women, we talked a lot over several months about the programme and how to approach it without getting sued or falling into the trap of blaming bad therapy on bad therapists rather than the more complex storyline about platformisation, low wages, work intensification and burnout.
As you would hope with the next generation of thinkers, they ignored everything I advised and did a programme about a company from the perspective of new therapy consumers. This inevitably runs the risk that bad therapists are regulated by public exposure but in the absence of institutions that can govern the digital therapy business I felt genuine hope watching the critical clarity of the young people going on the record about the damage that is being done.
It is these consumers who are right now challenging a solution focused business model, minus the solutions. And so this is a story about young people who will take the greatest hit and the greatest social cost of on-demand care. They are also the ones most likely to challenge it.
To watch a Channel 4 Documentary about online therapy platforms go here