Fast Company | Ruth Reader
In 2019, if you’re not texting your therapist or FaceTiming your therapist, you’re probably tweeting about your therapist. The stigma around therapy hasn’t entirely dissipated, but more and more people think it’s okay to seek help.
Several startups have emerged in the last few years to connect this disarmed population with mental health services. And yet, more than half of people who would like to see a therapist or psychiatrist aren’t able to, according to the National Council for Behavioral Health. The chase for greater mental-health accessibility has led to a rise in digital therapy apps, such as Talkspace, Moodnotes, Clementine, and Maven Clinic, that let you get help from a remote therapist.
But some clinicians are hesitant to lean into a purely online practice. “In fact, psychologists seem to spontaneously adopt a negative attitude toward this kind of service because, in their view, videoconferencing is likely to compromise the therapist’s warmth, sensitivity, empathy, and understanding,” according to a 2010 study on the use of telehealth services to treat post-traumatic stress disorder. Amid this telehealth trend, a few startups are pushing to update the full in-person experience.
Two Chairs, a mental health retail brand, is trying to upend the way that people go to therapists using technology to match patients to onsite clinicians. The startup has five clinics in San Francisco, with a new one coming to San Jose, and it recently received $21 million in funding from investors. Another company, Alma, raised $8 million in July for its coworking space for therapists. There are still others, including Kip, which combines in-person and in-app therapy, and Octave, which introduces clients to its roster of clinicians and coaches.
Mental health apps have gained popularity in part because they’re available to anyone with a reliable internet connection. They’re also typically a lot cheaper than traditional therapy. Talkspace, for example, offers plans ranging from $65 to $99 per week. Studies suggest that video chatting with a therapist is just as effective as being in the room with one. Still, critics are concerned that therapists are not yet well trained on how to conduct sessions remotely or how to handle an emergency situation from afar.
Some practitioners just prefer working in-person. They believe meeting face-to-face is the way to foster the best patient-therapist alliance, which some consider the strongest predictor of good outcomes. “We’re finding that relationships are best formed in person,” says Alex Katz, CEO of Two Chairs. The hurdle to getting on the couch tends to be price.
Typical in-room therapy can cost anywhere from $150 to $400 per session. Two Chairs and Kip charge $180 per session, though the latter submits insurance claims for reimbursement on behalf of its patients. Two Chairs also does group therapy sessions for $50 per person. Octave starts at $180 per session, but goes as high as $300. At Alma, practitioners set their own pricing, and some of it is on a sliding-scale basis.
All these startups have glossy offices with midcentury furniture and walls painted soothing earth and jewel tones. In addition to sprucing up the aesthetic of the therapy office, they are hoping to improve upon a good existing service. What they think needs tinkering differs slightly across brands, but they agree that the overall process of getting to a quality therapist is what needs fixing.
Two Chairs has designed matching technology to solve that nagging problem of how to find a therapist in the first place. Traditionally, you’d have to go through the daunting process of asking friends for recommendations or Googling and rifling through long insurer-provided lists of in-network therapists. Then, of course, you have to try them out, and if they’re not a fit, reignite the search. Two Chairs aims to skip past that trial and error.
“We’re finding in practice things like ethnicity, religion, age, someone’s lived experiences can all contribute to that sense of trust and therefore fit,” says Katz. Two Chairs takes information about who you are, the problem you’re looking to address, and your personal preferences, and matches you to a provider with a relevant lived experience and appropriate therapeutic background. For example, a client might be looking for someone who is familiar with Jewish family systems and can also treat for an eating disorder or depression. Two Chairs guides them to a matching therapist.
Octave and Kip also recommend prospective clients to specific clinicians, but both are more focused on defining what constitutes quality. They deal exclusively in evidenced-based therapies such as cognitive behavioral therapy, and they quantify progress and outcomes for clients.
Each company wants to ensure therapists are doing good work. Traditionally, in the U.S., the world of psychology is deeply fragmented. There is no comprehensive index where psychologists, psychiatrists, hypnotists, and social workers are listed by their degree, experience, expertise, healthcare coverage, and real-time availability. ZocDoc, Psychology Today, the American Psychological Association, and even Yelp do this to a certain extent, though these listings are not always up to date. And reviews aren’t the best barometer to gauge how well a therapist will work for you.
Two Chairs surveys all of its patients at the beginning and end of a course of treatment. This allows the company to know whether therapists are actually delivering value to clients. Although this approach is not well utilized in the U.S., it’s become quite common in the U.K. over the last decade. It emerged as a way to understand which therapies were proving to be most effective and therefore justified investment from the National Health Service. It also serves patients to know how effective their practitioner has been with past clients. For the moment, Two Chairs is keeping its success rates internal.
Alma may have the most novel approach to in-room therapy. Rather than addressing consumer problems directly, Alma is a workspace and community aimed at supporting individual therapists. Founded by physician Harry Ritter, who developed the way clients accessed care through insurer Oscar Health, Alma has been dubbed coworking for therapy, though that’s a misnomer. Alma is a digital platform that can provide therapists with a physical workspace in New York, but it’s also a community where therapists can learn about professional events, talk, and share knowledge. Therapists can join without needing to use the space.
“I wanted to make sure we created an ecosystem where they can get access to data and tools and resources and learning opportunities to evolve and be better at what they did,” says Ritter. “But I didn’t want to be overly paternalistic about the way that things needed to evolve.” The emphasis is on fostering discussion among industry experts.
Notably, Alma does not take on the task of designating the right therapist based on expert opinion and algorithms. Instead, on the company’s website, a prospective client can search for a member practitioner based on degree, services, price, and specialties. Alma, like Octave, also posts clinician bios with information about the types of therapy they practice, like cognitive behavioral therapy, psychiatry, or hypnosis. Rather than prescribing a certain therapist, Alma lets patients choose.
All of these brand-name practices may help connect patients and therapists—but that’s only if people can afford to go to therapy in the first place. Two Chair’s Katz likes to cite the well-traveled statistic that more than half of people with a mental illness do not get care. But the Two Chairs approach to lowering that percentage fails to comprehensively address the reasons why so many people go untreated.
According to data aggregated from the National Survey on Drug Use and Health between 2008 and 2014, the top reason people diagnosed with depression don’t get mental health care (47.7%) is that they simply can’t afford it. That reason ranks far above other factors such as insurance not covering it (6.5%). None of these startups begin to address the affordability issue, at least from a place of innovation. Finding a good therapist is an annoying process. But it’s an annoying process for a select group of people who either have the insurance or the cash on hand to cover a $180 per-session fee.
The second biggest reason? A little more than 22% of people believed they could handle the problems they were dealing with themselves. Another 15.2% thought they might be committed to a psychiatric facility or forced to take meds. These statistics don’t convey a need to find a good therapist so much as a need for transparency around what therapy is and what it can do. And while a portion of people haven’t sought help because they didn’t know where to go (16.7%), this is far from the largest reason people don’t seek care. At least in the U.S., that might be solved in part by greater education.
Katz touches on this idea in a personal essay he wrote for Fast Company about his partner’s difficulty navigating the mental health system and the reason for launching Two Chairs:
When she finally found a therapist who had availability, she discovered that it just felt off. She didn’t know what type of therapy she was looking for, but she knew this wasn’t it. Their time together felt forced and unproductive. She kept returning, week after week, because she thought it was her only option. After six months of no progress, she stopped. She was back to where she started.
“The problem from the people that I speak to is not that they have so many options and they are not sure how to choose between all of these fabulous options,” says Elaina Zendegui, a licensed clinical psychologist who has published on technology and psychotherapy. “Instead, it’s really that they are just trying to find someone.”
Especially in large cities, like New York and San Francisco, it can be difficult to just find an available clinician—not because they don’t exist, but because there isn’t a platform that does a good job of connecting the available supply to demand.
Zendegui sees promise in these new therapy companies if they can lower the barriers for trained therapists to practice. “You might have more people who are able to do a few hours a week, but don’t want to go full-time or are working part-time somewhere else,” she says. “Coworking spaces or hourly offices take out some of the risks of starting a practice.” If these newfangled therapeutic practices can ultimately bring out more therapists to answer the demand, “that’s great,” she says.