A young woman is lying in bed in the dark, curled up in the fetal position. In the background of the image, we see messages from friends concerned about her wellbeing flickering on her cell phone. She fends them off with laconic responses: “I’m busy,” or “I’m all right.” Then a message appears in an inviting glow: “I’m here to help.” The dark fades and gives way to a clear, soft light.
A few months ago, English-language ads like that began to flood my social media feed. They announced the debut in Israel of the BetterHelp app, which offers professional counseling that’s very different from the familiar version. Instead of regular face-to-face encounters, it provides online therapy via video conferencing, phone, real-time chatting and even email exchanges. Since its launch, seven years ago, the app has attracted more than a million users worldwide, and in April, under the auspices of the coronavirus pandemic, it entered the Israeli market as well.
As a therapist (who works with couples) myself, I was leery of the whole idea. My intuition told me that you can’t call this therapy per se. In my experience, messaging with patients between appointments is rarely able to convey the complexity a conversation elicits. An emoji blowing a kiss is not a successful substitute for real-time facial expressions and tone of voice.
But then I wondered why I was resisting the idea. Was it because of my professional experience? Or was it that I have a conservative approach that isn’t able to envision the therapy of the future?
I decided to give BetterHelp a try. I registered on the site – as a client.
First, I was asked to fill out a short, self-diagnostic questionnaire. What’s my economic situation? How’s the quality of my sleep? Do I suffer from depression, anxiety, chronic pain? Do I have suicidal thoughts or have I ever planned to put an end to my life? No biographical information was asked for. In fact, the app allows anonymity – other than their name, the therapist doesn’t know anything about the client.
Afterward I was asked to note what areas I would like to focus on in the therapy (relationship problems, addiction, depression, anxiety, life crises and so on). Finally, my credit card was debited for 580 shekels ($170) – the price for a month, all-inclusive, meaning up to four fulltime sessions and unlimited messaging. Now came the turn of the algorithm to find help for me within 24 hours.
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A message the next day announced that a match had been found. But it didn’t work for us, because the therapist didn’t want to use chat, only real-time conversations, by audio or video. I clicked a button to ask for a new therapist. The second one agreed to communicate by text messages, but barely had any time available. After a few unsuccessful attempts to make an appointment, I asked for another alternative.
An emoji blowing a kiss is not a successful substitute for real-time facial expressions and tone of voice.
I communicated by chat with the new therapist, and she replied once or twice a day. She went out of her way to make me feel comfortable, but her language was a bit elevated – it felt like we were involved in a formal exchange of letters. Also, because of the slow pace of correspondence between us, it took us a few days to get to a level of knowledge that would have been achieved within the first minutes of face-to-face therapy.
Another click of the button to request someone new. Three weeks after signing up for BetterHelp, I got a surprise. But more on that later.
Popular in the Emirates
Founded in 2013 by the Israeli-born entrepreneur Alon Matas, BetterHelp currently has a team of more than 11,000 therapists in the United States, who work with patients around the world, in a variety of different languages. According to Matas, 70 percent of the clients are women – about the same proportion as in traditional counseling. The company, and others like it (such as Talkspace, a New York-based firm that also offers online counseling) might prove attractive for people who can’t afford the high price of therapy in the private market, and for those who are too shy to seek in-person psychological help. According to Haesue Jo, who’s in charge of client user experience for BetterHelp in the United States, most of the site’s users are people who would otherwise have avoided counseling because of financial problems, difficulties accessing a therapist or fear of stigmatization.
Anonymous, online therapy also benefits people who are ashamed to seek help. In a Zoom interview from his office in the San Francisco Bay area, BetterHelp’s Matas says that while most of his company’s clients are from English-speaking countries, quite a few are from the United Arab Emirates, where mental health treatment is not so accepted. The easily facilitated connection, the anonymity and the distance allow people who have previously avoided counseling to avail themselves of professional help.
Israelis are generally receptive to therapy, but there’s another reason that makes this country an ideal market for the company: the cost. Despite the general openness to treatment, there is no insurance in Israel that covers its typically high costs – a situation that effectively rules out psychotherapy for many. In addition, Matas explains, Israel has almost no regulatory framework for online counseling.
Coinciding as it did with the coronavirus pandemic, the company’s debut in Israel stirred great interest in the community of psychotherapists. The lockdown and subsequent economic recession have prompted many clients to break off frontal therapy and led therapists to seek additional sources of income. The company currently works with several dozen Israeli therapists and has hundreds of users.
The therapists who were interviewed for this article requested anonymity, to avoid adversely affecting their own relationships with BetterHelp. All said that they had been briefly interviewed by phone and the conversation focused on their ability to operate the app technically; they were also asked to send in documentation of their licensing and accreditation. (The company works with licensed psychologists and social workers, who offer a variety of different therapeutic philosophies. None of them prescribe medication.) A subject that obviously occupied many of them was the company’s payment model.
How is text-messaging therapy paid for? The company determines the fee it pays therapists by counting words: 35 shekels ($10.25) for every 1,000 words of text – those of the therapist and client together. Because the company limits video and phone meetings to once a week, texting is one of the main ways therapists can increase their income. Which made me wonder about my own experience. One of the online therapists encouraged me to keep messaging her until we could meet. Did she do that because she thought it was right in terms of the therapy, or because it’s a way to earn more money?
My interviewees also told me that the company has a system whereby it rewards them for retaining patients. Those who keep a client for a month receive a bonus, and if the counseling continues for another three months, they get an additional bonus. Some of the therapists did not like the fact that this policy mixes monetary incentives with professional considerations.
“There were attempts to get management to revise its pricing method, so that therapists who believe in short-term treatment would not be affected,” one Israeli who works with the company related. “For me, that reflects a dissonance between the business dimension and the therapeutic side. The management replied that they would try to see what could be done.”
Payment for psychotherapists who work for BetterHelp via video conferencing or phone conversations is also lower than the standard in the private market. Israeli therapists who began working with the company in recent months say that their payment is between $25 and $50 for an hour of therapy (as compared with roughly $100-$150 for private sessions). In conversations in closed groups on Facebook, therapists working with BetterHelp say that, because of the problems they are having making a living, some prefer to treat their clients mainly via live chat or message exchanges, since that does not require the same investment.
Most of the site’s users are people who would otherwise have avoided counseling because of financial problems, difficulties accessing a therapist or fear of stigmatization.
The payment received also affects the caseload each therapist takes on. According to Matas, more than 25 percent of the therapists who work with BetterHelp in the U.S. choose it as their only place of employ. One of them told Haaretz that in closed online forums some of his colleagues said they take on a huge caseload, in some instances dozens of clients a week (whereas a standard wekkly caseload would be 15 to 25 sessions). On this point, Matas says that “the number of patients is not a significant factor; what counts is each patient’s needs and the therapist’s ability to invest in each patient.”
As a therapist, I found myself wondering whether it’s possible to treat so many people concurrently.
“I have mixed feelings about working with them,” a local therapist who works with BetterHelp says. “On the one hand, the company undoubtedly helped me during the lockdown in terms of the ability to earn a living, and I know that the clients who came to me would never have availed themselves of this service otherwise. So it made me very happy to have the possibility of helping these people. On the other hand, the [low] fee makes it impossible to keep up with it indefinitely.”
In addition, some of the interviewees maintain that some of the requests they receive are unsuitable for online counseling. “I was approached by people with complex traumas or serious personal disorders,” says one therapist, who decided to terminate his relationship with the company even before he began working with any patients. “That’s inappropriate for treatment of this kind. These are patients I would not accept in the clinic – I would refer them to a [full-service] mental-health clinic. Certainly I would not start online counseling with them.”
His feelings are understandable, in light of the professional responsibility accruing to therapists. BetterHelp is not considered the therapists’ employer legally, and does not take responsibility for the treatment. The company exacts payment from the clients and treats those offering counseling as service providers. Responsibility for the therapy and what occurs in it falls exclusively on the shoulders of the therapist.
It is impossible to ignore an issue affecting almost every app we download to our phones: privacy. An article published in February in the online magazine Jezebel claimed that third-party companies such as Facebook and Google have access to information about BetterHelp’s users. “Facebook knew what time of day we were going to therapy, our approximate location, and how long we were chatting on the app,” authors Molly Osberg and Dhruv Mehrotra wrote. For his part, Matas denies this unequivocally. “No medical or personal information is transmitted to any third party,” he says.
The allegation is not that the company transmits information at its own initiative, but that this occurs because a Facebook code is embedded in the site.
“According to a short and simple test I did, a Facebook code is embedded in the questionnaire,” explains Ran Bar-Zik, an Israeli journalist and expert on web privacy. “The code, which is easy to detect, allows Facebook to know who enters the site according to the IP address, or through his Facebook account, if he has one.”
Matas does not deny the existence of the code. “The fact that there is a Facebook or Google code on the site is meaningless,” he says. “There is no internet side today that does not include a Facebook or Google connect code for purposes of analysis and measuring the effectiveness of advertising, in a way that does not transmit the data of a specific user. The Haaretz website also carries just such a code. Is Haaretz violating its readers’ privacy?”
To which Bar-Zik replies that he would not “expect a sensitive site to contain such a code.”
Not only Zoom
A good many professionals have qualms about online counseling. Until the coronavirus outbreak, many of them doubted that people could experience a meaningful therapeutic process even via video conference. Even though opinions on this question have softened, therapy via exchange of written messages continues to arouse considerable suspicion. Matas commented on this in an interview with TheMarker last month: “[Many therapists] said the best method is the weekly 50-minute session. And I said, ‘Really, are you sure? Maybe the best method is a 10-minute talk every day. Or 35 minutes twice a week.’”
Matas isn’t wrong. Even though additional forms of treatment have developed over the years, until very recently, most people in therapy still found themselves going to 50-minute, weekly sessions. There is no doubt that the pandemic has compelled many professionals to rethink certain basic assumptions about the structure of therapy. In a world in which technology often determines the way we communicate, traditional counseling is considered conservative and inflexible. If therapy is examined as a product, it’s a prestigious, expensive one that is resistant to change.
Research on the subject is also developing slowly – though it lags far behind technological innovations. Still, studies have already been published about the effectiveness of online therapy. Research involving patients who suffer from depression and anxiety show that counseling via messaging can be as effective as face-to-face therapy.
Two studies conducted by researchers at New York’s Columbia University and published this year looked specifically at therapy by written means. One found that the degree of anxiety and depression experienced on the part of the client during therapy provided by exchanging messages, was identical to that in frontal therapy – attesting to the possible efficacy of the treatment, the researchers say. Similar results were observed in a different study, in which a significant reduction was measured in symptoms and there were reports of improved efficiency in work.
One of the online therapists encouraged me to keep messaging her until we could meet. Did she do that because she thought it was right in terms of the therapy, or because it’s a way to earn more money?
“I am a social worker, a psychotherapist and a couples therapist, primarily online, so I think the online medium has amazing advantages,” says Alon Aviram, who is working on a doctorate on the subject in the Hebrew University’s School of Social Work. “In certain senses, online therapy by video is similar to a home visit. It allows the therapist to see parts of the patient’s life that he would not see in his private clinic. It raises [additional] ethical, philosophical and psychological considerations, and that is something we must not ignore.”
As to therapy via text messages, Aviram says, “The main question is whether it is a synchronic or an asynchronic service – in other words, whether the help is provided in real time or not. For some, communication that is not timely can turn out to be a real disadvantage.”
In contrast, Gily Agar, a clinical psychologist, maintains that “therapy by messaging is a whole different animal, which is not continual and not a video therapy derivative.”
According to Agar, who operates a center offering online therapy as well as training in video-based therapy, “Something about messaging-based therapy undermines all the basic principles of a therapeutic meeting, not least the fact that there is no actual encounter. I am not arguing that it’s of no value, but what puts me off is the fact that there is not enough academic literature enabling us to learn about this type of communication. How long does an appointment last? Do both sides need to be connected at the same time? How does one identify what is normative and what crosses the line?
“There are numberless clinical and ethical questions that arise when the [physical] presence of both sides is removed simultaneously from the therapeutic equation. I can imagine that some aspects of an exchange of messages is also very liberating, which is in fact what therapists who work with live chats report. Subjects come up faster. But until the issue is better studied, I won’t feel comfortable about working like that.”
Therapy and laundry
After three disappointing experiences with the BetterHelp app, another a psychologist was found for me. This time I wanted to continue corresponding after our initial contact. Why? She took an immediate interest in my experience with the platform and in the therapists I had met. She praised me for my willingness to continue along the therapeutic path. She asked me about myself. What problem spurred me to seek therapy? (I did not tell her I was a therapist, but otherwise spoke candidly about myself and the issues I was facing during this period.) She asked me to correct her if she was imprecise. She tried to understand what my strengths are and what my support system is, how I dealt with crises in the past. She was articulate and spoke in everyday language, spiced with plenty of humor.
The chat format also turned out to be an interesting experience. The app makes it possible to read the therapist’s comments while she is typing, so I could see how she expresses herself in real time, and what she chooses to delete. In the course of the exchanges I was able to fold laundry and browse Facebook, which made the therapy experience less obligatory, for good and for ill.
I can definitely understand how for some people, the distances created by communication by messaging can be liberating and allow for more openness. For me, though, the experience was like a homeopathic version of therapy – something diluted and slow that doesn’t carry the potency that a full therapeutic session can have. An encounter, even if it’s via the screen, forces both sides to create eye contact.
The revolution that the sphere of therapy is undergoing today is almost an inevitable one. Traditional counseling is not accessible to many people and is not sufficiently adapted to a world in which physical and emotional closeness cannot be taken for granted. The research is not progressing at the rate of the technology, the therapists themselves do not succeed in implementing changes quickly, and the tech companies are entering the resulting space. They are succeeding in making therapy accessible to thousands of people who could not enjoy it previously and in moving the world of psychological treatment forward, into technological realms. But this comes at a price. It results in the creation of therapeutic hybrids, about whose effectiveness information is still lacking, opinions are divided and for which proper professional training is almost nonexistent.
Concerning the therapists’ complaints about the low fees, BetterHelp responded: “The staying power of the therapists is generally very high, with many of them working with us for many years. They began with a few clients and grew until BetterHelp became their ‘full-time job.’ That in itself shows that the payment is fair and very competitive. As a flexible platform, the scale of recompense and the success of the therapists can be very diverse. There are therapists on the web who earn more than $100,000 a year, and there are others who don’t work on it much and their pay is commensurate. For your information, the median income of therapists in the United States is $49,610, which translates into $23.85 an hour. We definitely think therapists should make more and are working toward that accordingly.”
As for the payment model, the company stated: “In synchronic meetings such as a video conference or a session in the clinic, the effort and time invested are measured according to duration. Text messages cannot be measured by time, and therefore the measurement is done, obviously, according to the amount of text. The claim that payment per words encourages therapists to ‘write more’ is no different from the claim that therapists arrange unnecessary appointments in order to make more money. The principle in the world of therapy is to trust in the therapist to adopt professional considerations that are not commercial in nature.”