What Therapy Platforms like BetterHelp Can’t Offer
Published on 5.6.24 at garyborjesson.substack.com
Most of us have been hearing about the online therapy platform BetterHelp (BH) for years. I hear their ads on high-profile podcasts such as Radiolab, WTF, and Mindscape. Here is its public-facing mission statement.
Making “mental health care” more accessible and affordable sounds great. But exactly what kind of help are clients getting? For instance, when you subscribe to a BH plan for a monthly fee of $65 to $90, are you actually doing therapy? According to BH
You can get therapy in four ways: Exchanging messages with your therapist Chatting live with your therapist Speaking over the phone with your therapist Video conferencing with your therapist You can use different ways at different times as you wish, based on your needs, availability, and convenience.
Notice how BH puts texting—the thinnest, least relational way of “getting therapy”—up front. (It also happens to be cheap and ultra convenient.) Notice too how their language commodifies therapy, making it into a thing you “get” the way you might get a loaf of bread. A big selling point is that the product is tailored to the client’s needs and convenience. But what if the client doesn’t know exactly what they need from a therapist? What if serving the client’s “convenience” actually worked against offering them better therapy? It’s likely both are true.
One could argue that what BH offers isn’t full-fledged therapy but something else. Which is fine, since a service like theirs can help our mental-health without being therapy, just as life-coaching can help without being therapy.
At a glance, a big problem is that BH’s service does not support building therapeutic alliances. (This is a problem because research shows that the quality of the alliance is the among the most important factors in whether therapy is effective.) To see why it would have a hard time supporting alliances, we need to think about frames. What psychoanalysts call a “frame” is a set of agreements between the therapist and patient that establish the alliance’s purpose and boundaries.
How does a frame support a good working alliance? Imagine a patient frequently forgets about, reschedules, cancels, or is late for a regularly scheduled session. If there’s a clear frame, this pattern of avoidance can be detected and explored together: What might it reveal about the patient’s feelings about the therapist? Or about what’s happening in the therapy? Or about how the therapist is behaving? Is their response reminiscent of other patterns in the patient’s life? Likewise, questions may come up around timely payment, how and when sessions begin and end, how frequently contact is made between sessions, and so on. In general, patients and therapists can learn a lot from the ways the frame may be bent.
With all this in mind, let’s look at BH’s service. You don’t get to shop for your therapist, but if you don’t like your therapist, you can “get” a new one at your convenience, like swapping out one loaf of bread for another. From a frame perspective, what might have been golden opportunities for insight and growth are sacrificed to the interest of customer convenience and satisfaction. After all, working through frame-related issues can be painful and upsetting, which is not great news if short-term customer satisfaction is paramount.
Absent a good frame, clients miss a chance to have help working through interpersonal conflict in a new way, learning from their alliance with the therapist how to tolerate (and repair) ruptures. These new skills can be applied in their other relationships. But with BH, if it’s not convenient to meet, you just cancel. If you’re not in the mood for a video session, you can talk on the phone or chat by text instead. If you don’t like the therapist, you can get another, probably without being encouraged to explore your discomfort directly.
BH makes it easy to avoid building a real alliance with a therapist. This is just as well, since the uneven quality of the therapists (what do you expect if a licensed therapist is earning less than $50/hour?), and the high turnover means BH cannot reasonably offer clients what a durable alliance offers. This can lead to setbacks. Someone in therapy for the first time might finally feel enough trust in their therapist to disclose something intimate and vulnerable only to have that therapist move on soon after. It’s not so easy to start over with another therapist.
Even if the therapist is good and does stick around, they lack the autonomy to establish a sturdy frame. Instead, they are subject to terms of service that reflect the convenience of the client and the corporation. Since the governing motive is profit, satisfying customers will always come before satisfying the conditions for good therapeutic alliances.
Finally, all online platforms suffer from the same constraint as all remote or virtual connections: the loss of physical and temporal proximity, and all that juicy, mostly unconscious, content we take in through our senses and sift with our brains for clues about the other. For some people, the thinness of virtual presence radically limits the value of the therapy. Some of us—especially if we’ve suffered serious attachment-related trauma—can’t trust others until we’ve been in the same room with them, repeatedly. Reliable animal presence offers felt connection, easier emotional co-regulation, and other unspokensomatic forms of reassurance that build safety and trust.
With this cautionary note about the limits of online therapy platforms like BH, we are now ready to look at the better help they can provide. Stay tuned.