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DANIEL:

From Schwartz Media, I’m Daniel James. This is 7am.

If you listen to podcasts, and let’s be honest, there’s a fair chance that you do, it’s likely that you’ve heard ads for a thing called Better Help.

It’s an app offering flexible, affordable therapy whenever you need it. Kind of an “Uber for therapy”.

Now, the American based owners are expanding the app further into Australia – recruiting Australian psychologists to try and capitalise on the failings of a mental health system which can be difficult to navigate and one which is buckling under the weight of demand.

So are we actually better off with BetterHelp and apps like it?

Today on the show, the Uberfication of mental health care in Australia.

Dr Ahona Guha is a clinical and forensic psychologist specialising in complex trauma and she tells us why a gig economy for psychologists isn’t the answer to our flailing mental health care system.

These are her views only, and we’re glad she shared them with us.

It’s Friday, August 16.

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DANIEL:

Doctor Ahona, when did you first start hearing about BetterHelp?

AHONA:

I think I'd say I first heard about BetterHelp about ten years ago, and that was just when I was listening to a range of podcasts, back in my pre-psychology days when I had more time.

Audio excerpt — Doughboys (podcast):

“This show is sponsored by BetterHelp. You know Mitch, I have some self-care non negotiables. I never skip leg day and I never skip therapy day.”

Audio excerpt — Doughboys (podcast):

“Wow Wags, good for you.”

Audio excerpt — Tim Dillon (comedian):

“Better Help is an online counselling service. It offers licensed professional counsellors who specialise in issues like depression, stress, anxiety, relationships, sleeping, anger, family conflict, self-esteem and more.”

Audio excerpt — Dating Detectives (podcast):

“I didn’t have a boyfriend to text anymore so might as well text a therapist, and it was a really great experience so we have an awesome offer for people who listen to the Dating Detectives.”

AHONA:

So kind of vaguely been aware of them for a while and certainly known that they've been a very, very big digital mental health provider in the States because they don't have the same healthcare system as we do here.

But in terms of when I realised or started to see them more in the Australian market, look, I'd say that was probably about 2 to 3 months ago. I started to just see ads coming up, both on LinkedIn because they were trying to advertise for clinicians and then also on my social media, where it looked like they were trying to target clients.

So I was quite alarmed, honestly, to see it start to creep into the Australian market and I was starting to wonder whether this would be attractive to clients who wouldn't really be stopping to maybe think through the implications of signing up for a tech entrepreneur based app like this.

DANIEL:

So from a patient's perspective, what's the difference between logging on to this app and seeking treatment through that app as compared to going and seeing someone like yourself?

AHONA:

So I'm a clinical psychologist and I work in both the public and the private mental health spaces. And obviously I can't speak for the entire public mental health system. But effectively, when you come into either of these services, you're typically referred by someone else, usually a GP, sometimes another healthcare provider. You come in, you'll do a range of assessments where we get a really good history as well.

So it's quite detailed, it's quite intensive. It's usually assessment based initially because it's not that I'm trying to diagnose and stop labels onto people, but it's more that that helps me provide better treatment once I've identified what a person's issues are.

So my understanding of BetterHelp, what you do is you sign up, you fill out a questionnaire, just like, you know, I've done for my dog's pet food delivery, but it's slightly, slightly different.

Audio excerpt — BetterHelp Ad:

“Starting your therapy journey has never been easier with BetterHelp. When you first come to the site, we'll ask you some questions about yourself and what you're looking for in therapy. We use this information to match you to one of our licensed therapists.”

AHONA:

I don't really know how they actually match and triage, but I can say that both in the public and the private mental health systems, you're thinking through things like the complexity of a client's needs, the seniority of a clinician, the type of intervention, and whether you're well matched and best suited to each other.

Audio excerpt — BetterHelp Ad:

“You'll get an email once you've been matched. This usually takes less than 48 hours.”

AHONA:

So you're matched. And then you have a shorter session a week, 30 to 45 minutes based on how much you're paying. The charges at this point in time are Australian $90 or $120. And if you pay the higher rate, you get the capacity to basically text your psychologist in quite an unlimited capacity. And you're told that they'll log in twice a day to respond.

Audio excerpt — BetterHelp Ad:

“As soon as you're matched, your therapist will introduce themselves and ask you some questions to get to know you better. This is your chance to get acquainted with your therapist.”

AHONA:

So it's really subscription based. Kind of like Netflix for mental health.

DANIEL:

Netflix is good for mental health, isn't it?

AHONA:

Well, I suppose it depends on what you're watching, but from the perspective of a clinician it's more like Uber-a-psych. You know, it's really starting to bring the gig economy into what is traditionally not a gig economy space at all.

DANIEL:

Yeah, right. It's pretty easy to see why a gig economy around mental health has opened up. Affordable and timely access to mental health professionals is a pretty appealing proposition, isn't it?

AHONA:

Look, I do agree, I think we have a very, very tricky mental health landscape across the world. We are in a reasonably unique situation here because we do have access to Medicare. Look, we certainly know that waitlists are spiralling and especially for more speciality services, but I do note that apps like BetterHealth can’t actually provide services to people who are seeking assessments and things like that. In the fine print is buried the caveat that they can't write letters for court, they can't do medical legal reports, and they obviously can't prescribe medication. Now, when you see a psychologist here, we also can't prescribe medication. But what often happens is we work as a care team, especially for more complex mental health issues, you know, if you're thinking something like PTSD, serious major depressive disorder, psychosis, bipolar – we all work together to effectively coordinate some of our interventions. And my understanding is that, app based platforms like BetterHelp just don't allow access for that because there's no contact outside of session with the person's team. And indeed, I believe the users can remain anonymous, which I think is very ethically problematic, because if there's a crisis, you know, the therapist is left holding that and doesn't know who to contact.

DANIEL:

So there's a series of alarm bells related to these types of apps. But the mental health system that we have isn't perfect either and people are continually falling through the cracks. Shouldn’t we embrace the disruption of it all?

AHONA:

So I'm not saying that app based services don't have their place. There's been very little research into the actual effectiveness of most app based services and most that have been assessed for effectiveness in terms of reducing symptoms, with things like text messages have been shown that they don’t actually work.

So there is scope to try new approaches and absolutely acknowledging that the mental health state in Australia is terrible. And I don't feel like there's a lot of federal political will at this at this point in time to improve that. But therapy is not 1800 phone a friend.

You know, it's really about helping you talk through your symptoms when you're there in session and building ways to cope outside of therapy. And I really do worry that that kind of constant possible contact leads to a level of dependence, and people just never exploring or actually using the skills.

You know, we have to be cautious. We have to test, we have to work based on the data, not on what sounds like a good idea or on what's going to help this app make money.

DANIEL:

Should you be worried about your data when using one of these apps? That’s coming up.

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DANIEL:

Dr Ahona, patient data and its privacy is paramount in any sort of health care setting.

AHONA:

Absolutely.

DANIEL:

When it comes to mental health particularly, there's definitely an expectation that what you say is private between you and your practitioner. What does the app actually do with the information that you give it?

AHONA:

I don't know. So I know that there's been a very, very big case brought against BetterHelp.

Audio excerpt — American News Reporter 1:

“All right. We're keeping an eye on your wallet tonight. You may be entitled to a refund if you used online therapy through BetterHelp because they're accused of selling information about your mental health.”

Audio excerpt — American News Reporter 2:

“The company agreed to a $7.8 million settlement. This is what the FTC, the agency says BetterHelp promised to keep users' information private, but the FTC says your information was given to Facebook, Snapchat, Pinterest, for advertising purposes.”

AHONA:

They sold consumers’ private data. So we're talking things like email addresses and the responses to the mental health questions that people complete as part of the intake. So they sold that to third party advertisers so that they could better target ads.

Audio excerpt — American News Reporter 3:

“BetterHelp says the settlement with the Federal Trade Commission is not an admission of wrongdoing, and adds that what they did is a standard for the industry.”

AHONA:

Data privacy is absolutely paramount in health care. Who owns the data, things like case notes, who has access to it – these are all things that when you attend a psychology-led service, are thought through very, very carefully.

If you are a registered health practitioner here, you're bound by an entire host of laws, effectively meaning that you can only share information either with consent for the purposes of providing health care or in certain key situations where you're mandated to. Like if a court asks for access to information. So there's so many protections, and when you're giving your data to a third party non clinically-led company that operates overseas, you have very, very few data privacy provisions.

DANIEL:

You mentioned earlier that they’re recruiting psychologists in Australia. I’m just looking at one of these ads now – they’re saying you can be a quote “an independent contractor” and earn between $111-135,000 a year, offering flexibility with no overheads. What do you make of that as someone who knows the inside of the industry? Is it tempting for someone like you?

AHONA:

Yeah. Look, there's, there's absolutely nothing about that that is tempting for me in the current Australian landscape.

I suppose my view, just looking at the pay that they offer they have a bit of a tiered model. So it looks like it's $30 USD if you do under 30 hours a week. And that's not 30 hours of overall work, that is 30 hours of clinical work, so clinical engagement with a client. And if you're over that then you make the higher rate of $45 USD, which is similar to what clinicians and public mental health get. But we also have access to annual leave, sick leave, professional development and quite a host of other entitlements. And all of that time is not clinical time. So if you're working 30 to 45 hours a week and just seeing clients back to back for that as appears to be the model, you will burn out very, very quickly.

It might be attractive to clinicians who might just be starting out, who might be trying to build up a bit of a referral base. But honestly, if I was going to have to work for that amount of time, I'd probably be finding work in a different industry.

DANIEL:

Podcast host.

AHONA:

Podcast host, except, that also sounds like very hard work where you're talking to people all of the time.

DANIEL:

So can I ask about your work then because you work in both the private and public sectors. You would never work for a platform like BetterHelp, but do you worry about the impact this sort of tech disruption could have on clinicians less experienced than yourself and the industry overall?

AHONA:

Look, so I work in quite the pointy end in both of my roles. So in my public mental health role we assess and we treat people who have been identified as possibly being at high risk of reoffending. And, you know, the types of behaviours that they might be engaging in are things like arson, stalking, intimate partner violence, sex offending, gender violence and making threats.

And then in my private work, I see a lot of trauma and complex trauma, as well as mood and anxiety disorders. I usually see, you know, anywhere between five to seven clients a day. And outside of that, I do things like, obviously making session notes, spending some time reflecting on sessions, tracking how we are going in. So all of this is outside of session work that, you know, usually happens after hours.

So the mental health profession is in flux, I think. I'm certainly post-Covid noticing a lot of almost a moral injury, a lot of burnout, a lot more people trying to find passive income and ways of trying to move into other spaces. So I am concerned about things that I'm seeing even outside BetterHelp, things like using AI where we are starting to rely more on machines. There's a couple of patient note taking software things that actually listen in to your sessions and then just transcribe a note for you. And I know a few people in private practice starting to use that, but just all kinds of implications from a privacy perspective. But I also think fundamentally, as you know, psychologists, we have to have a good grasp of why a person behaves the way that they do. And if we're relying on machines to give us those, those answers, they're going to lose some really essential case conceptualisation skills.

DANIEL:

So finally, given what we do know and what we don't know. What advice would you be giving anyone that's considering signing up for one of these apps?

AHONA:

I would say buyer beware. know what you're signing up for. I would ascertain whether your mental health conditions are mild to moderate. So if you're not hugely distressed, if this may be the one issue that you want to talk through and it isn't overly severe, then that might be okay. But I'd be looking through carefully the fine print, and I'd also be asking questions about the person you're seeing and what their qualifications are like. So approaching with a lot of caution if you do choose to approach, would probably be my suggestion. And then if you do have maybe slightly more severe difficulties or if there's a lot of distress or more complex issues, say you have PTSD, understanding that what BetterHelp offers are only 30 or 45 minute sessions. You know the capacity to do things like cognitive processing therapy for PTSD or maybe EMDR, you can't do any of that in 30 or 45 minute sessions.

So you're better off, I would say, trying to establish whether you can see your practitioner, even if it's, you know, via Telehealth within a more traditional therapeutic setting where you are offered, I guess the longer sessions, which are usually 50 to 60 minutes. And also continuity of care and maybe more wraparound care.

DANIEL:

Dr Ahona, thank you very much for your time.

AHONA:

Pleasure. Thanks for having me.

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DANIEL:

Also in the news,

In Parliament, the last sitting day of the week has been consumed by heated debate over visas to Palestinians fleeing Gaza.

Opposition Leader Peter Dutton suspended standing orders to debate his argument that there should be a blanket ban. With Independent MP Zali Steggall calling on the Opposition leader to quote “stop being racist” before withdrawing the comment.

And

There’s calls for the News South Wales Liberals State Director to resign this week, after the party failed to meet the deadline to enrol candidates in the upcoming council elections.

They failed to nominate 136 candidates across 17 councils meaning currently no Liberals will stand in areas like Camden, Northern Beaches and Wollongong in the mid-September elections.

7am is a daily show from Schwartz Media and The Saturday Paper.

It’s produced by Cheyne Anderson, Zoltan Fesco, and Zaya Altangerel.

Our senior producer is Chris Dengate. Our technical producer is Atticus Bastow.

Sarah McVeigh is our head of audio. Erik Jensen is our editor-in-chief.

Mixing by Travis Evans, Atticus Bastow, and Zoltan Fecso.

Our theme music is by Ned Beckley and Josh Hogan of Envelope Audio.

I’m Daniel James, this is 7am. See you next week.

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