Two Emails, One Message, and the Enshittification of Therapy

Last week an article by 404 Media was published about how the mental health platform Headway would be rolling out biometric face scanning for both clinicians and clients.

I saw this on LinkedIn and literally thought this was satire from something like the Onion before learning it was actually true.

Maybe a week before that, I saw the news that Alma, another therapy platform that was recently acquired by Spring Health (an employer-based therapy platform), announced that through its partnership with Aetna, it would be reimbursing 90837 sessions (53+ minute) at the same rate as 90834 sessions (about 45 minutes), and that they’d be reimbursing doctoral level clinicians at the same rates as master level clinicians.

These two emails have different surface level content: one about your face, one about your paycheck. It may seem like these are different issues because they’re different companies.

Except they’re not. They’re the same email, and a version of the same issue that keeps rearing its ugly face to us therapists time and again.

They speak to the fact that there’s a layer (or sometimes multiple layers when a health plan is involved) that sits between the clinician and their clients, and that layer has its own books to balance and its own prerogative.

Here’s the basic message that repeats itself in the way a 5th grader could understand:

 “Things were like that, but now they’re like this, and it doesn’t matter if you’re a licensed clinician with industry expert knowledge, you don’t get a say in it.”

To be clear, if you’re a therapist working with any of these (or other) Venture-Capital (VC) backed mental health “tech” platforms, I have no judgement toward you. This might be a great way to fill your caseload and retain what initially feels like a private practice. I’m also not trying to suggest that all VC-backed platforms are villains — they’re still getting more people into therapy seats, and I see that as a good thing given how hard access can be for clients in this field. And I know one thing for certain: had you been consulting about any of the above issues, and had your clinical expertise been taken into account, well, I don’t think I’d be writing this blog post.

So before I get to what these two emails cost, I want to talk about why they keep landing in our inboxes in the first place.

The Enshittification of Things

On a LinkedIn post about the Alma/Aetna situation, I came across the term enshittification and thought someone on social media was just making up a word that sounded outlandish (I love to make up words!).

But I looked into it and it turns out Cory Doctorow wrote a whole book on it — Enshittification: Why Everything Suddenly Got Worse and What to Do About It. And I could see this process unfolding example after example in the VC-backed mental health tech industry.

Here’s the part that made the two email announcement click into place for me. Enshittification isn’t one bad decision — it’s a predictable, repeatable lifecycle, and it runs in stages:

The good times

Oftentimes mental health tech platforms will get lots of funding, and the way they’ll attract therapists is by offering high rates, flexibility, faster credentialing, and/or lots of clients for your caseload, fast.

The squeeze

Then comes some sort of squeeze in some way or another. It could be cutting rates, or letting fewer therapists into the network. Or something else. In the case of Alma, it’s squeezing care (i.e., paying the same for a 53 minute session as a 45 minute session will essentially dictate care). For Headway it’s squeezing security — likely for a real reason, but with no regard for how it lands on providers and clients.

And it’s not just those two. Anecdotally, I’ve heard of other platforms that have:

• Lowered base rate pay per session significantly for new providers who enter their network
• Re-tooled the algorithm internally so that providers with higher rates who’ve been with the network longer don’t show up in searches (thus funneling clients to providers with lower rates)
• Reviewed direct messages between providers about their clients (on the platform)
• Threatened to kick providers off the platform for communicating with their clients about bringing them to another practice or their private practice
• Not listened to clinical expertise and dictated care to clients in a way that was contraindicated
• Offered little to no clinical support for therapists dealing with crisis situations

I have no hard evidence for those, but I trust all the individual therapists who’ve shared their experiences with me. Different platforms, different details — same squeeze.

The bad times

Finally comes the result of the second stage: the companies essentially try to claw as much value back for themselves and their investors as they can. I want to be honest that this stage is a forecast, not a diagnosis — but it’s where I think we as a mental health industry are heading with the VC-backed platforms, because the math points there.

These are companies doing exactly what they were built and funded to do: raise capital on the promise of returns, and that promise has to be kept. When the math gets tight (which is predestined), the levers it can pull to bring value back to investors are limited — and the clinician’s split, the clinician’s session length, and the clinician’s/client’s data are all within reach.

And here’s why the two email announcements aren’t two unrelated moves by two different companies. Doctorow’s version of this is a two-sided squeeze: first the platform is good to the people using it, then it leans on them to keep its business partners happy, then it leans on everyone to claw value back for itself. Map that onto our world and the clients are the users, the therapists are the business customers. Headway’s face scan degrades the experience on the client-and-therapist side. Alma’s rate change squeezes therapists directly. 

Your obligations as a clinician and the platform’s obligations are not the same. Yours are to your clients. Actual real people with real problems. Theirs are, in the end, to the people who funded them. Sometimes these two things can coexist, quietly and for a time. But oftentimes not forever.

These two instances with Headway and Alma are what it looks like when those obligations start to split.