Naomi Weizman was working as a secretary in a school counseling office when she started looking for a therapist. Like many, she found Talkspace, the digital therapy app, through an Instagram ad. Talkspace took her insurance. So she downloaded the app and set up her account, filling out a questionnaire about some of her needs and preferences.
But in March, Weizman filed a class-action complaint in California federal court, accusing Talkspace of lying about whether it has enough therapists to meet prospective patients’ needs and enrolling them in automatic payments regardless of therapists’ availability. Ari Scharg, an attorney for Weizman, said that Talkspace attracts users by promising that a personalized algorithm will match them with a suitable therapist.
The algorithm didn’t work out for Weizman. Talkspace couldn’t find her an available therapist who could meet her needs. While Weizman waited, she was unable to book appointments. And when she did get a new match, it was difficult to get on the therapist’s calendar.
Talkspace is reviewing the complaint. A company spokesperson told Truthout that the allegations are “not representative of the Talkspace experience, nor of our thousands of members who regularly utilize our services.” Yet Weizman’s story appears to be routine. On YouTube, users document countless similar experiences. For some, a Talkspace app download was the first time they reached out for mental health support.
Weizman v. Talkspace, Inc. focuses on the impact Talkspace had on Weizman as a patient. In recent years, media coverage of Talkspace and other therapy apps has likewise emphasized understandable patient concerns — questions around the quality of the therapy, for example, or about potential breaches of privacy. The Federal Trade Commission, too, has zeroed in on other apps’ advertising strategies, which may induce users to share sensitive health data.
But on the other side of the screen, critics say Weizman’s complaint reflects many of the issues faced by the providers of online therapy, even though Talkspace says it maintains “a network of thousands of providers licensed across all 50 states, averaging 9 years of experience, and provide[s] them with continual support and quality oversight.” Are working conditions for therapists, who already shoulder much of the emotional burden of caring for patients, only getting less tenable?
Talkspace was founded in 2012 as a group therapy platform. At first, the company sold packages of services to businesses, schools, and other institutions, but eventually transitioned to offer online therapy, allowing users to text with licensed therapists. The app was promoted as a “disruptor” that would expand access to therapy.
But with tech “disruptors” in other sectors –– from transportation to the delivery of restaurant meals and pharmaceuticals –– Talkspace’s early success hinged on the precarization of its workers.
Oren and Roni Frank, the company’s husband-and-wife founders, came from marketing and tech backgrounds. Critics say the company is an artifact of those industries –– an opportunity for venture capitalists to turn a profit, not a health care innovation. Indeed, when the Franks stepped down from leadership in 2021, they called themselves “entrepreneurs” who were “looking forward to [their] next adventure.”
Talkspace’s business model is no different than that of most digital health apps. Linda Michaels is a psychologist and the founder of the Psychotherapy Action Network (PsiAN), a grassroots organization that has been highly critical of Talkspace. Michaels argues that the model operates “at the expense of the mental health of people who are already exceedingly vulnerable.”
Talkspace came onto PsiAN’s horizon after the company began airing ads with the celebrity Olympian swimmer Michael Phelps. In July 2018, Michaels and her PsiAN co-chairs addressed letters of concern to advertising managers at the American Psychological Association (APA), as well as to APA leadership, several journalists, a professional listserv of the psychoanalytic division of the APA, and to Phelps. They decried the APA’s promotion of the Talkspace app, not only as a psychological treatment but also as a viable career option.
In particular, PsiAN argued that Talkspace’s contracted therapists were potentially in violation of the profession’s prohibition of dual relationships. These therapists, they argued, have a primary obligation to patients’ well-being but also act as corporate representatives with “primary obligations to meet ‘retention rates,’ sell additional services, and up-sell more lucrative services.”
Todd Essig, a psychologist who wrote repeatedly about Talkspace as a Forbes contributor, asserts that Talkspace places therapists in the role of agents of a subscription service. People who use the app come in as prospective patients or clients –– but quickly become consumers, customers and users. As users, their relationships with clinicians are dictated by business ethics rather than professional therapeutic ethics. Many of the regulations that bind therapists to these codes of conduct are waived in Talkspace’s terms of service, Essig notes. But customers can’t access the technology whatsoever without first agreeing to those terms.
Essig, who is an adviser to PsiAN, sees dual relationships as embedded in the apps’ business model. In 2018, he wrote that therapists had received letters from a Talkspace lawyer that threatened legal action “if they did anything to encourage or support someone ending their Talkspace subscription.” Two years later, Kashmir Hill and Aaron Krolik reported for The New York Times that after a therapist contracted by Talkspace recommended off-app resources to a client, she was contacted by the company and told to try to keep clients inside the app.
The APA did eventually revoke Talkspace’s advertising space. The conflict did not end there, however. In 2019, Talkspace forged ties with Optum, a unit of UnitedHealth Group, the largest health insurer in the country. PsiAN wrote another letter, this time to the president of the APA. A few weeks later, Talkspace sued PsiAN and its three co-founders for defamation, calling their letters and Essig’s reporting a “smear campaign.” Talkspace asserted that PsiAN saw the company as an “existential threat” to the survival of traditional brick-and-mortar clinics. They sought damages of at least $40 million. PsiAN had around $5,000 to its name at the time.
The case was dismissed in January 2020 for jurisdictional reasons, with a suggestion to refile in the proper jurisdiction. As with many SLAPP lawsuits, Talkspace did not refile the case.
Three years later, Michaels still calls the experience “harrowing.” And she is still greatly concerned that app therapists may be under pressure to cater to corporate priorities, rendering them unable to act in a client’s best interest and thus susceptible to violating primary therapeutic responsibilities.
“Like any other Silicon Valley startup,” Ari Scharg reflected, the company’s priority has been “to add paid users to their platform. That’s how their investors get returns on their investments.” Talkspace went public in 2021, a year into the pandemic, as telehealth boomed. “Now, their duty is to shareholders.” (Talkspace faced a class-action lawsuit later that year alleging it misled investors about its financials in the lead-up to its IPO.)
Corporate priorities are especially relevant in light of slowdowns in venture funding and the recent collapse of Silicon Valley Bank (SVB). Talkspace’s stock price plummeted from a high of $11 in January 2021 to $0.62 mid-March; its net losses have also grown every year since 2019. Last year, it lost $80 million. When interest rates are high and banks like SVB can’t give out loans, Talkspace and other apps may struggle to secure funding and meet their payrolls.
This breed of platform capitalism impacts psychotherapists and their working conditions as much as it impacts the patients for whom they care.
As on other digital apps, the majority of Talkspace’s therapists are not employees, but rather independent contractors who don’t receive sick pay or other benefits. Contracted therapists are able to see users via live video sessions or exclusively via asynchronous text messaging. Users, meanwhile, can text their therapists whenever they want and however much they want, though their therapist might only respond once a week, at an appointed time.
In The Distance Cure, Hannah Zeavin, a historian of psychology, psychoanalysis and psychiatry, writes that “patients can type any volume of new communications, whether or not the treating therapist is in the room, signed on, or due to check in on the patient for days.” She calls this “always-on therapy.”
Though live sessions pay therapists a fixed fee, messaging pays a variable fee based on the word count of therapists’ messages and the frequency of their correspondence. In 2019, Talkspace introduced a feature that allowed users to require therapists to respond to messages within a certain time frame. If the therapist failed to respond in the allotted time, they could lose pay. Some felt that the function “required them to work on demand, rather than on their own schedule.”
Relatively low pay also means that therapists’ caseloads on the apps often end up being “impossible,” said Zeavin. Talkspace therapists report getting paid around $21 per hour for texting sessions, though Talkspace lists the rates as between $24 and $27. Experts worry that low pay creates an incentive for therapists to overwork –– a recipe for burnout.
Rita Finta is a New York-based licensed mental health counselor who has been contracted by Talkspace since February. After receiving her license in December 2022, Finta began searching for online therapy companies “that pay well” and says she answered every application for online therapists that she found. Talkspace was her best option, she tells Truthout.
Finta is nearly 70, and she isn’t interested in working full time. Instead, she works about 20 hours per week for the app. But the company’s new compensation model, which allots bonuses based on the number of clinical hours worked, is “very weird,” she says. Under the model, clinicians receive a bonus of $250 at five clinical hours; $500 at eight; $1,000 at 15. That model “incentivizes you to take on more and more clients,” she says, but it’s not a linear incentive. When she wrote it all up in a spreadsheet, Finta found that she could make $84.95 per hour if she had 11 clients. But if she had 14 live sessions a week, she would make less per hour.
Finta says she has no one to talk with about these challenges. “I would love colleagues,” she says. “But in online services, you’re kind of alone.” And though there’s a call-in platform for clinicians, “you don’t make enough money to take time out of your [schedule] to chit chat.”
Frustrated by the system, Finta sometimes resorts to social media platforms and online support groups for therapists. There, she tells fellow clinicians that Talkspace’s pay is better than it is for other therapy apps, and suggests they work for the company too, in the hopes that, if enough therapists migrate toward Talkspace, the company will pay better.
Online, years-worth of employee reviews from several sites come together to paint a portrait of a fragmented, frustrated and insecure workforce.
On Indeed.com, former therapists in Talkspace’s network write that the work is “soul sucking and exhausting.” Caseloads are expected to be “higher than 60,” one former network clinician wrote. “Don’t do this to yourself, and don’t do this to the field. … They preach work/life balance but continue to overload you with work, I got so stressed that I would wake up in the middle of the night with stomach aches [sic], dreading the week ahead of me.”
Others felt that, when they did struggle with the work or the company culture, they weren’t able to speak up to leadership about their own well-being. This spring, after Talkspace made changes to its pay structure, other employees added that their income had seen significant cuts and was now “far below industry standards.” You “can do better on other platforms.” In February, former employees wrote that Talkspace “promotes burnout.”
Though a longtime Talkspace therapist noted that the company doesn’t incentivize high caseloads per se, it does offer limited-time bonuses to therapists who take on more clients during periods of high client demand, and therapists receive bonuses for long-term active clients and for having higher caseloads. The company officially reports that the average caseload is just 15 to 20 users –– on par with that of many therapists who work out of in-person clinics. But there is no caseload cap. Online, some Talkspace therapists report caseloads of around 50 clients. And in extreme cases, the numbers are higher: 80, 100, 200.
How Did We Get Here?
Mental health care delivery in the U.S. has been steadily scaled up since the 1990s. While the number of patients and the demand for treatment has risen steadily, the number of licensed mental health professionals hasn’t kept pace, leading to a massive increase in what Zeavin calls “therapeutic labor.” To function, the system relies on licensed clinical social workers, who comprise the largest percentage of mental health carers in the country. They are also disproportionately represented among therapists contracted by the apps.
The apps are especially alluring to social workers working toward their license. While they accrue clinical hours, they must work under the wing of a senior clinician’s license. Apps can provide that function. As such, these positions are attractive to socially vulnerable social workers, says Zeavin: those with debt, those who have responsibilities that may preclude them from a standard 9 to 5 schedule, or those who live in an area with few senior clinicians or group practices to provide a license to work under.
In a January 2023 presentation at the 41st Annual J.P. Morgan Healthcare Conference, Jon Cohen, Talkspace’s newest CEO, said that the network is made up of 3,000 part-time therapists. “Many of them, to be honest, are at home,” he said. Around 34 percent of those therapists, he noted, identify as a person of color.
Talkspace, meanwhile, pitches the job as a flexible one. After all, therapists can set their own hours and work from home.
Those perks belie the reality of app-work for many contractors. The apps do the service of hosting and referral, and thus “take a massive cut of the fee as the cost of being the broker,” Zeavin says.
Elizabeth Cotton, an employment relations researcher and psychotherapist, sees mental health services as undergoing a broader process of “platformization.” Cotton, who has a labor organizing background, describes platformization as a series of financial and industrial processes wherein services are turned into commodities marketed via online platforms.
Ultimately, platformization changes how mental health services are delivered but also makes “the jobs of the people delivering them more precarious,” Cotton says. Although worker advocates have brought attention to some of the struggles faced by gig workers in other industries, there is still too little public conversation taking place with respect to the effects of this work on psychotherapists.
The platformization of mental health care prioritizes the concerns of profit “over concerns about what’s happening in the therapeutic relationship –– every time,” Zeavin says. This is especially problematic given decades of research showing that the most important ingredient to a therapy’s success is the relationship forged between a patient and their clinician.
But on the apps, patients and therapists are left with little control over their relationship, making it impossible for them to co-create safe relationships.
The resulting insecurity is “devastating on both sides,” Cotton says. While users like Weizman are left “floored” and disappointed by their experience on the apps, therapists struggle without guaranteed clients or hours. Online platforms may also offer less professional development, leading to the long-term corrosion of skills. Finta, for one, has found that Talkspace’s training materials are outdated, and not provided in a “helpful, clinical fashion.” Two months into her work, she’s also not sure if Talkspace even provides supervision. “There’s maybe a weekly link,” she told me. “It might be peer supervision.”
So, Cotton says, although it may be easy to dismiss the therapists on the apps for being inadequate or underqualified providers, it’s perhaps unfair to expect anything different from them: “Just look at the conditions.”