Access for All

Tackling Therapy’s Biggest Challenge

A hand holds a cell phone

Denise is slumped in her chair, declaring that she’s not a believer in therapy. A middle-aged, Indigenous, transgender woman, she’s heard too many bullshit lines from therapist-types who insist they understand her struggles. They claim they have all kinds of knowledge and training they can use to soothe her pain. But they never really can.

The camera captures Denise’s frustration, along with her striped tank top and puka necklace, and the stark waiting-room wall behind her, with its off-the-rack modern art hanging askew. She looks directly into the lens and ticks off on her fingers the many issues all those professionals can never seem to grasp. “Do you know anything about being trans? Do you know anything about being Indigenous? Do you know anything about being on the streets? Or on drugs? Or losing everybody you’ve ever loved?” she asks. “Honestly, how the fuck can you help me?”

A professional counselor who’s just watched recorded footage of Denise from her computer at home responds. She’s similar in age to Denise, with dark hair curled to her shoulders in neat rows. Her own camera is angled upward toward her face, and we see not only the sherbet orange of the walls behind her, but also the white triangulating tops of doorframes and a ceiling. Haltingly, she begins, “Well, those are very good questions to ask yourself.” Then immediately she loses her thread: “And I agree with you, I may not be as experienced as . . . as experienced as you are . . . or maybe . . . or . . . your worlds . . . or what you’ve experienced—.”

Seeing her struggle to speak is confusing. Is she nervous? Her tone is flat and slightly beleaguered. Maybe she’s uncomfortable with Denise’s transgender identity or her unsparing honesty about her past experiences with therapists. Or maybe she just doesn’t like being on camera.

“But, meanwhile,” the counselor finally manages to say, “I have some experience, and some experience is better than none.” This last line is delivered triumphantly, and she looks directly into the camera before resuming, only to lose the thread again. “But that experience is something I can relate to . . . your situation. Such as being a transgender—.” There’s another elongated pause before she says, “I know that sometimes it’s not easy to feel . . . different. To feel like you don’t fit in . . . or you’re more like the opposite gender, in some ways. Some girls wanna climb trees or do things that the boys are doing—.”

Mercifully, the tape cuts off, leaving the viewer to process whatever they’ve just watched. Where was she going with that last line? But also, who knew that a professional mental health provider could struggle so much to string a few sentences together and convey a little empathy?

It’s not difficult to imagine Denise seeing this response and experiencing a wave of grim satisfaction, proving her point that mental health professionals, with all their training, just can’t help her.

But then a young woman—an art student, with no professional training in how to sit with a person in pain, how to listen—appears on the screen. It’s her turn to respond to Denise and she nods her head as she listens to Denise’s recording. Soft light filters through the blinds in her small room, illuminating the oversized tortoise-shell glasses that frame her face. She gazes into her computer’s camera, her body language quiet and centered.

“Those are absolutely fair questions to ask me,” she says. “I’m not trans, so I’ll never know that experience, but I do identify as queer and I’m a Black woman, so I do understand what it’s like to be part of a marginalized community. And I do understand what it’s like to be insecure in terms of housing. That’s something I had to deal with growing up.”

Like a friend who’s heard Denise’s pain and is intent on helping, there’s concern in her voice and a steadiness to her words. “I found myself asking the same questions that you’re asking me right now. What can anyone do to help me? Well, I can be here,” she answers. “And I can be a part of your support system. Sometimes, for me, it’s been about just not feeling so alone and helpless; and some of the best support I’ve found has been in online communities with people who identify as queer. I think this is just a new way of being supported. You know?”

As the video ends, you can imagine Denise nodding and thinking that maybe, just maybe, receiving help from this person would feel different.

“Wampold believes that psychotherapy isn’t contending with the fact that ‘the biggest risk for mortality is loneliness. Even a large social network doesn’t always give us what we want.'” PHOTO © ISTOCK / BHUPI

Empaths Are Us

The professional counselor and the artist may never meet Denise. They’ve taped themselves as part of a job interview meant to measure whether they can respond empathetically to confrontational clients. Both have been graded on their performance by a team hiring for a new online mental health support option called Peer Collective. During this hiring process, the team has discovered how few people, regardless of whether they’ve had any mental health training, are true empaths. Of their applicants, the number of people who exude a natural sense of empathy have been soberingly low: a measly 3 to 10 percent. But the team isn’t discouraged. They intend to continue screening applicants for empathy, home in on this special group, and train them to become peer counselors. Their goal? Nothing short of reconfiguring the mental health landscape in America.

Tim Desmond is the therapist, life-long activist, and mindfulness expert behind this project. It all began when a colleague asked him if a book he’d written on teaching self-compassion in therapy was going to make a difference for people in need of emotional support and healing. When he realized the honest answer was no, he started asking himself, Well, what will help? He focused on the therapy world’s biggest problem: access.

Desmond calls his solution Peer Collective, a scalable peer-counseling system that’s affordable, client driven, and designed to be an effective option for the tens of millions of Americans who can’t get therapy. One day, he hopes, it’ll employ hundreds of thousands, maybe even millions, of peer counselors, who, like the artist who responded to Denise, have proven themselves to be empaths.

Peer Collective has recently gone live with 50 peer counselors who’ve taken 1,000 calls—a tiny fraction of their ultimate goal. Desmond is rolling the platform out slowly to smooth out kinks along the way, and he’s hired a CEO who came from Uberworks and has experience with rapidly scaling gig-economy projects.

Desmond says Peer Collective, accessed via an online platform, differs qualitatively from therapy apps like TalkSpace, which favor ongoing relationships with licensed therapists. But it also differs from the flowering world of online peer-support groups like 7 Cups, which charge no fees to text with friendly, supportive peers in real time. Instead, Desmond finds value in charging a nominal fee for peer counseling. It ensures that the peers can be vetted, trained, and paid—and the counseling can be meaningful. Callers pay $14 for half an hour and $28 an hour. His counselors make $20 an hour.

The platform provides an abundance of choice. First, you answer a couple of questions about the kind of support you’re needing and whether you prefer to get it from someone of a certain age or race or gender. Then your screen populates with photos and bios, which may include the counselors’ own mental health backgrounds, such as any histories with depression or anxiety or receiving guidance or help from a mentor or professional. Some can respond in the moment, some later that day or week. If you want to talk to a counselor again after your first session, that’s just fine. Want to try someone else instead? That’s fine too. You’re the driver.

Compassionate Action

Will people seeking mental health support outside traditional therapy channels get the distinction and buy what Peer Collective’s offering? Desmond hopes so.

“The only reason I’m working 80 hours a week without getting paid is the idea that this could ultimately change people’s access to care,” he tells me from his home, a meditation retreat center that he cofounded in the woods of New Hampshire.

At first glance, Desmond seems an unlikely figure to spearhead a tech startup, even one with ambitions to deliver empathy on demand. We’re Zooming for this interview, and the spartan wood-paneled office he’s sitting in is on display. There’s a singular work of calligraphy nestled in the shelving behind him, and he hasn’t changed out of the dark robe he’d donned for the center’s online meditation session that day. The robe is a uniform of sorts for select monks and lay people who’ve been welcomed into Zen Buddhist Thich Nhat Hanh’s Order of Interbeing. Desmond has spent months on and off at the Vietnamese monk’s Plum Village in France and retreat centers in the US, and has taken a vow of dedication to “the continuous practice of mindfulness, ethical behavior, and compassionate action in society.”

Desmond grew up poor, with a single mom, and occasionally homeless in greater Boston. This early experience showed him not only what it means to lack access to basic health and mental healthcare, but added fuel to his drive to better the world around him.

Peer Collective isn’t Desmond’s first large-scale compassionate action: he’s written three books on self-compassion, played lead roles in big protest movements, and seen firsthand what radical perseverance can do. He helped organize the 1999 World Trade Organization conference protests in Seattle, which famously shut down the global meeting and caused an international incident. And he was a leader of Occupy Wall Street during protestors’ months-long takeover of Manhattan’s Zuccotti Park, a movement that called for a livable minimum wage, debt forgiveness, free college, and a universal basic income—goals pilloried by many a dozen years ago, but gaining traction now.

Desmond remembers an especially tense day at Zuccotti Park, when his activist, mindfulness, and therapy worlds converged. The city wanted to evict the protestors who’d spent months camped out in the Wall Street neighborhood park. Thousands of people were packed together as helicopters hovered overhead and armed riot police encircled them. Standing on a low wall after being asked to address the crowd, Desmond saw terror in people’s eyes. ”I wanted,” he says, “to project calm and serenity, but I was just as freaked out as everybody else.” It wasn’t just the cops and their firepower. He’d never spoken to a crowd this big and found himself wrestling with an unbearable sense of fear. What could he say to that many people?

The time he’d spent working with clients in therapy and the months he’d meditated with Thich Nhat Hanh had taught him that rather than quash his feelings, he should invite fearful sensations to swell so they could crest and then fall, drained of their power. “I spoke to the fear in me,” he remembers, just as he might suggest a client do, “and said it’s okay for you to be here. You can be as strong as you want to be.”

The fear crested and released him, handing him back his voice. “I don’t know about you all, but there’s no place in the world I’d rather be right now than here with you, taking a stand to make the world a better place,” he told them. “You’re beautiful people, and this is an amazing moment.” As he spoke, he says he got the profound sense that they could feel the love he was feeling for all of them. Their energy relaxed, and 20 minutes later, Bloomberg rescinded the evacuation notice. All the crowd’s terror turned to joy, and a whole lot of dancing. It reminded him, he says, that love and compassion are always available to us, regardless of what else we’re grappling with. And knowing that can be profoundly healing. In fact, Peer Collective relies on it.

“Counseling and therapy work; people just don’t have access to it,” Desmond says. “But what if, at their moment of need, they could push a button on their phone or computer and be connected to an exceptionally warm and empathetic person? What if connecting in this way was super affordable? And what if empathetic people could be paid a living wage to be on the other end of that call? Would we then have democratized empathy?”

Hey, Google

Desmond was wrestling with these questions when Google invited him to give a talk to a mindfulness group on its Mountain View campus. Afterward, David Yu Chen, one of the company’s software engineers, approached him and said he wanted to start a mental health project. He’d sought therapy after his mother had passed away, and when the therapist had told him, “It sounds like you’ve been experiencing anxiety for your entire life,” it was a revelation. Chen saw that therapist for a year, inspiring a passion to create a project that would make therapy more available to others. His collaboration with Desmond resulted in an early blueprint for Peer Collective, which Google’s famed in-house incubator, Area 120, approved. Desmond became the first Google nonemployee to lead an Area 120 team.

After years of wealth-disparity activism, Desmond didn’t relish going in to work for an international corporate behemoth each day. He wasn’t in it for the money, after all. But who better than Google to help him roll out something big enough to take on the gargantuan public health problem that is the lack of mental healthcare?

With the Google name behind him, Desmond contacted two of the most iconoclastic thinkers in the therapy field: Bruce Wampold, professor emeritus of counseling psychology at the University of Wisconsin, who’s long argued for the preeminence of the “common factors” of therapy over any particular modality; and John Norcross, a psychologist who pushes the field to welcome all avenues of healing that’ll move the needle for the millions of Americans that therapy doesn’t reach.

Both men had already identified the need for expanding access to counseling and support across the United States. “In America, our de facto mental health help is self-change,” says Norcross. Americans rely on online communities, books, and other forms of self-help, in the absence of adequate mental healthcare. Wampold agrees and contends that psychotherapy is too caught up in myopic arguments about the DSM and not focused enough on making counseling more available or contending with the fact that, as he puts it, “the biggest risk for mortality is loneliness. Even a large social network doesn’t always give us what we want.”

Driving to Google’s headquarters one day, Desmond called Wampold and asked, “If you needed to hire 100,000 counselors and they needed to be good, what would you do?”

“You wouldn’t focus on their training,” Wampold replied. “You’d test for common factors.” Wampold claims the difference in mental health outcomes between schools of psychotherapy hovers around zero percent. The common factors are what matter.

Common factors are what creates a therapist–client alliance, for instance reliably treating clients empathetically so they feel heard and accepted, or being on the same page about what they hope to accomplish.

“So, what we started doing at Google was testing a belief we had that we could predict with a decent level of accuracy how good anyone would be at counseling based on the common factors of therapy,” Desmond says. “It’s important to test because emotional intelligence is often contextual. You might have it at a cocktail party, but if a friend is going through a divorce, you might be a miserable support.”

But even if you test for empathy and emotional support, will that really go the distance for people who are struggling in life?

“Therapists want to believe they have a singular ability to make people change, but people have been doing it themselves since antiquity,” says Norcross. He loudly embraces self-help and lay people’s ability to help each other, citing a series of studies to emphasize that we can address mental health issues “without requiring people to go to full-time graduate programs.” One such study is Margaret Rioch’s in the 1960s, which showed that kind and nurturing housewives who received basic counseling training did as well helping those struggling with mental health issues as professionals. Another study came out of Vanderbilt University: it compared the outcomes of sessions with friendly college professors to those of psychotherapists and showed nearly the same therapeutic results.

“We know effective therapists have a set of sophisticated interpersonal skills that they can demonstrate in challenging encounters where someone is being aggressively questioning or withdrawn,” Wampold explained. “And we can assess these skills at the beginning of training and see if the potential therapist can stay engaged, be empathetic even when challenged, and decode the affect of what the person is expressing.” Most therapists and counselors never get such a test. At Peer Collective, that empathy will be highlighted and given a market value—a radically new development.

And yet, as Peer Collective got off the ground, Desmond’s radical vision met market pressures. The team’s goal of hiring one million peer counselors at $20 per hour was initially supported by Google, but California passed new laws covering gig workers, giving Google less leeway to hire those workers without providing them benefits and workplace protections. Google decided that hiring gig counselors wasn’t in its best interest, and after about a year of collaborating, Desmond and the company amicably parted ways. Since then, Desmond’s incorporated Peer Collective as a public benefits corporation, so it won’t need to maximize profits. Wampold is working with a new team at the University of Texas at Austin, continuing to research whether Peer Collective’s empaths give better counseling than control groups.

Desmond says he doesn’t want to displace professional therapists. He doesn’t use words like disruption to describe Peer Collective. Addition is his preferred term. He says, “I’m a licensed therapist, and much of my career has been working alongside clinicians. I don’t feel graduate degrees in this work are meaningless. I teach grad students. I love our field, and I know people care deeply about making a difference. Ultimately, we all know there are amazing providers out there. There just aren’t enough of them!” He thinks therapists could benefit from Peer Collective by having somewhere to send people on their waiting list, or patients who need a crisis resource, or a soothing chat between sessions.

“We need to take alternatives to therapy more seriously,” says Norcross. Speaking with a counselor via Peer Collective might not be as effective as seeing a licensed therapist long-term, but he contends that “right now, we’re maybe able to reach three percent of the population, so therapy isn’t the proper comparison to these options, because therapy’s not available to the majority of the population. The proper comparison is to nothing. Given that lack, what we therapists should be doing is helping teach ethics, boundaries, and relationship skills to those delivering peer-to-peer services like Tim’s.”

Between a Therapist and a Friend

I’m eager to talk with one of the people providing this peer-to-peer support and decide to walk through the sign-up process first. I answer questions about what emotional challenges I’m facing, how motivated I am to start receiving help, and whether I want someone to listen or help solve a problem or offer a new perspective on my life. I get to choose my counselor’s gender, age, and cultural identity.

I answer “no preference” to these last questions and wind up with 20 options of potential counselors. As I scroll through photos and bios, I can see their available times. A few of them are ready to listen to me right now. Tay, who’s between 21 and 30, says in her profile that she knows what it’s like to “be bullied, underestimated, and feel alone,” and has “struggled with depression and anxiety.” She loves Star Wars and is a Marvel fan. Jacqueline is over 50, Latinx, and “a mother of two beautiful adult children and four beautiful grandchildren. She says “we all matter and are beautiful just the way we are. I’m here for you. We can get through this together.”

In the end, I decide to interview Ari, who has young kids and multiple work-from-home gigs. She’s infectiously chatty, and though this is a journalistic exercise, within minutes of getting on the phone, I note that I can feel myself relaxing into what feels like a new friendship with a comfortably open soul. But when Ari tells me she teaches coding classes to high school students and dispatches for a trucking company, I waffle on whether she could possibly be right for this gig. She might seem cool, but what does she know about mental health?

“Before this, I’d not done any counseling,” she says, “but I’ve been on the receiving end of it. I went through a misdiagnosis of depression and anxiety before learning I was bipolar. I went into an inpatient care unit on one of my vacations and then six months of outpatient therapy, where I did art, music, and group therapy. I’ve been in one-on-one therapy twice a month since then, maybe 300 to 400 hours of therapy by now.”

She tells me her callers are mostly working professionals who need extra support. Some are in therapy but want to supplement the limited sessions their insurance covers per year. She starts sessions by saying, “Tell me your story,” and asks questions about what type of care they’d like.

Callers will say, “My therapist isn’t going to make any suggestions about what to do,” Ari says. In her view, what she offers is “real talk,” a chance to talk through their options. She’s met with people working through the whole gamut of career, marital, substance use, and body image issues. “I’ve had experience with all those issues and will tell them, ‘This is what’s helped me,’” she says.

Over the last year, most of the people who called in crisis were dealing with stresses related to COVID-19. “The main thing I deal with is people in isolation,” she says. “I just talked with someone who’s moved and now, during COVID, has no friends or support and is feeling lonely.”

Ari and I end up talking for the better part of an hour. She’s so warm and open and comfortable on the phone that I feel a tinge of regret hanging up.

I want to know more about how Peer Collective is working for those who are legitimately calling for help, so I arrange an interview with Ari’s client, Michelle, who’s 43, and was seeking someone, as she put it, “in the middle, between a therapist and a friend,” when she first used Peer Collective. Michelle lives in the South and used to be a teacher. She says she has ADHD, a bipolar diagnosis, and a regular therapist. She gives me list of ways in which talking with Ari differs from therapy. For one, Ari’s like a friend or confidant, but with extra training.

Therapy is rife with rules, formality, and questions of insurance, she explains, while “talking with Ari is just such a relief. You don’t have to worry about something you’ve said coming back to haunt you. It’s just like chatting with someone you’ve just met and really connected with. It feels authentic and cathartic,” she says. “I saw my therapist for 12 years and stopped when scheduling became a problem. But I’d also made some bad decisions that I didn’t want to tell her about. That’s the thing with being able to call someone you don’t know. You don’t feel scrutinized, as if something you’ve said is going to have impact down the road. I really like and respect and trust my therapist, but there were times I felt there were limits to what I could say, or the kinds of conversations we could have. She was in touch with my prescribing doctor. It was a safety net, but I always had to be accountable to her. It was a lot of pressure.”

Michelle goes on to say that if she doesn’t like working with Ari anymore, she won’t need to initiate an awkward conversation about why she’s ending treatment. If she wants to try another counselor, she’ll be able to make her selection based on personal details the therapists offer about themselves, and she’ll be out just $14, not $150 or more, if she isn’t helped by their conversation.

The more we talk and the more enthralled she seems with Ari and Peer Collective, the more concerned I become that she might abandon her relationship with her primary therapist, who knows her history and might recognize when she’s veering toward a crisis better than a peer counselor she’s spoken with on the phone only a couple of times.

When I ask her who’d be her go-to person during a mental health crisis, she says, “Honestly, if I had the choice in a crisis between calling my therapist or Ari, I’d feel more comfortable calling Ari. I feel excited that she exists. That’s something I didn’t expect. It makes it so you don’t feel as alone as you try to fight through life.”

While we were saying our goodbyes, I thanked Michelle for her honesty, but when she encouraged me to try the service and listed again all the ways it was superior to therapy, I felt myself going a little cold. Was peer counseling on this scale really safe? Should Ari be offering advice to someone with real mental health challenges? Should callers think they can replace their therapists with peer counselors?

Along with emphasizing that it is not Peer Collective’s goal to replace professional therapy, Desmond had assured me that his counselors get crisis training and that any calls that require a clinician’s intervention get one—via him for now. In this early stage, he’s committed to being available 24/7 for callers who need more than a peer’s help. Okay, but what about the clients who are regularly in crisis and potentially ditch professional help because Peer Collective is easier? When I asked him about the possibility of Peer Collective forcing this kind of either-or scenario, he assured me again that it’s a supplement to therapy, not a threat to it.

“Wampold believes that psychotherapy isn’t contending with the fact that ‘the biggest risk for mortality is loneliness. Even a large social network doesn’t always give us what we want.'” PHOTO © ISTOCK / LEOPATRIZI

I saw what Michelle meant about how using Peer Collective felt so much less frustrating, and strikingly more egalitarian, than waiting on a therapist whom you know nothing about but whose care you might desperately want or need. And for all the reasons Michelle mentioned, including the lack of accountability to a professional, I can’t help but think that if options like these take off, it could eventually disrupt the market for therapists.

When I posed this to Norcross, he insisted, “This project isn’t going to take away from anyone’s practice. Many of the people who’ll reach out for help won’t have the kind of qualifying diagnoses that a therapist would get reimbursed for.”

I think back to Denise. Being transgender, Indigenous, homeless, and wracked by loss might not be qualifying diagnoses, but her addiction would be. Yet she certainly wouldn’t be able to pay out of pocket for therapy. What might it mean if, instead, she could call the empathetic peer counselor-artist in the cool glasses every few days? Could they spend time sharing how much it hurts not to have a place to call your own? Could they brainstorm how to connect with a supportive community? Could her sense of well-being start to improve, the more she interacted with people who saw her, without diagnosing her, and made her feel they understood her life in ways she actually believed?

Perhaps, but would those counselors really be able to nudge her off the streets or keep the drugs at bay? Would those issues abate if she were getting the kind of empathy she’d been missing with the wrong professionals? Maybe talking with someone who could get her through the next day and week and month, for the price of a coffee and a bagel, might make her open to seeking out higher-level, professional strategic help again. We don’t know yet.

These days, Desmond isn’t just thinking through the many ways Peer Collective differs from therapy. It’s been three years since he and David Yu Chen put their pitch together for Google, and he’s still swamped—still working with his team to make sure the platform is easy to use and doesn’t fail, still deep in marketing discussions, trainings, and managing relationships with researchers who want to do pilot studies based on what they’re offering, and with curious healthcare companies that have started sniffing around about potentially one day adding them to their options.

I ask him how he’ll feel if Peer Collective doesn’t get the traction he’s hoping for and truly change people’s access to care.

“If this becomes just another company that’s competing in some online therapy space, then it didn’t achieve—.” He trails off and sighs. We’ve been talking a long time, and it’s late. He closes his eyes for a moment in that enveloping robe and takes a deliberate breath. “Here’s what I care about,” he says. “I care that it’s a place for people who are suffering to find someone they can trust.”



Lauren Dockett

Lauren Dockett, MS, is the senior writer at Psychotherapy Networker. A longtime journalist, journalism lecturer, and book and magazine editor, she’s also a former caseworker taken with the complexity of mental health, who finds the ongoing evolution of the therapy field and its broadening reach an engrossing story. Prior to the Networker, she contributed to many outlets, including The Washington Post, NPR, and Salon. Her books include Facing 30, Sex Talk, and The Deepest Blue. Visit her website at