Is the Soul of Therapy For Sale?

When Private Equity Infiltrates Our Practice

Magazine Issue
January/February 2024
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In the ’80s, when I was a young clinician fresh out of graduate school, I learned that our field—like all growing, evolving things—can change fast, and in unpredictable ways. Back then, concerned colleagues tried to discourage me from opening a practice that specialized in couples therapy, especially at a time when systems and family therapy were all the rage.

Then—overnight, it seemed—the expansion of HMOs and insurance panels changed every aspect of the therapeutic landscape. It created new rules around diagnosing and the number of therapy sessions that could be reimbursed. Therapists panicked, convinced that their livelihoods were at risk. But even as the medical model grew ever more dominant, clinicians—a creative bunch—found workarounds to the new obstacles they faced. Family therapy waned, my couples practice evolved, and I went on to write several books, including In Quest of the Mythical Mate, which has won awards for its contribution to the field of marital therapy. All around me, psychotherapy continued evolving, incorporating EMDR, energy psychologies, mindfulness, and neurobiology. And then, just as we were getting used to navigating it all, the rapid growth of internet marketing forced us to pivot yet again. Despite a widespread aversion to technology and a general preference for word-of-mouth referrals, therapists began creating profiles and joining online directories to be able to compete—for a fee, of course. As a therapist who’s been around for more than four decades, I’m used to riding waves of change, including many cultural shifts that challenged and spurred my own personal and professional growth. In addition to developing a well-known approach to couples therapy known as The Developmental Model, I’ve also developed a hard-won sense of unflappability. I’ve witnessed modalities come and go. I’ve seen clinicians adapt to new advances and changing trends. I’m not easily shocked or surprised. And yet, though I’ve sometimes worried about our field and where we were headed, I’ve never been as seriously worried as I am today.

This worry began in 2021, a year into the pandemic. Telehealth was already in widespread use, saving lives by making therapy possible, even under lockdown. I wholeheartedly endorse telehealth. My concern wasn’t about how this way of working affected therapy; it was about the growing presence of private equity money it was bringing to the business of therapy.

That year, my inbox started getting flooded with requests from telehealth companies looking to recruit me. You know the ones: companies with raving celebrity endorsements that claim to match clients with the perfect therapist for them—and therapists with clients who desperately need their services. And you’ve probably seen the kinds of emails I was getting: “We think you’re the right professional for our organization, and we’re going to make your professional life so much easier. Work for us, and you won’t have to do any marketing for yourself. Plus, you’ll be able to choose the clients you want to work with!

Of course I was skeptical, but I was also curious to learn more about the world of Big Telehealth, so one day, I took the bait as an experiment. I filled out a few companies’ forms and had interviews scheduled with representatives from two of them within days. I learned from one company that I’d be paid $35 dollars an hour if I worked for them part-time—$50 an hour if I saw clients 40 hours a week. At the time, the average hourly rate for therapists was about $110. Were these prices competitive? Hardly. I felt sick to my stomach, knowing that many clinicians agree to these terms, funneling their hard-earned fees to private investors and potentially triggering wage deflation for all therapists, not just those using these platforms.

To say therapists work hard is an understatement. We make huge investments in time, money, and energy just to become licensed. We study, train, get supervised, and get certified. Then we continue studying and training to stay current. Yes, we chose this field to help others, and yes, we’re caring people, but we deserve to make a living commensurate with the blood, sweat, and tears we invest in our work. Simply put, $50 an hour isn’t sustainable.

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Some therapists work with these big telehealth companies as a side gig, but I’ve known many who’ve had to rely on them as their sole source of income. One woman, part of an online support session I was holding for clinicians during the pandemic, told me how, to be closer to family, she’d moved from upstate New York—where she’d had a successful practice for 15 years—to Dallas right when the pandemic had hit. Rather than trying to launch a brand-new private practice in a new city, when almost nobody was seeing clients in person anyway, she’d decided to sign up with a big telehealth company. At first, it had seemed convenient: she could set her own schedule and see as many or as few clients as she liked. But soon, she realized she couldn’t support herself on the company’s meager pay. Over the coming months, I started to hear similar stories from colleagues—and I continued to receive emails from teletherapy companies in my inbox.

Then, one quiet Sunday evening, sitting in a comfy chair in my living room with my laptop, I decided to google myself. I know it might sound a little vain, but we can be sure our clients are googling us, so a quick check to see what they’re finding never hurts.

At the top of the search results, the usual things appeared: the website for the Couples Institute, which I’d founded with my husband, Peter Pearson, and a handful of articles and interviews I’d done for various publications. But then I noticed something unsettling and strange: an ad for an online therapy platform featuring my name and profile—even though I’d never worked with such a company, nor had I given them permission to use my name. My heart sank.

I clicked the profile, and the sinking feeling turned to outrage. Under my listed specialties was “anxiety disorders.” I’m not an anxiety specialist; I’m one of the early founders of couples therapy, as well as a trainer, author, and researcher. Next to the fake profile was a blue button. Book an appointment, it read, only there was a sharp red line through the button. Underneath, it read, “Ellyn Bader isn’t accepting new patients right now. Click here to get paired with another one of our expert therapists!”

I took a deep breath, trying to steady myself. Not only was this company using my name and reputation without permission—and getting the facts wrong—but they were doing it to siphon off clients! This advertisement was nothing but a poorly crafted ruse to sell their own therapists—or perhaps to make money from selling names to other entities, as some have been known to do. I was upset—and I knew that if this could happen to me, it could happen to any therapist out there.

How did these types of companies come to pose such a threat to our professional livelihoods? Quite simply, the pandemic provided the perfect opportunity for their growth and proliferation. The increased demand for mental health services, along with the wider use of telehealth, created fertile ground for big business and private investment to turn their attention to our field like never before. Now, with their massive advertising budgets, they’re going after clients aggressively, making it impossible for individual practitioners, or even group practices and small clinics, to appear at the top of online search results.

At a time when I’m hearing more and more stories about diminishing caseloads—a marked change from the height of the pandemic, when most clinicians were reporting full caseloads and long waitlists—this is particularly distressing.

It’s also scary that private equity companies are buying up brick-and-mortar treatment centers and group practices at rapid rates. Recently, I was chatting with a colleague whose father had run an addiction-treatment center in her Midwest hometown for 25 years. She told me that private equity companies have bought up almost all the treatment centers in her area—and then proceeded to lower the salaries of all the staff. I’ve heard similar stories from colleagues working on the west coast and in the south.

Why would any therapist work for such a company? I suspect that most of us aren’t aware of their private equity backing or who’s creating their treatment policies. And I can see how it may be attractive to new therapists who don’t have an established practice, or to clinicians who don’t have the time or energy to market themselves, or to those just looking to make a little money on the side.

Unfortunately, the reports from many therapists who’ve chosen this path are bleak. I’ve heard complaints that they hadn’t been able to reach a company representative in the midst of a client emergency, and they hadn’t been given the client’s contact information or an emergency contact ahead of time. Beyond simply telling the client to go to the emergency room, what are these therapists supposed to do if clients threaten to hurt themselves or someone else?

And what if the therapist needs support? As we all know, this line of work can be lonely and sometimes troubling—which is why members of my training groups consistently rave about the benefits of having a supportive community. It’s a surprisingly important part of avoiding burnout, one that’s being ignored by Big Telehealth. Their focus is on making a profit and satisfying their shareholders. I worry that’s what guides most of their decisions, not the best interests of therapists or clients. Unsurprisingly, when I looked up the board members for one top online therapy company, I didn’t see a single person listed who had psychotherapy experience—although many of their profiles did mention how much money they’d made for other startups.

So what’s the experience for clients using these platforms? A colleague recently shared that she decided to use one of these companies for couples therapy to address her partner’s heavy drinking and flirting with other women. They were assigned to a therapist who spent most of their session taking personal histories and hardly any time exploring their actual issues. She told me it felt like the therapist was going through a required checklist, and instead of helping her think critically about her relationship, this therapist assigned her a bunch of worksheets, many irrelevant to her situation. She didn’t go back.

Even worse, I’ve read articles about clients who were assigned to therapists on these platforms who not only weren’t a good match, but who violated their ethical codes, like the religious therapist who recommended the gay client he was paired with give up being queer.

Online mental health services offer unparalleled convenience, for clients and therapists, but I’m worried that in our rush to embrace these benefits, we’re losing the soul of psychotherapy. When you’re giving strict behavioral assignments for a set number of weeks, which so many of these companies recommend, your focus isn’t on building an in-depth relationship or understanding a person’s nuanced history and what they’re trying to accomplish. It’s on following a protocol that’s driven by profit.

I don’t pretend to know the solution to the problems I’m worried about with Big Telehealth. But I’m certain that being aware of them, and increasing awareness among our colleagues, local boards and associations, and larger communities is a good place to start.

We can support one another and inspire action. And in doing so, we’ll navigate this new terrain, continue to serve as many clients as possible, protect our integrity and livelihood, and preserve our deeply meaningful work, just as we’ve done so many times before.

 

See Ellyn Bader and more than 70 other leading experts in the field at the 2024 Psychotherapy Networker Symposium–live in Washington, D.C., or online.

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Ellyn Bader

Ellyn Bader, PhD, is a psychologist, co-director of The Couples Institute in Menlo Park, California, and co-creator of The Developmental Model of Couples Therapy. She’s one of the early founders of “couples therapy,” as well as a recognized thought leader and trailblazer in relationship therapy. She co-authored an award-winning textbook, In Quest of the Mythical Mate, and the popular book Tell Me No Lies: How to Face the Truth and Build a Loving Marriage along with her husband Dr. Peter Pearson. The two have appeared on Nightline, Good Morning America, O Magazine, Cosmopolitan, several NPR programs, and over 70 others.