Unless you’ve been living under a rock, you’re aware of the influx of internet-based mental health interventions exploding over the past decade, even more so during the pandemic.
Mindfulness apps, thought trackers, CBT courses and the Uberization of therapy has flooded headlines and newsfeeds for the past few years. It’s clear that mental health is in a spotlight at the moment, and that tech is doing its best to meet the need. And with its homework, education, and clearly defined strategies, CBT treatments have stepped to center stage.
But what happened to psychodynamic or relational approaches to mental health problems? Are they waiting in the wings for the world to emerge from the pandemic haze to re-enter the world with depth-based solutions? Or are they finding ways to stay relevant in a screen-dependent world?
Dr. Emily Anhalt believes that dynamic work can translate to the digital realm, and has built a platform to deliver the principles of depth psychotherapy through the internet. As a Silicon Valley clinical psychologist who counseled and advised the tech world and gave a popular TED Talk, Anhalt developed Coa, described by The Washington Post as a “mental health gym that takes a therapist-led approach to everyday health,” a program that would both meet the needs of clients seeking depth work and allow virtual interaction. I spoke with her (online) to download her data.
RH: How did you become interested in starting a mental health gym?
EA: I'm a clinical psychologist. I've been practicing about 12 years and studying psychology for about 17. I got into psychology for the same reason I think most clinicians do, which is complicated family dynamics that I wanted to understand. I also had the good fortune of having a very psychologically minded mom who really taught me that just by understanding things differently, we can really transform our relationship to them. I had a psych teacher in high school who told me that when you know a lot about psychology, you know a little about everything because the world is spoken in the language of relationships, and psychology is the study of relationships. So that really piqued my interest. And I grew up in Silicon Valley.
When I entered grad school and started studying therapy, a lot of the people I was working with were in tech, as was my partner, my family, and my friends. It started to become obvious to me that the things people in tech are struggling with in their companies are the same things we're all struggling with in any of our relationships. And that industry would really serve itself to become more self-aware as individuals and as a culture. So I started doing workshops and speaking engagements for members of that community while also seeing them in private practice. And I realized that a strength of mine is to take complicated psychological concepts and make them easy to understand. The response was really positive.
As I was working with people who were pretty high-functioning and very successful, it became clear to me that our mental healthcare system is far too reactive, and that most people feel like they have to wait until everything's falling apart to get support. But to me that's like waiting until you're diagnosed with early signs of heart disease to start doing cardio. I realized that I wanted my big mission in the world of psychology to be reframing the narrative of mental health from this reactive thing we only do when we’re unwell to being a more proactive thing that we do to maintain wellness, to help people think about going to the therapy more like going to the gym and less like going to the doctor, because a lot of mental health stuff is easier prevent than it is to fix.
I think the coaching industry sprung up as a result of people realizing that they want help but not feeling like they’re sick enough, and not realizing that therapists are very well-equipped to support people who aren’t necessarily broken. They just want to better understand who they are and level up in the world. That prompted this idea of a mental health gym. I met up with my co-founder, Alexa Meyer, who was working on a similar idea, and together we decided to try to bring clinical integrity to the world of mental health tech.
RH: So your mental health gym is more focused on the prevention of mental health problems?
EA: Right. I think a lot of the mental and emotional anguish that people feel is a result of not being given the space and tools and support and permission to feel their emotions as they happen. If we can teach people how to lean toward their uncomfortable emotions instead of away from them, a lot of bigger problems will be prevented.
RH: You were trained as a psychodynamic therapist, and this space is dominated by CBT work. A lot of folks come to treatment saying, "Give me tools, give me tricks and tips” and that sort of thing. I'm wondering how you wed those together in Coa. What kind of psychodynamic thoughts are you bringing to this?
EA: I'm all for tools and tricks and I think CBT has plenty to offer as a tool. But my feeling is that trying to lead the mental health revolution with CBT is colluding with the defense. People want a quick and easy solution because that would be quicker and easier. It's not actually what works, and Coa is one of the only analytically informed mental health startups. I feel very strongly about that because I believe the true way to healing and feeling better in the world is not about “whack-a-moling” symptoms. It's about helping people understand the root of their suffering. It's about helping people face just the existential complications of being a human and about building relationships. And really at its heart, psychodynamic therapy is about understanding your relationships through your relationship with your therapist.
Everything we do at Coa is rooted in psychodynamic thinking, even when we do offer CBT frameworks and tools, the idea is, look, here are some things to get you through a tough time but ultimately if all you do is fix a symptom without understanding what the symptom is trying to tell you, then you're just going to have it pop up as a different symptom later. Jonathan Shedler, who is a leading voice in this modern psychodynamic space, talks about how most symptoms like depression and anxiety are akin to a fever, which is a nonspecific symptom.
RH: A fever is a signal.
EA: Right, the fever itself is not usually the problem. The fever is what's alerting us that there is a problem. And if all we do is take Tylenol and quiet a fever over and over and never find out what it's trying to tell us, we're doing ourselves more harm than good. And I think in the world of mental health tech companies are saying, "Oh, we want a quick, easy solution, great. Here's a quick, easy solution." But that's not actually what's going to help people heal. So we're trying to do something different.
RH: Clients often present with something like, "I'm anxious. Help me calm down." We can give them a breathing exercise, but they don't often know there are other steps that can be taken to help them address the deeper underlying issue.
EA: And that's also why this metaphor of the gym is great because it's like, don't wait until you're having debilitating anxiety to work on yourself. If you start doing the work now, you might never get to the point where you're desperate for a tool because you’ll have equipped yourself with the ability to face things when they're small problems, instead of waiting until they coalesce into one really big problem. So, again, we're happy to help people think about how to manage difficult moments, but what we pair that with is the ongoing long-term work to diffuse issues over time.
RH: You mentioned that one of the crucial parts of dynamic work is the relationship with the therapist. How does that translate to the mental health gym? Are people building relationships with the people who are working with them? How does that work in that context?
EA: The mental health gym supports people through three different avenues. One of them is one-on-one therapy matchmaking, and all of the clinicians in our network are psychodynamically trained. They practice in all kinds of ways but they all believe that the relationship is key to a person getting better. We provide a free matchmaking service where we help you find a really great therapist. Right now, that's in California and New York, but we’ll be expanding, and we're certainly interested in connecting to psychodynamically trained therapists all over the place. The second part of what we do is therapist-led emotional fitness classes. These classes, which are all created and taught by licensed therapists, are helping people with their ongoing, proactive emotional health work. We've essentially figured out what an emotional push-up is and how you do one. That's what we're teaching in our classes.
The curriculum is based on research I did about a decade ago, where I interviewed a hundred psychologists and a hundred entrepreneurs and asked them, "How would you know if you were sitting across the table from an emotionally healthy person? What does that look like? What does that feel like? What do they do? What do they not do?" This research was an interpretive phenomenological analysis, so I coded all the interviews for themes. Out of this research came what I call the Seven Traits of Emotional Fitness.” These are the seven things that emotionally healthy people are working on all the time: self-awareness, empathy, mindfulness, curiosity, playfulness, resilience, and communication. In our classes, you're learning how to work on those seven things a little bit at a time.
And then the third component of what we do is community. You're doing this work alongside other people who are also interested in working on themselves. Our philosophy is emotional fitness is an individual journey but a communal pursuit. Just like when you go to the gym, you have to lift your own weight, no one else can do that for you. If you're doing it alongside a bunch of other people who are also lifting weights and who can spot you and show you where you've been and where you're going, it's a lot easier to keep on that routine. So that's what we're doing in these classes. You're doing your own psychological work but you're doing so alongside other people who are also working on themselves and with the safe container of a licensed clinician. I'll specify the classes are not meant to be group therapy. They are classes. It’s a way of learning things. So individual therapy, these classes, and community.
RH: To build community, are you hoping friends will join together, or are there ways to meet other people?
EA: We help people find like-minded folks. We have classes for BIPOC-identified leaders, for people in romantic relationships, for female-identified folks. We help people do this work along people with a shared experience.
RH: Where is therapy stigma right now?
EA: We've come a long way, but we have a very long way to go, obviously. It's been very cool to see public figures talking more about being in therapy and about doing their own work. And I get the sense that this younger generation is much more comfortable talking about therapy. It's more of an option, which is so great, but there still is a big stigma. And I think the true root of that, if I'm putting my psychoanalytic hat on, is that we all have a fear of dependence. It's scary to realize that we don't have everything we need and that we need others to get to where we want to go.
RH: Twenty-somethings always seem to strive for independence, but maybe asking for help isn’t so scary right now.
EA: I think there will always be a complicated relationship with that kind of support, but I think that we're making our way. And what I've seen that’s very cool with Coa is a lot of people come in because they like this metaphor of the gym. They don't necessarily see themselves as someone who needs therapy but a huge percentage of people who take our classes end up asking for help finding a therapist because we're able to demystify and destigmatize the idea of doing that kind of work.
RH: Certainly we're in a different place now than we were in 2019. Back then, people weren't talking about their anxiety or burnout nearly as much. Now, many therapists have full waitlists. People talk about therapy a lot more now and are very open about it, they're not hiding it.
EA: Well, the pandemic was a forcing function. I'd say if there was a silver lining, it was that. I don't think anyone can now deny that life is going to throw things at you that you're not necessarily equipped to handle on your own. And I think necessity has really created a sort of permission to open this space up to more people. Even really strong, capable people had a really tough time over these two years. I think it shifted this idea that you have to be broken to need support.
RH: I remember early on in the pandemic, some of my clients whom I’d been working with for a long time on their anxiety or depression noticed the people around them suddenly experiencing their own mental health crises. They then felt equipped to help share what had worked for them.
EA: Yeah, It's been a unifier in a way.
RH: You mentioned that one of the fears people have about therapy is the fear of dependence. There's also the fear of knowledge: "Oh my God, what happens if I open the door and look inside, what am I going to find?" That can be pretty terrifying.
EA: We're so good at hiding things from ourselves.
RH: We are. Do the classes and community help break down that wall?
EA: Definitely. It's very bite-sized. You're exploring things a little at a time and with a lot of support. It feels more approachable. The way we define mindfulness at Coa is becoming more comfortable being uncomfortable. It's really just this core idea that this work is hard. If you go to the gym and you're running on the treadmill and you aren’t uncomfortable, you're probably not getting any stronger. Similarly with your emotional work, it’s going to be a little bit uncomfortable, but that discomfort is in service of growth and strength and the ability to do more than you could before.
RH: Was any of your research surprising for you or did anything unexpected come out of it?
EA: It was validating more than anything, this idea that just like physical health, emotional health has components. If you want to be physically healthy, you need to sleep well, you need to eat well, you need to exercise, you need to have friendships. All of these things contribute. It was nice to see that there are some overarching ways that people can approach emotional health because it can feel very nebulous. It's nice to have clear places for people to start. I think that was helpful.
I'd say one thing that was delightful for me to see was the importance of play and playfulness. The way analytic thinking approaches conceptualize play is that play is how anything new is created. Therapy is essentially teaching people how to play. Play is saying “yes and,” and removing constraints and being able to imagine a reality that's not quite there yet. These things are so important, and it was nice to see some evidence that supports the importance of play in a healthy psychological life. I read a study years ago that showed that people who play regularly live longer by a significant number of years than people who don't play regularly. That's how important it is.
RH: And yet so difficult for a lot of adults to do when they have their nose to the grindstone.
EA: Play is vulnerable. When we play our guard comes down naturally, and that's scary if you're a person who works really hard to keep your guard up. So it's tough to do, but then when you do it, you see a lot of benefit from it.
RH: Where do you want this to go?
EA: We're already nationwide in the sense that anyone can take our classes. In fact, we have people from every continent, except Antarctica, taking our classes. We want the therapy to be available in all 50 states but really our goal is to be the SoulCycle or Peloton of emotional fitness. What Nike did for running or Lululemon did for yoga, we want to do for mental health, without sacrificing clinical integrity. If you think about 20 years ago, if someone said they were going for a run, you'd be like, "Why? Who's chasing you?" And now it's just a given. "Oh yeah, of course you're going for a run." That's our hope, that 10 years from now saying you're going to an emotional fitness class will be as unremarkable as saying that you're going to a yoga class.
RH: I work in a big building that’s filled with therapists, in a therapy-friendly area, and I still see people getting on the elevator and looking down as if everyone knows what they're there for.
EA: For sure. And the other aspect of this for me is not just to change things for the consumer, but also for clinicians. I want therapists to know that there are lots of ways to make use of the hard work that you've done to become a clinician. There are a lot of people out there with a megaphone who have no idea what they're talking about, and we really want to support people who've done the hard work to understand the human condition and be able to support others on a bigger scale. Like I said, all of our classes are taught by licensed therapists, and for the one-on-one therapy we make it easier to find good clients that are the right match for you. We want to help therapists become better known and heard for the wealth of knowledge that they have.
RH: So this is a step beyond therapist listing websites. You're talking about actually looking at clients and therapists and saying "I think these two might be a good match."
EA: Right. We also have billing software that makes it really easy to be paid and all of that. We don't hire our therapists, we want therapists to maintain autonomy. Our therapists are going to make a lot more with us than they would in a group practice or working at a clinic. In exchange, we get to provide our community with really quality, vetted, experienced therapists.
RH: Many therapists might look at this and think, "Oh, this tech stuff, it's too fancy." How are you countering that?
EA: Clinical integrity is one of our most important values, and I hold it strongly in everything we do. I know that every interaction with us as a company is part of the therapeutic experience, and we take that really seriously. First of all, we're one of the few mental health companies that's actually being run by a clinician. I'm making sure that everything we do is thoughtful in that way. All of the people creating and providing services are licensed clinicians, and they're being paid well. We’re not using technology to replace the relationship.
The goal of the app is not to keep people in the app and away from actual relationships, it's to connect people to each other and to their clinician. We really try to treat our employees with the same integrity and psychological mindedness that we treat our customers. We have a deep respect for confidentiality. We're not selling customer data as a way of making money. We really think that part is important. The goal is to change what it means to be in mental health tech. Like I said, it's one of the very few—if not the only—analytically-informed venture-backed startups, and we intend to maintain that as we scale.
RH: What does “Coa” mean?
EA: Coa is short for Coalesce, which means growing together. That's what we're helping people do: grow not only together, alongside each other, but together as a community, and to come together to support each other. That's our goal, and it's been really cool to see how it's landing with people.
RH: What would you have to say to a skeptical therapist who says "That may be too young for me or too techy,” or something similar? What might help them understand your mission a little bit better?
EA: Well first of all, I'd say I understand and appreciate the skepticism because there are a lot of people out there doing it the wrong way, and I'm glad therapists are being thoughtful about who they engage with. But I'd also say it's better experienced than explained. There's really no downside to working with us as a clinician. We don't take money from you unless you're actually making money. And our therapists have had such amazing success, and see their clients for a really long time because our matchmaking process is really thoughtful and thorough. So I would say just come give it a try, come drop in on a class or talk to us. I think you'll see we’re really doing things quite differently.
Ryan Howes, PhD, ABPP, is a psychologist, writer, musician, and clinical professor at Fuller Graduate School of Psychology in Pasadena, California. Contact: firstname.lastname@example.org.
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