The problem with subscription mental health services: Is there evidence to support their efficacy? (A serious issue)

Our mission as an evidence-based psychotherapy practice is to bring awareness to less than optimal practices that you may come across. It feels like our duty to bring the problems with subscription services to your attention.

There are many considerations when choosing a service to manage a medical or mental health issue. However, keep in mind that convenience may be incongruent with what is therapeutic. (You will see this phrase again later.) Here are some questions that occur to me on this matter:

• Are the services ongoing? Am I charged for each one or is it a monthly fee?
• Who are the clinicians (what is their experience) and are they compensated fairly?
• Do I get the same clinician each time or is it more like a consultation service?
• How often can I utilize the services? Does this match my goal in therapy?
• Is there a limit to the clinician(s) expertise and do I get a clear answer when asking this question of my clinician?

Additionally, there are ethical considerations with subscription services. There are also ethical considerations for on-demand therapy services (a clinician available right away). At face value, it seems like a good thing. Who wouldn’t want that? What could go wrong? Let’s think about this in the context of who is the client. When your therapist is on-demand… and you demand to see them, per se, then does the therapist become YOUR client? Traditionally trained psychologists are taught to always consider, in any given therapeutic relationship “who is the client?” This helps us determine how to apply our guidelines. On the one hand, the clinician is the expert, on the other hand, the client is the expert in their own experience. However, in order for this relationship to actually be therapeutic, there are boundaries and limitations just like with any other professional relationship. The purpose of therapy is to learn coping skills and to manage one’s mood independently, with the advice and guidance of a professional while providing an opportunity for the client to practice these skills independently. Any app or service (whether it be subscription, on-demand, or something else) that compromises this or enables the client to reach out to the therapy at any time is not actually promoting the long-term wellbeing of the client (unless in the case of an emergency). Think about this.

We often don’t question services that are convenient and seemingly reduce barriers to treatment; however, convenience may be incongruent with what is therapeutic. For example, let’s imagine that a young adult who has been meaning to seek therapy comes across an ad for a therapy service that seems to be convenient and might fit their needs and lifestyle. This individual becomes emotionally dysregulated relatively frequently and has traits of dependent personality disorder. Having a service with therapy on demand is going to reinforce the cycle of depending on others for their own wellbeing. There are other examples as well such as with clients who may have attachment issues, OCD, phobias, generalized anxiety disorder, etc. where therapy on demand is counterproductive. We have a term for behaviors that enable and reinforce a maladaptive coping style in anxiety: safety behaviors. (I’m not affiliated with this practice- I just really like their chart.)

Another thing that subscription services do is create a power dynamic that is unclear. A client may be entitled to having a therapist on demand because that is what was advertised/promised. This creates difficulty in implementing a therapeutic strategy that promotes independence and subsequent improved functioning/symptom reduction in the client. Why can’t the treatment still be applied? Because the client does not know the treatment protocol. Under normal circumstances, the client trusts the clinician to implement it and guide the client. When the client is not aware of the treatment, then certain demands and expectations interfere with the protocol. We really need treatment outcome studies for subscription services and randomized control trials comparing them to efficacy to traditional therapy (once weekly 45 minute appointments). Many treatments have a protocol that is evidence-based, which may also be difficult to implement with therapy on demand. Any evidence-based practice needs to be re-validated for use in a different modality such as telehealth or on-demand therapy, or texting therapy.

Sure, it might be better than not seeking therapy at all, but do the results result in improved long-term functioning?

It is increasingly important that practitioners in these settings provide recommendations to the client for other therapeutic avenues if the current modality is not demonstrating symptom or distress reduction. There is good evidence to support online therapy/telehealth, but the on-demand frequency is not yet been demonstrated as therapeutic. We have published best practices in the area of online therapy, and they should be understood and adhered to. It is also a clinician's job to understand the limitations of treatment and the settings in which it was not validated. This is our ethical responsibility. Just like anything else these days with catchy advertising, please ask many questions to make sure the service you will get is the service you are seeking and will meet the needs that you have.

But what if you don’t know what needs you have? This is a topic for another post. But! My practice has an upcoming service that can help with this. Therapy Needs Assessment. This is an assessment to help the client understand what type of therapy, therapist, and modality is most helpful and targeted given the concern at hand. It’s like an expert consultation for HOW to seek therapy. Appointments are available to schedule beginning April 17th.