Marketing Mental Health Care: A Rising Challenge

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Mental health is having a moment. As online counseling, holistic medicine and unlicensed alternatives to therapy proliferate, psychotherapy remains a critical high-quality service. However, as the world shifts to accommodate more interest in (and access to) psychotherapy, corporation- or government-driven directives often compromise our ability to provide a consistently valuable service.

A recent New York Times article described a new project by CVS: to provide mental health services in their drugstores, complete with a rationale about how this would provide cheap services that were much more available to the public than current services. My colleague, Dr. Linda Michaels, with whom I serve on a Covid-19 advisory committee of the American Psychoanalytic Association, called this article to my attention. Her published New York Times letter, written with her colleagues Drs. Janice Muhr and Nancy Burke, as co-chairs of the Psychotherapy Action Network, could not have said it better:

While we face a growing mental health pandemic following the Covid-19 pandemic, the retail offerings from CVS, Walmart, and Walgreens are unlikely to help in significant ways.

Selling mental health assessments and offering a short series of cognitive-behavioral therapy (CBT) to the masses is what Britain and Sweden have already done in their national health care programs, and those programs have been costly and unmitigated failures. Not only was short-term CBT unhelpful, but mental illness actually increased in Sweden, and Britain is still reeling from the cost overruns and dismal results of its CBT program.

We know what helps people who are suffering — a trusted relationship with a well-trained professional who will help get to the root of issues. CVS’s services seem unlikely to provide that, and may be mainly designed to reduce expenses for its partner Aetna. We see insurance industry reform as much more helpful than new programs that offer watered-down services marketed as “therapy.”

A compelling op-ed letter to the Times — as difficult as these are to get published — is not a loud-enough alarm bell to warn of the dangers here. Tempting though it may be, the practice of “marketing” rigorous psychotherapy through untested mediums is fraught with complications.

Admittedly, it’s easy to understand the appeal of this idea. For starters, CVS and other popular pharmacy chains have enormous marketing potential; they lead with the message that psychotherapy is too difficult to access — and too expensive — and they can do it cheaper, faster, and better. (We have only to cite the example of the way CVS and their few competitors have cornered the market not only on drugstores, forcing smaller stores out of business, but have contributed to the rising prices of pharmaceuticals in the process.) The implications for sole practitioners or small businesses are not encouraging.

Moreover, there is also the issue of motive. Few consumers may know that CVS merged with Aetna in 2018 — like other insurance companies, Aetna has an incentive to limit coverage and reduce reimbursements. By conflating psychotherapy with retail therapy, CVS has taken on Aetna’s goals. The end result will not be a “cheaper, faster, better” treatment, but rather a full-scale reduction in standards of practice and professional compensation: a profit-driven model that considers the needs of the company before the needs of the client. (As you can tell, I’m not a fan.)

It’s not just CVS angling for industry inroads. Consider the proliferation of apps and online offerings that market their services by promising that you’ll be connected with a licensed therapist — “from anywhere, at any time. Save money while receiving high-quality care.”

The marketing materials for such therapy establishments do not mention that monthly out-of-pocket costs can far exceed the costs of seeing a quality therapist in person. A full-service package can run about $400 a month, far in excess of what most people in therapy would pay using their insurance. The marketing materials of companies also do not clearly disclose that information about customers may be used and sold for advertising purposes.

It behooves all of us to be familiar with these developments. Certainly, some of our colleagues will sign up for these platforms, but I believe they will run into serious problems, namely, not being free to conduct therapy well or as long as or frequently as may be indicated, and of being captured by corporate machinery. Many therapists already feel constrained by insurance companies like Aetna that second guess clinicians’ judgment. And, as other industries demonstrate, the benefits of mass production come at a significant cost.

The one-stop-shop approach might work well when you need to develop some photos and pick up some Tylenol, but the limits of this service are obvious. For one: The critical, intimate relationship between patient and psychotherapist is not something one can buy at a store. CVS’ “therapist of your choice” has, of course, already been vetted and chosen for you through a business model, not necessarily for quality of service.

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Consider two case studies on the efficacy of such programs: Sweden and Britain offered CBT on a large scale, hyping their national plans as providing better service at large savings. Launched in 2008, Great Britain’s disastrous program forced the closing of effective local services, and then the program was found to provide insubstantial relief to its patients. The service lost so many referrals that the number of people who befitted was very small; meanwhile, practitioners felt depressed that their work was so often a failure even while they were pressured to work long hours. Under the pressure of the new system, many talented psychotherapists simply burned out. (Paul Atkinson, 17th February 2020)

A comparable national experiment in Sweden found similar results: with respect to psychotherapy, narrowed choice disables a functional system. I cite one report (quoted here as translated from Swedish):

Rehabilitation Warranty strong economic governance of only cognitive-behavioral therapy (CBT) has quickly made the Swedish mental health narrower, less competent and less accurate. . . During the same period, according to the OECD, for a share of poor mental health, sick leave, and psychotropic drug consumption is one of the West’s largest. (Svenska Dagbladet: January 13, 2016.) (Emphasis my own).

These two national programs were “sold” to legislators and the public. They ultimately, and tragically, impoverished their country’s mental health by displacing and replacing what had been competent and flexible local services in the name of cost savings and efficiency. Now in our country, the advent of full-service online therapy, as well as the merging of psychotherapy and pharmacy services, likewise threaten the demise of the industry as we know it.

Large-scale changes to the messy, nuanced, deeply personal, and highly effective practice of psychotherapy must be scrutinized from every angle. The fate of the practice of psychotherapy must be taken seriously. As we witness the next chapter in the corporatization of mental health, we should do all we can to warn against the dangers of shopping for psychotherapists at the same place you shop for bubble gum.