Advocacy, Autonomy and the Future of Psychotherapy with Linda Michaels of PsiAN

welcome to Mental Health Evolution, a podcast about what's changing in mental health and why it matters. I'm your host, Rachel Harrison, inviting you into honest conversations with people from all perspectives in the field. Clinicians, tech founders, investors, insurance companies and all the folks in between. Let's explore what's working, what's not and what's next.

Welcome back everyone to the Mental Health Evolution Podcast where we are talking about how the landscape is quickly evolving in the mental health industry. Today we are joined by Dr. Linda Michaels, a psychologist in private practice in Chicago and co founder of the Psychotherapy action network, or CYAN. Dr. Michaels brings a background that spans clinical practice, psychoanalytic training and organizational consulting, along with experience advising organizations on strategy and systems level change through cyan. Her work focuses on how psychotherapy is being shaped by post pandemic shifts, the rise of digital mental health tools, and the growing influence of corporate and and platform based models in the field. So as always for our listeners, we like to highlight a few articles before we start talking to our guests and these will all be in the show notes if you hear something of interest that you want to dig into a little bit more. So the first article here is called they Thought They Were Doing good But It Made People why Mental Health Apps are under Scrutiny and This article by the Guardian examines the rapid expansion of mental health apps after the pandemic when demand for care surged and services quickly shifted online. It raises concerns that while these tools expanded access, they also introduce questions about quality, safety and the growing influence of commercial incentives in mental health care. The next article I want to highlight is called Chatbots and AI Therapy are Filling Gaps in Mental Health Care, But Regulation is Lagging. And this is from the Washington Post. We've also definitely had some podcasts about regulation, so feel free to check those out as well. But this article explores the increasing use of AI driven tools to address gaps in mental health care access. It highlights both the appeal of these technologies in a strange system and the concerns about oversight, clinical validity, and whether regulation is keeping pace with the adoption of these tools. And then lastly, the third article I want to talk about is actually from the group that our guest represents today. This report is from Cyan and it's called Practice Management what Therapists need to Know. And in this report, CYAN looks at the rise of practice management companies that support therapists with billing, scheduling, insurance, navigation and other administrative functions. You might have heard us refer to them as MSOs or managed service organizations on this pod. It also highlights concerns from clinicians about transparency, autonomy, and how these platforms may be changing the structure of private practice and psychotherapy delivery. So without further ado, I would like to say thank you so much Dr. Michaels for joining us today.

Oh, thanks Rachel. So glad to be here.

So let's dive in. I am really curious about the Psychotherapy Action Network or cyan, and kind of how you got started and what it's all about.

Yeah, we got started in 2017 and what it's all about basically is providing a voice for psychotherapists and highlighting what are some of the key issues in people accessing quality, effective psychotherapy, and also in empowering and supporting the clinicians who provide that care. So we started off like I said in 2017 and as you mentioned in your opening notes, that was certainly a time pre pandemic, but still a time of great need for psychotherapy. People were more and more open to seeking help. Stigma's been going down. It's good. People really though, were confused about how do I find a good therapist, what steps do I take, how do I pay for it, what do I do at a time of increasing need. There was actually a lot of limitations in the and reduction in the field itself. What do I mean by that? More and more grad schools were just mainly teaching the family of CBT therapies, more research dollars were going into that same area. Professional guidelines were coming out based. There are many ways to help people and we were really only teaching and studying and researching kind of one family of therapies. And it was just such a mismatch between what we should have been doing as a field, which is, you know, making more people more aware of the diversity of tools and types of therapies that are available so they could find the one that might help them the best.

Great. And then how has that sort of evolved over time? I know that the pandemic has really changed everything, I would say in our field, in some ways really great that so many people reached out for care during that time, also that we were able to do telehealth and still help people that way. But it certainly has been a spotlight, I would say, on the field and I think has led to a lot of the evolution of things. We're seeing like tech companies and MSOs or private management companies, all kinds of AI chatbots that are acting as therapists. All of these things, I think evolved out of so many people taking a, a good look at our kind of quiet, if you will, little industry over here and thinking, ooh, how could we add things to that?

Yeah, I mean, I think over time what we have seen at Psychotherapy Action Network is, you know, starting off, you know, there's so much confusion, like I was saying about, I mean, the 400 therapy brands and what does evidence base actually mean and how has that phrase been misused and if not co opted and all the different ways the insurance industry has been so problematic and failing to provide parity coverage for mental health. But yes, now with the pandemic and even post pandemic, the introduction of these totally new stakeholders like private equity investors, venture capital investors, big tech, Google, Amazon, joining with the insurance industry, I mean, all of this is really unprecedented in our field. And so we are looking into all of that and again, trying to stay true to how do we promote access to effective psychotherapy and how do we support the clinicians who provide that care? And now how do we cut through all of this, all of this clutter to really continue to do that in our mission?

Yeah. And so what are some of the examples of ways that you do support both therapists and people looking for care?

Yeah, I mean, one of the main things, if we think about the public, we have done several large nationwide market research studies with the general public, and these are with over 3,000 individuals representative of the US population weighted to be just a mirror of the US population demographically. And we really wanted to bring in the voice of the public into all of this and not just be talking amongst ourselves as professionals about what is therapy or how should it be done. But what do people want from us? What do people want from therapy? How do they find therapy? What stops them from seeking out or finding effective psychotherapy? So from our two large quantitative research studies, we really learned a great deal that had not been asked before. And that kind of draws on my previous career in the business world, doing a lot of big market research studies for major corporations. But we found that people really want, of course they want a safe space, they want a therapist who's non judgmental, all of that good stuff. But they, you know, really understand therapy is going to take some time. It's going to take some time to understand their issues and unravel them. And they really look at therapy as a way to invest in themselves and their future. You know, it's not a drag, it's not, you know, they're worried about how they're going to afford it, of course, but they really also want a therapy that goes beyond symptom management and really helps get to the root of their issues. So they know there's something deeper and they want to go deeper and they want to figure that out.

That's great, I love that. And then how are you supporting therapists in providing that or in the everyday work that they do?

Yeah, we've done a lot. I mean, we have, you know, written a lot, we have published articles, we have a book, we've done other research which I think we'll talk about in a minute with therapists on the practice management companies. We have a really active policy team that is looking, scanning the landscape and what do we need to be working on? You know, we have a lot of position papers, we've done a lot of petitions to say, you know, practice guidelines have to incorporate all the evidence, not just a part of the evidence. The World Health Organization needs to have a psychotherapy manual that includes all the psychotherapies that are evidence based, not only a subset of. And so I think across all of our petitions we've had like over 120,000 signatures and gotten supported different legislation and things like that. So we're really trying to do a lot, again, not to teach people how to do therapy. That's why they went to grad school and have their consultation groups and consultants, but rather how to function in this world. Looking at the bigger picture, the bigger systems that in which you know, we're all trying to, to function and run our practices.

I love that conceptualization because I think what I find most often when I talk to either practice owners or individual therapists operating right now, they're so good at looking internally. Right. Especially at the care of their clients. And then beyond that, a lot of them have taken the look at their own business structure and how they're running things, and that feels like a big step. But very few, it's a much smaller number, are looking at what's happening around us in the industry. And I think for a long time, I've been in this field since 98, and we didn't really have to. It didn't seem like think about that. I mean, maybe we should have then too. But now there are so many players and so many things happening every single day. Legislation wise, consolidation wise. They're just big things happening and we have to. So it's a lot of things to be paying attention to. Which is why I love that your organization helps sort of distill information and do petitions and help people know where they might best get support or support things that are happening.

Yeah, yeah, absolutely. And we've had a lot of, you know, pushback and information sharing about apps and chatbots and things like that, the digital mental health tools, if you will. So much so that, you know, a big part of our history, which was terrifying at the time, but now I feel proud of, is that we were actually sued by Talkspace for one of our letters that we, Our letters of concern that we wrote to. I'm a psychologist, we wrote it to the American Psychological association, and Talkspace promptly sued us for defamation and libel and $40 million in damages, which, like I said, was absolutely a terrifying and harrowing experience to go through. But the lawyer who represented us did so pro bono because she clearly saw this as a First Amendment free speech issue and as an example of a big company trying to, you know, bully us into silence. So, you know, you have to ruffle some feathers, I. I guess, and along the way, but we definitely got the attention of, of Talkspace and we've spoken out and petitioned the FTC against better help as well. And so, I mean, there is definitely a lot that we can do and, and we must.

Wow, that's inspiring because I think that it's easy. Like, one of the things that I see when I look across all the different disciplines with therapists is we don't have a whole lot of unifying bodies in this particular advocacy. Right. We have the apa. We have the nasw, and those are certainly great. But this seems like a time when we all need some unifying advocacy.

Yeah. And that actually from the very beginning was one of our pillars, is that we welcome all disciplines, people with all degrees, all theoretical orientations. You know, we want to bring people together and break through those silos, because having those silos where we only talk to people who have the same orientation or degree as we do, that's how we limit our own power. And, and so really cutting across those silos and artificial barriers and really bringing together the energy of the professions is, I think, a key part of our strength. And I think that's why we have nearly 7,000 members individuals and about 90, 95 organizational members. So we're really trying to build that collective voice and source of support.

I love that. And for our listeners, if that's something that's of interest to you, we will certainly include ways to get involved with organization in the show notes as well. But I want to take a few minutes to dive into this article specifically about practice management companies. How would you describe these companies in plain language and what is it that you think is most important to note about this article?

Yeah, I mean, in plain language, what these companies are is they are a middleman that sit in between the therapist and the insurance company. So they take a cut for doing so and they get paid by the insurance company. And they really function like a group practice, except at a humongous scale. Some people call them mega group practices, but they purport to offer a number of the benefits that you would get if you join a group practice. However, in our research, we found that really they only offer a sliver of those benefits. I mean, the reasons a lot of therapists join a group practice is for marketing support for colleagues for their own health insurance benefits. And well, these mega groups do offer marketing support. I mean, they don't offer the colleagueship that you don't get benefits. You do become a 1099 contractor to these companies and they do your billing. They will credential you with the insurance company at the beginning. They'll do the billing. And they do offer some attractive things like payment every couple of weeks on a regular payment schedule. So you're not going to be waiting, like, when is the insurance company going to pay me for these sessions? I already did. And they also, as part of their value proposition and their marketing materials, say, if you join us, you will make more money because we represent tens of thousands of therapists and we can negotiate a better deal with you. For you with the insurance company than you can get on your own. Well, in our research, which, you know, these were becoming very popular and we wanted to do some research and hear what actual therapists experiences were with these companies. In our research study surveying nearly 700 therapists, we found that, well, you have a 50, 50 chance of actually making more money. 50% of the therapists said, yep, I am making more. But 50% actually said, no, I'm not, I'm making the same. Or a third said, I'm actually making less. So there are really a lot of trade offs as well. Like I said, you become a 1099 contractor to this entity. They hold all of the patient data. So if you ever le have to re credential and recreate all of that data yourself. And then I think, you know, one of the big things is that there's really virtually no transparency on who actually owns these companies. Who are you actually becoming a contractor to? And we asked, you know, if you knew that these companies had major ownership or investment stakes by the insurance companies, would you work with them? And 85% of the therapists said no. I mean, we're trying to find ways to limit our exposure to insurance companies. But in fact all of these practice management companies have major ownership or investment stakes by insurance companies. United Blue Cross, Cigna. And that is not made clear to therapists. So I think there's a real difference in terms of what their marketing message is. And then when the realities are.

Yeah, exactly. I mean that was, that was something that really stood out to me in the article as well is knowing that 70 or 60% or whatever of these companies is owned specifically by the insurance company. They're kind of paying themselves then. Right?

Okay, yeah, the percentage is actually a lot higher than that. It's virtually all of them. And yes, the insurance company, every time you do a therapy session, the insurance company is paying itself as an owner or a major investor in these practice management companies. And then of course there's a lot of data privacy concerns. Headway right now is being sued in a class action for sharing data with Google. And just conveniently, just so happens, Google is one of the owners of Headway. So that made it very easy for Headway to share data with Google. And now there's the whole kind of AI scribe function or feature that these companies are marketing where you know, using AI tools or recording entire therapy sessions to create a transcript and then produce a documentation, a note or progress report or treatment plan or something like that, using AI tools. And then if you Dig way down deep into the terms of service. You see, they say all of our AI stuff is handled. We outsource that to a third party AI company and we trust them to, to keep it de identified and anonymous and at arm's length and all that stuff. But you know, we've heard so many times we've learned the lesson that data can be re identified and you know, it's not all that safe. But the companies are really trying to keep that at an arm's length. But recent studies also, recent article, I should say, also shows that, you know, Talkspace, for example, is mining all of its, the text transcripts it has between clients and therapists to create, train and create its own LLM. Yeah, I read that. Yeah. So, you know, I think this is just the wave of the future with all of this material that clinicians are making available to these practice management companies will be used by those practice management companies to ultimately create AI LLMs or chatbots to try to substitute for human therapists.

Yeah, and just to be clear, large language models is what you're talking about with LLMs.

Yeah, yes, yes, those are my personal initials, LLM. But that's not what I'm talking about.

Do you want to tell us something about yourself? Don't pick your mic. Am I talking to a person or not? Oh goodness. Well, that is all such good information and so much to process. We are about out of time for this episode, but I would love it if you have something that you think is really important to leave with our listeners, whether they be businesses in the industry, therapists themselves, or clients seeking care.

Yeah, I will say on the client side, you know, to keep looking for a therapist who will provide you the kind of therapy and the kind of relationship that feels like a good fit, a good trusting fit for you. It's out there, you can find it. And we are actually launching some tools to help people do that. A nationwide directory of clinics. And then I will say for the therapists out there to remember, you know, any business decision that you take for your practice at heart is really a clinical one. And to pay as much care and consideration and thought in how you do your billing or all those kinds of things as you do with any decision you're making in treating your patients. And that, you know, we're never going to have the money or the deep pockets or the lobbyists or whatever that all these corporations have, but we have the knowledge, the care, the training, the standards of our profession and that should guide us. It means a lot. And we also really have to stick together because we're not going to have those deep pockets. But we do have all that other good stuff and we have to stick together and push back to protect and advance our profession. Wow.

I love that. On that note, Dr. Michaels, thank you so much for being here. Thank you for the advocacy work that you're doing and we will definitely provide opportunities for people to connect with you if they're interested in the show notes.

Well, thank you so much. And you are doing your personal advocacy and creating this pod and making it available to everyone. So I really commend you for that and really appreciate your efforts.

Thank you to our listeners. We will be back next week with more relevant issues in the mental health industry. Bye for now.