Mental health startup Basis wants to replace therapy, but mostly provides a friend for a feeOctober 11, 2018
Andrew Chapin joined Uber in 2011, back when the company only had about 30 employees. Two years at Goldman Sachs had helped prepare him for stressful environments, but he still suffered from anxiety as he worked his way up in the ride-sharing company, eventually becoming an executive focused on global financing. He exercised, meditated, and did yoga, but therapy never seemed accessible.
The problems that Chapin — co-founder and chief executive of a new startup called Basis — lists are familiar to anyone who has tried to navigate the world of mental health services. Therapy was too expensive. He didn’t have time to find a therapist and attend regular appointments. And there was still a stigma around needing therapy in the first place.
Basis, Chapin tells me, hopes to “create a much more acceptable, convenient alternative to seeing a therapist.” Clients use the app or website to book a session with one of their unlicensed specialists. It’s cheap: $35 for one 45-minute session, compared to therapists who can charge upwards of $100 and often don’t take insurance. It’s convenient: specialists are often available same-day, you talk via video or phone so there’s no commute, and there’s no commitment beyond one session. Venture capitalists are certainly interested: the company has already raised $3.75 million.
But an unlicensed specialist is not the same as a trained therapist, which raises important questions about effectiveness, standards, and potential liability. And there’s a reason therapy usually lasts for more than one session — that’s what makes it work. Factors like training and on-going sessions, in fact, are what make therapy therapy instead of simply a chat with a friend.
Video therapy and telemedicine are not new. The practice is backed by peer-reviewed research and regulated by groups such as the American Telemedicine Association. It does, indeed, solve the hassle of a long ride to an office or clinic.
But Basis does not offer traditional video or chat therapy. Unlike apps like TalkSpace, Basis doesn’t connect you to licensed therapists, who are governed by professional boards and have at least a masters’ degree in social work. The service connects you to Basis specialists that complete about 15 hours of online training and, according to its website, don’t need a healthcare background or formal training in psychology. A GED, emotional intelligence, and a desire to help might be enough. (For context, training for the volunteer suicide hotline organization Samaritans involves eight 3-hour modules and observing a mentor for up to six months.)
That’s a far cry from the standards that professional therapists follow, says John Torous, a digital health researcher who is also a psychiatrist at a teaching hospital affiliated with Harvard Medical School. Therapists take professional licensing exams, are bound to federal laws about patient confidentiality, are required to report issues like child or elder abuse, and learn where to properly refer people for different levels of care. “Saying ‘unlicensed therapist’ is saying ‘unlicensed airplane pilot,’” says Torous. “They’re not a pilot then.”
Therapy licensing provides a promise for what a client can expect. “When you license people, what you’re really trying to do is to demonstrate that there is a level of training or quality in the services delivered and that people are going to behave in an ethical, appropriate manner,” says Peter Yellowlees, a psychiatrist at the University of California at Davis and a past president of the American Telemedicine Association. “And you have absolutely none of those guarantees if you use unlicensed people.”
Both federal and state law limit who can claim to provide mental health services, so although the Basis website claims it is “the modern approach to mental health,” Chapin notes that specialists cannot diagnose or treat medical conditions or offer medical services. What about liability? I ask. What if someone calls and is suicidal? “That’s something we’ve thought about a lot,” Chapin says. He adds that Basis has been in contact with the National Suicide Prevention Lifeline and has adopted that group’s best practices.
Basis’ chief science officer Lindsay Trent has a doctorate in clinical psychology and worked as a research psychologist at Stanford University. She developed the training programs for the specialists and checks in with them frequently, so every specialist that completes the training spends time (remotely) with her. (Chapin declined to say how many specialists the company employs, but mentioned that only 20 percent of applicants have made it through the training process.)
Specialist training consists of self-directed modules to teach common and clinically sound techniques such as structured problem-solving and motivational interviewing. Specialists also practice with video recordings and audio prompts, and participate in simulated sessions. “The model is one used frequently in medical training for doctors and nurses as well,” says Trent, who tells me that research shows you don’t need a PhD or a lot of training to be effective at therapy. “That finding is counterintuitive, even for me and I spent a decade in school,” Trent adds. The idea is that, over time, clinicians start to rely on intuition and stop using best practices anyway, and so “paraprofessionals or individuals who have been trained produce the same outcomes.”
The idea that anyone can be an effective therapist is wonderfully counterintuitive, but it’s not quite supported by the research — at least not the way that Basis is claiming. Trent referred me to various psychology studies to support her point, but the studies don’t support such grand claims.
One study that Basis provided investigated whether psychotherapists improved over time and found mixed results. However, the subjects in the study were already licensed psychotherapists. Similarly, another study Basis pointed to followed 22 PhD-level psychologists already working in university counseling centers. A third study from 1999 painted a more nuanced picture, but it even stated that “there is no consensus that experience affects outcomes,” claiming that some articles say that experience has no effect while others suggest the level of experience has a “strong, positive, linear relationship to outcome.” This article noted that it’s possible unlicensed paraprofessionals and therapists might be equally effective, but the academic definition of paraprofessional is likely different from the Basis definition. Typically, paraprofessionals are full-time workers who don’t have a specific professional credential — think teachers’ aide or healthcare clinic workers. It’s not just a catch-all word for “someone without a degree.”
It’s clear that many factors go into being a good therapist. The world would have many more good therapists if more training automatically equalled better performance and better outcomes. The research paints a complicated picture, but it’s a leap to go from “more experience isn’t automatically better” to “someone with 15 hours of remote training can be as effective as a PhD.”
When I booked a Basis session, I was matched with a specialist who is a lot like me: a 20-something Asian woman named Angie. I had selected that I wanted to talk about relationship problems and spoke honestly with her about a genuine issue in my life: that my mother has early-onset dementia and lives far away and I feel both horrified and helpless.
I liked Angie. She was easy to talk to, empathetic, and good at summing up what I said with statements like, “you feel like there’s a lot to deal with and you’re overwhelmed.” (True.) She asked all the “typical” therapist questions — how much social support I was getting, what techniques I’d tried to make myself feel better — and tried to keep the discussion concrete and workable. For example, when I said I wanted to “feel better,” she probed further by asking what “feeling better” would actually look like.
Angie was also realistic, both about my situation and what could be accomplished in our session. “We’re not going to be able to find a solution for this complex problem today,” she said, and then asked me to think about concrete steps I could take in the short-term. (We decided that I’d try to email my dad more.)
Talking to her felt comfortable, like talking to your emotionally intelligent, type-A friend who likes to be helpful. And maybe that’s the real problem with Basis.
The question therapy skeptics always ask is, “Why should I go to therapy when I can talk to my friends for free?” Basis doesn’t provide a good answer to that.
People pay for therapy because it’s a chance to talk to someone (who’s not involved in your life) in a consistent, structured, and reliable way. Picking the right therapist is important. You develop a rapport with your therapist and build trust over time, and the experience of that stable relationship is crucial to creating change. Therapy requires a number of sessions to really explore the issues, instead of a one-off chat that, says Torous, “might mean you’ll inevitably go along with whatever the patient thinks is the best approach because you don’t have time to discuss anything else.” So even though Basis’ “next steps” approach might be appealing to impatient folks who just want advice, the advice itself may not be the best.
To be fair, Basis doesn’t claim to solve all your problems. It’s not trying to help people who are suicidal. It doesn’t explicitly say it’s better than a $300-per-hour therapy session. But with messaging about how PhDs aren’t necessary and claims that mental health help has required paying hundreds of dollars per hour and visiting an office “until now,” the company oversells its usefulness. “Ultimately, you’re going to get what you’re paying for,” says Yellowlees. “You’re getting hopefully commonsense advice, but you’re not paying for any more than that because it’s unrealistic to say that you can help people in any meaningful way like this.”
And while the chat can be helpful, there are plenty of other, cheaper places we could turn. “Each of us knows someone in our lives that we can talk to that could be helpful and that person may not have trained experience in therapy,” says Torous, who points out that there are also plenty of free peer-listening groups, like 7 Cups of Tea. “But we don’t pay those people to talk to us when they’re distressed. We’re trying to commercialize something that’s like ‘supporting friends.’” Plus, friends often see our situation more clearly because they’ve talked to us for more than 45 minutes.
Basis may have started because Chapin wants people to take mental health more seriously, but its business model makes mental health seem frivolous. If mental health is important, and it is, people should be taking the take the time and effort to get real help. To truly help people, we should be doing things like working to reduce the cost of the service, instead of creating a poor man’s version that actually increases stigma by encouraging the therapy-phobic to choose a “specialist” instead. “I don’t think you’d see this in another field,” says Touros. “I don’t think you’d ever see a startup claiming that if you need surgery, they’re going to connect you with unlicensed people.” It doesn’t take mental health seriously at all.
We should see Basis for what it is: a $35 chat that could be useful, but not necessarily more so than confiding in a friend. The company shouldn’t use the language of therapy while not obeying its standards or, most likely, offering its benefits. Basis is to therapy what a cognitive-behavioral workbook is to sessions with a trained professional. One shouldn’t pretend to be the other.