Latest / The Mental Health Evolution / Ep 38: Advocacy, Autonomy and the Future of Psychotherapy with Linda Michaels of PsiAN

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Ep 38: Advocacy, Autonomy and the Future of Psychotherapy with Linda Michaels of PsiAN · The Mental Health Evolution

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(Transcribed by TurboScribe. Go Unlimited to remove this message.) This podcast is part of the Frederick podcast
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network.
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Learn more at listenfrederick.com.
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Welcome to Mental Health Evolution, a podcast about
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what's changing in mental health and why it
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matters.
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I'm your host, Rachel Harrison, inviting you into
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honest conversations with people from all perspectives in
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the field, clinicians, tech founders, investors, insurance companies,
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and all the folks in between.
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Let's explore what's working, what's not, and what's
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next.
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Welcome back, everyone, to the Mental Health Evolution
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podcast, where we are talking about how the
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landscape is quickly evolving in the mental health
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industry.
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Today, we are joined by Dr. Linda Michaels,
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a psychologist in private practice in Chicago and
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co-founder of the Psychotherapy Action Network, or
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CYAN.
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Dr. Michaels brings a background that spans clinical
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practice, psychoanalytic training, and organizational consulting, along with
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experience advising organizations on strategy and systems-level
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change.
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Through CYAN, her work focuses on how psychotherapy
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is being shaped by post-pandemic shifts, the
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rise of digital mental health tools, and the
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growing influence of corporate and platform-based models
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in the field.
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So, as always, for our listeners, we like
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to highlight a few articles before we start
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talking to our guests, and these will all
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be in the show notes if you hear
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something of interest that you want to dig
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into a little bit more.
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So, the first article here is called, They
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Thought They Were Doing Good, But It Made
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People Worse?
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Why Mental Health Apps Are Under Scrutiny?
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And this article by The Guardian examines the
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rapid expansion of mental health apps after the
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pandemic, when demand for care surged and services
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quickly shifted online.
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It raises concerns that while these tools expanded
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access, they also introduced questions about quality, safety,
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and the growing influence of commercial incentives in
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mental health care.
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The next article I want to highlight is
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called, Chatbots and AI Therapy Are Filling Gaps
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in Mental Health Care, But Regulation Is Lagging.
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And this is from the Washington Post.
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We've also definitely had some podcasts about regulation,
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so feel free to check those out as
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well.
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But this article explores the increasing use of
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AI-driven tools to address gaps in mental
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health care access.
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It highlights both the appeal of these technologies
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in a strained system and the concerns about
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oversight, clinical validity, and whether regulation is keeping
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pace with the adoption of these tools.
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And then lastly, the third article I want
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to talk about is actually from the group
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that our guest represents today.
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This report is from Cyan, and it's called,
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Practice Management Companies, What Therapists Need to Know.
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And in this report, Cyan looks at the
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rise of practice management companies that support therapists
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with billing, scheduling, insurance navigation, and other administrative
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functions.
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You might have heard us refer to them
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as MSOs or managed service organizations on this
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pod.
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It also highlights concerns from clinicians about transparency,
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autonomy, and how these platforms may be changing
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the structure of private practice and psychotherapy delivery.
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So without further ado, I would like to
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say thank you so much, Dr. Michaels, for
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joining us today.
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Thanks, Rachel.
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So glad to be here.
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So let's dive in.
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I am really curious about the Psychotherapy Action
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Network, or CYAN, and kind of how you
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got started and what it's all about.
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Yeah, we got started in 2017, and what
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it's all about basically is providing a voice
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for psychotherapists and highlighting what are some of
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the key issues in people accessing quality, effective
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psychotherapy, and also in empowering and supporting the
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clinicians who provide that care.
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So we started off, like I said, in
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2017, and as you mentioned in your opening
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notes, that was certainly a time pre-pandemic,
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but still a time of great need for
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psychotherapy.
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People were more and more open to seeking
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help.
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Stigma has been going down.
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It's good.
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People really, though, were confused about how do
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I find a good therapist?
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What steps do I take?
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How do I pay for it?
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What do I do?
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At a time of increasing need, there was
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actually a lot of limitations and reduction in
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the field itself.
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What do I mean by that?
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More and more grad schools were just mainly
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teaching the family of CBT therapies.
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More research dollars were going into that same
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area.
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Professional guidelines were coming out based.
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There are many ways to help people, and
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we were really only teaching and studying and
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researching kind of one family of therapies.
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It was just such a mismatch between what
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we should have been doing as a field,
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which is making more people more aware of
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the diversity of tools and types of therapies
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that are available so they could find the
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one that might help them the best.
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Great.
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Then how has that sort of evolved over
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time?
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I know that the pandemic has really changed
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everything, I would say, in our field.
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In some ways, really great that so many
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people reached out for care during that time.
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Also, that we were able to do telehealth
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and still help people that way.
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But it certainly has been a spotlight, I
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would say, on the field and I think
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has led to a lot of the evolution
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of things we're seeing, like tech companies and
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MSOs or private management companies, all kinds of
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AI chatbots that are acting as therapists.
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All of these things, I think, evolved out
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of so many people taking a good look
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at our kind of quiet, if you will,
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little industry over here and thinking, ooh, how
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could we add things to that?
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Yeah, I mean, I think over time what
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we have seen at Psychotherapy Action Network is,
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you know, starting off, you know, there's so
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much confusion, like I was saying about, I
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mean, the 400 therapy brands and what does
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evidence-based actually mean and how has that
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phrase been misused and if not co-opted
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and all the different ways the insurance industry
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has been so problematic and failing to provide
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parity coverage for mental health.
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But yes, now with the pandemic and even
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post-pandemic, the introduction of these totally new
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stakeholders, like private equity investors, venture capital investors,
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big tech, Google, Amazon, joining with the insurance
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industry, I mean, all of this is really
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unprecedented in our field.
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And so we are looking into all of
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that and, again, trying to stay true to
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how do we promote access to effective psychotherapy
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and how do we support the clinicians who
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provide that care and now how do we
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cut through all of this, all of this
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clutter to really continue to do that in
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our mission.
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Yeah, and so what are some of the
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examples of ways that you do support both
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therapists and people looking for care?
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Yeah, I mean, one of the main things
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that if we think about the public, we
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have done several large nationwide market research studies
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with the general public and these are with
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over 3,000 individuals representative of the U
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.S. population weighted to be just a mirror
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of the U.S. population demographically.
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And we really wanted to bring in the
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voice of the public into all of this
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and not just be talking amongst ourselves as
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professionals about what is therapy or how should
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it be done, but what do people want
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from us?
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What do people want from therapy?
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How do they find therapy?
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What stops them from seeking out or finding
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effective psychotherapy?
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So from our two large quantitative research studies,
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we really learned a great deal that had
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not been asked before and that kind of
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draws on my previous career in the business
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world doing a lot of big market research
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studies for major corporations.
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But we found that people really want, of
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course, they want a safe space, they want
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a therapist who's non-judgmental, all of that
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good stuff.
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But they, you know, really understand therapy is
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going to take some time.
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It's going to take some time to understand
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their issues and unravel them.
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And they really look at therapy as a
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way to invest in themselves and their future.
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You know, it's not a drag.
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It's not, you know, they're worried about how
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they're going to afford it, of course, but
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they really also want a therapy that goes
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beyond symptom management and really helps get to
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the root of their issues.
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So they know there's something deeper and they
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want to go deeper and they want to
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figure that out.
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That's great.
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I love that.
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And then how are you supporting therapists in
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providing that or in the everyday work that
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they do?
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Yeah, we've done a lot.
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I mean, we have, you know, written a
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lot.
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We have published articles.
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We have a book.
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We've done other research, which I think we'll
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talk about in a minute, with therapists on
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the practice management companies.
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We have a really active policy team that
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is looking, scanning the landscape and what do
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we need to be working on.
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You know, we're have a lot of position
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papers.
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We've done a lot of petitions to say,
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you know, practice guidelines have to incorporate all
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the evidence, not just a part of the
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evidence.
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The World Health Organization needs to have a
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psychotherapy manual that includes all the psychotherapies that
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are evidence-based, not only a subset.
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And so I think across all of our
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petitions, we've had like over 120,000 signatures
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and gotten supported different legislation and things like
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that.
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So we're really trying to do a lot,
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again, not to teach people how to do
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therapy.
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That's why they went to grad school and
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have their consultation groups and consultants, but rather
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how to function in this world, looking at
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the bigger picture, the bigger systems that, in
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which, you know, we're all trying to function
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and run our practices.
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I love that conceptualization because I think what
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I find most often when I talk to
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either practice owners or individual therapists operating right
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now, they're so good at looking internally, right?
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Especially at the care of their clients.
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And then beyond that, a lot of them
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have taken the look at their own business
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structure and how they're running things.
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And that feels like a big step, but
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very few, it's a much smaller number, are
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looking at what's happening around us in the
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industry.
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And I think for a long time, I've
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been in this field since 98, and we
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didn't really have to.
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It didn't seem like, think about that.
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I mean, maybe we should have been too,
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but now there are so many players and
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so many things happening every single day.
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Legislation-wise, consolidation-wise, there are big things
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happening and we have to.
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So it's a lot of things to be
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paying attention to, which is why I love
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that your organization helps sort of distill information
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and do petitions and help people know where
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they might best get support or support things
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that are happening.
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Yeah.
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Yeah, absolutely.
12:09
And we've had a lot of, you know,
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pushback and information sharing about apps and chatbots
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and things like that, the digital mental health
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tools, if you will, so much so that,
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you know, a big part of our history,
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which was terrifying at the time, but now
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I feel proud of, is that we were
12:29
actually sued by Talkspace for one of our
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letters that we, our letters of concern that
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we wrote to, I'm a psychologist, we wrote
12:38
it to the American Psychological Association and Talkspace
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promptly sued us for defamation and libel and
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$40 million in damages, which like I said,
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was absolutely a terrifying and harrowing experience to
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go through.
12:53
But the lawyer who represented us did so
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pro bono because she clearly saw this as
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a First Amendment free speech issue and as
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an example of a big company trying to,
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you know, bully us into silence.
13:08
So, you know, you have to ruffle some
13:11
feathers, I guess, and along the way, but
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we definitely got the attention of Talkspace and
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we've spoken out and petitioned the FTC against
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better help as well.
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And so, I mean, there is definitely a
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lot that we can do and we must.
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Wow, that's inspiring because I think that it's
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easy, like, like one of the things that
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I see when I look across all the
13:40
different disciplines with therapists is we don't have
13:43
a whole lot of unifying bodies in this
13:46
particular advocacy, right?
13:48
We have the APA, we have the NASW,
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and those are certainly great, but this seems
13:53
like a time when we all need some
13:55
unifying advocacy.
13:58
Yeah, and that actually from the very beginning
14:00
was one of our pillars is that we
14:03
welcome all disciplines, all people with all degrees,
14:07
all theoretical orientations.
14:09
You know, we want to bring people together
14:11
and break through those silos because having those
14:15
silos where we only talk to people who
14:18
have the same orientation or degree as we
14:21
do, that's how we limit our own power.
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And so really cutting across those silos and
14:29
artificial barriers and really bringing together the energy
14:32
of the professions is, I think, a key
14:35
part of our strength.
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And I think that's why we have nearly
14:38
7,000 members and individuals and about 90,
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95 organizational members.
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So we're really trying to build, you know,
14:49
that collective voice and source of support.
14:52
I love that.
14:53
And for our listeners, if that's something that's
14:56
of interest to you, we will certainly include
14:58
ways to get involved with organization in the
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show notes as well.
15:03
But I want to take a few minutes
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to dive into this article specifically about practice
15:08
management companies.
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How would you describe these companies in plain
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language and what is it that you think
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is most important to note about this article?
15:17
Yeah, I mean, in plain language, what these
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companies are is they are a middleman that
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sit in between the therapist and the insurance
15:28
company.
15:29
So they take a cut for doing so,
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and they get paid by the insurance company.
15:36
And they really function like a group practice,
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except at a humongous scale.
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Some people call them mega group practices.
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But they purport to offer a number of
15:49
the benefits that you would get if you
15:52
joined a group practice.
15:53
However, in our research, we found that really
15:56
they only offer a sliver of those benefits.
15:59
I mean, the reasons a lot of therapists
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join a group practice is for marketing support,
16:04
for colleagues, for their own health insurance benefits.
16:10
And, well, these mega groups do offer marketing
16:13
support.
16:14
I mean, they don't offer the colleagueship that
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you don't get benefits.
16:18
You do become a 1099 contractor to these
16:21
companies, and they do your billing.
16:24
They will credential you with the insurance company
16:26
at the beginning.
16:27
They'll do the billing.
16:28
And they do offer some attractive things like
16:31
payment every couple of weeks on a regular
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payment schedule.
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So you're not waiting, like, when is the
16:37
insurance company going to pay me for these
16:39
sessions I already did?
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And they also, as part of their value
16:44
proposition and their marketing materials, say, if you
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join us, you will make more money because
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we represent tens of thousands of therapists and
16:53
we can negotiate a better deal with you,
16:55
for you, with the insurance company than you
16:57
can get on your own.
16:58
Well, in our research, which, you know, these
17:01
were becoming very popular, and we wanted to
17:04
do some research and hear what actual therapist
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experiences were with these companies.
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In our research study, surveying nearly 700 therapists,
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we found that, well, you have a 50
17:16
-50 chance of actually making more money.
17:19
50% of the therapists said, yep, I
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am making more, but 50% actually said,
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no, I'm not.
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I'm making the same, or a third said,
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I'm actually making less.
17:29
So there are really a lot of trade
17:32
-offs as well.
17:34
Like I said, you become a 1099 contractor
17:37
to this entity.
17:38
They hold all of the patient data.
17:40
So if you ever leave, you have to
17:42
recredential and recreate all of that data yourself.
17:46
And then I think, you know, one of
17:48
the big things is that there's really virtually
17:52
no transparency on who actually owns these companies.
17:56
Who are you actually becoming a contractor to?
18:01
And we asked, you know, if you knew
18:03
that these companies had major ownership or investment
18:06
stakes by the insurance companies, would you work
18:09
with them?
18:10
And 85% of the therapists said, no.
18:13
I mean, we're trying to find ways to
18:15
limit our exposure to insurance company.
18:19
But in fact, all of these practice management
18:21
companies have major ownership or investment stakes by
18:25
insurance companies, United, Blue Cross, Cigna.
18:30
So, and that is not made clear to
18:32
therapists.
18:33
So I think there's a real difference in
18:34
terms of, you know, what their marketing message
18:37
is and then when the realities are.
18:40
Yeah, exactly.
18:41
I mean, that was something that really stood
18:44
out to me in the article as well
18:46
is knowing that 70 or 60% or
18:49
whatever of these companies is owned specifically by
18:52
the insurance company.
18:53
They're kind of paying themselves then, right?
18:57
Yeah, the percentage is actually a lot higher
18:59
than that.
19:00
It's virtually all of them.
19:01
And yes, the insurance company, every time you
19:03
do a therapy session, the insurance company is
19:05
paying itself as an owner or a major
19:08
investor in these practice management companies.
19:12
And then, of course, there's a lot of
19:13
data privacy concerns.
19:15
Headway right now is being sued in a
19:17
class action for sharing data with Google.
19:20
And just conveniently, just so happens, Google is
19:24
one of the owners of Headway.
19:26
So that made it very easy for Headway
19:28
to share data with Google.
19:30
And now there's the whole kind of AI
19:32
scribe function or feature that these companies are
19:37
marketing where, you know, using AI tools or
19:41
recording entire therapy sessions to create a transcript
19:45
and then produce and documentation, a note or
19:49
progress report or treatment plan or something like
19:52
that using AI tools.
19:54
And then if you dig way down deep
19:56
into the terms of service, you see they
19:58
say all of our AI stuff is handled.
20:01
We outsource that to a third party AI
20:03
company and we trust them to keep it
20:06
de-identified and anonymous and at arm's length
20:09
and all that stuff.
20:11
But, you know, we've heard so many times
20:13
we've learned the lesson that data can be
20:16
re-identified and, you know, it's not all
20:19
that safe.
20:20
But the companies are really trying to keep
20:22
that at an arm's length.
20:24
But recent studies also, a recent article, I
20:27
should say, also shows that, you know, Talkspace,
20:29
for example, is mining all of the text
20:34
transcripts it has between clients and therapists to
20:38
create, train and create its own LLM.
20:43
Yeah.
20:43
So, you know, I think this is just
20:46
the wave of the future with all of
20:48
this material that clinicians are making available to
20:54
these practice management companies will be used by
20:57
those practice management companies to ultimately create AI
21:01
LLMs or chatbots to try to substitute for
21:06
human therapists.
21:08
Yeah.
21:08
And just to be clear, large language models
21:11
is what you're talking about with LLMs. Yeah.
21:14
Yes.
21:15
Yes.
21:15
Those are my personal initials LLM, but that's
21:17
not what I'm talking about.
21:19
Do you want to tell us something about
21:20
yourself?
21:21
Am I talking to a person or not?
21:25
Oh, goodness.
21:27
Well, that is all such good information and
21:31
so much to process.
21:32
We are about out of time for this
21:35
episode, but I would love it if you
21:37
have something that you think is really important
21:40
to leave with our listeners, whether they be
21:43
businesses in the industry, therapists themselves or clients
21:47
seeking care.
21:49
Yeah.
21:50
I would say on the client side, you
21:52
know, to keep looking for a therapist who
21:56
will provide you the kind of therapy and
21:59
the kind of relationship that feels like a
22:01
good fit, a good trusting fit for you.
22:04
It's out there.
22:05
You can find it.
22:06
And we are actually launching some tools to
22:09
help people do that, a nationwide directory of
22:12
clinics.
22:13
And then I will say for the therapists
22:15
out there to remember, you know, any business
22:19
decision that you take for your practice at
22:21
heart is really a clinical one.
22:23
And to pay as much care and consideration
22:26
and thought in how you do your billing
22:29
or all those kinds of things as you
22:32
do with any decision you're making in treating
22:34
your patients.
22:36
And that, you know, we're never going to
22:38
have the money or the deep pockets or
22:40
the lobbyists or whatever that all these corporations
22:43
have.
22:44
But we have the knowledge, the care, the
22:47
training, the standards of our profession.
22:50
And that should guide us.
22:52
It means a lot.
22:54
And we also really have to stick together
22:56
because we're not going to have those deep
22:57
pockets, but we do have all that other
23:00
good stuff.
23:01
And we have to stick together and push
23:03
back to protect and advance our profession.
23:07
Wow.
23:08
I love that.
23:09
On that note, Dr. Michaels, thank you so
23:11
much for being here.
23:13
Thank you for the advocacy work that you're
23:15
doing.
23:15
And we will definitely provide opportunities for people
23:18
to connect with you if they're interested in
23:20
the show notes.
23:21
Well, thank you so much.
23:22
And you are doing your personal advocacy and
23:25
creating this pod and making it available to
23:27
everyone.
23:28
So I really commend you for that and
23:30
really appreciate your efforts.
23:32
Thank you.
23:33
To our listeners, we will be back next
23:36
week with more relevant issues in the mental
23:39
health industry.
23:40
Bye for now.
23:42
Thanks for listening to the Mental Health Evolution
23:45
podcast.
23:46
Join the conversation, find us on socials, send
23:49
us your thoughts and tell us what you're
23:51
seeing in your corner of the mental health
23:53
world.
23:53
Until next time, stay curious and keep evolving.