Her mentor replied that whether or not to report was up to her, but recommended she instead advise her patient that, if caught, the family could lose the child to the state. The mentor warned the therapist that she might be at risk of legal retaliation from the patient if she abided by her duty, in license and law, to report child endangerment. The warning was unfounded; her state protects against that kind of retribution.
But thanks to Talkspace’s policy of patient anonymity, the therapist didn’t have access to her patient’s contact information, or even her name — factors that impeded her ability to warn the authorities. Unless patients tell them more, Talkspace therapists know patients only by their user name.
“So now I get to live knowing a [young] baby is being driven around by a drunk woman, I have no way to file on them, and Talkspace has put me in this position,” the therapist said in an interview in October, her voice breaking.
In the beginning of December, Talkspace sent therapists a new online course about the confidentiality policy. The new policy states that, if a therapist believes patients are a danger to themselves or others, they should ask the patient for contact information. If the patient won’t provide any, the therapist should contact the tech support manager or clinical leadership to see what contact information is available.
• Talkspace’s policy of patient anonymity impedes the ability of therapists to report dangerous situations
• Multiple therapists have been refused contact information when attempting to report behavior that poses a risk to patients or children
• Talkspace employees can read patient-therapist conversations for “quality control”
• While claiming to be merely a platform for independent therapists, Talkspace exerts control over therapist scheduling and interactions with patients, even giving therapists mandatory scripts
• After pay changes, Talkspace made an official policy that therapists could no longer complain in Slack
• It’s unclear which government agencies are responsible for regulating therapy apps like Talkspace
But prior to that, emergency policies were less clear. Therapists were instructed to contact a member of clinical leadership in the event of active suicidality or a specific threat to an individual; one therapist was told by Talkspace that, in the event of an emergency, someone would call 911 and give police the client’s IP address. Multiple former workers told The Verge they had reported a safety concern, and were denied access to client contact information.
Like many on-demand apps, Talkspace’s business model blurs the distinction between employee and contractor. But because Talkspace is dealing in health care, it raises another set of questions as well: if an app dictates much of how clinicians talk with patients, and totally controls access to client records, is it just a platform? Or is it a medical clinic, and thus subject to stricter rules and liabilities? If a patient is anonymous to their therapist, who is responsible for their safety and the safety of those around them?
For Talkspace therapists, the result can be confusing, and for patients, potentially dangerous. The Verge spoke with two current Talkspace therapists and five therapists who have left the company recently. Each described an atmosphere of micromanagement and disillusionment, a therapy clinic placing too big an emphasis on client retention at the expense of therapists’ well-being. All but one of the therapists expressed concern that the company doesn’t place enough focus on patient safety. They all spoke on the condition of anonymity, due to concerns over retaliation. Talkspace therapists sign a nondisclosure agreement, putting them at risk for speaking out.
All but one of the therapists expressed concern that the company doesn’t place enough focus on patient safety
In the last few months, the company has been making changes, not just to their safety policy, but to how they treat their workers, particularly around issues like time off policies and other employee / contractor tripwires. Several therapists linked the changes to a $15 million Series B funding round, announced in June, which put Norwest Venture Partners managing partner on the Talkspace board.
When reached by email for comment on this story, Talkspace co-founder Oren Frank suggested (incorrectly) that The Verge was conspiring with psychologist and Forbes blogger Todd Essig, who has written blog posts critical of Talkspace. Frank declined to speak on the record.
After being sent detailed questions by The Verge. Frank sent several legally threatening emails to editorial staff at The Verge, as well as to the CEO of Vox Media, The Verge‘s parent company, one of which answered two of The Verge’s questions; he never answered the others.
Over the next few days, Oren and his wife, Talkspace co-founder Roni Frank, sent three emails to all current therapists, telling them not to talk to journalists without approval, and warning them about sharing internal documents.
Talkspace is part of a small but growing ecosystem of “tele-health” companies, which seek to connect patients with health care providers over the internet or phone. They range from Spruce, where clients can message and video chat with dermatologists, to Maven Clinic, which allows women to access clinicians across the spectrum of women’s and children’s health. Major insurance companies, like Blue Shield of California, contract with telehealth companies to provide medical care to rural patients, or those with mobility issues.
Mental health care, in particular, is ripe for disruption. Of the 43 million American adults who will deal with mental health issues this year, less than half will receive appropriate care, according to the community-based nonprofit group Mental Health America. It’s difficult for many Americans to find affordable treatment, and stigma can discourage many from looking. Abusive relationships, too, can prevent people from getting help.
A handful of apps, including Talkspace, aim to make therapy less expensive and more accessible. Talkspace costs $32 a week for individuals, and signing up is simple. After entering your email and username, a chat room opens, and an intake counselor asks a little about you and why you’re signing up. The counselor then brings another therapist into the room and you begin the session, texting periodically throughout your day and receiving asynchronous responses once or twice a day. For a premium, $69 a week, you can also schedule four video chat sessions per month.
Talkspace claims to have 1,000 therapists and 300,000 active users… Competitor BetterHelp claims to have 1,000,000 sign-ups in total
Demand for this kind of therapy has been significant. Talkspace claims to have 1,000 therapists and 300,000 active users (although several therapists The Verge spoke to indicated that many of their paying clients at any given time were “radio silent,” that is, paying without using services). Talkspace competitor BetterHelp claims to have 1,000,000 sign-ups in total.
“…In some cases, Talkspace’s offered services may not be completely substitute (sic) for a face-to-face session by a licensed Therapist. You should never rely on or make health or well-being decisions purely on use of Talkspace. Never disregard, avoid, or delay in obtaining medical advice from your doctor or other qualified healthcare Therapist, or by traditional face-to-face appointment; (sic) because of information or advice you received through Talkspace.”
The informed consent statement provided by therapists directly to users as of late August 2016 reads, “Although risks are rare, I am aware that there are possible risks which include that the information I am able to give may not be sufficient for a diagnosis…If my therapist believes I need additional or other services, they may refer me to another specialist or type of care.” It never mentions that patients shouldn’t rely, or make decisions purely based on, Talkspace therapy.
Talkspace bills itself as “therapy for all,” advertising itself as treatment for service members with PTSD and other vulnerable populations. Until recently Talkspace allowed therapists to treat people anywhere in the world, but now if the patient lives in the United States, therapists must be licensed in the same state. Therapists are still allowed to take international clients.
Talkspace classifies its therapists as 1099 contractors, meaning that they don’t fall under the labor protections granted to full-time employees, though the company has a range of methods for controlling the way therapists work. Each therapist has a state license, in fields such as clinical social work and marriage and family therapy.
All therapists receive about half of what their clients pay to Talkspace. In the past, there have been stipends for “full-time” therapists who maintained a minimum number of patients, as well as for mentors, who received a small payment for guiding groups of newer therapists. Both of those programs have been eliminated.
Talkspace classifies its therapists as 1099 contractors, meaning that they don’t fall under the labor protections granted to full-time employees
“Each Talkspace therapist manages his or her own online private practice,” the company says in its FAQ for potential therapists. “Thus, the time commitment varies from therapist to therapist. We recommend therapists carry a minimum caseload and respond to clients daily.”
In the past, the company has demanded strict schedules from their therapists.
“When I first started, you were expected to be logged in six out of seven days,” a former Talkspace therapist told The Verge, explaining that the company later bumped that down to five days a week. “After your client posted, there was a countdown timer. If you didn’t respond after eight hours it would flash.” The flashing timer — which both patients and therapists could see — was later removed from the platform, according to the therapist.
One of Talkspace’s on-boarding requirements is to complete several online learning courses; new policies are often explained through a new required lesson. In an on-boarding slide for therapists from about a year ago, the company wrote, “Regardless of if you are out of town or at home, you need to log on twice daily as agreed upon as a provider, to engage with your clients. Once you’ve been a provider for SIX MONTHS then: Talkspace will allow one week off each year.” Therapists were also required to offer a free, 30-minute live session to every client, within a week on either side of the vacation time; many therapists have dozens of clients.
Those policies have loosened in the last few months. Now, there are no rules around vacation time, except that therapists have to give patients advanced notice, and let Talkspace know they’ll be away. The policy about live sessions before vacations has changed, too. Now there are two choices for therapists: either offer a 30-minute live chat to every client, or have clients freeze their accounts so therapists don’t get paid for time off.
Therapists also have a number of “scripts” they are instructed to insert into their chats under certain circumstances, which calls into question Talkspace’s claim that it is merely a digital landlord for therapists in private practice. Some of the scripts are mandatory, including one to advertise video chats. Therapists who don’t send the video script within 10 days of starting therapy don’t get paid for that month of working with the client, according to a memo distributed in July.
The company seems to keep close watch on patient attrition, and punishes therapists if too many patients leave
A script for therapists to use when introducing themselves to new clients reads, “My approach is collaborative, so we will both share our thoughts and ideas as we decide how we will work together…Let’s start by talking a bit about your goals as we begin this process. ”
Rules around scripts appear to have loosened lately. A July memo sent with the above script said it had been “tweaked…to sound more conversational,” which seems to support the accounts of several former therapists, who told The Verge they were intended to be used verbatim. However, a memo from November reads: “For your convenience, here is a sample script for time off. You should personalize it so it is in your voice.”
The company seems to keep close watch on patient attrition, and punishes therapists if too many patients leave. One current therapist described being punished with a 30-day ban from “PeopleSpace,” the room where therapists can get new clients, after patients left for reasons she didn’t feel reflected poorly on her work.
“It was like, what are you saying? I should keep people on just to get their next month’s payment?” the therapist told The Verge. “Just because they leave doesn’t mean I’m a bad therapist.”
Therapists working at Talkspace, like many platform-based workers, have been subject to sudden changes in pay. Last summer brought several changes in compensation. Mentors, senior clinicians who advised small groups of newer Talkspace therapists, stopped getting paid monthly stipends for the extra work, and the positions were eliminated. Additionally, a monthly stipend of approximately $1,500 for full-time therapists was taken away.
Then, in the middle of July, the Slack channels therapists used as both a water cooler and a primary line of communication with the company exploded in anger. Therapists wanted to know why they’d received unexpectedly small paychecks for the month.
The timing of paychecks had been shifted, a memo the next day explained, so that therapists’ payments would now be prorated. Before the change, therapists would receive their full half of whatever money Talkspace had gotten from their clients in that pay period. After the change, payments were meted out to therapists based on how many days they’d worked that month, allowing Talkspace to withhold payment if therapists broke rules. The change happened suddenly, meaning therapists got fractions of their usual paycheck in July, leaving many of them struggling to keep up with bills.
“We didn’t get paid for a month. It hurt people, and people left because of that,” a current Talkspace therapist told The Verge. “It was a significant pay difference — I was just starting out and really counting on that money.”
The Verge asked Oren Frank why the company made the change, and how many therapists left after the incident. “The fact that we grew to a certain scale and went to daily versus monthly Client based financial proration, effecting (sic) the timing, but not the amount of a Consulting Therapist’s collected fees, is really not a story of scandal no matter how you re-package it,” he responded by email.
“They make you promote the videos, because they want you to do video chat within the platform.”
Many therapists missed the initial memo about the changes, buried on the third page of a mid-June announcement from co-founder Roni Frank announcing higher-priced therapy plans. The change in pay structure was attributed to “User concerns.” Another memo a few days later suggested an additional reason for the change: the company would no longer pay therapists for their work if they didn’t follow the rule requiring the use of a pre-written script to advertise video chats to clients. (Both memos were reviewed by The Verge.)
“They make you promote the videos, because they want you to do video chat within the platform,” a former therapist told The Verge. “You have to offer it to them, and if you don’t then you don’t get paid.”
In response to the paycheck backlash in Slack, Talkspace closed at least one channel that Talkspace therapists used to talk amongst themselves. They also made a new rule for therapists, telling them Slack was for clinical use — not complaining.
“They put out some email with clinical guidelines about how we could converse on Slack, and how it was important not to say anything negative about the clinical team — basically telling us to shut up,” a current therapist told The Verge.
A former Talkspace therapist told The Verge she estimates at least 30 therapists left after the pay cut, or were cut loose for complaining too much. She decided to quit as well, so she let some of her patients know she was considering leaving, and that if she did they were welcome to continue seeing her through a different platform, or transfer to a new Talkspace therapist.
According to the therapist, one of her patients requested a transfer through the app, and a “matching agent” was transferred into the room. Shortly thereafter, the former Talkspace therapist says she was locked out of her account, with no access to medical records. According to a therapist contract from spring 2016, Talkspace owns all medical records and the therapist has no right to take them when they leave the platform, underscoring the question of whether Talkspace is just a platform for therapists to communicate with patients, or a medical provider hiring employees to staff their online clinic.
According to a therapist contract from spring 2016, Talkspace owns all medical records
The therapist learned that her patients were given a new Talkspace therapist, and informed that she had engaged in unethical practices and had been let go. “I got emails from a couple of my clients and they were like, ‘I don’t understand,’” she told The Verge. (Therapists, unlike patients, are not allowed to be anonymous on the platform.) “A lot of them were traumatized…I didn’t get to say goodbye, and that left me really hurt and broken, because I care about every client I had.”
This goes against the National Association of Social Workers’ ethics guidelines for ending therapy, which cautions therapists to do everything they can to “avoid abandoning clients who are still in need of services.” Therapists and patients, after all, aren’t interchangeable parts, and therapy is based on trust built between the two people.
Multiple therapists came to The Verge with similar stories. Several of them told The Verge they had received a threatening email from John C. Reilly, Talkspace’s general counsel.
“While, as Independant Consultant, you are absolutely free to work with one or more on-line platforms and create your practice as you see fit; you may not use the Talkspace Platform to conduct tortious interference with a Talkspace.com registered users (sic),” one of the letters read. “[A]s you are an Independent Therapist, we will let the state license boards govern your ethical responsibilities in this situation.”
As for how Talkspace found out about the therapists telling clients they’d leave, it is not clear who can read patient conversations or when. Co-founder Oren Frank declined to clarify the policy to The Verge.
It is not clear who can read patient conversations or when
Several former therapists were cut off from the platform and sent warning letters about poaching clients from Talkspace, after they told patients they were quitting and offered them a choice between coming with them to a different platform or staying with Talkspace. In at least one of those cases, a client requested a therapist transfer, and the “matching agent” who came into the room was able to read their previous therapy transcripts. In another case, a senior clinician told a therapist that her attrition rate was too high, and he would be “reviewing” some of her therapy transcripts and giving her advice.
A Talkspace lesson slide from about a year ago on “quality assurance” discusses reading rooms:
“We strive to provide the best therapy possible. To do so, we periodically test the room. These tests are performed randomly by Talkspace. During such a test period, or at any other time if an issue is identified regarding quality and (sic) assurance, [a member of the management team] will contact you to discuss the issue. In addition, rooms can be monitored in very particular circumstances by only licensed, clinical staff who have administrative privileges to do so.”
No definition of “test” is given on the slide.
While patient privacy can be a problem in online therapy, so too can patient anonymity. Though the exact requirements vary state to state, most states require therapists to report evidence of child abuse to an appropriate government agency. Many others also require therapists to report elder abuse, or warn the police or the intended victim if the therapist is worried about potential violence. This can be difficult, if not impossible, when therapists don’t know who their patients are.
A joint publication by the National Association of Social Workers and the Association of Social Work Boards, one of the few sets of standards developed for chat-based therapy, recommends that “Social workers who use electronic means to provide services shall represent themselves to the public with accuracy and make efforts to verify client identity and contact information.”
Until recently, the four-year-old company’s recommendation for helping patients who were a danger to themselves or others was to contact a member of senior management, according to current and former therapists. In a message to a therapist, a clinical leader said that, in an emergency, the company could give the police a client’s IP address, which is not always accurate.
In several cases uncovered by The Verge, Talkspace therapists asked a Talkspace employee for client contact information after they felt obligated to report dangerous situations and were rejected. More than one case of possible child endangerment went unreported, after therapists were denied even an IP address.
More than one case of possible child endangerment went unreported, after therapists were denied even an IP address
The therapist who felt she was legally bound to report a child being driven around by an intoxicated person told The Verge she had brought up the issue not just with her mentor, but with a senior member of the Talkspace clinical team. Still, she couldn’t access the client’s information. Another former Talkspace therapist said she spoke with the same clinical team employee for an hour about a pregnant substance abuser. She, too, was not given contact information. Instead, she was told to refer her patient to a higher level of care, which means helping the patient find a local therapist, or more intensive treatment, such as rehab.
Still other therapists ran into roadblocks with suicidal patients; their primary option consisted of sending patients a script that suggested they call 911, contact a suicide hotline, or go to the hospital. The therapists were instructed to stay in the chat with the client. If the therapist was worried about client safety, they could also contact a senior clinician to “discuss next steps,” according to a training slide from about a year ago. There were even fewer options for international clients, who might not have access to an emergency number in their country.
In many states, therapists are legally allowed to break confidentiality and inform emergency contacts if a patient is suicidal. In some cases, they can even be sued if they don’t. But that’s impossible without the emergency contact information that most medical providers collect.
In the beginning of December, the company sent therapists a lesson plan with new rules for emergencies: ask the client for contact information first, before asking Talkspace for “any contact information that we have available.”
Talkspace declined to clarify what contact information would be made available under the new policy or under what circumstances.
For contrast, Talkspace competitor BetterHelp deals with potentially dangerous situations by screening out potential clients who are actively suicidal, and easily allowing therapists to request an anonymous client’s personal information in the case of suicidality, abuse, or potential violence. One former Talkspace therapist, who now provides therapy through Betterhelp, described her experience with mandated reporting there, after a client told her about beating his wife in front of their children.
“You go to the top of the screen, and you can request client information. It said, ‘Why do you want this information?’ I said, ‘It’s because of client [and child] endangerment.’ Within a minute or so, the client’s name and address appeared.”
Anonymous therapy also poses a problem for so-called “duty to warn” laws. Many states require therapists to warn individuals whom their client might hurt or kill, or to notify the police. These laws are often called Tarasoff laws, stemming from a 1969 incident in which UC Berkeley student Prosenjit Poddar told a psychotherapist he wanted to kill his classmate, Tatiana Tarasoff. The therapist didn’t warn Tarasoff or her family; Poddar stabbed Tarasoff to death a few months later.
The Verge obtained several slides that were included in a training course from about a year ago. In one of the slides, on ethical guidelines and protocols, the company addresses risk of harm to others by implicitly advising therapists to ignore duty to warn laws:
The company addresses risk of harm to others by implicitly advising therapists to ignore duty to warn laws
“If a person makes a specific threat against someone else, the therapist will contact [a member of the clinical leadership]. The therapist should provide an empathic response about how hard it is for the user to reach out for help. The therapist should then explain to the person that this threat will be reported to Talkspace, but at the same time they can help the person to not act on the threat.”
The new lesson plan, introduced a few weeks ago, directs therapists to request information from patients and Talkspace in these kinds of emergencies. “For clients who are high-risk for suicidal or homicidal ideation, it is essential to try and obtain their emergency contact information,” the new lesson explains. “It is up to therapists’ discretion as to who and when you ask for this information.” Talkspace didn’t respond to a request for clarification on the policy.
Whether clients at high risk of suicide or homicide are appropriate for chat-based therapy is another question entirely. Talkspace has a warning at the bottom of their website, explicitly telling clients that, if they are in a life-threatening situation, they should call 911, a suicide hotline, or go to the ER, as opposed to using Talkspace.
However, the company’s FAQ page claims, under “How can Talkspace improve my life,” that the app can assist with suicidal thoughts. Many of the conditions Talkspace says it can help with, like addiction and eating disorders, pose serious medical risks to patients — including death — if not properly treated.
“Talkspace is therapy for all — that’s a great goal, but I think therapy for all via the internet is not the right goal,” one former Talkspace therapist told The Verge. “Maybe the way to reduce risks is to screen out people with more severe symptoms and disorders. It’s not taking their money, that’s for sure.”
Even outside of concerns about mandated reporting, anonymous therapy is challenging because the therapist may be missing key information.
“I’ve been having the heebie jeebies about the idea of a therapist not knowing who their patients are,” Leslie Wolf, professor of law and the director for the Center for Law, Health & Society at Georgia State University’s College of Law, told The Verge. “You can be anybody on the internet.”
Essig, the psychologist and Forbes blogger who has been one of the strongest critics of Talkspace, agrees. “It is impossible to simultaneously obey licensing laws, standards, and professional ethics, and also provide anonymous therapy. It’s roughly comparable to un-hygenic surgery,” he told The Verge. “You cannot do crisis management if you don’t know where a person is.”
In an email obtained by The Verge, which was sent after Essig began reporting on Talkspace, the company warned all clinicians not to talk to him, and that all communications with the press must go through their communications manager. The Verge received similar treatment.
After several attempts to get comment for this story, Oren Frank requested an off-the-record phone call. When The Verge declined, he responded, “My only response on record is no comment. I’ll be happy to meet you F2F if you’re ever on the right coast and tell you about Talkspace – naturally it’ll be off the record :)”
“I will not hesitate to have The Verge answer legally, financially and professionally.”
After receiving a list of detailed questions, Oren Frank emailed various editors at The Verge, as well as the CEO of Vox Media. “I will not hesitate to have The Verge answer legally, financially and professionally to any unsubstantiated claim, anonymous quote, or libelous statement that results in damage to our business,” he wrote in one.
In another, he referred to this article (which he had not read) as “a follow up on a hate piece written by a Forbes troll,” as well as “completely false and misleading,” but failed to explain which questions contained false or misleading information. A few days later, he sent a 1,200-word email to the Vox Media CEO and several Verge editors, answering two of The Verge’s questions, which he said Essig had “clearly scripted.” He did not answer the others.
Though The Verge interviewed Essig for this article, he was not apprised of The Verge’s reporting methods or sources, nor was he involved in production of the story.
After the requests for comment, Roni Frank sent two emails to current Talkspace therapists, warning them not to talk to journalists without approval, and promising to send them talking points.
After receiving a final list of questions from The Verge, Oren Frank emailed every current therapist. He said he knew one of them was sharing internal documents with a third party, “most likely…Forbes Blogger Todd Essig and at least another freelance “reporter” who are using such information out of context and with little evidentiary support to try and harm Talkspace’s reputation and future by crafting malicious “scandal pieces” (sic).” he wrote. He then reminded therapists that they had all signed nondisclosure agreements, and promised to update them as soon as the company finished its internal investigation.
Therapy apps like Talkspace deal with sensitive data and potentially risky situations, but it’s unclear which government agencies will take responsibility for regulating them. The FDA released guidance in 2015 outlining what types of apps it will consider medical devices worthy of regulation, and which ones are too low-risk to warrant it. Talkspace doesn’t fit perfectly into any of the examples.
It’s not just an automated way for patients to learn about a disease or manage a medication schedule, which would mean the FDA gives it a pass. But it’s also not a device that directly diagnoses a disease, or that operates an insulin pump, which the FDA would have to approve before market. It’s something in between.
“The FDA has been hammered by Congress and industry who are saying, ‘Don’t over-regulate this market, it’s a bright spot in our economy.’”
“The FDA is out of its comfort zone [with apps], but it’s been aware of these issues for a long time,” Nathan Cortez, associate dean for research and a professor of law at Southern Methodist University’s Dedman School of Law, told The Verge. “The approach has been relatively hands off unless there’s a major problem or scandal. The FDA has been hammered by Congress and industry who are saying, ‘Don’t over-regulate this market, it’s a bright spot in our economy.’”
Therapy provided by a licensed professional, of course, is a kind of treatment — and Talkspace itself asks therapists to pick a likely diagnosis for each patient in the clinical notes section. In a training slide from a year ago, therapists are instructed to enter a client’s diagnosis and severity; a former therapist who left more recently described the diagnosis section as a drop-down menu with a number of potential disorders.
Patti Zettler, an associate professor at the Center For Law, Health & Society at Georgia State University and a former associate chief counsel in the FDA’s Office of Chief Counsel, cautioned that all of these legal definitions are extremely case by case, since the FDA historically has declined to regulate how health care professionals practice medicine (a good example is the legality of off-label prescriptions, where doctors can prescribe drugs for medical conditions the drugs aren’t FDA approved to treat).
“If the entire context implies something’s intended use, a disclaimer isn’t sufficient to get it out of FDA oversight,” Zettler told The Verge.
Another question to ask is whether Talkspace is a medical provider hiring therapists to staff its business, or a platform for use by independent therapists. This would affect their relationship with a number of regulatory agencies, including the IRS and in-state agencies that regulate medical providers’ behavior, such as record-keeping.
Like a lot of startups relying on independent contractors instead of employees, many of Talkspace’s rules and practices suggest the company has already toed the line of employee classification.
“If you were a therapist running your own business, would you have a range of freedom of decisions that is taken away by Talkspace? It seems to me there are some indications that the answer is yes,” said Ben Sachs, the Kestnbaum Professor of Labor and Industry at Harvard Law School. “Talkspace’s business is providing therapy to the client. It’s central, it’s integral to it — that suggests employee status.”
A current therapist expressed confusion over whether she was really self-employed. “It’s weird — it feels like it’s your private practice, but not really, because you’re micromanaged,” the therapist told The Verge.
A training slide from a year ago seems to bear out her feeling of being controlled. “Remember that your objective is not to determine if a client qualifies for therapy since they are active participants who have subscribed to the service. You are also not to solve problems or just give advice,” it tells therapists.
When asked about whether Talkspace was misclassifying employees as independent contractors, Oren Frank said that a licensed therapist would be “a very different case study” than a “minimum wage housekeeper or a new immigrant” driving for a car company.
“It feels like it’s your private practice, but not really, because you’re micromanaged.”
“Many, if not all, of these therapists are well aware they make less “hourly” using Talkspace versus a traditional face-to-face practice, but in return, help many mire (sic) people. Almost all have other day jobs,” he wrote.
Some of the recent policy changes have targeted areas that the IRS might use to determine whether employees are being misclassified as contractors, such as moving to a more flexible schedule for therapists, and adding unlimited vacation time. But flexible scheduling isn’t enough to determine whether someone is an employee, according to Sachs.
The fact that Talkspace sets pay rates, on the other hand, indicates employee status, according to Sachs. “To be your own business means to set your own rates,” he explained. Anonymity of clients, too, struck him as pointing toward the therapists being employees, although he said it’s a novel consideration and there is no specific case law to point to.
“It strikes me as…controlling the terms and conditions of the way work is carried out. You’re a therapist and you don’t get to know who your clients are, because Talkspace has decided as much,” he told The Verge.
Contractors, Sachs said, are far more vulnerable than employees.
“Essentially all of the employment protections we have in this country — that’s employee discrimination protections, minimum wage and overtime, unemployment compensation, worker’s compensation, occupational safety and health — all of those things are available to employees and not to independent contractors,” Sachs told The Verge. “It’s a way of shifting an enormous part of the social contract onto workers and off the employer.”
The risks and burdens of work are shifted onto Talkspace therapists in other ways, too. Therapists are required to maintain their own liability insurance, rather than being covered by Talkspace’s insurance, and their contracts contain a “hold-harmless” clause. That means therapists agree to pay any legal fees or judgements in lawsuits filed against them — or, potentially, against Talkspace, because the contract explicitly states that therapists will have to pay “for claims directly against Talkspace for actions caused by or related to the Therapist’s use of the Platform.” Given how much control the company exerts over therapists in their policies and practices, this covers a lot of ground.
In many cases, therapists’ liability insurance won’t cover “hold-harmless” clauses, because some insurance companies don’t want to pay for situations where someone or some entity (like Talkspace) has been indemnified against liability.
“All of the risk is on the therapist, all the work is done by the therapist, but there’s a tremendous amount of fear and control — and they dangle this carrot, that you’re part of something big and important,” a current therapist opined. “It’s neurotic handcuffing.”
Talkspace policies leave room for confusion when considering state record-keeping policies, as well. In many states, therapists legally must keep the patient’s medical records for between two and eleven years, depending on the state. Those laws exist in case of malpractice lawsuits or court cases involving a patient’s mental health.
“All data collected on the Platform through your use of the Site remains the sole property of the Site and its corporate owners.”
The company acknowledges this data retention requirement in their public FAQ. The site states that “chat dialogues themselves cannot be deleted because the therapists are required by Federal Law to keep records on file for a specific period of time,” despite the fact that, according to Talkspace contracts, the company owns all treatment records, and therapists lose access to those records once they’ve left.
“All data collected on the Platform through your use of the Site remains the sole property of the Site and its corporate owners. You have no rights to the ownership, removal or deletion of data on the site,” a therapist contract signed in the spring of this year explained. Data, here, means all patient records, and, given therapists’ experiences with losing access to therapy transcripts and clinical notes, seems to cover those, as well.
That sort of ownership of patient records would make sense if Talkspace were a medical provider, like a community health center or hospital — but not if it’s a platform, divorced from the care itself.
“There’s certainly still unanswered questions. Consumer apps are changing what the paradigm is,” Wolf of Georgia State University said.
No matter where the regulatory dice fall for Talkspace, all the therapists The Verge spoke with stressed that Talkspace and other telehealth therapy providers have the ability to achieve something important: access to mental health care for people who need it.
“I was so excited about Talkspace, I referred a bunch of my friends [as therapists], and some of my close friends became subscribers. My best friend…was a client of one of the rockstar therapists at Talkspace, and had a fantastic experience,” a former therapist said.
“When all of this stuff came crashing down, her therapist was one of the first to experience the dark side,” she continued. “My best friend was very misplaced, she had a really difficult time, and then I left. It was kind of an avalanche of shit this year.”
Editor: Josh Dzieza
Illustrator: Justin Renteria