Coaches vs therapists: which is the better model for improving mental resilience in general?

CEOs from Ginger, Octave, BetterUp, Two Chairs, and BetterHelp weigh in

Every year, for the last four years, Vator and UCSF Health Hub have been coming together for an annual event centered around the mental health space. Of course, a lot has changed in that time. Thanks to COVID, which caused widespread mental anguish, while also exposing flaws in our healthcare system, especially when it comes to mental health, we now know what we need to address.

On Wednesday, at the latest of these salons, we put together a panel of entrepreneurs in the mental healthcare space to talk about what's happening: Russell Glass, CEO of Ginger; Alon Matas, President of Teladoc’s BetterHelp; Alex Katz, CEO of Two Chairs; Sandeep Acharya, CEO and co-founder of Octave; and Alexi Robichaux, CEO of BetterUp. 

One of the big topics that came up on the panel, which was moderated by Dr. Archana Dubey, Global Medical Director at HP, and Bambi Francisco Roizen, founder and CEO at Vator, was about the difference between providing licensed therapists versus coaches, and the effectiveness of each of those approaches. Of course for more clinical situations, therapists are needed, if not psychologists or psychiatrists. But for those who are baseline resilient or even languishing, as the new term goes, couldn't a coach be just as effective as a therapist? Russ Glass of Ginger says studies show 80 percent of Ginger members can be treated or helped by coaches. 

Alexi Robichaux of BetterUp believes the majority of people and upwards of 80 percent definitely don't need therapists. In fact, it's BetterUp's contention that it's not even desirable for society to want to provide therapy to everyone. Even though the figures show that 1 in 5 people suffer from a mental condition, Alexi would argue that many of those folks are sub-clinical and could be better served with a more positive approach of mental health.

The conversation kicked off with Dubey asking the panel about their key differentiators to which Glass responded, for Ginger, it's that the company provides real-time access to behavioral health coaches 24/7.

"If you have a need, it could be the middle of the night and you're having trouble sleeping, you're having a panic attack, you're just anxious about something that's going on in your life, you're feeling depressed, whatever it happens to be, we are there for you," he said, telling a story about a Delta Airlines flight attendant was having a panic attack on a flight because someone wouldn't put their mask on. Within 10 minutes of using Ginger, they were able to go back to work.

The second differentiator Glass mentioned is that the company starts everybody at the behavioral health coaching level, and those coaches are determining just how much care somebody needs. In fact, over 80 percent of the company's members can be handled at that subclinical level, not needing to see a therapist.

Finally, for those who need more care, the third differentiator is that the Ginger platform is collaborative, meaning it doesn't refer out to therapists or refer out to a network of psychiatrists. Instead, Ginger brings them into the care team.

"So, now you've got a therapist and a coach, or a psychiatrist and a coach, if medication management is needed. That right level of care in a team environment leads to better outcomes. We step people down out of that higher level of care as soon as possible so those licensees can go to support the others in the world that need them and we go back to coaching for longitudinal care and making sure patients don't have recidivism. That model, I think, is quite differentiated in the world of mental health support. It's highly scalable and it's cost effective," said Glass.

Dubey followed up by asking him if coaching on Ginger done live or digitally, to which Glass responded that 100% of Ginger's coaching is live, with coaches doing synchronous care in real-time.

"That synchronous care is all done by a chat today so think of it like a HIPAA-compliant Facebook Messenger kind of an experience. Those coaches bring in exercises, they bring in activities, they and the system itself ‘prescribes’ what would be the most relevant content or relevant experience for those members," he said. 

Katz was the next panelist to answer, and he said that the differentiator for Two Chairs is that, "it's really all about creating the absolute best therapeutic relationships."

"We know from the research, the clinical alliance between a therapist and a client, it's ultimately by far the best predictor of outcomes and care. And so, for that reason, we have put our matching system really at the heart of our care model and we've spent the last four years honing and iterating on that model and it really emphasizes collecting a ton of data from clients, both digitally, but also in the context of a 45 minute matching appointment, in-person, with a licensed clinician," he said.

The company is then using all of that information and data to make personalized matches, making it so that folks are dramatically more likely to initiate care and to complete a course of treatment, leading to better outcomes. To make sure that it saw those outcomes, the company made the decision early on to make all of its therapists full-time employees.

"We're putting a ton of time into vetting those folks, training those folks, it's a profoundly diverse team in terms of training, theoretical orientation, background identity, and that diverse strong team enables us to make really strong therapeutic matches," said Katz.

Acharya then answered, noting that Octave Health has focused on two things: outcomes, and betting on the notion that providers who have been trained in evidence-based modalities, and have a focus on using measurement in their care, can ultimately drive better outcomes.

"We target a slightly more acute population because we have been accepting insurance for the last few years. So, about a half to two thirds of our population is dealing with moderate to severe levels of acuity. And so, the focus on evidence-based treatment, and the focus on outcomes, is ultimately how we're going to focus on long term differentiation," he said.

"Building a data set that demonstrates where we're providing efficacious treatment is critical and then doing it with some level of efficiencies for payers. So, for folks that we think are coming in with mild to subclinical needs, we are routing to coaching where possible, because we think that's actually a better match. Coming from primary care, I have a value-based orientation and we're thinking about it very similarly in mental health." 

When he answered the question, Matas noted that BetterHelp focuses on the clinical side, and deploys only licensed therapists and traditional therapists, rather than coaches.

"Our differentiator is that we're purposely not trying to be innovative, which means we're trying to bring the trident to science of therapy, but we're trying to make it more affordable and more accessible to people that don't get care. The biggest problem is not necessarily that the care that has been offered is not good; it's good, it’s just most people, the vast majority of people, that need it are not using it because it's so difficult and so expensive. So, this is really what we're trying to change," he said.

One thing that does help BetterHelp stand out is its size and scale; in January of 2015, the company was acquired by telehealth service Teladoc for $3.5 million. It now has close to 20,000 active therapists on its platform. 

"We can match a person to the best therapist for that person, which is not necessarily the best therapist because it's such a personal experience and there’s so much nuance on people's needs and demographics and preferences. When you have such a large network, then you can do a much better job in finding the right care and the right provider that would create the right alliance with a member."

Robichaux was the last to speak, and he agreed with Glass in that the majority of people can be helped with coaching, rather than therapy.

"That's the insight we built BetterUp off of: we really think of ourselves as the top of the funnel for most people's experience with mental health. The reality is most people don't need therapy, and I think probably what's most unique to our approaches is we don't think it's productive to tell most people they need therapy, nor do we think it's realistic to say that we could give most people therapy at a global level, nor should that be desirable that most people would need therapy. If we really were good at prevention, most people wouldn't need therapy, by definition," he said.

Francisco turned the discussion to how BetterUp's clients are perceiving the idea of coaches and working toward self-actualization? Robichaux explained that society's cultural dialogue around mental health being about removing mental illness didn't help his cause. "So we focused on coaching. Yet what we were actually doing was mental health, resilience, mild anxiety." By focusing on performance, leadership, promotion and on the outcomes people want when they are healthy, he found use and adoption was off the charts. If rigor is the root of performance, then BetterUP intentionally made their focus about performance. For our population.  

What most people need, Robichaux noted, is likely a mix of positive psychology, a focus on strengths, a focus on self actualization, a focus on resilience and well being. So, what BetterUp has built in "is really rigorous triage and escalation paths for the small percent of people who do have acute mental illness and do need to partner with folks on the clinical side and we want them to get back there."

"But we know that's not most people and so as we think about BetterUp, we're really focused on how do you get really good at coaching? And if you're really focused on coaching, then it's not just behavioral health coaching, how do you intersect that to people's career aspirations? How do you intersect that into their family dynamics? And how do you bring the same heavy weight of academic research many of you all do on the clinical side to the non-clinical realm? That's where we've tried to specialize in as a company, bringing clinical rigor and research to the non-clinical domain."

Francisco asked BetterHelp's Mata whether his customers needed therapists or whether they could just use a little coaching.

"There's some misconception around therapy. You don't need to be severely depressed, or in a clinically diagnosed disease, in order to benefit from therapy. Therapists help in a very wide spectrum of situations and everyone with significant challenges, which is a lot of people, can definitely benefit from therapy."

He then called the coach versus therapist "always kind of a murky line."

"What is the line between coaches and therapists, from both legal, ethical point of view but also from quality and impact point of view? A lot of the appealing factors in coaching, if we're all honest, is also cost. The fact that coaches are less expensive and less in demand and more scalable, from a state line point of view, but also from just an inventory point of view, than therapists," Matas said.

"But we should not be confused: if someone needs therapy or counseling, they need to see a therapist, they shouldn't be seeing a coach, and that's a very, very tricky line to handle, and there's no definite truth. What is the line between performance improvement in just generally feeling happier to therapy? I think we should err on the side of providing the best care possible and that care today is therapy."

Glass pushed back, mostly agreeing that if somebody needs therapy, they absolutely need therapy, but he disagreed with the notion that it's a murky line, calling it "antiquated."

"Maybe a decade ago that was true. I think that it is highly data driven at this point; we know very specifically, in fact our systems can predict, when somebody is going to cross that line into needing the interventions that a licensed therapist can provide versus interventions that a coach can provide. And so, I really believe in order to scale care in this country, we have to be more careful about making sure that those therapists that have the level of licensure that they have and have the ability to provide interventions that are licensed interventions, are being used for the people that need them," he said.

"And then you use the coaches for the ones that don't, and we have now published and peer reviewed results that show coaches are just as effective at driving PQH down, at driving resilience up, as therapists when appropriately used, when used for the right level of care and level of need. So I don't think it's murky anymore."

Acharya also responded, noting that it's not just cost, but access, as there are between 50 and 100 million Americans who have a need, so we don't have enough licensed providers to address all of those patients.

"With that said, I don't think any of us know because we're targeting different populations. I wish we could stare at the full data set of Americans to understand, truly, what proportion of the population needs therapists versus coaches. I suspect it's going to be somewhere between your respective answers: 80% needs coaching, and none of them need coaching. It's our collective duty to figure out how large we can make that so we can drive greater efficiency and help more people, putting costs aside," he said.

While he agreed with Glass about cost reduction, he noted that it's also true that people need mental health support whether or not there's an accompanying medical condition or opportunity for costs in the system.

"Frankly, the problem is that we just need more investment in behavioral health, period,  because it's the right thing to do. Given that, how can we use it most efficiently? This is an area of challenge we're all going to be wrestling with; our own data isn't suggesting it’s 80%, I hope it is, but maybe the folks that we're targeting have a higher acuity level, and that's part of how we think about it." 

In response, Matas brought up the fact that therapy is very well defined and also regulated,  whereas coaching is undefined and unregulated.

"That's a very clear line: in order to be a therapist, and to provide therapy, you need have education and certification, training, internships, and every two years to go through a bunch of tests. That completely does not happen in coaching, where it's a free for all, every company will define their own standard, their own vetting, and of course they will say that they're doing a great job. That's a very, very important line to distinguish between a regulated industry that has been around for decades and and evolved around the science, to something that is unregulated," he said.

"The other thing to remember is that every therapist can provide coaching; no coach can provide therapy. So, definitely on the option of whether you want someone to make a bet that, Yes, we will find the exact point where it's going from not needing a therapist to needing a therapist and we’ll make this determination and based on what? Then that's why talking abouting err on the side of having a therapist and if it's more on the light side and less severe side, that's fine too, if it’s provided by therapists."

Robichaux called this "a false choice architecture."

"It's kind of like saying, ‘do you want to go to your general physician or would you like a personal trainer?’ ‘I like both,’ is the answer and both exist, and one is unregulated and one is regulated, and both are health," he said, while also contesting the notion that coaches are cheaper than therapists.  

"Therapists are significantly cheaper than certified executive coaches by multiple factors, which should not be the case, maybe we can all argue, but it actually is if you just let the market price elasticity. And that's because of HMOs that negotiate therapists down to a fixed rate. So there's a rack rate for therapists. The average executive coach that is certified is significantly, by factors of 3 to 5x, more expensive than a therapist per hour. And so, we can all argue about the equality of that, but that coaching is cheaper, just as a point of fact, is patently false." 

The better analogy would be someone trying to build their muscles: you don't really go to your general physician for that, you go to a physical trainer, you go to physical therapy.

"We have in the physical health system very complimentary solutions that address different acuity of care, and they have different cost factors. We don't have that yet in mental health, and so I would just encourage us to not think of this false either or choice architecture and really the answer is, how is this complimentary? How do we provide a continuum of care? And we probably do need to massage some of the cost structures underneath that to enable more mobility of care across. But, for us, what we found is the user in that way, and it doesn't help them to encourage them to think of it that way."