The rapid expansion of online therapy has changed how mental health care is delivered. What used to be mainly an in-person service has increasingly moved to video calls, apps, and direct-to-consumer platforms, especially as the COVID-19 pandemic accelerated this shift. For patients, these changes have created new ways to get support; for providers, they have brought both opportunities and challenges as therapy transitions into digital spaces.
Livia Garofalo, researcher at the Data & Society Research Institute (USA), examines this transformation from the providers’ perspective with the study Doing the Work: Therapeutic Labor, Teletherapy, and the Platformization of Mental Health Care.
Supported by the Internet Society Foundation’s Research Grant Program, this project explores therapists’ experiences with teletherapy and platform-mediated care. It emphasizes how professional expertise, licensing standards, and clinical practices interact with algorithmic management, productivity incentives, and platform dynamics.
The report also considers broader issues raised by the digitization of therapy, such as autonomy, burnout, and the impact of emerging tools like AI. It underscores the importance of prioritizing providers’ voices in discussions about digital mental health, ensuring that those who deliver care are not only adapting to technological changes but also actively shaping them.
In this interview, Livia Garofalo shares insights from her research, including the benefits and drawbacks therapists report when working through digital platforms, the risks posed by algorithmic matching and gig-like work structures, and the potential impact of AI-driven ‘therapy chatbots’. She also emphasizes how technology is transforming the conditions of therapeutic work, the effects on providers and patients, and what this could mean for the future of mental health care.
This interview with Livia is part of the Research Program Interview Series – The Future of the Internet. The series aims to foster in-depth discussions with researchers from our community of grantees, promote the sharing of their findings, and amplify the impact of their research.
Interview with Livia Garofalo
Internet Society Foundation: What were the objectives of your research?
Livia Garofalo: The project really looked at how providers of mental health services are seeing their profession changing through the shift to telehealth and platform therapy. So, what I was really interested in looking at is how their experiences of these shifts are affecting their therapeutic labor and their therapeutic work with their clients, and how it affects the livelihood of themselves as professionals.
Internet Society Foundation: Why where you interested in this topic?
Livia Garofalo: So, since the pandemic, we’ve seen a lot of people seeking mental health services, on the one hand, and, on the other, sort of the burgeoning of platforms and sort of digital mental health on the other. And so, most of the focus has been on the users of these services, on many people who are seeking these services and are finding an easier time, perhaps connecting to a therapist than before. But what I really wanted to see is: what is the cost of this to the providers? Who are the therapists who are providing this work, and what are their experiences?
Internet Society Foundation: What did you find when you started speaking with the therapists?
Livia Garofalo: I found that therapists have appreciated some of the shifts to teletherapy. Therapy used to be something that you did in an office, with a provider in person, and so shifting that encounter to the Internet or through virtual care has been positive in accessing patients and being more flexible with their own schedules. However, the entrance of platforms has kind of determined a lot of how these providers do their work, right? So they are, especially in some configurations, they’re being subject to a lot of dynamics of platformization and gig work that other professions or other kinds of work and labor are seeing.
Internet Society Foundation: What did the therapists report as a negative aspect of this shift?
Livia Garofalo: Some of the things that the providers shared were that: I, for example, don’t have control over how I get matched with my clients. The platform is determining my schedule, it’s determining my fee, sort of. Sometimes, that is a cost-benefit with not having a private practice or not doing a lot of the administrative load. But some of these therapists felt that the ability for clients to switch therapists anytime was affecting the depth of the work that had to be present for the therapeutic relationship to be successful. A lot of other therapists mentioned that it’s hard to make a living. So, some of the platforms determine how much they can pay per session. And sort of this idea that there’s this constant availability of a therapist on the other side of the platform at all times means that the boundaries between work, the boundaries between providers, professional time, and personal time get very blurred. And so, increasing this feeling of being burnt out, which is already very present in mental health care as a profession.
Internet Society Foundation: Do you consider that these problems are affecting the quality of the therapy some patients have on these platforms?
Livia Garofalo: Yes, I think the quality, in the sense, also of the kind of therapy. So, and this, again, is listening to these therapists saying, because it’s so convenient, it doesn’t mean that it’s always appropriate, for example, to have virtual care or remote sessions. One provider sort of felt like, he said, I feel like I’m an Uber driver. I feel like I constantly have to be available. And sort of the same logic that is applied to some of those kinds of work is now being applied to something that has to do with health care. That is, where there’s a liability, there’s a response, therapeutic responsibility. So, on the one hand, there’s a lot of increased access for people to access services through these platforms and telehealth in general, but it does come at a cost for both providers and users in some cases.
Internet Society Foundation: Did your study investigate how this trend particularly affects underserved social sectors that do not have access to technology?
Livia Garofalo: That was something that some providers commented on. We have remote care, but some people have very bad Internet. Some people don’t have a private space in their homes to do therapy. Some people don’t have the best smartphone to do a session that will hold the connection, which is what you’re trying to have a space for quite private things to speak about. And so, in a way, there’s not; it’s not that technology solves everything. It allows for people who would have, maybe even never stepped into an office, because they wouldn’t, or didn’t want to be seen stepping into an office, access therapeutic services. But, on the other hand, the inequality that pre-exists and is structural is definitely sort of embedded in how people seek these services, and if they’re able to receive them.
Internet Society Foundation: What did you find about how AI is being used in these therapeutic platforms?
Livia Garofalo: On one hand, there’s a lot of sort of algorithmic management, which is not quite AI, that sort of determines a lot of the nudges that the therapist, as a worker, receives. But we spoke about it, I did ask about chatbots and therapy chatbots that are being sort of marketed very aggressively. And so, there were two different opinions. On the one hand, a lot of fear about what this is going to be like; some people are going to get the AI therapist, and some people are going to get the real sort of mental health provider. On the other hand, many providers say nothing can really replace a human-to-human therapeutic relationship. Even though maybe some of these chatbots might be able to mimic empathy, they are not actually empathetic, right? So, it’s a very new field that they’re approaching as providers, and I feel like therapists are thinking about that, but they also have to keep doing all the actual labor of care that they’re doing. But they’re sort of balancing the fear, with some mild optimism, with concerns that some of these AI chatbots would be causing harm, right?
Internet Society Foundation: And what problematic aspects did you find in the way algorithms match patients with therapists?
Livia Garofalo: It really changes how therapists find their clients, right? In some of these more direct consumer platforms, you are matched instantly with a provider. And on the other hand, you’re much with a client and user, and some of this dynamic mimics a lot of dating apps. So, one provider was saying that it’s kind of a Tinderization of therapy. And so, on the side of the therapist, some people try therapy for a couple of sessions, and they drop off, and the therapist gets ghosted by their client. But that doesn’t sort of relieve the provider of the duty of care, right? If they’re still seeing them in their docket, they still are technically sort of responsible for them and for their care. So, it’s a double-edged sword, for sure.
Internet Society Foundation: What is the next step for your research? What do you want to be changed?
Livia Garofalo: One of the objectives of this research was also highlighting the experiences of therapists as workers. As part of a workforce that has been under a lot of pressure, especially since the pandemic. And so, also letting potential patients and clients know what their therapist is potentially experiencing. I think a lot of what I heard was that teletherapy and platform therapy are here to stay. They are reality. It has helped many people. Providers just want to have a say in how this is done. And so, having conversations where they can really shape and inform these services and these tools, and not have some of the top of these platform companies determine how these services are delivered without the input of those who are providing them.
Internet Society Foundation: Would it be beneficial for providers to have an opinion on how these platforms operate?
Livia Garofalo: Having providers involved, and at the top of some of these companies, and some of these companies do have this, but just and also much more transparency on the part of some of these platforms, on their compensation, on their sort of practices in general, would make providers feel that they’re not being exploited, because that’s how some providers felt throughout this process.
Internet Society Foundation: Do you feel that we are talking about mental health much more than we used to?
Livia Garofalo: Yes, I think that’s the sort of thing we’re in a kind of an interesting juncture in a paradox, right? On the other hand, we’re talking about mental health much more, and there is some lessening of the stigma around experiencing mental health distress, and at the same time, access to services is very unequal, still, right? And so that pressure converges on providers and therapists who are trying to manage sort of the traditional challenges of providing therapy with the new shifts to these technologies.
Internet Society Foundation: How did the Research Grant Program help you with your research?
Livia Garofalo: The Internet Society Foundation was absolutely foundational to doing this project. I was able to speak to 50 providers and do some group sessions with providers. I was also able to, in collaboration with two mental health professionals, actually gather a small group of therapists in New York to have an in-person workshop where we really talked about the difficulties of providing remote care, and also the hopes for the future. What do providers want to see? And so, the Internet Society Foundation and the funding for this project was instrumental in doing that.
Know more about this research:
– Report Doing the Work: Therapeutic Labor, Teletherapy, and the Platformization of Mental Health Care
– the report launch webinar (with video and transcript of the conversation).