Why 1:1 therapy can’t solve today’s mental health crisis

Written by Ariela Safira

Contributions by Dr. Onisha Etkins, Madeleine Tremblay, Olivia Auxier & Reese Shebel

This article originally appeared on Fortune.com here.

Ever since I started working on mental health care 10 years ago, every individual I meet can speak to me, privately and intimately, about their mental health journey and the battles it comes with — debilitating insecurity, suicide attempts, eating disorders, self-hate, social anxiety — but until recently, those stories never came above the surface in public spaces. Workplaces did not talk about mental health, schools did not talk about it, and battling with depression was certainly not a conversation someone shared with their manager at work.

Over the past 18 months, something profound happened: we all stopped pretending. Employees’ formerly secret battles with depression, anxiety, PTSD, and more…evolved into the number one concern workplaces are looking to solve over the next five years. In one quick swoop, mental illness skyrocketed and employers, health plans and health systems were immediately pressured to solve the need.

I am watching CEOs, CHROs, and Heads of Benefits sprint to onboard mental health benefits to support their teams. It’s a beautiful act of support, but doing so without an understanding of our mental health care system and what today’s solutions can and can’t offer you can, at best, do nothing for your organization, and at worst, damage it, as we perpetuate a broken mental health care system.

We must do this the right way.

What we’re facing

CEOs, CHROs, Heads of Benefits, you know this all too well.

  1. Mental illness is skyrocketing; 76% of US workers reported at least one symptom of mental illness last year alone. The situation looks nothing like it did even 3 years ago.
  2. Every employee engagement survey you see reports mental health as the #1 issue in your organization.
  3. And yet, utilization of your mental health benefits is extremely low — the average utilization rate of mental health benefits across our country is 2% . We consider it impressive when utilization rates reach 10%, which means we consider it impressive when 90% of employees have no access to care.
  4. This is impacting the bottom line: absenteeism, productivity, turnover rates, customer NPS. Today, mental illness drives 200 million lost workdays each year and between $17 billion to $44 billion to employers annually.
  5. Employees are now going directly to their people managers to discuss their depression, anxiety, and other mental health conditions. But people managers do not have the tools to manage these conversations. The repercussions can be dangerous.
  6. Every mental health offering is promising you phenomenal access to care — no wait times, diverse networks of therapists, high utilization, improvements in outcomes. But, you’re not seeing that in practice.
  7. You’re to blame. You have little to no training in mental health, and have been rushed to find a working solution for your workplace…when no solution on the market can solve the issue we’re facing today. This isn’t an HR problem; it’s a mental health care problem. You were given an impossible task.

You care. Any person who is as close as you are to the profound rates of mental illness wants to help–it just isn’t clear how.

The Problem’s only getting worse


History shows that post-pandemic rates of illness only grow. When we look at previous pandemics or large scale traumatic events, we see that mental health continues to decline and to impact the lives of individuals for years to come.

The future population of our workplace

By generation

In less than a decade, Gen Z and Millennials will make up 60% of our global workforce. They are the future foundation of our workplaces — but this generation is also our sickest.

Mental illness is already a substantial issue for employers — and it is going to become profoundly worse. Not only do we need solutions to treat mental illness at scale, but we also have to start preventing illness.

By profession

From truck drivers and manufacturing employees, to store associates and hospitality workers, deskless workers make up 80% of our global workforce and face high rates of mental illness, yet have remarkably poor access to care.

  • Research shows that mistreatment by customers — something that 62% of restaurant employees experienced in 2021 alone — drives burn out and leads to mental illness.
  • BIPOC make up 40% of retail workers — but our country’s therapist population can only support 1.7% of people of color in America.
  • And most aggressively impacting business bottom line is the jarringly fast turnover rate of hourly workers–50% of hourly workers quit within 120 first days.
  • 47% of hourly employees report that they cannot easily anticipate what days and times they will work week to week, making an hour of 1:1 therapy appointment every week inaccessible. What’s more, 39% of hourly workers reported that their work schedules negatively affected their health.

Deskless workers make up 80% of the global workforce, and yet, deskless workers have few–if any–working mental health care options to support them.

So where do you turn to?

CEOs, CHROs, and Heads of Benefits — you’re most likely looking for 1:1 therapy to solve this issue, and you’re in one of two places:

  1. You have an EAP or therapy covered by your health plan, and you have already witnessed the flaws firsthand — 2+ month long wait lists, no therapists of color, low utilization — and you are thinking, “Is there another 1:1 therapy network that is larger and more diverse to solve the issues of my employees?”
  2. You have already added an additive 1:1 therapy solution to your EAP and health plan, and have seen that the problems remain the same. You’re thinking, “Is there a better 1:1 therapy network to add?” Where do I go from here?

In either case, you’re assessing which 1:1 therapy option is most likely to solve the mental health crisis. The problem is that 1:1 therapy is not the solution. No 1:1 therapy network will solve this problem.

Why won’t 1:1 therapy solve my organization’s mental health problem?

Let me start by saying: a good therapist can change your life via 1:1 therapy. But the problem is that we don’t have enough therapists, and therapy does not work for everyone. You’re no longer solving for 1 or 2 employees who need care — you need a mental health solution that can support the 76% employees in need.

Therapy isn’t for everyone.

Despite the advances we’ve made, 47% of people don’t utilize therapy because they view it as a sign of weakness. People need care. People want care. But 1:1 therapy isn’t right for them. They need and deserve a different option.

And even those who want therapy can’t get it.

We do not have enough therapists in this country to offer weekly 1:1 therapy at scale. Across our entire country, if we added every single therapist in America to one power-network, we would only have enough therapists to provide weekly therapy to 7% of the US population. Every employer (and person) is fighting for the attention and schedule of a therapist workforce who can only support 7% of Americans. And this doesn’t even take into account the fact that most mental health specialists do not accept insurance — almost one third of therapists don’t accept insurance at all, an estimated 45% of psychiatrists do not accept any form of insurance, and a much larger proportion of both accept only a very limited set of plans, making it extremely difficult for patients to find suitable, in-network referrals.

The problem is more profound for employees of color. In order to improve mental health, clients need a therapist of their same race. With only 50,000 mental health specialists of color in this country, we can only offer weekly 1:1 therapy to 1.7% of people of color.

So what does this look like in practice?

Your employees wait on waitlists — on average, a person waits 6 weeks for an available therapy appointment. For employees of color, this is remarkably worse — an identifiably Black, working-class man has to call an average of 80 therapists before he is offered an appointment well-suited to him. By comparison, a middle-class white woman only has to call five.

And once they do find an available appointment, it’s on Tuesdays at 1 PM, or Thursdays at 4 PM. How many of your employees can reliably leave work, every week, for a full hour during a weekday? Whether you’re an investment banker clocking in 100 hour work weeks on a privileged salary, or a store associate managing multiple jobs on hourly pay, taking one hour out of your work day per week is unfortunately unrealistic.

As a result, people who need care do not receive it. They suffer progressively more because of it. After facing symptoms of mental illness, it takes an average of 11 years for a person to reach care. People spend 11 years in a mental health decline, with no intervention or help, until they face crisis and finally reach care. What’s worse is that when we wait to treat people until they reach crisis, we are remarkably less capable of helping them — it’s incredibly hard to treat crisis; sometimes even impossible; and it is always expensive. We lose lives because of it.

We need a model of care that meets people sooner in their mental health journey so that we can prevent crisis.

But what about my employees who do use our therapy network?

You cover 3–10 1:1 therapy sessions, and you pay a tremendous amount to cover only that. On average, a person needs 13 1:1 therapy sessions to see improvement, and the cost of care averages $250 per session out of pocket. This means an employee has to pay a total of $750 to $2,500 out of pocket in order to see mental health improvement — even when utilizing a benefit “their employer covers.” This is if they’re lucky enough to find a therapist with continued availability in the first place.

Where do we go from here?

So what does the future of care look like? What does care need to look like to support your employees?

  1. Scalable Mental health solutions must be able to reach our entire US population. We need a mental health solution that Shake Shack, Target, Apple, Walmart and every other employer can use at once — without putting their employees on waitlists.
  2. Affordable Your budget is limited. You want to provide care for your employees, and you need to do it under the confines of a budget.
  3. Confidential and trustworthy Unlike many other forms of health care, mental health is an intimate and vulnerable part of us. Talking about hating one’s own body, battling with recurring nightmares, navigating an affair, struggling with panic attacks, facing suicidal thoughts — these are challenging topics to face within our selves, and even more challenging to share aloud with another person. As a result, the time it takes for someone to engage with 1:1 therapy after symptoms of mental illness is 11 years. We need to build a mental health care system that meets people at their step zero — before they are in crisis, likely when they aren’t yet comfortable sharing this issue with a stranger — to ensure that they never reach that tipping point. We need to create a solution that people trust, where people can work on their mental health even if and when they are intimidated to share their mental health struggles aloud.
  4. Accessible when your employees need it Your employees need care during various hours of the day — when they’re spiraling in bed at 2 am, overcoming anxious thoughts ahead of a meeting at 2 pm, facing grief after death or divorce. They need care that meets them where — and when — they’re at.
  5. Inclusive Your company’s success is contingent on being a workplace that fosters and promotes diversity. You need a mental health benefit that supports all employees across all races and all genders.
  6. Clinically effective You need a solution that works. There’s no doubt that mental health is a fuzzy area of health care, but we do have literature-backed clinical assessments that we must lean on to measure: is this solution driving the results we need?
  7. Engaging You have implemented benefit after benefit that barely exceeds a 2% utilization rate. Where is the solution for the remaining 98% of employees who are in need?

This is not an HR problem; this is a mental health care system problem. If you want to find the right solution for your organization, you need to think outside of the confines of 1:1 therapy, and focus on the results you’re looking for a mental health benefit to deliver. If you want to find the right solution for your organization, let’s chat Real.