Linda Huber Annotations

Across Scales and Systems (

Sunday, August 9, 2020 - 3:39pm
  • deutero [reflective/learning capacity]: How are people and organizations denoting and worrying about the phenomena you study?

Academic researchers in IS, psychology: Generally I think online therapy ISN’T being framed or studied within the “platform labor” academic research community. I think that research about teletherapy more generally seems to be focused on the patient/client experience, and whether it changes the therapeutic effectiveness to do it online. It is also discussed as reducing stigma and increasing convenience for the patient, although this may be emphasized more by the teletherapy companies themselves rather than the research. 

Public health organizations discuss telehealth as a tool for creating access to care where it otherwise isn’t available. 

The therapy profession up until covid still seemed to think of teletherapy as an edge-case, as not clearly “legitimate” or “evidence-based”. 

  • meta [dominant discourses]: What discourses constitute and circulate around the phenomena you study? Where are there discursive risks and gaps?

Discourses of “evidence based treatment”, of scalability of labor and access to mental health services, discourses of risk and prevention

Discursive gap: gig workers, platform laborers, women and mother workers

  • macro [law, political economy]: What laws and economies undergird and shape the power the phenomena you study?

Mental health regulations - state licensure is a huge barrier for mental health professionals to enter the practice and to maintain it as they move around the country 

Managed care - Very difficult for therapists to get reimbursed by insurance companies, often reimbursements are quite low and have a high requirement in terms of justifying treatment. Means that many therapists don’t accept insurance if they can help it. Also means that accepting insurance guarantees patients/referral stream for the therapists since there are so few options for those looking for in-network providers. 

ALSO, insurance-based treatment venues (e.g. platforms that work w/ insurance companies, community mental health centers getting medicare/medicaid reimbursements) fundamentally require different approaches, different work (more outcome-oriented), than non-insurance-based treatment (e.g. private practice without insurance, DTC platforms). 

“Economies of scale” - therapy is a very human-labor intensive work (not very scalable) but is in very high demand and has a huge market, so there is reason to figure out scalability in order to tap into and profit off this huge market/demand

  • meso [organizations]: What organizations are implicated in the phenomena you study? What geopolitics are in play?

Platform companies & startup tech culture (very US-based)

Massive insurance companies, the economies and incentives of a private, profit-driven insurance landscape

Employers looking to provide premium mental health services to employees 

The US state that minimally funds public mental health services 

  • bio [bodies]: What are the bodily effects of the phenomena you study? 

The stress and fatigue of emotional labor of therapists

The stress and fatigue of patients suffering from mental health issues while also trying to navigate an inaccessible mental health system

Therapists providing care for young children from their home while also providing teletherapy (see: therapist who described nursing her child below the camera while doing teletherapy)

Separation from the clinic, the office, from colleagues when doing teletherapy

Ability for therapists to see into their patient’s homes

The difficulty of helping patients in distress remotely (E.g. can’t walk them to an inpatient clinic, can’t hand them a box of tissues)

  • micro [practices]: What (labor, reproductive, communicative) practices constitute and are animated by the phenomena you study? 

Practices of time-management and time-autonomy: managing time across multiple teletherapy platforms (using a master calendar, using one platform to fill last minute cancellations from another platform); managing caseload on platforms (different settings and options with each platform); setting time-boundaries with clients verbally on platforms that promise on-demandness; balancing childcare and reproductive labor responsibilities; giving time for emotional processing, self-care time in between sessions. Contrast with the lack of time-autonomy in community mental health clinics, in private-practice when you need to drive to a physical office to see local patients. 

Practices of virtual community-building - using facebook groups and forums as a way to figure out how to build your career and your practice as a therapist. 

Emotional labor; extreme burnout with high-risk, high-needs clients who are seen in low-resourced settings, although also comes with high degrees of satisfaction in terms of “making an impact”; emotional labor associated with ongoing connection and contact in-between sessions that some platforms offer; going to therapy themselves or reaching out to supervisors as a way to help manage and process emotions. 

  • nano [language, subjectivity]: What kinds of subjects are produced by and imbricated in the phenomena you study? 

The “working well” or the “worried well” being serviced by platforms and private practice, in contrast to “high-risk” “high-needs” populations being serviced at agencies/community mental health centers 

The “Risky” patient constructed by platform screening surveys and questionnaires, those who are Not appropriate for telehealth (contested, grey areas that differ depending on the therapist’s risk tolerance) 

Therapists as “entrepreneurs”, creating their own private practices in order to escape the pressures of community mental health. (Versus...therapists as wage laborers, “trading hours for dollars”, as gig workers for platforms) 


  • edxo [education and expertise]: What modes of expertise and education are imbricated in the phenomena you study? 

Entrepreneurial expertise (self-promotion, creating a workable business model across multiple streams of income)

Platform expertise 

Insurance and reimbursement expertise 

Mental health expertise (different niches/working with different populations)

Technical expertise

  • data [data infrastructure]: What data, infrastructure, analytic and visualization capabilities account for and animate the phenomena you study? 

Managed care a very data-driven tightly run machine, in which insurance companies are always working the margins to reduce costs, reduce utilization, while maximizing outcomes (e.g. maximizing “healthiness”). In mental health, particularly tricky to measure “healthiness”. 

Therapy entrepreneurs as bookkeepers to make sure they are maximizing their revenue, minimizing costs. 

  • techno [roads, transport]: What technical conditions produce and delimit the phenomena you study? 

Teletherapy platforms presume robust internet infrastructure, presume that both therapist and client have access to devices and technical expertise. Often, those clients who are high-risk or high-needs are those clients who do NOT have internet or device access or expertise. 

Complex technical infrastructures required to do mental health remotely, requires therapists to gain expertise in HIPPA compliant video platforms, in EHRs, in online billing. 

  • eco-atmo [ecology, climate]: What ecological and climatic conditions situate the phenomena you study? 

I’m not entirely sure how to answer this one. One maybe relevant point is that a teletherapy world requires a lot less of people driving cars. A lot of current community mental health these days has therapists or social workers drive TO clients, heard from interviewees that they were spending a lot of time in their cars and in traffic. 

  • geo [earth systems]: What geological formations, contaminations, resources and scarcities ground the phenomena?

Again I’m not sure how to answer this exactly, although rural populations (e.g. farming communities, mining communities, communities that may be more focused on extracting resources from land) notoriously have difficulty accessing the human services infrastructure of mental health?


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