Launch HN: Daybreak Health (YC S20) – Online counseling designed for teens
32 comments
I may not have anything actionable to say, but I can at least tell my side of the story. I am a teen in the US mental health "system." It has been quite a ride to say the least. I was living with debilitating anxiety and depression going into a new school, but I didn't even know it. I am thankful for my parents for calling a crisis number to get someone to talk to. It has been a tough few years trying to regain the time I was left untreated. Medication and regular (individual and group) therapy has been a huge help with anxiety and depression, as well as my ADHD and schizophrenia. I am finishing up my time at a therapeutic high school and will be attending RPI in the fall (at least for now it looks like I will be going to campus, yay!). It has been a struggle, but because of the support I have received, I am in a much better place than I was.
During the whole quarantine, I have had no complaints about online therapy (unlike online school). I can say personally you do not lose out by going the online route. It is certainly more convenient, and because it is (mostly) one on one, you don't have the issues that come with a 50 person zoom call. I really appreciate that you get parents on board because having an open dialog is extremely important.
I have two specific questions though: (0) How will you deal with crisis situations? How are you planning to take on the legal responsibilities that come with that? (1) Any potential solutions to improving access to psychiatrists and medication? Therapy is just one piece of the puzzle to my ongoing recovery. Medication really helps, but I am concerned that these teens might miss out on that important part.
Thank you for doing what you are doing. If I did not get help, I probably would not be here leaving this comment today.
During the whole quarantine, I have had no complaints about online therapy (unlike online school). I can say personally you do not lose out by going the online route. It is certainly more convenient, and because it is (mostly) one on one, you don't have the issues that come with a 50 person zoom call. I really appreciate that you get parents on board because having an open dialog is extremely important.
I have two specific questions though: (0) How will you deal with crisis situations? How are you planning to take on the legal responsibilities that come with that? (1) Any potential solutions to improving access to psychiatrists and medication? Therapy is just one piece of the puzzle to my ongoing recovery. Medication really helps, but I am concerned that these teens might miss out on that important part.
Thank you for doing what you are doing. If I did not get help, I probably would not be here leaving this comment today.
Thanks so much for sharing your story. It is stories like yours that inspire us every day, and that will inspire more teens and parents to seek treatment. And I'm happy to hear that your treatment has put you in a better place, and you are headed off to RPI. To address your questions:
1) Crisis situations: safety is our #1 priority. We create a safety plan that includes coping skills, strengths, local resources and people to contact. If a crisis situation arises we have this in advance as a resource. We recognize online can create more challenges than in person for maintaining a safe environment, so we also refer patients who we believe might need more intensive care to in person treatment.
2) We firmly believe telehealth is a great vehicle for psychiatry. We haven't quite arrived there yet, but it is on our 'roadmap' to have psychiatrists. And in the meantime, we refer out for teens who need medication support.
Thanks again for sharing your story!
1) Crisis situations: safety is our #1 priority. We create a safety plan that includes coping skills, strengths, local resources and people to contact. If a crisis situation arises we have this in advance as a resource. We recognize online can create more challenges than in person for maintaining a safe environment, so we also refer patients who we believe might need more intensive care to in person treatment.
2) We firmly believe telehealth is a great vehicle for psychiatry. We haven't quite arrived there yet, but it is on our 'roadmap' to have psychiatrists. And in the meantime, we refer out for teens who need medication support.
Thanks again for sharing your story!
Integration with medical systems would be amazing; my friends at top tier universities (e.g. Berkeley) want mental care but aren't sure if it's covered
from my experience there has been a constant refrain about CAPS (Counseling and Psych - usually called CAPS in school systems) departments everywhere being
1) hard to access 2) underfunded 3) unresponsive
super excited for this product :)
from my experience there has been a constant refrain about CAPS (Counseling and Psych - usually called CAPS in school systems) departments everywhere being
1) hard to access 2) underfunded 3) unresponsive
super excited for this product :)
Thank you! We would love to work with CAPS departments. Out of curiosity, do you have any people you could introduce us to who might be able to tell us more about CAPS at specific schools?
Congrats on the launch. I think this is an important issue and it is good to see some focus on this area.
How did you arrive at your pricing? I am curious how, if a therapist normally costs $200 per session, you can offer it at less than half that price? Are the counselors certified differently? What's unique about Daybreak that makes it cheaper to offer therapy?
Another question I'm curious about - do you address medication at all? How does that work, do you have psychiatrists that patients can talk with? Or is medication out of scope?
Congrats again!
How did you arrive at your pricing? I am curious how, if a therapist normally costs $200 per session, you can offer it at less than half that price? Are the counselors certified differently? What's unique about Daybreak that makes it cheaper to offer therapy?
Another question I'm curious about - do you address medication at all? How does that work, do you have psychiatrists that patients can talk with? Or is medication out of scope?
Congrats again!
Thanks for the kind words.
On Pricing - our counselors are certified to practice and pass a rigorous interview process ensuring the highest quality. All are licensed to practice in California and have 5+ years experience working with adolescents. The primary differences are: 1) real estate (our therapists work from the comfort of their homes, so we don't have that cost), 2) cost of living (because we can work with therapists in varied geographies, their cost of living may be lower than in the highest demand/need geos), 3) value prop (adolescent-focused therapists want to work with us because of our flexibility and focus on teens which is rare to find)
On medication - today we refer out if patients need medication. It is an area we are actively thinking about how to better serve in house!
On Pricing - our counselors are certified to practice and pass a rigorous interview process ensuring the highest quality. All are licensed to practice in California and have 5+ years experience working with adolescents. The primary differences are: 1) real estate (our therapists work from the comfort of their homes, so we don't have that cost), 2) cost of living (because we can work with therapists in varied geographies, their cost of living may be lower than in the highest demand/need geos), 3) value prop (adolescent-focused therapists want to work with us because of our flexibility and focus on teens which is rare to find)
On medication - today we refer out if patients need medication. It is an area we are actively thinking about how to better serve in house!
Access to healthcare is a big challenge in the US because of cost: your pricing seems to be very accessible but I’m curious if you have any specific ideas around how you can make therapy more accessible to people who can’t afford these prices.
I guess my question is whether your vision is a digital version of traditional therapy, or if you see your mission as making therapy more accessible which _currently_ is digital traditional therapy but could evolve substantially over the coming years?
I guess my question is whether your vision is a digital version of traditional therapy, or if you see your mission as making therapy more accessible which _currently_ is digital traditional therapy but could evolve substantially over the coming years?
Thank you for the great question about access: access and quality are our twin aims when it comes to delivering mental health support to teens. The product is in service to those aims.
So to answer your question: our current product reflects what we think is the best solution to increase access to therapy while maintaining quality. Over time, as we learn more, the product could evolve to become even more accessible (e.g., more digital) if we are able to maintain quality with that solution.
One other piece I'll say on access: for a healthcare company the 'insurance plans' control the keys to access. From Day 1 an important part of our strategy is pursuing reimbursement so that the cost of our services reaches $0 for teens and families who need it and cannot afford the out-of-pocket cost. We are not there yet, but it is our goal!
So to answer your question: our current product reflects what we think is the best solution to increase access to therapy while maintaining quality. Over time, as we learn more, the product could evolve to become even more accessible (e.g., more digital) if we are able to maintain quality with that solution.
One other piece I'll say on access: for a healthcare company the 'insurance plans' control the keys to access. From Day 1 an important part of our strategy is pursuing reimbursement so that the cost of our services reaches $0 for teens and families who need it and cannot afford the out-of-pocket cost. We are not there yet, but it is our goal!
Great job! What would you say are the most challenging gaps between online sessions compared to traditional in-person sessions? What are your plans to bridge the gaps?
Very important area to explore. Let me first start by saying the the evidence suggests that telepsychiatry is as effective as in person therapy for adolescents (article link below), and our data shows that it is more engaging as measured by session attendance and number of weekly engagements.
That said, there are three primary challenges in the online environment.
First and most simply, it is harder to create rapport online. We require for that reason that all of our teens use the video sessions (in addition to messaging and the app), and we place high importance on the match itself (which we can do since we have a group of diverse counselors across California geos). We also place high importance on the therapeutic alliance and give our counselors techniques during training to develop that online.
Second, privacy can be a challenge in small or crowded homes. We work closely and set expectations with parents to ensure that our teen clients receive privacy during their session times.
Third, online counseling is still primarily best for mild to moderate acuity. At the more severe acuity levels, or with psychotic disorders for example, we haven't yet nailed how to treat online effectively and safely. We screen members during the assessment and refer them out if in-person counseling is better. We also put an emphasis on our online safety plan, which gives us knowledge of parent whereabouts and trusted contacts in the case that a crisis situation does escalate.
Link to efficacy of telepsychiatry in adolescents: https://togetherthevoice.org/wp-content/uploads/2020/04/AACA...
That said, there are three primary challenges in the online environment.
First and most simply, it is harder to create rapport online. We require for that reason that all of our teens use the video sessions (in addition to messaging and the app), and we place high importance on the match itself (which we can do since we have a group of diverse counselors across California geos). We also place high importance on the therapeutic alliance and give our counselors techniques during training to develop that online.
Second, privacy can be a challenge in small or crowded homes. We work closely and set expectations with parents to ensure that our teen clients receive privacy during their session times.
Third, online counseling is still primarily best for mild to moderate acuity. At the more severe acuity levels, or with psychotic disorders for example, we haven't yet nailed how to treat online effectively and safely. We screen members during the assessment and refer them out if in-person counseling is better. We also put an emphasis on our online safety plan, which gives us knowledge of parent whereabouts and trusted contacts in the case that a crisis situation does escalate.
Link to efficacy of telepsychiatry in adolescents: https://togetherthevoice.org/wp-content/uploads/2020/04/AACA...
This is cool. Do you have any documentation around the security controls implemented to protect sensitive communications between patients and therapists? Among others? I presume this is ultimately still protected information under HIPAA
Thanks. This is an important question. You are exactly right that under HIPAA, there are a few basic data protection requirements. These encompass administrative, physical and technical requirements. A few examples of the technical requirements: all protected data must be encrypted at rest and in transit, each medical professional authorized to access PHI must have a unique identifier to monitor access, and automatic log-off must be implemented to protect data. We've architected from Day 1 to be able to meet these needs. You can read more about HIPAA requirements here: https://www.hhs.gov/hipaa/for-professionals/security/laws-re...
Amazing - you all are doing vital, lifesaving work! Curious - did you determine that you needed to use any existing software systems to help with regulatory compliance, such as any big-name EMR solutions and/or single-sign-on with the same? Or were you able to meet HIPAA requirements with standard web application tools & stack? Do you feel any choices of language, database, even things like advisory board, etc. made this easier to do?
Working with existing software systems make this compliance much easier. Many of the big name service providers (Twilio, Sendbird, Auth0, Heroku, AWS, etc) have out-of-the-box HIPAA compliancy. And working with an EMR is tablestakes for a healthcare provider, we definitely did not build that from the ground up! Our work is about bringing these solutions together into a unified UX and ensuring compliancy / security across the stack, while gradually introducing secure and compliant native functionality. Language itself does not have a huge impact (we've seen it done in many different languages), but having the right advisor can make the build process a lot easier if they know what to look for!
Congrats on the launch!
Question: your site emphasizes a "guarantee of good counselor match". Importance of a rapport and trust between coach and teen (especially) is hard to overvalue.
How does this guarantee translate into practical terms? Is it a guarantee to have access to/try all currently available coaches before making the choice, or more like a "money back" kind of guarantee?
Question: your site emphasizes a "guarantee of good counselor match". Importance of a rapport and trust between coach and teen (especially) is hard to overvalue.
How does this guarantee translate into practical terms? Is it a guarantee to have access to/try all currently available coaches before making the choice, or more like a "money back" kind of guarantee?
Definitely agree the rapport and 'alliance' between the two is paramount!
How it practically plays out: teen members can switch between counselors on our platform if they are not satisfied with their first match. If they don't find a match that is a fit within the first few sessions, we do offer a money back guarantee.
We do also focus in the upfront assessment on gathering the input we need from both the teen AND the parent to make the matches we select higher quality. This input includes goals, needs, specialty areas, interests and hobbies -- among other inputs.
How it practically plays out: teen members can switch between counselors on our platform if they are not satisfied with their first match. If they don't find a match that is a fit within the first few sessions, we do offer a money back guarantee.
We do also focus in the upfront assessment on gathering the input we need from both the teen AND the parent to make the matches we select higher quality. This input includes goals, needs, specialty areas, interests and hobbies -- among other inputs.
"That is why an average of 11 years pass between when a teenager first needs mental health support and when they eventually start receiving it in their 20s or even later."
As a medical student interested in psychiatry and rehab, that is mindblowing and touching.
I really with you the best with this!
As a medical student interested in psychiatry and rehab, that is mindblowing and touching.
I really with you the best with this!
I’d also love to learn more about increasing access for young people. I spent many years working with low income teens and unfortunately this pricing is entirely out of reach. Do you have any plans to offer free services for the young people most in need who could never afford to pay out of pocket.
I’ve also worked with young people whose parents, even if they could have afforded it, didn’t believe in therapy and weren’t willing to support their child’s efforts to obtain it. So yet another reason why access is super important.
Just as a reference point, I run OkaySo, we offer free support on sex, relationships, and identity to young people. Happy to chat and connect. elise at okayso dot co (not com)
Thanks for this work!
I’ve also worked with young people whose parents, even if they could have afforded it, didn’t believe in therapy and weren’t willing to support their child’s efforts to obtain it. So yet another reason why access is super important.
Just as a reference point, I run OkaySo, we offer free support on sex, relationships, and identity to young people. Happy to chat and connect. elise at okayso dot co (not com)
Thanks for this work!
Thank you for your great comment and for your important work at OkaySo.
We recognize that our current pricing, while an improvement over private practice, is still out-of-reach for much of the country. Our plan is to: 1) continue to evolve the product to reduce cost of care while maintaining quality, 2) pursue partnerships with health plans and eventually Medicaid (which covers the lowest income teens) so that our services can be offered for free to those teens. We are very open to other funding models to increase the access of our services for teens as well! I'll reach out to learn more
We recognize that our current pricing, while an improvement over private practice, is still out-of-reach for much of the country. Our plan is to: 1) continue to evolve the product to reduce cost of care while maintaining quality, 2) pursue partnerships with health plans and eventually Medicaid (which covers the lowest income teens) so that our services can be offered for free to those teens. We are very open to other funding models to increase the access of our services for teens as well! I'll reach out to learn more
Thanks, this is a vital service, especially now when many teens are struggling and virtual is the only option. Designing specifically for virtual may be an advantage over therapists who usually work in person, but are now trying to do the same thing online, but may see challenges in adapting their approach. I didn't see this on your FAQ. Can your counselors prescribe medications, or make referrals if they think it may be needed?
Thanks for the kind words! We do believe designing for virtual first offers a lot of advantages vs. tacking it on to a traditional practice.
You ask a great question, and we'll add it to our FAQ. We currently refer out for the medication prescription needs, and are evaluating bringing the capability in-house.
You ask a great question, and we'll add it to our FAQ. We currently refer out for the medication prescription needs, and are evaluating bringing the capability in-house.
Are y'all hiring JS devs at all? I'd love to work for a company with such a great mission.
Thanks for the kind words about our mission! We aren't currently but that may change in the next 6 months. Can you shoot me a note alex at daybreakhealth dot com and I will connect you to our CTO?
What's your current understanding with the problems and/or pitfalls of psychiatry? Serious question.
There is very noticeable lag when navigating the site. Clicking the counselors link takes seconds to open. This on a top of the line android phone.
I strongly suggest you do performance a/b testing.
I strongly suggest you do performance a/b testing.
It seems that template they use is just terrible.
It is not trivial for this service how your website looks. It should provide some confidence that you know what you are doing.
It is not trivial for this service how your website looks. It should provide some confidence that you know what you are doing.
Thank you both for the usability feedback, on both the performance and the UX side. We will absolutely take that into account in future iterations. And agree 100% with performance testing!
Btw, I dont think the site is terrible. The lagging made it hard for me to learn more about the product. Hope it didnt come off as snarky
I'm pretty skeptical about online therapy. Creating yet another abstraction between human and human seems to be going entirely in the wrong direction.
One of the big issues with the lockdown was that many municipalities considered substance abuse meetings (AA and others) as non-essential. These types of programs do not work anywhere near as well online. Meanwhile liquor stores remained open as essential.
One of the big issues with the lockdown was that many municipalities considered substance abuse meetings (AA and others) as non-essential. These types of programs do not work anywhere near as well online. Meanwhile liquor stores remained open as essential.
Thanks for the push, this is something we think about a lot.
I'll start by saying that we look to data to drive our perspective here. The the evidence suggests that telepsychiatry is as effective as in person therapy for adolescents (article link below), and our data actually shows that it is more engaging as measured by session attendance and number of weekly engagements than traditional therapy benchmarks. The way teens engage with the world is changing (to more digital), and rather than try to swim against the current, we hope to reach the most teens by meeting them where they are, and then changing their behavior in ways that matter. Our programs do focus on the importance of things like limiting screen time and developing healthy relationships.
Ultimately I won't disagree with you -- in-person is at least as effective and for many people can be more effective. However, what we are hoping to do is increase access to those people for whom going to an in person session might present to high a barrier, whether it be geographically, financially, or from a stigma perspective.
Article on efficacy of telepsych: https://togetherthevoice.org/wp-content/uploads/2020/04/AACA...
I'll start by saying that we look to data to drive our perspective here. The the evidence suggests that telepsychiatry is as effective as in person therapy for adolescents (article link below), and our data actually shows that it is more engaging as measured by session attendance and number of weekly engagements than traditional therapy benchmarks. The way teens engage with the world is changing (to more digital), and rather than try to swim against the current, we hope to reach the most teens by meeting them where they are, and then changing their behavior in ways that matter. Our programs do focus on the importance of things like limiting screen time and developing healthy relationships.
Ultimately I won't disagree with you -- in-person is at least as effective and for many people can be more effective. However, what we are hoping to do is increase access to those people for whom going to an in person session might present to high a barrier, whether it be geographically, financially, or from a stigma perspective.
Article on efficacy of telepsych: https://togetherthevoice.org/wp-content/uploads/2020/04/AACA...
Actually, online therapy can be more effective than in-person:
[1] https://www.thelancet.com/journals/eclinm/article/PIIS2589-5...
[2] https://healthsci.mcmaster.ca/news-events/news/news-article/...
[1] https://www.thelancet.com/journals/eclinm/article/PIIS2589-5...
[2] https://healthsci.mcmaster.ca/news-events/news/news-article/...
I’ve done online therapy. It works just fine for me. I have a lot less anxiety over video in a comfortable setting than driving to a location to meet in person.
My psychiatrist has found doing things over video is much more effective than in person for most of her patients. It’s easier for me to take 20 minutes out of the start of my work day than spend two hours after my work day to drive to her office, wait to have an appointment in person, and then drive home.
My psychiatrist has found doing things over video is much more effective than in person for most of her patients. It’s easier for me to take 20 minutes out of the start of my work day than spend two hours after my work day to drive to her office, wait to have an appointment in person, and then drive home.
The evidence supports that behavioral therapy like CBT and DBT is effective. It works to treat diagnosable conditions like anxiety and depression, and it also works to help young people feel happier and achieve their goals [1][2][3][4][5]. But too often teens don't get the mental health support they need because it is stigmatized, difficult to schedule and attend, and expensive. At Daybreak we bring counseling to the teen on a digital device and we charge less than half the cost of a traditional therapy session.
In October of 2018, my younger brother nearly lost his life due to the lack of accessible mental health resources supporting our young people. He is not alone. 1 in 5 teens struggle with a diagnosable mental health condition, but estimates suggest that up to 1 in 3 actually struggle with anxiety - or between 6 and 10M total teens [6][7]. That means the odds are greater than 50% that if you are the average parent raising a family in America with 2 kids, one of your children will struggle with a mental health condition in their teens.
To make matters worse, 80% of teens who need mental health support do not receive care today [8]. This results in deteriorating academic performance, increased rates of juvenile crime and substance abuse, and suicide rates that are at an all-time high. Every day, 17 young people commit suicide in the US. It is the #2 cause of death among 15-24 year olds, after accidental injury and ahead of homicide [9]. This isn't a niche problem.
Our current system makes mental health support nearly impossible to get for a teen. Stigma makes it hard to admit to yourself you want support, let alone talk about it with your parents. There is a shortage of therapists who specialize in adolescents, making it hard to find a therapist that is close enough to drive to on a weekly basis. Private practice therapy averages more than $200 per session. Even if you could afford to pay, you're going to be met with 2-3 month wait lists. And when you finally do arrive, you sit on an awkward couch in an environment that you may not be comfortable in. That is why an average of 11 years pass between when a teenager first needs mental health support and when they eventually start receiving it in their 20s or even later [10].
That is why we started Daybreak Health. Everything we’ve built is designed intentionally for teens and their parents. Teens can download the Daybreak mobile app and are instantly connected to a live guide (Mon-Fri 7am-7pm) who asks about mental health goals and needs. After a video assessment where we loop in the parent, we create a plan and match teens with a counselor based on goals, needs, interests, hobbies and more. Once matched with a counselor, teens meet with them once a week through a 50-minute video call, and can message them on a daily basis through the app. Our counselors help teens develop emotional life skills and work towards goals in a personalized plan that has thematic focus on teen-specific areas like school, healthy relationships and more. Teens can also meet with small moderated groups of other teens on those same topics. And parents are a core part of the process, starting with the assessment, through planning and regular progress reports. For all of this we charge an $89/week subscription, less than half the price of a single 50-minute session in traditional private practice.
Dr. Neha Chaudhary, our lead Clinical Advisor, is a foremost expert on adolescent mental health and co-founder of Stanford's Lab for Mental Health Innovation. Together with her and experts from UCSF we have designed a program for teens grounded in clinical science, while at the same time reimagining the way it is delivered to teens. The core of our clinical program is rooted in evidence-based methods like DBT and CBT, but we have taken these approaches and brought them into an easily digestible online experience.
But there is a problem: stigma around mental health stops people from sharing their great experiences with counseling, so its benefit is under-appreciated. If you know any parent or teens who might benefit from counseling, make sure they know about its benefits. And if you have thoughts about how to solve the awareness problem, or any stories you can share that may help us better understand the needs of teens and parents, we would be grateful. Thank you!
Sources:
[1] https://www.sciencedirect.com/science/article/abs/pii/S00057...
[2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3073681/
[3] https://acamh.onlinelibrary.wiley.com/doi/abs/10.1111/j.1475...
[4] https://acamh.onlinelibrary.wiley.com/doi/abs/10.1111/camh.1...
[5] https://www.tandfonline.com/doi/abs/10.1080/0963823060118209...
[6] https://www.cdc.gov/childrensmentalhealth/access.html#ref
[7] https://www.nimh.nih.gov/health/statistics/any-anxiety-disor...
[8] https://www.cdc.gov/childrensmentalhealth/access.html#ref
[9] https://www.nimh.nih.gov/health/statistics/suicide.shtml
[10] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1361014/
Visit us at www.daybreakhealth.com