‘The problem in this country is that people lack depth. We don't know how to answer “How are you?” with anything more than “Fine.” Family dinnertime conversations don't have greater depth than “How's work? How's your boss?”’
Ariela Safira, founder of digital mental healthcare platform Real, is explaining why the US has a mental-health problem – and why she believes the way we talk about and deal with our feelings needs a fundamental shake-up.
‘I fully believe this is what's leading us to confusion over identity, to depression and anxiety,’ she continues. ‘The root issue isn't depression – it's the lack of depth. People are hitting quarter-life and mid-life crises, having a moment of: wait – what am I doing, who am I? We have no idea how to answer those questions.’
An endemic in a pandemic
The need for affordable, easy-to-access mental healthcare has arguably never been stronger. The rate of adults suffering from depression tripled in the US in the early days of the pandemic in 2020, according to the Boston University School of Public Health. In 2021, it got worse. The rate of depression now stands at nearly one in three Americans. The same study stated that one of the biggest predictors of depression is low household income. With a course of therapy typically costing thousands of dollars, traditional mental healthcare is largely the preserve of the wealthy – or those with enough insurance to cover it.
Enter Real, an app designed to build up the tools and awareness to learn, talk about and improve your mental health before you reach crisis point. For $23.99 a month, users can access online group sessions and on-demand therapist-led programs called pathways. These address specific struggles and common concerns that keep people up at night, using non-intimidating language. Program topics range from ‘WTF am I doing with my career?’ to ‘What to do with all this anxiety’ and ‘Communicating like a damn good partner’.
Although this is her first business venture, Ariela's concept of low-cost, high-impact mental healthcare has already attracted big-name investors. Backers include actor Gwyneth Paltrow and US football superstar Megan Rapinoe and, in 2022, Ariela was named as an honoree of business magazine Forbes' 30 under 30.
Revelations from rehab
Ariela's drive to change the way we treat mental health began when she was 19. While she was studying math and computational science at Stanford University, a friend attempted to take their own life. It was Ariela's first exposure to the traditional US mental healthcare system – and to the social stigma that stops us from admitting when we're not in a good place.
‘It was the first time I knew someone close to me was going to therapy. It was the first time I'd seen a rehabilitation facility,’ she says. During her visits to her recovering friend, Ariela felt these often underfunded, understaffed clinical spaces ‘made no sense. And, like an immigrant, I asked: why does the system work the way it does?’
Ariela grew up with a Yemeni-Jewish father and a Polish-Catholic mother in New Jersey. She credits her parents' attitudes and experiences as immigrants for her drive to start a business and her desire to look at old problems in new ways. While she hadn't engaged with the mental healthcare system before her friend's suicide attempt, she says, ‘I was raised with mental health as a clear principle in my life.’ This openness, she says, stood in stark contrast to the silence surrounding mental health in US society.
‘My dad was raised in a commune. He deeply values community, understanding others, patience and calm. He spends more time talking about the richness of vegetables than of dollars. I think that really guided me to approach the mental healthcare system not from a place of illness, but wellness. A huge issue in mental healthcare is that we're treating illness. We're not asking: how do we build a well community?’
Thus began her obsession with reimagining the mental healthcare system. ‘I threw myself at it. At the time, it wasn't in pursuit of building a company. It was [me asking] why, at 19 years old, is it the first time I'm learning that therapy's a thing? No wonder my friend didn't get help until rock bottom.’
Frustrated, and amid a spate of teenage suicides in Stanford's neighboring city of Palo Alto, Ariela dropped out of university to find solutions outside of mainstream education. But, David Kelley, a course tutor, business founder and designer, convinced her to come back. The prolific designer (he's the man behind the design of the original Apple mouse, the ‘lavatory occupied’ sign on Boeing 747 planes and the first portable defibrillator, among others) advised her that finishing her degree would help legitimize her ideas to investors.
It proved to be wise counsel. Back at Stanford, Ariela was making connections. Later, as a postgrad, she worked on healthcare design at David's consulting firm IDEO, as well as at Cityblock, a spinoff from Google's parent company Alphabet that builds healthcare into urban planning. She also traveled to research with world-leading mental healthcare providers, such as the Mersey Care NHS Foundation Trust, in Liverpool in the UK. But she still wasn't satisfied. ‘I was thinking: I've seen every mental healthcare model, and none of them work – even the well-funded ones. If even Google can't fund this [and make it work], I'm confused. How is this success when we're reaching only 2% of the population? All of my friends are still ill. What are we doing here?’
From flatshare to funding
At this point, she decided to train as a therapist, leaving work to join Columbia University's clinical psychology program but, again, dropped out – for good this time. ‘The CEO of Cityblock and his wife were constantly telling me: “Don't pursue more schooling. Found a company.” The exact words his wife gave me were: “If we saw a man with your brain, we would say: here's $50 million, start a company. With women, we say: why don't you give a medical school $400,000, and become a doctor?”’
Ariela took the leap to founding a business at 24. ‘I didn't approach it with a clear list of action items. No financial model, no deck. Just [the] certainty of: we're gonna solve this,’ she says. On her Instagram, Ariela posted a picture of the bathroom in the flatshare she lived in during the early days of all-night brainstorming sessions. The walls are dotted with sticky notes and the bathtub is filled with research papers, in ‘the one room I could light up without waking anyone up’.
When it came to raising cash, Ariela says she messaged a few investors on LinkedIn. One of the few who replied was Anu Duggal, a partner at venture capital firm Female Founders Fund. Many conversations, introductions and planning sessions later, Anu had helped Ariela build a concept and raise an initial $2.5 million in funding.
By anyone's standards, it was a giddying fast rise to success. By March 2020, Ariela was weeks away from opening a million-dollar flagship mental health studio in the Flatiron District in New York City. She had pitched Real as a physical space where, for $30 a month, members could access a comforting, carefully designed studio dedicated to supporting their mental health. Users could attend unlimited educational events led by therapists and access in-person, one-to-one therapy and salons where people could talk and share experiences. A digital app wasn't the plan.
Then the pandemic hit, dashing Ariela's dreams and making the bricks-and-mortar healthcare space she had spent years researching and planning unworkable. But, she says, ‘it ended up being probably the best thing to happen to us as a company’.
It also forced Ariela to decouple her own sense of self-worth from the success of her business. ‘I have a quarterly check-in with myself where I ask: do you feel like you have a separate identity from Real? I really think a lot of founders get lost. They get their identity lost in their company. I, for my own wellness, need to know Real can collapse tomorrow, and I, Ariela Safira, am well. My identity is intact. This business didn't work, and we're two separate things.’
Real didn't collapse. Just eight days into the pandemic, Ariela and her team pivoted away from the studio plans and launched Real to the People – a platform providing free online, at-home therapy for a month. Then followed a summer of beta testing of what would become the Real app. During this experimental phase, Real offered free group and one-to-one therapy sessions – an absolute steal in a country where the average 45-minute solo therapy session costs anything between $100 and $250.
But something strange happened, which once again meant Ariela needed to alter her business model. ‘Everyone preferred group therapy over one-on-one. It was a huge surprise – a free one-on-one session is a way better deal than a free group.’ She also realized that about half of the people were joining groups anonymously. ‘Names hidden, videos off. Nearly every man did that, and the majority of people of color did as well.
‘We would follow up to say, “Hey, if you want a more private experience, we have one-on-ones available.” Time and time again, people would say, “I want to be in this group… I just don't want anyone to know I'm in a group on infidelity. Or on body dysmorphia.”’ This influenced the app's focus on themed, pre-recorded sessions that allow users to tune in whenever they feel like it – an anonymous, subscription-based reworking of traditional therapy, which Ariela says fits in with the way people live their lives.
‘When it comes to the on-demand nature of Real, I have the ability to pick and choose the moment I need to engage,’ she says. ‘If you want to go to one-on-one therapy or to live group therapy, you might get an appointment on Mondays at 2pm. But Monday at 2pm, I'm thinking about my pitch deck. I'm not thinking about my childhood trauma. But catch me on Friday at midnight, and I'll have shit to talk about.’
It seems Ariela isn't alone. Online searches for apps relating to anxiety, anger and depression rose by 328%, 324% and 156% respectively during the lockdown in the UK, according to ORCHA, which reviews mental health apps on behalf on healthcare providers such as the UK's National Health Service and the Mental Health Commission of Canada. Instead of joining long waiting lists and spending thousands on in-person therapy, people are searching for instant relief at the App Store. As a result, Real is jostling for position among thousands of other online options offering better mental health.
Ariela believes Real's difference is in its data. ‘There are two extreme sides of the scalability and efficacy spectrum in the market, and Real is on neither of those sides. We have the really well-branded wellness companies – Calm, Headspace. They invest a ton in [branding] and are offering tools that are therapeutic though, more often than not, [they] don't have clinical results, don't have promised outcomes. From an investor perspective, the strategic value of that isn't as high. [They're] low-cost, well-branded, meeting far more consumers, but not impacting them in ways that have financial value for investors. ‘On the other side of the spectrum, we have really unscalable, human clinician-delivered services – that don't necessarily have proven efficacy, to be clear – but, because they're driven by a clinician, we trust them more. They also aren't a phenomenal financial investment for an investor [because], first and foremost, there's no scale. You're limited by the number of clinicians you have. Secondly, the margins don't really exist. Like, a clinician makes a whole lot of money. So, if you need to make money on top of that […] your margins are looking quite low.’
An app for the ‘therapy curious’
Ariela has described Real as an app for the ‘therapy curious’ rather than for those who can afford in-person traditional therapy. But, if mental health is notoriously unpredictable, hard to treat and unique to everybody, how can you measure the success of an app promising to improve it? Is self-directed, app-based therapy the future? How do you make sure you drive positive, rather than negative, change in people when they're feeling low?
Dr Stephanie Collier is an instructor in psychiatry at Harvard Medical School and a psychiatrist at McLean Hospital in Belmont, Massachusetts. She says we're still in the early days of knowing how effective wellness and mental healthcare apps can be, and emphasizes that data privacy and security concerns are a major risk – we are, after all, revealing some of our most vulnerable personal information when interacting with such apps. But she says one potential benefit of a shift towards digital therapy may be to wean the US healthcare system off drugs as the first line of defense against mental illness.
‘If you go to see a primary care doctor feeling depressed, and you score high in a screening scale, they'll want to do something – very often that's prescribing an antidepressant. [Countries like] the UK are different, because they recommend therapy first, but that option isn't as accessible here. So, if doctors say instead: “Why don't you try this evidence-based app?”, that might eventually decrease the impulse to prescribe an antidepressant. That might be a big benefit.’
Accurate performance data, she stresses, will be key to the future of such apps. Unlike many of the heavily branded wellness apps that have mushroomed in recent years, Real deploys clinical screening tools such as PHQ-9 and GAD-7 surveys (which diagnose depression and generalized anxiety disorder, respectively) to help identify health problems and track improvements. Users also have access to a tool called Pulse, which charts their mental health over time, using metrics such as feelings of connection, energy levels and optimism.
Ariela says Real is currently delivering an average 33% reduction in depression symptoms in a single month of using the app and 38% in anxiety. The figures, she says, ‘are even higher for severely depressed and really anxious populations’.
The evidence-based nature of the app and features like Pulse are what drew psychiatrist and Stanford professor Dr Nina Vasan, who served as a healthcare advisor to both the Obama and Biden US presidential campaigns, to join Real. While at Stanford, Ariela took a class called Designing for the 2 Billion: Leading Innovation in Mental Health. Nina was the course instructor – and she now serves as the company's chief medical officer. She tells us that the app's potential to reach people in a way that's simply not possible for one-on-one therapists is a core part of its appeal to her.
Despite the importance of clinically backed and evaluated evidence supporting the use of apps for mental health, Ariela says that success to her isn't quantified by numbers. ‘When I think of how I want to see Real in the next few years, it's not about clinical efficacy scores. It's not about the PHQ-9 and the GAD-7.’ Instead, Ariela says the long-term goal is delivering something less tangible.
‘The change I want to make is to see greater depth in people. Having the ability to understand: who am I as a person? How am I as a person? And, as a result of that, having the ability to understand who my partner is, who my family is. That's the more impactful thing we're bringing to life. The clinical scores are just how we translate it to stakeholders.’
As for her own mental health? A recent learning is that: ‘I need to have a clear investment outside of work. I don't work on weekends for the most part. I've been good at that, but I think it takes more than not working. It takes investment in doing another thing, ensuring I'm accountable to another thing – as opposed to working insanely for five days a week and sleeping through the weekend.’
‘I'm not going to be a non-parent who gives advice to parents but, from where I sit, I do think my founder peers who are parents have that clearly defined. I don't know if it's healthy for them – that their life is “work” and “child” – but they at least have a thing outside of work such that they're not so lost in their work. I'm sure they say it's so much easier to be a non-parent and run a company. I believe that. But that example's a really strong one of asking: what am I really fully accountable to, outside of Real? Last month was the first time I read a book [that was] not about mental healthcare in two years. That, I think, is incredibly unhealthy.’
So, what's her advice for staying well while scaling a business in a pandemic, during a time of intense geopolitical volatility? ‘I think what's required is an investment in something outside of work… and that's not something to talk to your investors about. They would love for you to be [constantly] at it, but [you] really [need to] have those check-ins and certainty of: I am a human outside of this; I am a daughter; I am a friend. It's hard. It's all the harder when you run a company in a pandemic and there's nothing else to do. I might as well just work, but it's not healthy.’
By Olivia Gagan