Two Chairs | A Conversation about Thoughtful Therapy with Alex Maceda
I’ve sat in uncomfortable chairs in rooms with badly painted walls. I’ve awkwardly handed over a cheque or counted out cash at the end of a session. I’ve missed weeks of help because scheduling hadn’t worked out with the shape of my week. I’ve stumbled down stairs afterwards crying and fled to my car for solace. I’ve found people, then dropped them when it didn’t work, but made sure that I felt like I was the cause of the ending and not them. All of the above, all of it is wrong, but all of it is what can happen in our experience of therapy.
We are huge advocates of the practice of therapy and have been in and out of it (between us) for most of our adult lives. Sitting with a therapist has saved us again and again. We’re happy to spread the cause that #therapyiscool, and we’re in the business of making all our mental health tools, including talk therapy, more present in our lives.
But as we do this, we also need to acknowledge that the model of how therapy is given—not the content or the relationship parts—but all those things around it such as booking, payment, design, and fit, make it really, really hard to have a good experience at best and to get the help we need at worst. We pay more attention to how we go for a haircut, then how we go for therapy, and that makes no sense at all.
That’s why we were relieved to discover Two Chairs, a San Francisco start-up (hold the judgement) that’s making therapy all about you in all the ways that it hasn’t been so far and really needed to be. That means when you step into one of their seven therapy clinics across the Bay Area, you enter a setting that actually has your back as a person in the world.
Here the design of the spaces matters, not just in terms of beautiful furnishings with yellow (brand color) flourishes amongst the muted tones, or the LaCroix stocked in the fridge, and carefully chosen Phaidon art books on the coffee tables, but in psychologically impactful ways too. How the chairs are arranged affects how comfortable you might feel as a therapy go-er depending on your life situation. The art on the walls can subtly shift your mood. The presence of plants actually makes for a calmer environment.
Yes, therapy here is given the modern makeover it so, so badly needed, but it’s also been given one that takes into account what science is telling us about the environments and processes we need to best function as people. This is all Two Chairs Therapy’s Alex (Amac) Maceda’s domain. As the Director of Brand Strategy, Amac is responsible in her remit for interior design and client experience, working through all these details with not just operations and designers, but also clinicians and clients, who are folded into the process of what goes on before and after, as well as during a therapy session.
We had the opportunity to talk to Amac about why the model of delivery has been so broken but also why therapy in itself isn’t.
Claire: Let’s start with what Two Chairs is changing about the experience of therapy from the client’s side. Although we’re huge believers in therapy, we know that it’s really hard to just get the help that’s needed. How are you responding to this?
Amac: At Two Chairs, it’s all about access. We think of access as all the barriers that the system puts in front of you when you want to start care. The most classic example is that you are probably in crisis and you know that you want to go to therapy. You go online and Google. You maybe find 10 names. All of them are phone numbers only. Three of them call you back. Two of them don’t have availability. One of them can see you 30 minutes away at 2pm. Even when you’re opted-in, the system makes it so hard for you to get care. It’s such a disheartening experience, especially when you are engaging with it for the first time.
Claire: It’s hard to say,“I need to go to therapy,”and it’s even harder when you are trying to do this, and it’s still not coming together.
Amac: For a lot of people by the time they are asking for help, they have probably gone through quite a bit. Also, a lot of people are afraid to ask for help that first time. Whether they don’t know where to start or fear the stigma, there are so many things that you find yourself up against. Imagine that after taking so long to get to that realization, there’s still 20 barriers that they didn’t even know existed. When Two Chairs first started, that was the problem that we were trying to solve: How can we make engaging in high-quality care as easy as possible for those seeking it.
Claire: Can you talk me through how you are doing that in practice?
Amac: Some of the things we are doing are so simple, and take inspiration from different consumer brands, but are not typical in a health care setting. Things like online scheduling—it takes less than five minutes to schedule an appointment—and convenient locations—all of our clinics are located near major transit hubs. We want clients to be able to get in and out. We want clients to get on with their day and have the experience of therapy be as seamless as possible in daily routines.
Claire: You also have a unique offering in how the therapy journey starts way before clients are physically in a room with someone. Can you tell me about that intake piece?
Amac: We have a really dedicated care coordination team, and see them as a helping hand before clients even start care. They help clients think through questions like, “I don’t know if therapy is right for me, but someone recommended it,” to “how much can I expect to be covered with my insurance plan?”
What I think is really unique with Two Chairs compared to private practice or other group practices is our emphasis on matching. It’s clinically proven that the strength of the alliance between the therapist and the client is the biggest predictor of success, rather than the therapeutic approach taken by the therapist. However, the current system is not set up to match well.
Choosing a therapist can be really intimidating for anyone, and at Two Chairs, we try to make that as easy as possible. What that looks like from a client perspective is: you book an appointment online, receive a series of emails about what to expect in your appointment and then we send you a client profile to fill out.
The profile is a detailed intake form asking what some of your goals are for therapy, some demographic information, and questions that try to get at what modality might work for you, including,“How structured of a thinker are you?” from very structured to not structured, and,“How much do you want to be challenged in therapy?” from pushing back to I want a therapist who listens more. We’re not asking you to choose a modality, but rather we’re getting at some of the qualities that might move you towards one type of care or another.
Claire: That’s an interesting technology-driven part of your approach that hasn’t had a place previously in therapy. How important is the personalized data-driven piece to the Two Chairs model?
Amac: The self-reported data from the client goes into a matching algorithm that has been built in-house by our engineering team, and is founded on the latest data science. But our approach is not founded on data only. That information forms a hypothesis that a consult clinician (a position unique to Two Chairs) uses for a first consult. They prep with all the intake data, but they use their clinical expertise in that first in-person appointment to move the data around and to form a recommendation based on this human interaction. It is that person who then matches you with an ongoing clinician.
We match on so many different factors, from demographics, lived experience, and any specific preferences, like, “I can only come in at 8am in Oakland and I want to see a female who is middle aged.” We take this all into account when matching.
Claire: So, they take what they understand as you as this person on paper and you as this person in space, then put you in contact with the person who would be your therapist? If someone then goes to that therapist, and that’s not a good match, do you then rematch them? That’s one of those broken parts of classic therapy, that bad matches do happen and then someone drops out of therapy because of this even though they still need help.
Amac: Yes, that is where the consult clinician is so powerful—they become that point of contact throughout the process if anything is wrong. But we do have an over 90% success rate with the first match. Clients tend to be in therapy for quite a long time, though our goal is not to keep you in therapy forever. We’re now just over two years old, and at this stage, we’re seeing clients come back for new courses of care, and to work on new issues in more proactive ways versus more reactive ways.
Claire: I’m interested in this narrative of therapy positioned within life maintenance, like something you fit in on a regular basis. I’ve noticed that in the language of Two Chairs, that you are positioning therapy as a self-care tool rather than just as crisis management.
Amac: We have a good mix of clients who are brand new to therapy, and also those who are returning to therapy. On the new to therapy side, it’s been so powerful to see clients coming in for the first time who are telling us that they’ve been looking for a therapist, but that it had felt too intimidating, and that Two Chairs made it so easy. And on the flip side, we’ve had clients who have been in therapy for years who are coming more proactively, and treating therapy as a tool that is part of their life.
Claire: Do you approach those two needs differently in the intake process given that therapists have their own specialisms, such as trauma or situational issues, or work more generally, in a style that can be more holistic and generalized?
Amac: Yes, there’s all this self-reported data on the client side but I think what people don’t think about as much with Two Chairs is that we also have all this self-reported data on the clinician side too. Our matching tool includes their clinical expertise in session and the data we have about the clinicians about how they self-report their stylist preferences, their studies and research backgrounds.
Claire: How do you deal with the inclusivity piece? Therapy has been charged with being very narrow in its focus.
Amac: There’s a few different aspects to inclusivity, and certainly one of the hardest is financial. We’re still an Out-of-Network provider and we charge $180 for a session. That’s under market in San Francisco. But we aspire to be In-Network which we know will help a lot in terms of that financial piece. We know that the bigger we get the more power we have to be in network and then we can open access to more people.
On the other side, one of the narratives around therapy is that traditionally minority communities are less served within therapy and that gets back to our matching system. A big part of what we hear from clients is that we have a very diverse population of therapists across demographic and lived experience, qualities like gender, race, and sexual orientation. We consciously build for that. The feeling that someone understands your lived experience is very important, so we hire against that.
Claire: What happens after a therapy session? I always had this issue with therapy where I would sit in this non-descript room, see my therapist, and then come out with whatever raw feeling that I had, but then I have to go on the tube and get myself home. Can people hang out? Can they linger in the waiting room or sit with a cup of tea before heading back out into their non-therapy worlds?
Amac: I personally feel so passionately about this. Imagine that you cried during therapy and then you have to go to the bathroom to check your face and then sit in your car doing breathing exercises to collect yourself before going back to work. It doesn’t happen always, but for many of us, myself included, we’ve been there once or twice. For much of therapy, there’s no after. We think a lot about how you enter, but no one ever thinks about how you leave.
That’s something we’re addressing in all of our newest clinics and bringing that concept into the space. We’re introducing decompression areas to the extent that we can where you have separate exits and semi-private areas where you can sit and journal. We have essential oils and rocking chairs, so you can take a few moments if you need to. Each of our therapy rooms have a small mirror right before you exit so you can check how you look. These are all the little thoughtful details that we know from experience or from our clients speak to where they are at in that moment and we try to pull that into the design of the space.
Claire: Two Chairs didn’t go down the route of becoming an app but has invested in bricks and mortar and that in-person piece. Why is that aspect of just being in the room with someone so important. I know Two Chairs Founder Alex Katz has talked about Sherry Turkle’s Reclaiming Conversation: The Power of Talk in a Digital Age as a foundational text, and I wonder how this folds into your approach?
Amac: We know it’s clinically proven that in person is better. You lose so much when you are not in the room: like body language, tone, how a person is presenting, and how they seem to feel.
We also know that we are in a generation where we keep talking about how much digital is taking over our lives, and how much interaction is going through a screen. To be able to interact in person, especially around topics that are so deeply personal and that a lot of clients are talking about for the first time, allows us to bring a lot more empathy and understanding to the experience.
Claire: You have all the science backing up therapy, but you also have the science backing up the in-person piece. We’re at this moment that those two pieces are coming more and more together.
Amac: Yes, there’s so much care and attention paid understandably to the clinical setting. The hard part goes on in the therapy room. But there’s so much across the whole experience that matters—being able to be in person, to walk into a space and to feel a sense of calm, to have a cup of tea and to sit there for a moment, to take an hour out of your day in a beautifully designed setting that addresses our needs as a person.
Claire: Do you find that therapy is as stigmatized as when you started even a couple of year ago?
Amac: I certainly feel the stigma has decreased—but we have a long way to go. I find myself in a lot more open conversations about it, but know it’s a self-selecting group of people around me saying they go to therapy and that they love it. Even then, they are sharing in small conversations but not necessarily projecting it in public.
As someone who has worked in brand and marketing at different companies, I find it to be a very unique and specific reflection of where we’re at culturally with mental health. I used to work in fashion, and we had tons of user generated content on social media—people were posting pictures and tagging our brand, being advocates for our sustainability efforts, sharing our mission with friends—they wanted to be publicly associated with us. That’s not quite the same at Two Chairs—yet. We had our first tag from a client testimonial for Two Chairs only a couple of months ago, which was so powerful and exciting. Even two years ago, it would be hard to imagine someone posting about their experience with therapy on Instagram and thanking their mental health provider. It’s happening, but it’s still rare. Which makes sense—how many people do you know are going to therapy and taking a selfie and saying, “I had a great therapy session?”
There’s still a little bit of a ‘coming out’ that people do when they start to publicly associate themselves with mental health, mental illness, and therapy. Even people who are very mental health positive are not necessarily saying I’m going to therapy every week.
I was there six years ago, when I told a friend that I was in therapy and I remember feeling so scared. When they just said, “that’s great”, this relief washed over me. But even that makes such a big difference. It can be so powerful.
Everyone is on their own journey with telling their personal mental health story, but we hope that the work we’re doing at Two Chairs is making therapy a little more approachable, and creating more space so that you can talk to people about your experience with therapy when you’re ready. We want to humanize therapy more. In the past couple years there have been more and more mental health stories of famous people, often with this narrative of a grand fall from grace and then rise, which is inspiring, but not representative of most people’s experience. We’ve introduced an initiative called #TalkTherapy on our blog where we put more stories out there to show there’s a breadth of experience, that it’s positive or that it’s negative, sometimes life changing and sometimes it’s not, but we try to normalize the breadth of what happens to people in therapy.
Claire: How has Two Chairs been received on both sides, client and therapist, since launching?
Amac: We’ve seen over 2000 clients in the San Francisco Bay Area over the past two years. Last month we opened our fourth clinic in two years within San Francisco. We are one of the biggest group providers in the Bay Area at this point.
We are creating demand for therapy—we know this because a large percentage of our clients are coming to therapy for the first time, but there’s still a lot of latent demand for therapy. We’re the first consumer brand in a space that has existed for a long time and what we’re offering is a high-quality version of a something that is already there. We’re not trying to create something new that people don’t understand; we’re a better-quality version of what’s out there and we’re adding new aspects to it that make it more compelling for clients. In San Francisco there’s an emphasis on wellbeing, wellness, and self-improvement, and it’s really exciting to be in the generation that’s opening the conversation around mental health.
To learn more about Two Chairs visit their Website, Instagram, and Facebook
