“The model breaks if the average session count hits fourteen.”

“Fourteen exactly?”

“Thirteen point eight, if you want the decimal. At fourteen, our cost to acquire a customer plus the clinician’s hourly rate exceeds the lifetime value of the user. We’d be paying to treat them. So, the algorithm needs to lean toward the mild-to-moderate presentations. We just won’t bid on the high-complexity keywords.”

I sat there, watching the logic settle into the room like fine dust. There was no malice in it. Nobody was twirling a mustache or plotting the downfall of the vulnerable. It was just arithmetic. In the world of scalable mental health platforms, complexity is a bug, not a feature. If you have a single, clean difficulty-say, a specific phobia of spiders or a recent bout of travel anxiety-you are a dream customer. You are predictable. You fit the “six to eight sessions” box. You are profitable.

The Market of Artificial Selection

But if you show up with three interacting difficulties-perhaps a chronic sleep disorder, a neurodivergent profile that makes standard CBT feel like wearing a wool sweater in a sauna, and a decade of suppressed trauma-you are expensive. You are slow. You are unpredictable. And in the sleek, optimized world of modern health-tech, you are quietly becoming nobody’s target customer.

We talk about the “mental health crisis” as if it were a failure of capacity, a lack of boots on the ground. But that’s a half-truth. The market isn’t failing to meet complex needs by accident; it is selecting against them with ruthless efficiency. Platforms optimize for conversion, providers protect their margins, and commissioners buy volume because volume looks good on a spreadsheet. The result is a system that grows fastest at the shallow end, while the deep end is repeatedly dismissed as a “workforce problem.”

I remember a specific pitch deck from a few years back. Slide six was the unit economics. It was a masterpiece of optimistic forecasting. It showed a beautiful trajectory of growth, predicated entirely on the idea that every person seeking help is a “standard” unit of distress.

There was no line item for the person who doesn’t get better in two months. There was no budget for the clinician who needs extra supervision because the case is heavy. In those eleven words, the deep complexity of human experience was sanitized for investor comfort.

Optimized for the Easiest Fix

This isn’t just about money; it’s about the design of the tools themselves. When you build a system for the “average” user, you aren’t just making it simpler; you are making it exclusionary. Over a decade, this compounds. You end up with an entire sector optimized for the people who arguably needed the least help to begin with. We report the shortfall as “unmet demand,” but it’s actually a design choice, repeated a thousand times in a thousand meetings.

I’ve caught myself doing it, too. In my early days as a recovery coach, I’d look at a referral and feel that slight, instinctive tightening in my chest when I saw a “dual diagnosis” or a history of multiple relapses. My brain was already calculating the energy drain. It’s a survival mechanism for the practitioner, but when it becomes a feature of the system, it’s a catastrophe for the patient. We start to see complexity as a personal failing of the client rather than a limitation of our own models.

The irony is that the “difficult” cases are where the real work happens. It’s where the most profound transformations occur. But you can’t scale a profound transformation. You can’t put a “buy now” button on a three-year journey of self-discovery and neural rewiring. So, the industry pivots toward the “quick win.” We’ve turned mental health into a high-volume retail business, where the goal is to move as many units as possible through the checkout.

This is why specialized hubs are becoming the last line of defense. When a practice is organized around clinical specialism rather than general counseling, the math changes. You aren’t trying to fit a square peg into a round “six-session” hole. You’re building the hole around the peg.

I’ve seen how this works at

Mind a Porter, where the infrastructure is built to handle over 50 specific mental health difficulties across dedicated pathways. It’s a different philosophy. Instead of asking “how do we make this person fit our model?”, the question is “what does this specific condition actually require according to the evidence?”

If you have ADHD and burnout, you don’t need a “generalist” who will spend four sessions asking you how you feel about your mother. You need someone who understands the dopaminergic pathways of the ADHD brain and how they intersect with occupational exhaustion. You need a specialist. But specialists are expensive, and they don’t scale easily. They require higher fees and more support. In a market that prizes “access” (which is often just code for “high volume of low-intensity care”), the specialist is an anomaly.

We are currently building a world where the most distressed people are the ones with the fewest options. If you can’t be “fixed” by an app or a trainee therapist in eight weeks, you fall into the gap. And that gap is widening. We see it in the way “mild to moderate” has become the default setting for almost every new mental health startup. It’s the safest bet for investors. It’s the easiest story to sell.

Gaslighting by Spreadsheet

But what happens to the person who isn’t mild? What happens to the person whose life is a tangled knot of grief, neurological difference, and physiological symptoms? They become the “revolving door” patients. They go from one short-term intervention to another, never quite getting to the root, always being told they are “too complex” for the current service. It’s a form of gaslighting by spreadsheet. We tell them there is help available, but when they show up, the help is only for a version of them that doesn’t exist.

The spreadsheet removes the person
before the clinician even sees the chart.

I think about that “thirteen point eight” sessions number often. It’s a ghost that haunts the industry. It’s the point where a human being stops being an asset and starts being a liability. If we don’t start valuing the “deep end” of the pool, we are going to end up with a mental health system that is a mile wide and an inch deep. We’ll be able to help everyone who is slightly stressed, and no one who is truly suffering.

The Starting Point, Not the Obstacle

There is a specific kind of exhaustion that comes from being a “complex” patient. It’s the exhaustion of having to explain your history over and over again to people who are clearly looking at their watches. It’s the feeling of being a problem to be solved rather than a person to be heard. When a service is built on specialism, that dynamic shifts. The “complexity” isn’t an obstacle; it’s the starting point. It’s the data that informs the treatment plan, not the reason to reject the client.

We need to stop pretending that the current market failure is a glitch. It’s the intended outcome of an incentive structure that rewards speed over depth. Until we change the unit economics of care-or at least acknowledge that some humans require more than thirteen point eight sessions-we are just building a very expensive waiting room for the people who need us most.

The next time someone tells you a service is “scalable,” ask them who it leaves behind. Ask them what happens to the person with the three interacting difficulties. If they don’t have an answer, or if they start talking about “initial focus on mild presentations,” you know exactly where you stand.