A few minutes into his first livestreamed conversation with Byron Bernstein, Dr. Alok Kanojia got his caveats out of the way. This was not a therapy session; this was just conversation. Colleagues had warned him, he explained, that blurring the line could get him sued.
“I’m a psychiatrist,” he said, “but I can’t treat your depression over the internet.”
“Yeah, gotcha,” Mr. Bernstein said.
Dr. Kanojia’s fleece jacket bore the logo of Harvard Medical School, where he had done his medical residency. But he had also been a gamer who had followed Mr. Bernstein’s record-shattering career. He beamed at the younger man with undisguised admiration.
“So tell me,” he said, clasping his hands together. “What are we talking about today, buddy?”
Mr. Bernstein, known in the gaming world as Reckful, tweaked the volume on his Twitch feed — thousands of viewers were waiting — and the two men plunged in.
The next hour and 53 minutes were intense even by the standards of Twitch, where video gamers often field questions about every aspect of their lives. As reactions flooded in, Mr. Bernstein opened up about his older brother’s death by suicide. He spoke about his own suicide attempt, his terrible experience with lithium, the nights he fell asleep wishing he would not wake up.
It was a riveting thing to watch: a fragile, brilliant young man opposite a probing, empathic doctor. The two men clearly liked each other, and Mr. Bernstein said he was improving. They had six conversations, with live audiences that climbed into the hundreds of thousands. Then, a few months later, the dialogue ended, tragically, with Mr. Bernstein’s death by suicide at 31.
What was Dr. Kanojia’s role in Mr. Bernstein’s life? The close-knit, high-drama world of Twitch has debated this for nearly five years. Dr. Kanojia, now 41, has said that he never entered into a doctor-patient relationship with Mr. Bernstein, and that offline he encouraged him to seek medical care. His critics say he violated professional ethics, exploiting a vulnerable man and allowing him to believe that he was in treatment when he was not.
Two years ago, one of those complaints made its way to the medical registration board in Massachusetts, where Dr. Kanojia is licensed to practice.
Ethical quandaries like this are arising more these days as the practice of mental health care expands beyond the traditional one-on-one private session. It is now common for licensed clinicians to interact with members of the public on livestreams, video calls or social media. Many operate life-coaching businesses that are separate from their clinical work, holding therapylike sessions that are not subject to medical regulation.
In the meantime, Americans are hungry to learn about other people’s mental health struggles, and willing to share their own. Therapy sessions are the basis of a popular podcast and a hit streaming series. On Twitch, some streamers began using a “mental health” tag to indicate that, as they played, they would talk freely about their history of depression or anxiety.
Into this space stepped Dr. Kanojia, known on Twitch as Dr. K.
Dr. Kanojia declined to comment for this article, citing “a longstanding policy of not discussing private relationships in public settings,” and referred questions to his wife, Kruti, the co-founder and chief executive of Healthy Gamer, their mental health platform and coaching business.
Pushing the Envelope
Dr. Kanojia started out by telling Mr. Bernstein’s about his own unusual path. The child of two physicians, he played video games so obsessively in his teens that he nearly flunked out of college. At 21, on his father’s advice, he traveled to India and spent three months on a Hindu ashram, studying meditation and yoga and, for a while, contemplating life as a monk.
Upon his return, envisioning himself as “the next Deepak Chopra,” he went to medical school, completing his residency at Harvard’s prestigious teaching hospitals. He was now at the pinnacle of elite psychiatry, but when he asked his mentors about video game addiction he was disappointed to find they knew nothing about the gaming world.
Clinical care felt too limited: A successful psychiatrist, he once said, “is someone who has a really nice private practice and a really fancy office and charges $600 an hour.” That would never be enough to address the needs he saw. “I realized I can’t, like, single target this,” he told Mr. Bernstein, using a gaming term for a limited attack. “That’s why I started streaming.”
As he sought to launch his new coaching business, Twitch offered both scale and speed. In 2019, Dr. Kanojia began streaming interviews with prominent gamers, unpacking their mental health struggles in conversations that sometimes lasted for hours, while viewers showed their approval with donations and subscriptions to Healthy Gamer.
The interviews with Mr. Bernstein were especially raw. A celebrity gamer since his teens, Mr. Bernstein had a vast audience, and shared intensely personal material: his breakups, his childhood trauma and his bouts of depression. In conversation with Dr. Kanojia, he almost immediately began recounting his lowest moments, sometimes breaking into sobs.
The videos drew some criticism, mostly from other mental health professionals in the gaming world.
“It was a voyeury situation that was very compelling for people to watch,” said Rachel Kowert, a research psychologist and the founder of Psychgeist, a studio producing content on gaming and science.
She said the conversations were indistinguishable from therapy; at one point, Dr. Kanojia specifically comments about Mr. Bernstein’s psychiatric diagnosis, remarking that “what you are describing is not clinical depression,” but “that your life is empty.”
“He is giving exact advice for specific people, instead of general advice, which is therapy,” Dr. Kowert said.
Regulations barring psychiatrists from commenting publicly on individuals who are not patients date back to the 1960s, when a magazine published an issue polling psychiatrists about the mental health of Barry Goldwater, the Republican presidential nominee.
The rules are there to ensure that providers are always guided by the best interests of the patient, said Dr. Charles Dike, a member of the ethics committee of the American Psychiatric Association.
“Once you get into the media, you begin to wonder who you are serving,” said Dr. Dike, a professor of psychiatry at Yale Medical School. “Are you serving yourself? Are you serving advertisers? Are you serving some other third party?”
Though clinicians may initiate online interactions by warning that they do not constitute treatment, Dr. Dike said those caveats would not shelter them from regulatory or ethical oversight because the individual might act on their advice.
“A doctor-patient relationship starts when you begin to provide medical advice using your training, your expertise, your knowledge to someone,” he said. “Whether or not you call them your patient is irrelevant.”
Dr. Kanojia presented himself as an innovator, straining against a medical system that was unable to meet the needs of young people. But he was also conscious of professional guardrails — he brought them up in conversation with Mr. Bernstein.
“Hopefully I don’t get sued because I’m not really delivering medical care,” he said about an hour into their first conversation. “You know, what happens if someone comes on stream and then kills themselves or something like that?”
“I’ll try not to kill myself anytime soon for you,” Mr. Bernstein replied with an easy smile.
“Yeah, thank you,” Dr. Kanojia said, his expression serious. “I appreciate that. I’m serious.”
“Yeah, no problem,” Mr. Bernstein said.
Offline, Dr. Kanojia was taking other measures, Ms. Kanojia said. Though the first conversation between the two men was spontaneous, Dr. Kanojia went on to ask Mr. Bernstein to sign a waiver acknowledging that he understood that he was not receiving treatment, she said.
For a while, the conversations appeared to be benefiting everyone. Mr. Bernstein described Dr. Kanojia’s approach to mental health as “AOE,” or “area of effect,” a gaming term describing a move that affects multiple characters in a single area. Many viewers commented that they had been inspired to seek out mental health treatment themselves, Ms. Kanojia said.
“It was so much more powerful than anything I’ve seen in a public health setting,” she added.
But there remained ambiguity about the nature of their conversations. In their second interview, Dr. Kanojia asked Mr. Bernstein if he had a therapist, and the gamer remarked that he had tried therapy a few times but had never seen it as useful enough to continue.
“This time, I do,” he said. “Well, OK this is not ‘therapy,’” he added, making air quotes with his fingers.
In their sixth interview, Mr. Bernstein was buoyant, remarking that “everything in my life started working out as soon as we started talking.” He credited Dr. Kanojia with steering him toward success in his work and social life. The two men agreed to continue their conversations offline.
That was in February 2020, just before Covid shutdowns rippled across the country, thrusting many people into profound social isolation. Mr. Bernstein’s condition deteriorated over the spring, and one of his friends became concerned that he would harm himself, according to the Massachusetts licensing board.
On June 30, 2020, the friend was so alarmed that he reached out to Dr. Kanojia, who “followed standard referral guidelines, including referrals for outpatient care, higher levels of care and the use of emergency services,” the board found. This would include referring him to specific clinicians or treatment centers, Ms. Kanojia said.
Mr. Bernstein died by suicide on July 2, 2020.
“We made all the standard referrals and guidelines — I wish they had been acted on sooner,” Ms. Kanojia said. Many things made Mr. Bernstein reluctant to do so, she said: He had been involuntarily committed in the past, and his older brother had died by suicide after starting antidepressant medication.
“We do live in a broken system,” she said. “Why would this person want to engage?”
In a video released two days after Mr. Bernstein’s death, Dr. Kanojia made no effort to hide his grief for the younger man. Mr. Bernstein, he said, had put his coaching business on the map. “Ninety-nine percent of you are here today because of Reckful,” he said.
Welling up with tears, he recalled watching Mr. Bernstein playing World of Warcraft, long before the two met, and wondering if he could ever be as good. “What do we do when a champion falls?” he asked. Openly sobbing, he begged his viewers to live.
“I tried with Reckful, I really did,” he said. “But I can’t do this alone. Cause at the end of the day, I’m not superhuman. I’m just me. I have two hands, I have one heart, I have one voice, I have two ears. I’m human.” The stream cuts to a black-and-white portrait of Mr. Bernstein.
Mr. Bernstein had been dead for two years when a newcomer to the streaming world decided to file a complaint against Dr. Kanojia.
The newcomer, Max Karson, did not know Mr. Bernstein or Dr. Kanojia. But he studied psychology in college, and his father and grandfather are psychologists. He takes a strict view of boundaries in psychotherapy; in an interview, Mr. Karson said that he was “raised to believe that any therapist who doesn’t end the session at the 50-minute mark is harming the patient.”
Mr. Karson said he had been shocked by the interviews, which he said “blatantly” flouted ethics guidelines and benefited Dr. Kanojia by attracting an audience and donations. He spent a month reviewing them, compiling a video record that highlighted moments of blurred boundaries, which he submitted to the licensing board along with a written complaint.
“Reckful did not know if Dr. K was his doctor or his friend,” Mr. Karson said in an interview. “And a blurry, unboundaried, pseudotherapeutic relationship is inherently harmful to the patient. That’s why it’s against the rules.”
Mr. Karson said he worried that people outside gaming didn’t understand “the highly unregulated and abnormal environment created by the platforms.” Popular streamers, he said, command intense loyalty and trust from large audiences, something that is particularly dangerous in the area of mental health.
He is a content creator himself, of course — his handle is Mr. Girl — and he acknowledges that this was part of his motivation: The critiques of Dr. Kanojia were “entertaining for my audience, to watch me file a complaint against this guy,” he said.
“My audience, it’s like Christmas for them,” he said.
Before Mr. Karson filed the complaint, Healthy Gamer had begun introducing “self-corrective actions to address the most problematic aspects of guest interviews,” the company said in a statement last month. “The nature of Healthy Gamer interviews have been contentious for a long time,” the statement said.
The changes included advance scheduling of interviews; a “boundary-setting call” so guests could identify topics that were off-limits; the option of deleting the interview if guests weren’t comfortable with the result; and a referral packet for mental health services, Ms. Kanojia said. Videos are introduced with a written disclaimer warning that the content “is not a substitute for professional medical care,” she added.
And while Dr. Kanojia still does streamed interviews, they are less frequent, she said, because they are “less impactful” than they were in those first years.
“People don’t have the same appetite for long-form interviews that they did,” she said.
Dr. Mark Komrad, a psychiatrist who serves on Healthy Gamer’s scientific advisory board, said psychiatry was still adjusting to formats like streaming and coaching, which blur the line between what is and is not clinical care. The complaint against Dr. Kanojia is “one of the first times” this line has been explored by an official body, he said.
“These are pioneering times, and one of the things we have to say about Dr. K is that he really has been a pioneer in this kind of thing, and he’s been learning,” said Dr. Komrad, an instructor in psychiatry at Johns Hopkins University School of Medicine. “As the saying goes, they’re building the plane while trying to fly it.”
‘Passed with Flying Colors’
In June, after a two-year investigation, the Massachusetts licensing board issued Dr. Kanojia a reprimand, claiming that he “had engaged in conduct that undermines the public confidence in the integrity of the medical profession.”
A reprimand is a “severe censure,” according to a spokeswoman for the licensing board. In an average year, the board receives 610 complaints and takes disciplinary action only in around 8.6 percent of them. Around 1.8 percent of complaints result in reprimands.
But it is one of the lesser punishments available to the board, with few practical consequences. The board opted not to revoke Dr. Kanojia’s license, or to fine him, require him to perform public service or limit his medical practice.
In a video posted last week, Dr. Kanojia expressed relief at the outcome of the process, calling it “healthy.”
“This is exactly why medical boards exist because, occasionally, you will have a doctor who tries to do something different, and is it OK, or is it not OK,” he said. He framed the reprimand as a vindication, of sorts, since the board did not find him negligent or responsible for Mr. Bernstein’s death or conclude that he was conducting therapy on the internet.
“That’s the most important thing, is that we don’t need to change a single thing about our process,” he said.
In the years since Mr. Bernstein’s death, Healthy Gamer has become a flourishing for-profit business, employing 200 coaches and staff members and providing coaching certification. Dr. Kanojia’s profile is rising: He hosted Dr. Vivek Murthy, the U.S. surgeon general, on his Twitch stream and published his first book. This summer, the Kanojias were invited to the White House to attend a round table for influential YouTubers.
Ms. Kanojia said the reprimand would not affect their long-term plans for Healthy Gamer to “solve the labor problem” in mental health by offering coaching.
“We shared our procedures, and there was no pushback,” she said. “We kind of passed with flying colors, I would say.”
Mr. Karson, who filed the complaint with the licensing board, described the reprimand as “better than nothing.” But he doubted it would have much impact, since Dr. Kanojia’s fans would not view it as a serious punitive action. Mr. Karson has since been banned from Twitch; he said he had been given no official reason. “My audience is shrinking, and his is exploding,” he said.
“What’s next for Dr. K is he’s going to keep doing what he’s been doing, which is what anybody does, once they get away with something,” he said. “Fly straight and narrow and hope it doesn’t come back to haunt him.”
Gary Bernstein, Mr. Bernstein’s surviving brother, said that their family had had no involvement with the complaint against Dr. Kanojia. He had not seen Mr. Bernstein’s streamed interviews until after his death, a blow that left their parents “just exhausted with grief.” He has since watched them, and he said what he saw made him uncomfortable.
Dr. Kanojia “seems like a very caring, nice guy,” he said, adding, “On the other hand, he did sort of dangerous stuff,” wading into deep emotional territory that had brought his brother to tears.
“He was doing that on stream, right?” he said. “Maybe he could think that can have negative repercussions. But that didn’t seem to stop him.”
If you are having thoughts of suicide, call or text 988 to reach the 988 Suicide and Crisis Lifeline or go to SpeakingOfSuicide.com/resources for a list of additional resources.