Can digital therapy meet the needs of a larger and more diverse patient population?
Image: Flickr/Bryce Johnson
Around this time last year I had just made the decision to move to New York City for grad school. I had many concerns. How would I build a community? Where would I find refuge? Would I have the guts to ride my bike around?
The biggest thing on my mind, however, was finding the right therapist.
Months before my move, I made several trips to New York to date around. I recounted stories from my childhood and romantic relationships to a series of strangers. Finally I settled on someone, a soft-spoken man with kind eyes. After seeing him for a few months, though, it became clear that things wouldn't work out between us. I called it off.
I told myself I would find another therapist immediately. I looked through my insurance company's list of providers and poked around Psychology Today. Friends tried to set me up with their therapists. But the hunt was slow, and by the end of winter I was starting to feel like maybe I just didn't need therapy at all.
Then, all of a sudden, a few Major Events collided and life turned rabid.
I kicked myself for slacking on my therapist search. This is exactly why I sought therapy in the first place—to have a safety net when things got messy. Now I felt as if I were holding too many glass ornaments, terrified that everything was about to shatter.
That thin-glass fragility was there the morning I looked up in the subway and saw an ad for Talkspace, sold as "Unlimited Messaging Therapy, Starting at $19 a week" (the price has since increased to $25 a week).
Therapy is a recent addition to the many parts of our lives that are now digitized. We use remote technologies to get groceries, do laundry, buy shoes, and catch rides. For the New Yorker who is always on the run, being able to line up the next task on one's smartphone is the perfect way to capitalize on the empty, in-between spaces in life.
To me, online therapy is most reminiscent of online dating. You can do both while commuting, waiting in line for the bathroom, or lounging at home with no pants on. Both cut out the middle steps: getting to a mutually agreed upon location at a mutually agreed upon time, worrying about in-person impressions, and crafting out a delicate exit plan. If you don't like the therapist you're talking to, you can request a new one without having to look into his kind therapist eyes.
For all these reasons, texting therapy felt like a shortcut, which I immediately distrusted. How could it be anything but a Band-Aid substitute for in-person therapy? I felt suspicious of the fact that therapists and patients often would not be communicating in real time—that their correspondence might be punctuated by long gaps, much like actual email or text messaging. I thought about all of the potential for misunderstanding that comes with not being able to read someone's eyes or body language.
I also desperately needed support. So I decided to give Talkspace a try.
$25 a week
Talkspace is an online platform that connects therapists and clients. Its main offering is unlimited texting therapy for $25 a week. To start, users just need to register with an email address. They do not have to provide their real name or any other identifying information.
In addition to texting therapy, users have the option of 30-minute live video therapy sessions for $29 each, or they can participate in online public therapy forums for free. For Valentine's this year, Talkspace added a couples therapy option.
Since its launch in 2012, Talkspace has garnered more than 200 active therapists and more than 100,000 total users, with several thousand paying users. In early May, the startup raised $9.5 million in venture capital financing, bringing its total funding to $13 million.
Oren and Roni Frank, co-founders of Talkspace, got the idea to create the platform after couples therapy saved their marriage. Both gained a deep appreciation for psychotherapy, but were dismayed to learn how inaccessible therapy is to most people.
"In the last decade, every year, between 40 and 50 million Americans were referred to a therapist," said Oren Frank, now the CEO of Talkspace. "Out of those 40 to 50 million people, on average just 6 or 7 million people actually get therapy every year."
Recognizing a deficit, the couple set out to expand the surface area of possible contact between patients and therapists. The internet seemed like a good place to start.
The "talk space"
Immediately after I registered for a Talkspace account, the website directed me to a chatroom, where a consultant introduced herself. She told me she would help me find a therapist who would be a good match for my needs. (As a side note, Talkspace recently announced that it is partnering with IBM to use Watson, IBM's Jeopardy-winning artificially intelligent computer, to assist with the process of matching users and therapists.)
We messaged for a bit about how I was feeling and what I was looking for in a therapist. After about half an hour, she offered to describe how Talkspace works. My therapist and I would chat in a private chatroom—a "talk space"—that I could enter whenever I wanted to dump my thoughts.
Almost immediately, having a dedicated space made me feel better. In my mind I pictured a completely empty room with pristine white walls. Anytime I wanted, I could come in and scribble a thought on a wall.
Terms and conditions
Talkspace is a relatively new arrival to the online therapy scene, and it's somewhat different from its predecessors, which mostly paired online educational modules with messaging support.
The curricula for modular therapies usually span two months and involve weekly tutorials, each of which might last 30 minutes and feature something like an interactive walk-through lesson with text and multimedia. Modules are supplemented with assignments and check-ins with a therapist, either via messaging, video conferencing, or phone calls.
Modular online therapies are built on a therapeutic approach called cognitive behavioral therapy. Developed in the 1960s as a hands-on alternative to Freud's psychoanalysis, CBT focuses on teaching people the skills to identify and eliminate their negative thought patterns. It relies on different treatment manuals for different disorders, which have been honed through scientific experiments.
"CBT is very manualized, which allows us to create these modules and mini-lessons," said Marina Gershkovich, a PhD candidate in psychology at Drexel University who researches and develops internet-based interventions for anxiety disorders.
The bulk of academic research on online therapies has looked at these manualized therapies. In the past decade, studies have found that modular online therapy can be effective for a wide range of disorders, including depression, anxiety, post-traumatic stress disorder, obsessive-compulsive disorder, and panic disorder.
Because CBT is all about fostering independence, it actually translates well to remote, structured online therapies, according to Gershkovich. "Part of CBT is having the patient be their own therapist, and giving them the tools to eventually learn to do them on their own," she said. On some level, the goal of CBT is to render itself obsolete.
Talkspace takes a slightly different tack. Rather than working towards distancing the therapist-client relationship, the platform provides the option of having the therapist-client relationship available 24/7—literally in one's back pocket. It also does not prescribe to any single school of psychotherapy, leaving the quality and style of therapy up to each individual practitioner. If modular online therapies value patients' skill development above all else, Talkspace seems to value the therapist-client relationship above all else.
"We do not guarantee the verification of medical degrees, qualifications, licensure, certification, credentials, competence or background of any Therapist."
The terms go on to state that Talkspace cannot absolutely uphold therapists' qualifications: "While Talkspace does research and verify certain documents of the Therapists using the site, we do not guarantee the verification of medical degrees, qualifications, licensure, certification, credentials, competence or background of any Therapist."
Nonetheless, Oren Frank assured me that therapists who sign up for Talkspace go through a rigorous screening process, involving background and license checks, clinical interviews, technical training, and treatment of a mock patient for a week or two.
Therapists have to undergo extensive training to learn Talkspace's protocols and how to use the platform, said Christy Paul, a licensed mental health counselor who joined Talkspace about two years ago and now practices therapy online full-time. The whole process takes nearly a month, she told me.
Talkspace does not recommend any single approach to its therapists, said Paul. She thinks it's best for Talkspace therapists to use a combination of approaches. "We are person-centered so it's unique for each client," she said. "The best approach is to integrate techniques."
I spoke with five researchers who study the effectiveness of online therapy, and none were too familiar with Talkspace beyond having heard of it. Most research thus far lies behind more structured, prescriptive approaches than Talkspace, they told me.
These researchers, all of whom work with modular online therapies, understood online therapy as part of a nested therapy model, which can cater to clients with different levels of need.
"Online therapy sits very well in what's called the stepped care model," said Nicole Pugh, a psychotherapist and director of research at Vancouver Coastal Health in Canada.
In this model, she explained, patients who aren't dealing with severe issues, but still have some concerns, can do online therapy. Patients struggling a little more might participate in therapist-assisted online therapy. And patients experiencing multiple disorders, or more severe conditions, might be better suited for face-to-face therapy.
As such, modular online therapy tends to act as a supplement to face-to-face therapy, not a replacement, said Pugh, who coordinates modular online therapy programs at Vancouver Coastal Health.
Several of the experts I spoke with mentioned that modular online therapy can have elements of self-help. "It comes down to your motivation to use it—the degree to which you're self-structured," said Michelle Newman, a professor of psychology at Penn State.
Oren Frank adamantly argued that that was not the case with Talkspace. "It's not coaching, it's not giving advice, it's not peer support," he said. "What we are offering is therapy. It's not self-help."
Frank believes that the real value of therapy lies more in the individual relationships that therapists develop with their patients than the particular clinical approach they use.
"My personal belief is that 'therapy' equals 'therapist,' and the ability of the therapist to create a real strong bond, relationship, and attachment with a patient is the key for success," he said. As a result, Talkspace leaves it up to the therapists to craft those relationships as they see fit.
A benign spirit
After texting with him for about two weeks, I decided I liked the therapist my consultant chose. His profile said he was a licensed social worker. His approach was pragmatic, which was comforting in the midst of my otherwise chaotic life.
We came up with goals and timelines. When I sent him rambling, sentimental messages, he rarely tried to challenge them or analyze them for their subtext. Instead, he would regurgitate the content of what I said and ask if he understood me correctly (this is a fact-checking strategy for online therapists to make sure they are not misinterpreting, I later found out).
Historically I have been drawn to more free-form, insight-oriented therapy, but for some reason my Talkspace therapist's practicality did not bother me. Perhaps my standards were different—I didn't expect him to completely overhaul my thinking. In some ways, it was a relief to just focus on action-oriented self-care instead of constantly diving into the depths of my psyche.
I felt close with my Talkspace therapist, but not quite vulnerable, perhaps because he never felt completely real to me. He was more like a benign spirit, or a guardian angel—somebody whose presence helped me along but who never fully materialized.
There were pros compared to in-person therapy. Typing out my feelings forced me to synthesize and make sense of them. I could take my time fleshing out thoughts without the distraction of a pair of eyes watching me and taking notes. I liked being able to go back and read through past exchanges.
There were also cons. Most of the conversations I had with my Talkspace therapist were not in real-time, which meant that it could take a day or two to have a conversation that might have taken 30 minutes in person. Because of the stop-and-go rhythm of the messaging, I sometimes lost momentum on trains of thought. I found myself yearning to express half-formed, meandering thoughts without feeling compelled to edit and make my words linear.
One of the biggest arguments in favor of online therapy is that it democratizes therapy. Online therapy removes many barriers to entry, such as travel, waiting times, treatment costs, and working appointments into one's schedule by taking off work or shifting other responsibilities around, said Nick Titov, a psychology professorial fellow at Macquarie University in Sydney, Australia and project director of MindSpot Clinic, a phone and online therapy service.
Furthermore many people are geographically isolated from mental health practitioners, he said, and that puts a huge burden on them when they want to access therapy.
Online therapy can also reach an entirely new audience of people who are not interested in seeing a therapist in person, according to Titov. "We need to be mindful that a lot of these people don't want to speak with a therapist," he said. "We can't make patients talk to us, and we have to be realistic about that."Titov has even seen online therapy work as something of a gateway therapy. Someone struggling with social anxiety, for instance, might initially avoid face-to-face therapy but feel more comfortable seeing a therapist in person after participating in online therapy.
"Therapy can, and should be, anonymous, stigma-free, simple, affordable, and comfortable. And this is exactly what Talkspace is."
But online therapy might work better for certain problems over others, and for some people—such as those who experience psychosis or distorted perceptions of reality—it could be even be potentially dangerous.
"Certainly for clients with more disturbed issues like borderline personality and other severe mental health problems, this would not be appropriate," said Michael Gordon, an assistant professor of clinical psychology at Trinity College Dublin in Ireland. For those patients, according to Gordon, texting might have to be used in conjunction with face-to-face therapy for additional support.
Any online therapy platform needs appropriate alert and support mechanisms to identify life-threatening situations, according to Drexel's Gershkovich. "Severity is definitely a factor," she said. "If you're treating people with depression, you will have to assess suicide risk. If that risk is there, a higher level of care may be indicated."
All of the manualized online therapy programs my sources knew of thoroughly screen patients to ensure that people receive appropriate help if their lives are at risk.
On the bottom of every page of its website, Talkspace makes this disclaimer: "If you are in a life threatening situation, do NOT use this site. Call the National Suicide Prevention Lifeline, a free, 24-hour hotline at 1.800.273.8255."
During my Talkspace experience, however, nobody ever directly asked me whether I had thought about suicide. I was also never asked for a medical history. I was not suicidal—but I couldn't help thinking that if I were, and didn't feel like talking about it, it might not have come up.
When I asked Oren Frank about this, he told me that it is up to the discretion of Talkspace therapists whether or not they want to ask their patients directly about suicide. He has faith that the therapists on Talkspace are experienced enough to recognize when somebody might be at risk.
If a Talkspace therapist does identify that a client might be suicidal or self-harming, there is a careful process for referring that person to a psychiatrist or emergency room, Frank told me. "We don't deal with psychiatric issues," he said.
"There's a huge gap between hinting at it and actually being suicidal."
Frank suggested that if my therapist did not ask me about suicide, it's likely that I just didn't exhibit any warning signs. "There's a huge gap between hinting at it and actually being suicidal," he said. "These people are really well-trained to actually note that difference."
Christy Paul agreed that therapists can generally pick up on suicidal clues from clients. "Generally they may tell us, but if not, we can recognize signs by what they are telling us or current circumstances," she said.
While Talkspace therapists do not ask clients for a medical or psychiatric history at the start of a relationship, as an in-person therapist typically would, that information does eventually come to light through the course of the online relationship, Paul explained.
Because interactions over Talkspace are asynchronous, gathering that information might occur across a longer span of time instead of immediately. But the end result, Paul insisted, is not that different.
"In face-to-face therapy, a client will be spending the first hour with the therapist who will gather this information," she said. "It's important that we establish a relationship with our clients. And in doing so, we gather this information."
Suicide risk is a serious consideration with online therapy, acknowledged Titov—but he made the point that the risk is similar with unsupervised self-help.
Titov thinks that the degree to which self-guided online therapies can help people ultimately comes down to their own initiative. If a person is suffering but committed enough, he said, online therapy can give them the resources to make a change.
"A lot of work has shown that how the material is presented doesn't matter, whether it's face-to-face doesn't matter," Titov said. "If the ideas are presented in a helpful, meaningful, and engaging way, people can benefit."
This growing body of research questions psychologists' assumptions that face-to-face time with a therapist is necessary, said Titov, and brings the focus of therapy away from therapists and back onto patients.
"It's forced us to challenge our paradigms and heuristics about the nature of interpersonal psychotherapy," he said. "The reality is there are 168 hours in a week—one hour of therapy isn't going to have a huge impact on a patient. What's important is what the patient learns, takes away, and brings into their life."
The fact of the matter is that online therapy is a new modality and, as a result, people will naturally be skeptical, Frank told me. "This is an extremely traditional profession. It started around 150 years ago and basically did not change much," he said.
"There are some people that will tell you this is not real therapy or real treatment," said Frank. "I can tell you that after a couple years of doing this, while having hundreds of therapists on the platform—all of whom have done extensive face-to-face therapy before—that this is not the case."
Frank strongly believes that online therapy does not necessarily offer a lesser service than in-person therapy. "It's, in a way, surprisingly similar to traditional therapy," he said. "It's just done in writing."
In fact, the main difference between Talkspace and in-person therapy, in Frank's opinion, is that Talkspace is accessible to more people. "We all love face-to-face therapy," he said. "We're not out to replace it or fight it or say there's anything wrong with it. It's a wonderful profession. It's just that it's a product for the one percent. No one can afford and access it."
Frank's point that Talkspace is more flexible—and therefore more accessible—was definitely true for me. During a crazy spring semester, when the painstaking process of finding a therapist seemed otherwise impossible, Talkspace was a quick source of much-needed support.
But as my semester rolled on, I got buried under work and the novelty of online therapy wore off. I started posting in my Talkspace chatroom less and less frequently. After a while, my therapist was always the one to initiate contact.
As with any form of online communication, digital therapy can be easy to neglect.
As with any form of online communication, digital therapy can be easy to neglect. During really busy periods, I would ignore the notifications on my phone and in my email altogether. I felt guilty about my absence on Talkspace, but nowhere near as guilty as I used to feel when bailing on in-person therapy appointments.
After two months, I had lost enough steam that it was no longer worth it for me to keep paying for Talkspace.
"Therapy for how we live today," goes the company's catchphrase. The problem is, what if I don't like what Talkspace says about how I'm living today?
Therapy is hard work, and I don't always want to do it. As much as I try to prioritize my mental health, it can be difficult when it's put head to head with a pressing deadline or a tantalizing social engagement.
It's true I could have set up a weekly meeting with my Talkspace therapist. He offered to chat over video or phone a few times, and the one time we were able to coordinate a call, we had a fruitful conversation. But I just didn't feel the same degree of commitment. Call me old-fashioned, but being in the same physical space with the same human at the same time every week fosters some sense of loyalty in me.
With in-person therapy, regardless of how much I have to say, I have to sit with someone, face-to-face, for 45 minutes. Sometimes I'd go to an appointment thinking I had nothing to share but end up talking the whole time. Sometimes just the act of sinking into that familiar couch would trigger feelings I didn't know I had.
With Talkspace, I never slowed down and just sat there—if I didn't have anything to say, I'd just keep moving. It's maybe counterintuitive, but knowing that I could start a conversation with my Talkspace therapist whenever I wanted actually made me feel less urgent about getting my thoughts out in the moment.
I finished my crazy spring semester a few weeks ago. Now that I have some more time on my hands, my thoughts have turned towards therapy again. This summer, just like the last one, I'll be dating around for a new therapist the old-school way.
Finding a therapist is a long, imperfect, and exhausting process. But it's worth it to me, at least for now. Talkspace was a great companion for a while; it's just that I'm looking for something that asks me to make a deeper commitment.
Like every meaningful relationship, therapy involves compromise. That means that, sometimes, I will have to show up to a mutually agreed upon location at a mutually agreed upon time, even when I don't feel like it. Sometimes I will have to stare into a pair of eyes, even when it's uncomfortable. And sometimes I will have to sit still, even if just in silence.