Our brains crave company. Although, as human beings, we are perfectly capable of conducting daily activities in a solitary fashion, we must eventually seek out contact with someone else – preferably friends or family – lest our brains begin to atrophy. Indeed, studies on lab animals suggest that prolonged isolation can lead to reduced production of neurotrophic factor, essential for the creation and maintenance of neural pathways, as well as symptoms of stress, anxiety and depression.
For many people around the world, the pandemic was just such an isolating event. A recent survey by the World Health Organisation found that reports of anxiety and depression rose by a quarter after 2020. And while the WHO found that 90% of governments around the world had increased their provision for mental health services in response to this rise in demand, ‘major gaps and concerns remain’ as millions continue to seek in-person help from historically underfunded psychiatric services. In the UK, for example, the current average wait time to see a therapist on the NHS is 18 weeks.
Other alternatives are available. Just as the pandemic witnessed a sea-change in remote work, thousands of psychotherapists discovered that they could conduct sessions with their patients using video conferencing software. The realisation was immediate and profound, with US telehealth provider MDLive alone reporting a five-fold increase in demand for its services.
Online platforms such as BetterHelp and Talkspace also saw massive growth, after marketing campaigns with endorsements from Olympians such as Simone Biles and Michael Phelps promised consumers easy access to therapists through video appointments or instant messaging services. A cornucopia of mobile apps sprouted alongside them, meeting a seemingly massive unmet demand for the treatment of lower-level mental health conditions like OCD, anger and chronic stress.
Do these platforms work? The contributions of mobile apps to improving mental health remains unclear. A recent meta-analysis of studies into the efficacy of mobile mental healthcare apps “failed to find convincing evidence in support of any mobile phone-based intervention on any outcome”. Another survey of 179 apps designed to treat anxiety and depression found that only three used peer-reviewed studies to inform their treatment models.
Services built around a tangible connection between therapists and patients fare much better. Recent studies suggest that therapy sessions delivered by video are just as effective as in-person sessions, although the research remains less clear cut on the efficacy of messaging.
Meanwhile, the major players in online therapy continue to enjoy strong growth. BetterHelp – an online platform that matches therapists to individuals seeking help – reported $700m in revenue in 2021, in both the US and international markets, while revenue at its competitor Talkspace grew by 49% compared with the previous year.
Even so, clinicians have expressed concerns that these types of for-profit services are a poor sticking plaster for chronically underfunded mental healthcare networks across the Western world.
“From the perspective of individuals being matched with care, and making care more accessible, it is a good thing,” says Lauri Goldkind, a professor in social work at Fordham University. “One might argue, however, that it is also a failure of the mental health safety net to give rise to the system to begin with.”
The history of online therapy
Delivering mental healthcare remotely is nothing new. The basic template for online therapy can be traced back to the late 1950s with the emergence of hub hospital networks in rural America, explains Dr Marlene Maheu, a clinical psychiatrist and the founder of the Telebehavioural Health Institute (TBHI.) These hospitals, explains Maheu, would house psychiatric specialists who were regularly consulted over the phone by physicians with lists of symptoms for obscure conditions, often in places that were hundreds of miles from the nearest city.
Things began to change with the arrival of the internet, which afforded psychiatrists new ways to engage with patients. Not every experiment succeeded. Email support, “was a great idea that went nowhere,” recalls Maheu, after it became clear that medical professionals had no idea whether anything was being typed in the message came as the result of coercion. Video appointments, meanwhile, gained traction relatively quickly, to the point where the costs of booking them could be claimed under the US federal health insurance program, Medicare.
By the late 2010s, platforms such as Talkspace had emerged to capitalise on the demand for mental health services among individuals who couldn’t meet a therapist in person. “Even just setting an appointment can be very difficult for people,” especially those with busy lives and careers, explains Thomas Derrick Hull, the company’s lead for clinical research and development.
“I think it’s easy to underappreciate the miracle that is created through these kinds of platforms in connecting somebody to a therapist or a psychiatrist in just a couple of days.”
Platforms like Talkspace and BetterHelp offer to connect individuals with licensed therapists through video sessions or through a dedicated messaging platform. Licensure doesn’t just include qualifications in psychotherapy: therapists can also possess qualifications in social work, for example. This is potentially confusing for patients seeking help, explains Goldkind. “From a consumer’s perspective,” she says, “how do I bet which one of those is the person that I might need?”
At Talkspace, therapists are also required to have at least 3,000 hours of clinical experience. Moreover, says Hull, patients are required to fill out an introductory questionnaire when they join the platform, answering questions on what help they’re seeking and their personal preferences when it comes to the delivery of care. This helps the company decide which therapist is best to take on their case, according to their experience and availability.
Therapists contracted to Talkspace also receive supplementary training in delivering therapy through video appointments and instant messaging. In the case of video sessions, says Maheu, this training should be rigorous. “It’s not a three-hour thing,” she says. “It’s something that is cumulative, based on their training that they’ve already had.”
Something as simple as determining the location of a patient during a therapy session, for example, is critical in determining how to deliver meaningful care. “They could be sitting in traffic,” says Maheu, talking to their therapist about issues that might have a triggering effect for them in the moment. “If they have an accident, are you responsible? Technically yes, you are.”
Is text therapy effective?
Talkspace has its own training programme for delivering therapy through its messaging platform, says Hull, which lasts at least 30 days and not only walks applicants through regulatory and ethical standards, but also assesses just how ready the therapist is to tackle a typical caseload of patients through the platform’s messaging service.
“There’s a little bit of a learning curve when you move from being in-person,” he concedes, not least the non-verbal cues in patients that therapists can use to aid in diagnoses.
Even so, the method has its advantages, not least in its capacity to radically expand the accessibility of therapy beyond set time slots. In her own survey of therapists working for online therapy platforms, Goldkind found practitioners could develop a rapport with patients through instant messaging, especially those who were comfortable with using the written word to convey their innermost thoughts.
Hull also points out the granularity of detail about a patient’s life that can be obtained through instant messaging, revealing the ups and downs in a person’s week that are self-censored or forgotten during in-person sessions. As such, he says, “we haven’t encountered a hard limit yet” on the type of therapy that can be delivered through instant messaging.
Despite this, Talkspace and its competitors make it clear from the outset that their therapy services are not suitable for patients likely to self-harm or who feel suicidal. Academic consensus on the effectiveness of messaging as a medium for therapy, too, remains mixed. While Talkspace has produced research supporting its claims that messaging is useful in treating symptoms of depression and anxiety, a recent meta-review of studies in the space concluded that messaging’s contribution in that area was not only mixed, but that previous investigations into its efficacy carried a high risk of bias.
For Maheu, the limitations of the medium are obvious. Delivering care through text-based messaging, after all, deprives the therapist of any visual or audio context that might inform how they deliver therapy. The meaning of a text that reads ‘I can’t take it anymore,’ for example, might imply any number of things depending on the individual and their situation.
“If you’re the clinician, what does that mean?” she says. “Does that mean she’s going to kill herself? You don’t know. There’s not enough data there to find out what that means. You can’t tell by the voice amplitude, or how quickly they’re speaking.”
Messaging-based therapy is also a model that dilutes the quality of therapy that a psychiatrist can deliver, Maheu argues. “They have their office hours, and they get a text in, and they’re in the middle of answering that – and another text comes in,” she says. “Now, their focus is split.”
For his part, Hull remains confident in the protocols that support Talkspace’s mental health messaging services (the company adds that it "offers therapists flexibility and allows them to engage with clients whenever and wherever works best" for patients.) For one thing, the evolution of instant messaging over the past decade has allowed the company to include elements of audio and video inside the same message stream between therapist and patient, affording the former more access to relevant contextual information.
Fundamentally, explains Hull, messaging is a valuable tool in broadening access to mental healthcare generally. “That’s [why] the messaging therapy innovation is important, because it allows for…many interactions, while maintaining quality,” he says.
Even so, Maheu has her doubts. “People have severe problems, and you’re going to address that in text messaging?” she says. “Where’s the data that says you can do that? That’s what I want to see. And I’m not seeing it.”
Who is liable for online therapy?
Liability is another area of concern among critics of large online mental healthcare platforms. Therapists are effectively employed by these firms as independent contractors, which also means that their legal responsibility for counsellor’s conduct is minimal. However, Talkspace takes its responsibilities in this regard very seriously, says Hull, allowing customers to switch therapists when the relationship isn’t working, as well as instituting clear complaints procedures and investigating cases of suspected misconduct.
So far, regulation of online therapy platforms has been light - in the UK, for example, there is no statutory regulation of psychotherapists - but there are signs this is changing. In the US, for example, mental health start-up Cerebral was investigated by the Department of Justice for 'possible violations' of the Controlled Substances Act in its prescription policies.
Privacy is another lightning rod for the space. In September, the US Federal Trade Commission issued a policy statement reminding the sector that it falls under the Health Breach Notification Rule, mandating that customers should be informed if data at these firms has been hacked or leaked. Nine months later, a group of US senators called on BetterHelp and Talkspace to shed more light on their privacy policies. While both companies both issued statements that everything shared by customers with its counsellors was strictly confidential, the Mozilla Foundation would later recommend that users specifically revoke any permissions to share medical data with both platforms, lest they be used for marketing purposes.
Despite this spark of interest from legislators, however, online therapy platforms have largely been left to regulate themselves. Maheu believes this is a disaster in the making, especially given what little research has been conducted into the effectiveness of message-based therapy. Individuals that have tried and failed to get help using the method, she explains, might consider more intensive interventions to treat their conditions to be futile.
“When I started practice, we were trained to take care of those outliers first,” says Maheu, “because there is no other system. The other system is the police – if the police get there in time.”
Many have argued that this worst-case scenario is already happening in the US, UK and Europe, as historically underfunded mental healthcare systems groan under the weight of post-pandemic demand for their services.
Even so, says Goldkind, the emergence of for-profit services like Talkspace, BetterHelp and a host of smaller providers is more than just the free market meeting this demand in its own way – it’s also symptomatic of a maturing international conversation about mental health generally.
The growing chorus of advertisements for talk therapy through accessible online platforms is evidence that the stigma of seeking psychiatric help is diminishing. “That, I think, is not a bad thing,” says Goldkind.