A Psychologist's Take on Why Online Therapy Isn't as Effective as the Real Thing
Opening an emotional can of worms over text is not the smartest idea.
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We live in an age of instant gratification. A click or a swipe promises near-immediate access to anything one might want. Does the thing that makes buying shoes and finding dates convenient—aka your phone—also work for psychotherapy? Since we text our friends and family more than we likely talk to them, why not do the same with a therapist? Easy, quick, no stress.
Maybe, perhaps, and definitely not.
Rates of mental illness are rising. The CDC estimated in January 2018 that roughly half of Americans will receive a mental health diagnosis during their lifetime. And that’s likely an underestimate; it doesn’t include people who are never diagnosed because they lack access to care. Bottom line: Most people will be in a position to want or need mental health care during the course of their lives. Unfortunately, quality therapy is often difficult to find and keep.
Getting started is especially hard. Time, energy expended, and both insurance and out-of-pocket costs can feel overwhelming. In response, app-based online therapy platforms like Talkspace and BetterHelp have emerged. As a clinical psychologist and certified psychoanalyst, I understand why many people—especially younger and underserved people—turn to therapy apps as a substitute for difficult-to-access established treatments.
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These platforms market convenience and happiness at one’s fingertips. On their homepage, Talkspace says that with their app, “anyone can get therapy without traveling to an office—and for significantly less money.” BetterHelp, which charges $65 a week, also boasts its on-demand nature, that you can get therapy “at your own time and at your own pace.” Talkspace has payment plans that begin at $49 a week. For this price, these apps assign you an “e-counselor” whom you can text or set up video chats with on an as-needed basis.
They’re making some dazzling claims. And if you’re in emotional pain, it’s totally reasonable to see these apps as an easy and effective form of help. I get it—when you’re suffering, you want relief, you want it badly, and you want it yesterday. However, it’s simply not that straightforward.
People cope with emotional pain in many different ways, and seek therapy when these coping methods stop working. The initial phase of therapy is almost always fraught; it is an extremely difficult and vulnerable task to open up about emotions, whether they’re long-repressed or otherwise powerful. Shame about not being able to handle the difficulties of life and hitting some form of rock-bottom necessitates skill, tact, and patience on the part of the therapist. The nuances of these encounters are by their very nature not conducive to being managed well by text-based therapy apps.
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Beginning to talk about—and therefore to think about—experiences that have long been repressed can increase symptoms and harmful behaviors before they get better or go away. One of the major dangers of online therapy is opening a can of worms that cannot be adequately contained and makes things worse instead of better. Without someone who can see you through this vulnerable time (literally and figuratively), you may be taking a big emotional risk without fully knowing it.
When I meet with a potential new patient, I always tell them that therapy is an investment of resources with many potential benefits and not without risks, including an increase in severity and frequency of symptoms. I always ask that when and if this happens, they tell me so we can understand what might have triggered them and work together to figure out why this happened and what we can learn together as a result.
For example: Let’s say you come in after fighting with your spouse, and we talk about what got you so agitated. You realize that the word your spouse used to describe you, “selfish,” is a word your parents used to describe you as a child. This realization sparks a flood of memories from the past, in which you felt disapproval from your parents and angry about it. You may become distraught, find yourself having a hard time sleeping, have sharp changes in mood, and difficulty focusing. Sometimes people can’t make the link between these events until they come in and talk to me about what went on in between sessions. Once people are able to make those kinds of connections, it is much easier to not get so flooded with emotions when future conflicts like this happen.
Okay, so you might be thinking, well, that all may be true, but any treatment at all is better than nothing. I disagree. Lackluster treatment is not always better than no treatment at all when it comes to therapy. Studies of therapeutic effectiveness have shown that the “goodness of fit,” or quality of the relationship between a person and their therapist, is the number one variable in a successful treatment. This research discusses how use of the therapy relationship is a key factor in the efficacy of psychotherapy. In short, the relationship you have with your therapist will have many of the same attributes of those you have with other important people in your life, because we all tend to operate on assumptions and expectations about people based on what we have learned over time about how people interact with us (therapists call this “transference”).
The difference with a trained therapist is that it is their job to notice when these patterns start to emerge and point them out to be explored together with you. The result is a real-time, lived experience of yourself relating to another person who can help you replace self-destructive patterns with more beneficial ones. But these relationships take time to develop and, in my professional opinion, an online, relatively anonymous encounter cannot simulate the helpful aspects of a caring therapeutic relationship.
I should add that it’s probably true that many people seek help because they are lonely and struggling and not necessarily looking for a caring relationship. They may fear being judged by others. Totally legitimate concerns. However, a therapist’s job is not to judge but to be curious along with you about yourself. And it is the very isolation of anonymous text-based therapy that propagates the loneliness and stigma instead of mitigating it.
Therapy apps have no real-time relationship, so they have no way of determining what goes wrong and what goes right. People are hard-wired to seek connection; technologically mediated text messages are not the same as making eye contact with another human being who is intently listening to you as you start to say your most private thoughts out loud. Earning “secure attachment” (feeling generally secure in your relationship to yourself, those around you, and the world in general—the lack of which is generally what creates the symptoms for which people seek out treatment) is hard work and evolves not only from verbal interaction but the often unexpected benefits of having non-verbal cues noticed and responded to. This is what attachment theorists call “attunement” and is at the core of good-enough relationships, therapeutic and otherwise. It is also pretty much impossible to receive via smartphone.
I reached out to both companies to get their takes on a few aspects about the apps that bother me. Because I have doubts about the apps’ ability to control the quality of their counselors, I looked into who the counselors are. While I was assured that they are licensed mental health specialists, the BetterHelp Terms of Service indicates that they “[do] not determine whether any counselor is qualified to provide any specific service.” The same disclaimer says that they “do not represent to verify, and do not guarantee the verification of, the skills, degrees, qualifications, licensure, certification, credentials, competence or background of any Counselor.”
Talkspace seems to have a fairly strong vetting system; a rep tells me that their providers are “fully licensed, can practice independently, and are qualified to diagnose and treat all mental illnesses,” and they they accept social workers, counselors, marriage and family therapists, and psychologists who are licensed at the highest level in their respective states.” Still, both sites’ Terms of Services indicate that it’s important to “talk to an appropriately qualified health care professional for diagnosis,” which supports my point about how important those first few meetings are.
I asked about the apparent lack of informed consent—the info about potential risks and benefits involved in treatment given to patients at the beginning of care—and BetterHelp replied: “BetterHelp provides the technology and the tools for counselors to conduct their own practice. The informed consent process is to be completed by each counselor, once the client has been matched. Each state and license type may have their own requirements regarding informed consent, so each counselor goes over this with each client individually.”
Regarding informed consent, Talkspace's legal team sent me their statement, which includes this statement: "Informed consent continues throughout the course of therapy and my therapist will continue to talk with me about risks, benefits or educate me on the process of therapy as we go along." While not untrue, this policy is also insufficient in my view, as it places the burden on the counselor and the app consumer after the client has already paid for a product.
As someone who holds a doctorate in clinical psychology as well as a four-year postdoctoral certificate in psychoanalysis, I assure you that education, training, and experience mean the difference between someone who can listen and home in on problematic patterns in thinking and someone who is able to say, “I’m here for you.” I don’t discount my bias as someone who has been on both the giving and receiving end of in-person therapy. But I do know that people are hardwired for connection to others, and there is simply no replacement for sitting in the same room as someone and having your pain witnessed and validated.
So, while you may find yourself wanting to reach out immediately to someone who can help you, please know you are doing so at your own risk. At this point, there is minimal research, little quality control, no emergency protocols if you get into a crisis other than to call 911 (other than the apps’ disclaimers that they are not equipped to manage an emergency), and little informed consent about the risks and benefits. When something seems too good to be true, it usually is.
Correction: A previous version of this article incorrectly stated that Talkspace did not respond to the writer's request for comment on informed consent. The updated version reflects the information the company provided.
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