As it turns out, when I first signed up over the winter I was barely ahead of a wave that is now cresting in the midst of the coronavirus pandemic. Our new combo of health-related angst and travel restrictions has spurred the uptake of all kinds of e-therapy apps, including BetterHelp, 7 cups and Woebot (“No couches, no meds, no childhood stuff.”)(Also, no humans: Woebot is a chatbot.)
Users of another bot, Wysa, have tripled since covid-19 hit, says co-founder Ramakant Vempati, while managers at Talkspace (“Therapy for how we live today”), who previously boasted 1 million users, say volume is up 25 percent.
“The anxiety out there is at an all-time high — unfortunately,” Talkspace chief medical officer Neil Leibowitz says. He says clients are seeking more help with relationship problems or loneliness, depending on their housing situation, as well as “overwhelming” money worries.
The bright side of all this misery — at least for the e-therapy industry — is that stay-at-home orders are driving more of the uninitiated and even the downright skeptical to conquer the hesitation that Leibowitz described as the biggest previous obstacle to permanent inroads in the market. Once the crisis dies down, he predicted, “some people will go back to face-to-face therapy, but I think a large number will be converted.”
Potentially speeding that trend along is President Trump’s expansion of telehealth benefits for Americans receiving Medicare payments, while suspending some parts of HIPAA, the health privacy law that previously strictly regulated providers of remote care.
I’d signed up for a Talkspace plan that for $160 a month (a $100 winter discount) let me text at will and receive at least one “asynchronous” answer a day. I could also chat on video for an additional $65 per half-hour. That’s theoretically cheaper than face-to-face therapists, who depending on credentials and location, charge $100 or more an hour, unless you’re paying co-pays of $10 to $30 a session with a good insurance plan. (But I mean really good.)
The low cost and convenience of “seeing” my counselor, a licensed marriage and family therapist with 20 years of experience, beat my analog-therapy hands down. Not covered by insurance and barely affordable, that process had obliged me to dress up and drive to an office twice a week, where I mostly — and reluctantly — was pushed to focus on why I was sabotaging my relationships and career.
Did that mean my secrets might one day be scrutinized by health insurers seeking preexisting conditions or by someone selling anti-anxiety supplements?
Leibowitz later assured me that Talkspace complies with HIPAA confidentiality rules. Even so, the knowledge that our texting could be monitored at least by someone like Leibowitz (who subsequently confirmed this was true) strained my bond with my therapist. We were both on our best behavior, like an Uber passenger and driver striving for a five-star rating, and while I was extra-cautious, she sometimes sounded canned.
“If your shame were to deliver a speech about you, what would it say?” she asked early on.
At other times, she seemed genuinely connected and insightful — like when she gently scolded me for saying I’d gotten “distracted” from work in the years I’d spent caring for my children and parents.
“It’s dismissive of the value of attending to them,” she wrote.
I’d chosen Talkspace because it seemed like the juggernaut of e-therapy plans, with more than 5,000 licensed counselors and lots of glowing media reviews. It has also become a reimbursable option under more than 40 employee benefit plans, including those covering workers at Whole Foods, Veritas, and the Postal Service. Just last May, the platform signed up with UnitedHealth Group’s Optum, making it available to 2 million more potential customers.
The ventures hold the promise of extending mental health services at a time when fewer than half of all Americans with mental illness are receiving treatment.
Yet some experts call these deals premature, given there’s little to no evidence that texting therapy actually works.
“The potential of digital mental health services is around increasing access and quality, not to make patients into guinea pigs with downscaled services,” says Harvard Medical School researcher John Torous, chair of the Smartphone App Evaluation Task Force for the American Psychiatric Association.
By the time I talked to Torous, I’d learned enough about Talkspace that I no longer felt comfortable sharing my secrets, and switched over into reporter mode. The model’s research deficit is obvious from Talkspace’s own site. The relevant page offers four promising quotes from respected journals and institutions that link to other pages that on close reading simply aren’t relevant. Two pertain to studies about real-time video therapy, which compared to texting indeed has some solid supporting evidence. A third relates to a rigorously structured kind of correspondence course. The fourth link takes you from a Columbia University insignia to an unrelated page from the British Journal of Psychiatry.
Asked whether he agreed there was insufficient research, Leibowitz said: “By saying you don’t have evidence showing it’s effective doesn’t mean it’s ineffective.” Even so, he promised to send me a “preview copy” of what he described as a brand-new, yet-unpublished study that would show that Talkspace users had “outcomes pretty similar to face-to-face therapy.” The next day, however, a Talkspace media consultant emailed that the study was unavailable.
In Boston, health economist Adam Powell pointed out that health plans have only a fixed amount of insurance premium dollars to spend on interventions, which he said ought to make them wary of partnerships with vendors that have not been able to prove they are superior to time-tested practices.
“Every dollar spent on a digital tool is a dollar that cannot be spent elsewhere,” he says.
Such concerns have yet to deter investors who have poured at least $110 million into Talkspace. But they do perturb many flesh-and-blood therapists.
In 2018, the Psychotherapy Action Network (PsiAN), which champions therapies of “depth, insight and relationship,” wrote to the American Psychological Association, accusing Talkspace of “a clear attempt to deceive the general public.”
Talkspace then sued PsiAN for $40 million, saying its allegations were false and that “brick and mortar” therapists were “threatened by Talkspace’s success.” A federal district judge in the District dismissed the suit this year, citing lack of jurisdiction. Leibowitz said he wasn’t sure whether Talkspace will refile it.
Some therapists who work for Talkspace have their own objections, expressed in online reviews complaining of low salaries ($30 to $35 an hour, according to Salon) and being treated like “therapy robots.” (Leibowitz declined to discuss salaries.)
Text-therapists may also justifiably wonder whether they are doing any good. Hundreds of studies have demonstrated the critical role of the patient-therapist relationship in making therapy successful. But in one recent survey, therapists reported that they doubt they can achieve strong relationships with e-therapy.
No wonder. Humans tend to lie a lot, even when we don’t really mean to. Yet in the company of others, we betray ourselves with fleeting signals: a sudden slouch, an angry puff of breath, a fearful widening of eyes. The bulk of what we say is nonverbal, untranslatable to texts.
Looking back, I realize the pivotal moment in my own real-life therapy came on the morning my psychiatrist caught me locking his office door on my way out.
“Why are you locking my door?” he asked. “Don’t you want me to see other patients?”
“I’m not locking your door!” I retorted. Then I looked at my thumb, which was still on the knob. Of course I’d heard there was such a thing as the subconscious, but had been resisting, until then, that a part of my brain could take over the rest of it like that. The discovery, combined with about three more years of sessions, brought lifelong benefits.
Among these gifts was that I learned to trust my gut — to know fairly quickly whether something or someone was right for me or not. I quit using Talkspace after the first five days.
Katherine Ellison is a journalist and author whose most recent book is “Mothers & Murderers: A True Story of Love, Lies, Obsession . . . and Second Chances.”