What if you could treat a client while waiting in line for your morning coffee, walking the dog, or pausing between episodes of your favorite show? Throughout sessions, your client would remain anonymous. You’d never know his or her name, and you’d never meet in person. Sound a little too convenient? Or maybe like a license suspension waiting to happen?

More than a thousand therapists are now practicing in just this way through the mobile online therapy platform Talkspace. For as little as $32 per week, Talkspace will match users, based on their presenting problems, with licensed therapists. With this basic plan, the two agree to daily check-ins at mutually agreed-upon times, and communicate purely via text.

The company pitches its platform to therapists as a way of generating new income, having scheduling flexibility, and being available to clients who may otherwise not have access to services. According to company estimates, more than half a million people have used Talkspace since its founding, less than five years ago. According to The Verge—a technology news site operated by Vox Media—therapists are paid about half of what users pay; individual plans go as high as $99 a week for two daily check-ins. Clients and therapists negotiate the duration of messaging sessions. However, high-tier plans include a handful of live video sessions, which are limited to about 30 minutes. Talkspace also offers couples therapy, and users can even gift therapy credit to family and friends. “Give the gift of happiness,” one Talkspace ad reads. “Offering someone a path to a happier life is more valuable than any material gift.”

Telemental health isn’t a new phenomenon. But there’s been a recent spike in the popularity of apps like Talkspace and similar offshoots, including BetterHelp, Joyable, CounselChat, Couples Counseling, and Kip. Since November 2016, Talkspace’s user base has grown 70 percent faster than initially projected. According to the company’s CEO and cofounder, Oren Frank, who started Talkspace with his wife after couples therapy saved their marriage, the uptick is most pronounced in female and minority users, an effect some are attributing to anxiety caused by the presidential race and Donald Trump’s election. Still, while it might seem that text therapy would appeal most to a young, tech-savvy crowd, many therapists say the medium is equally popular among older clients.

Why are so many people gravitating toward mental health apps like Talkspace? Although scheduling ease is a big draw, some are attributing its appeal to the number of people who can’t otherwise afford in-person treatment, or who avoid it because of stigma. According to Mental Health America’s 2017 State of Mental Health in America report, 56 percent of American adults with a mental illness didn’t receive treatment last year. Finding a qualified therapist who practices nearby is often an issue for people, says Lynn Bufka, associate executive director of practice research for the American Psychological Association (APA). In a May interview with NPR, she added, “There are also clinical disorders that make it really hard to actually get to psychotherapy, no matter how convenient a location may seem. Or perhaps you have a physical condition that makes travel challenging.” For all these reasons, apps like Talkspace provide therapy that’s both accessible and affordable—“therapy for all,” as the company’s tagline reads.

A Controversial Therapeutic Space

Despite Talkspace’s popularity, the use of text messaging as a medium for therapy has been a source of controversy in the clinical community, adding fuel to the ongoing debate over whether therapy is truly effective if a clinician isn’t meeting clients in person. Does text therapy protect client confidentiality? Will it safeguard against clients’ potentially dangerous behaviors? Can apps that host therapy effectively verify clinicians’ credentials and adequately prevent them from practicing in states where they’re not licensed?

Tensions flared last December, when Cat Ferguson of The Verge consulted with three disgruntled former Talkspace therapists who addressed some of these issues for an investigative piece. Since Talkspace therapists sign a nondisclosure agreement, the three spoke on the condition of anonymity, skewering Talkspace for its client anonymity policy and claiming it impedes therapists’ ability to report dangerous situations. On multiple occasions, according to the story, Talkspace refused to provide client contact information when therapists attempted to report dangerous behavior, and its employees had purportedly been allowed to monitor client–therapist conversations for “quality control.”

Talkspace, its terms and conditions state, “does not offer therapy services directly to clients.” Rather, the terms proclaim that it’s merely a “platform” on which therapists and clients can conduct their business. This and additional disclaimers stating that Talkspace isn’t intended for “medical diagnosis” or “advice concerning which drugs or treatment may be appropriate for you,” allows Talkspace to exist outside of Food and Drug Administration jurisdiction. As a consequence, clinicians are entirely liable should clients decide to take legal action. A contract all therapists using Talkspace must sign reads that therapists will have to pay “for claims directly against Talkspace for actions caused by or related to the Therapist’s use of the Platform.” However, in many cases, therapists’ liability insurance doesn’t cover instances where a therapy app like Talkspace has been used. “All of the risk is on the therapist,” said one clinician interviewed for the Verge piece. “All of the work is done by the therapist, but there’s a tremendous amount of fear and control—and they dangle this carrot, that you’re part of something big and important.”

When initially contacted about these issues, Talkspace’s Frank emailed several editors at The Verge, as well as the CEO of Vox Media. “I will not hesitate to have The Verge answer legally, financially and professionally to any unsubstantiated claim, anonymous quote, or libelous statement that results in damage to our business,” he wrote. Shortly thereafter, he sent an email to all therapists on Talkspace, reminding them that they’d signed a nondisclosure agreement, advising them not to talk to reporters, and promising an internal investigation into leaks.

Only hours after The Verge had published the article, Frank posted a rebuttal on the open-publishing site Medium, titled “Response to False Accusations Against Talkspace,” in which he defended the app’s user anonymity and other policies. “Should we eliminate crisis lines because we don’t know who is calling?” he asked. “For a certain percentage of therapy clients, anonymity is a prerequisite to getting care.” He denied that Talkspace had impeded therapists’ attempts to inform authorities of dangerous client behavior. “We have no hesitation in helping the therapists on our platform to contact the authorities when the law or the ethical codes require it,” he wrote. As for third parties accessing clinical conversations, he noted that this was true only in the sense that a licensed therapist—although not the clients’ therapist—handles intakes, and third-party reviews were permitted if clients requested them. In these instances, he added, a “senior clinician,” never an employee without a clinical background, would perform the review.

Also speaking out as a Talkspace advocate is 86-year-old renowned psychotherapist Irvin Yalom, professor emeritus of psychiatry at Stanford University. In his upcoming memoir, Becoming Myself, he writes of his initial reaction to the idea of text therapy, “It seemed a distortion, a dehumanization, a parody of the therapy process.” But after receiving a call from Frank, who eventually asked him to supervise therapists responsible for Talkspace staff training, he warmed to the idea. To Yalom’s surprise, even after Talkspace started offering the options for therapists and clients to leave voice messages for one another and to meet via live videoconference, most clients preferred texting and declined these other forms of contact.

Yalom notes that although it’s not the same therapy offered in face-to-face encounters, it still has value. “I urged Talkspace to launch some careful outcome research, and the initial findings indeed support the presence of significant change,” he writes. “If clients have a panic attack in the middle of the night, they can immediately text their therapist. Though the therapist will not read the text for hours, there is still a sense of immediate contact. Furthermore, clients can easily review their entire therapy, every word they have told their therapist, and thus gauge how much progress they have made.” Since 2012, Yalom has served as an advisor to Talkspace, along with several other clinicians.

Adjusting to a New Platform

Even among supporters of other telemental health platforms, like phone and video sessions, text therapy is still controversial. “Let’s say a client comes into session and they’re drunk,” says Marlene Maheu, executive director at the Telebehavioral Health Institute in San Diego. “What’s our immediate focus? We need to address the intoxication first. But if you can’t gauge someone visually, how are you supposed to do that? Even when I’m on the phone with a client, I can hear if there’s desperation in their voice. I can tell if they’re crying. I can hear if there’s a child screaming in the background. I can’t tell any of that in text messaging.”

For its part, Talkspace does have a video and audio feature through a secure provider that it notes is HIPAA compliant. The option comes at an additional cost, and, says Frank, “lets people have a virtual face-to-face experience with their therapist—once they’re ready.”

Maheu, who has more than 20 years of experience in telemental health and, by her own estimates, has trained more than 20,000 clinicians in the new field’s therapy ethics, says she sees too many psychotherapists jump on the text therapy bandwagon without looking to see if these apps have safeguards. They also, she says, often fail to see that their ethical and legal obligations haven’t changed, despite conducting therapy through a new medium. “Many clinicians aren’t properly trained in doing text therapy,” Maheu says. “They think it’s a whole new game. But this isn’t a new treatment: it’s a new way of doing what you’re already supposed to be doing. Therapy without standards is akin to a surgeon saying, ‘I’m going to perform surgery, but I don’t have the right scalpel I need because the hospital doesn’t provide it.’”

Many supporters of text therapy say it’s not intended to be a replacement for face-to-face sessions, and acknowledge there are shortfalls in not being able to read body or vocal cues. In fact, a section of Talkspace’s terms and conditions seems almost deferential to in-person therapy. “In some cases,” the policy reads, “Talkspace’s offered services may not completely substitute for a face-to-face session by a licensed therapist. You should never rely on or make health or well-being decisions purely on use of Talkspace.”

Others, like psychotherapist Kate Anthony, cofounder of the Online Therapy Institute, based in the United Kingdom, say that text therapy is a sign of the times, and more clinicians need to catch up. In fact, she says, when the therapist is trained in proper text therapy protocol, like good record keeping, answering the client promptly, and having a mutual agreement with the client about what their relationship entails, it’s not even necessary to augment text therapy with in-person sessions.

“It’s important to consider where psychotherapy is with technology and communication,” Anthony says. “The whole profession is going to get very left behind if we continue to insist that face-to-face is the only way of working. The field of psychotherapy is all about communication. It’s time we stepped into the 21st century and got a grip on how people communicate today.”

The debate over therapy apps and the viability of text therapy is still unfolding. APA’s Bufka says, “I suspect down the road these types of technologies will evolve in different ways, so that we’ll have mental health care that doesn’t look so much like psychotherapy as it has been traditionally delivered, but provides some useful interventions.” And in a February edition of the APA publication Monitor on Psychology, Amy Novotney interviewed several clinicians who called for psychotherapists to play a greater leadership role at online mental health companies. They “need our knowledge and competency at the heart of their decision-making process,” said one clinician who’d worked with an online therapy company. “We understand the responsibilities that we have to users in a very different way than you do if you come from a technology background.”

Oren Frank has seemed increasingly open to therapists’ input, admitting in his Medium piece that Talkspace may have made mistakes when it came to transparency. “As we grow and succeed in helping more people, we have made missteps in how we communicate our priorities to the therapists on our platform,” he wrote. “When that happens, we make sure we make each mistake just once. I’m a strong believer in ethical businesses, and that the way we treat each other, our employees, clients and partners must be fair and kind.”


PHOTO @ Pexels/Porapak Apichodilok

Chris Lyford

Chris Lyford is the Senior Editor at Psychotherapy Networker. Previously, he was Assistant Director and Editor of the The Atlantic Post, where he wrote and edited news pieces on the Middle East and Africa. He also formerly worked at The Washington Post, where he wrote local feature pieces for the Metro, Sports, and Style sections. Contact: clyford@psychnetworker.org.