Left to Our Own Devices

Sorting Through The Bewildering World Of Therapeutic Apps

Magazine Issue
November/December 2016
A man stands looking at a tablet as app icons float around him

I have eight mental health apps on my iPhone, and I’m curious about a bunch of others. My current favorite is Pacifica, which is part mood tracker, part mindfulness coach, and part commiserating friend. Meanwhile, I’m trying to get my courage up to try the popular 7 Cups of Tea, which allows me to chat about my troubles with a volunteer who’s been trained as an “empathetic listener.” Hmm. I have a lot to say, but does some stranger in Helena, Montana, or Teaneck, New Jersey, really want to hear it? (I’m only slightly reassured by the app’s promise that “we won’t think you’re weird.”)

Maybe for now, I’ll just open Headspace, which offers daily 10-minute guided meditations with a former Buddhist monk. I like his gently authoritative, it’s-all-okay demeanor. Sitting down on my living-room couch, I tap an icon and begin.

A decade ago, nobody knew what a “mental health app” was, except perhaps a few prescient techies in Silicon Valley. If therapy clients needed extra support to manage anxiety or get to sleep, they might make use of a CD or an mp3 download that offered self-hypnosis or the soothing sounds of ocean waves. There were, and are, endless self-help books, but if you’re anything like me, as soon as you finish one, you forget about 80 percent of it, and there you are, left again to your own self-doubting devices. Over the last several years, internet chat groups have proliferated, but if nobody replies to your desperate 3 a.m. post, you’re out of luck.

Today, we’re entering a new and fast-expanding universe of emotional self-help—one populated by smartphone apps. They offer tools for everything from depression, social anxiety, and binge eating to phobias, postpartum problems, and substance abuse recovery. They’re even available for such complex conditions as borderline disorder, PTSD, schizophrenia, and bipolar disorder. On an iPhone or Android, anyone can click an icon and track their state of mind, try mood-boosting activities, or get instant feedback on their body–mind status via wearable biosensors that “talk back” to smartphones. Many apps also offer the chance to text with others facing similar issues, engage in real-time talk sessions with therapists, and get immediate crisis help.

The choices are breathtaking. A recent search of Apple’s App Store turned up 1,490 programs for anxiety relief, 2,193 for relationship help, and 948 for depression management. By the time you read this, more will be on the market. There are enough apps for addressing bipolar disorder for a blog called Healthline to post “The Best Bipolar Disorder Apps of 2016.” Some apps rely on a particular therapeutic model, with cognitive behavioral therapy (CBT) leading the pack at more than 4,000 iPhone offerings. Clearly, people are interested: Headspace counts more than 5 million users, while an app called PTSD Coach has been downloaded in 80 countries since it was unveiled in 2011.

Institutions are getting on board, too. The US Department of Veterans Affairs has created a division of mobile mental health services that encourages vets to try out designated smartphone apps. And Coastline, one of the nation’s largest employee assistance programs with clients in 40 states, has begun to recommend particular behavioral health apps to the 180,000 employees it represents. Organizations ranging from the Gottman Institute to startups with names like Electric Eggplant and Archie’s Empire continue to bring new mental health apps to market, many of them relying on venture capitalists to fund their projects.

Meanwhile, health policy organizations are pushing for the expansion of digital support systems. In its Mental Health Action Plan for 2013–2020, the World Health Organization urges the promotion of self-care through the use of mobile health technologies. A 2016 report issued by the National Institute of Mental Health (NIMH) called “Technology and the Future of Mental Health Treatment” announced the award of 404 research grants on app development and other innovative mental health interventions. And in an unanticipated move last year, Thomas Insel resigned as the longtime director of NIMH to join Google Life Sciences, observing in Fortune magazine that the mental health world is “seeing an explosion of interest on the device side” and “many technology companies think mental health is the next frontier.”

For many clinicians, the proliferation of mobile apps on the mental health scene may come as a surprise, even a bit of a mind-boggler. Therapists who use Skype or FaceTime with clients participate in a familiar face-to-face, two-person experience, but a behavioral health app, by contrast, is typically deployed by one person, anytime and anywhere—on the train to work, in the dentist’s waiting room, or while toiling on the treadmill at the gym. Whether we’re comfortable with the idea or not, many clients are already using these apps, or soon will be, and will likely look to you for guidance. But from the thousands of choices out there, how is a therapist supposed to distinguish a helpful program from a useless or even harmful one? A few apps have been studied for effectiveness and safety, but most just hang out in unsupervised digital space, designed by entrepreneurs without pertinent input by clinicians or independent researchers. As John Torous, a Harvard psychiatrist who chairs the American Psychiatric Association’s Smartphone App Evaluation Task Force, recently observed in the journal Nature, “Right now, it almost feels like the Wild West of healthcare.”

Given the stunning speed with which technology morphs and expands, we can expect that behavioral health app developers will continue to pioneer new forms, gather more personal information from users, and extend their marketing reach to include not just individuals, but clinicians, researchers, and major healthcare providers. Even as therapists struggle to get a handle on these new apps as possible adjuncts to therapy, this is just the first wave of the smartphone incursion into mental health territory. In some cases and places, mobile apps are selling themselves as actual providers of psychotherapy, or at least therapy-like help. Since solace-by-app is here to stay, how might clinicians become a meaningful part of this mental health game changer, in ways that might benefit both themselves and their clients?

Exploring the App Universe

Mental health apps come in several distinctive, often inventive formats. They can be grouped into five categories: mood tracking, activity-based, mindfulness practice, real-time interaction, and technology-assisted. Many apps incorporate multiple formats, but most tilt toward one particular kind of service. Typically, they start out free but soon upsell, encouraging users to buy a more extensive, feature-heavy package. Some apps make an effort to be therapy friendly, making it possible for a client to share his or her experience with a therapist’s own smartphone, in turn allowing clinicians to track clients’ between-session progress or slippage.

Mood Trackers. These apps act as portable mood journals, allowing users to rate their emotions and symptoms over time, with the goal of understanding possible links between state of mind and specific thoughts, behaviors, and even the presence of particular people, such as one’s spouse, boss, or latest OkCupid date. Popular mood trackers include Moodlytics, gottaFeeling, Optimism, Mood 24/7, and Moody Me.

I decided to try out Optimism, mostly because of its uplifting name. As a moderately tech-impaired person well into the second half of life, I immediately warmed to the app’s easy-to-follow segments: Core Data (your dominant mood that day and how you coped with it), Stay-Well Strategies, Triggers, and Symptoms. I liked, too, that I could customize these sections to my own personal habits. I added “meditation” to my Stay-Well catalog, and deleted “behind with housework” from my Symptom list, since I basically don’t do any. With these tweaks, I was ready to go.

Ironically, my Optimism experience left me somewhat dispirited. As I slogged daily through the 13 Triggers and 15 Symptoms (including feeling worthless, feeling hopeless, relating poorly, and suicidal thoughts), I began to feel as though life were a series of downers against which “Stay-Well Strategies” seemed a puny defense. Granted, the purpose of Optimism is charting, not cheerleading. And the app might work better for someone working with a therapist since it features a Clinical Dashboard, which allows users to send summaries of their daily records to their in-office therapist. But for a stand-alone user like me, Optimism was a lonely experience. At the very least, I longed for a person-like entity who could encourage me along the way—a sort of Siri with an LCSW.

Activity-Based. These apps typically offer a suite of self-care tools to cope with daily challenges and boost life satisfaction. Some, like SuperBetter, are geared to young people, allowing the user to create a superhero identity and specific adventures to reach an objective, such as Reducing Stress or Being Awesome. There are hundreds more activity-based apps: Quitter helps people let go of unhealthy habits, while Sleepio addresses insomnia. The highly rat­ed PTSD Coach offers crisis intervention for those suffering flashbacks and overwhelming emotions. BreakFree specifically targets—irony alert!—addiction to technology.

I was initially attracted to the app Pacifica because of its homepage, which features a meltingly beautiful, apricot-hued sunrise. But what won me over was its full-service array of tools, including journaling, chat groups, guided deep breathing, and a “thought diary” featuring a CBT-approach to challenging unproductive beliefs. A few weeks ago, I logged on to try to address my growing anxiety about a dinner party my husband and I were hosting that evening. I’m not a huge fan of cognitive behavioral approaches, so my expectations were low-to-medium. To my considerable surprise, within 15 minutes I’d moved from a previously unconscious belief that “it’s got to be perfect” to the more benevolent mantra of “it’s gonna be fine.” Following this left-brain exercise, I felt the need for a break, so I tapped Pacifica’s Relax Now icon and treated myself to Bach’s Cello Suite No. 1.

My party turned out to be, well, memorably imperfect. I forgot to turn on the oven—which meant we didn’t sit down to dinner for a full hour after the last appetizer had been eaten. But I managed to quiet my inner complaint choir and focus on what was working: the appetizers had been delicious and filling, and the conversation continued to flow. (The wine and beer helped mightily.) Finally, we served dinner: our guests crowed over it, and I saw that my hectic best was, indeed, quite satisfactory. I credit Pacifica for that. Without that immediate access to help on a Saturday morning, I wouldn’t have given myself the time or awareness to shift my disastrous definition of dinner-party success.

Mindfulness. A sizable chunk of behavioral health apps focus on mindfulness practices—some 1,147 at this writing. A 2015 study published in the Journal of Medical Internet Research sifted through 700 of them and ranked Headspace, Smiling Mind, and iMindfulness as the best of the bunch. My personal favorite is Headspace, which offers a free, 10-day series of 10-minute guided mindfulness sessions called “Take Ten,” with the option of hundreds more for an annual subscription fee.

I tried out “Take Ten,” and frankly, I couldn’t wait to participate in each session. In my experience, what makes Headspace not just good but extraordinary is the presence of Andy Puddicombe, a 43-year-old Brit whose manner projects a kind of trustworthy gravitas. Puddicombe, who’s a Buddhist, begins each session with a brief introduction to a particular element of mindfulness practice, and then guides the meditator through a brief body scan. After that, we’re encouraged to focus on our breathing. “Our practice is not about getting rid of thoughts or emotions,” he regularly reminds us. “It’s about changing our relationship with them.” No pressure, just an invitation: “Let’s have a go at that now.”

It’s hard for me to judge the impact of “Take Ten,” since I also practice another form of meditation most mornings. Headspace is my evening discipline, although discipline is altogether the wrong word; mindful nightcap might be more like it. It provides me with a dependable oasis of calm and perspective following a usually intense day of wrestling with words. I enjoy being guided, rather than always going solo, on the path of awareness. It’s the only app I’ve tried so far that tempts me to plunge in and subscribe.

Connection-Centered. These apps provide real-time emotional support by therapists, trained coaches, or volunteers. One of the best known is Talkspace, a dedicated therapy app that gives users a choice between unlimited text messaging with a licensed psychotherapist (for a fee of $128 per month), or a package of texting along with four video sessions with a clinician ($276 per month). Other apps offer instant support from nonprofessionals, such as Joyable, which promises to reduce social anxiety if you purchase a $99 monthly package that includes the services of a coach trained in cognitive behavioral approaches. Meanwhile, 7 Cups of Tea, which has been downloaded in 189 countries and is available in 140 languages, bills itself as a source of free compassion. Its corps of on-call volunteers—“active listeners from all walks of life”—offer private, one-on-one sessions that give users a place to vent, brainstorm, and get support for emotional challenges.

7 Cups of Tea, as I mentioned earlier, is the app that I found intriguing but that triggered something resistant and judgmental in me. Free compassion—really? From some random, online-trained person in Sacramento or Slovenia? I browsed the list of currently available listeners, among them Cuddleking2001 and Supportive Sock Monkey. My sarcasm muscle started to spasm: awesome. My kind of people. At the same time, the app is so frequently mentioned on blogs and social media that I felt duty-bound to give it a try.

When I log on, up pops a long list of concerns I can choose to work on, including a romantic breakup, eating disorders, domestic violence, and LGBTQ+ issues. I’m reassured that at any time during the conversation, I can be referred to a psychotherapist. Not wanting to get over my head—or that of my lay listener—I choose the comparatively safe “getting unstuck.” Instantly, I get a text from a self-described “friendly bot” called Noni, who assures me that my “real human listener” will log on soon—someone who goes by the handle of SundanceForYou. (I’ve changed the name a bit.) After a few moments, a new text appears: “Sundance here. How are you?”

I text Sundance back about a longstanding problem. “I want to make time for creative stuff, but I seem to fill up all of my time with work.”

Silence from Sundance.

I begin to feel a little annoyed. Is this “active listener” thoughtfully considering my dilemma or rushing home from the grocery store, weaving through traffic in hopes of making it through a yellow light?

I grump, “Are you still there?”

Into the void, Noni the Bot steps in. “We’re here for you.”

Sure you are, I think.

Sundance suddenly returns. “But to keep yourself happy,” he texts, “you need to do what makes you happy.”

Me: “I totally agree. But I feel a conflict between making time for art and taking on too many work projects. That’s where I’m stuck.”

Sundance: “Money is equally important, but I’m saying if you give 100 percent to your work, at least give 20 percent to things you love.”

Math confusion aside, I feel a tiny uptick of hope. Could I just act on that, without figuring it all out first? But before I get a chance to respond, a new screen pops up with the directive “Review Sundance.” What? It’s over? Not even so much as a goodbye-and-good-luck from my new bud? Miffed, I give him middling marks. (Somehow, I’ve decided he’s a guy.) I look for the logoff button.

“What kind of creative work do you do?”

OMG, he’s back! Did he read my review? Arrggh!

We text some more, with Sundance now asking more about my creative interests as I, in turn, feel increasingly excited about them. I tap, “Maybe instead of just thinking about it, I need to just DO it—use that 20 percent.”

“Yes, like the Nike tag line.”

I thank Sundance for his help. He asks me what kind of work I do.

“Writer and editor. You?”

“Sales and marketing manager.”

After we text our goodbyes, I check my watch. Sundance was with me for 45 minutes, and never once attempted to wrap things up. Our exchange was far from blip-free, but he hung in there long enough for me to discover something I could try. Without further handwringing, I joined a class in collage-making.

Wearable Technology (More than a Mood Ring). These days, Silicon Valley types are busy creating the next wave of behavioral health apps, those that collect brain and body data using sensors built into smartphones. These wearable apps—sort of Fitbits for the soul—can record and analyze brain states, social interactions, vocal tone, movement patterns, and other markers of emotional status. Promoted as tools for self-awareness, the programs transmit the analyzed information from sensor to smartphone. Users, in turn, are prodded by the app to take steps to shift their mood and behavior.

Of these next-generation apps, Muse is getting a lot of word-of-mouth advertising. It aims to help people get the most out of meditation practice by using a sensor-studded headband that tracks brain signals during sessions and translates them into weather sounds. If you get yourself into “the zone” during meditation, you’ll hear the hum of calm, settled winds. But if you’re sitting there cross-legged, chanting Om while worrying about whether you’ll have enough money to see you through retirement, you’ll hear the sounds of seagulls cawing, accompanied by thunder, rain beating on pavement, and winds blowing. At $249, this headband-with-benefits is an investment, but a friend who’s used it for three months is impressed by its right-brain/left-brain features. “You get this sensuous, rich experience of immersion in nature,” he says, “and then right afterward you can look at this precise chart of your progress.” While he hasn’t yet made big gains toward a calm body–mind, he thinks he’s trending positive.

Digital Phenotyping: The Next Big Thing

To reimagine a line from the film The Graduate: “Just one word: biosensors.” Muse is just an early, relatively rudimentary example. The possibilities of apps to track and transmit mental health information ever more efficiently have researchers, policy wonks, and venture capitalists buzzing. Harvard professor Jukka-Pekka Onnela, who’s won a $1.5 million New Innovator Award from the National Institutes of Health (NIH) to study mood disorders using cellphone data, has coined the term digital phenotyping to describe the moment-by-moment quantification of a person’s behavior using electronic devices. This groundbreaking capacity is part of why Thomas Insel made the jump last year to join the Google Life Sciences group. In a recent interview with Science magazine, Insel marveled at the possibilities of moving beyond the cumbersome process of measuring people’s biomarkers through blood tests or brain scans and instead assessing the information anywhere, anytime, on a smartphone. “When I saw that this is the place where you can marry technology to a huge public health need,” he said, “there was no turning back.”

And money is beginning to change hands. As of mid-2016, Talkspace and Ginger.io had raised 28 million apiece; the website Angel.com currently lists 514 investors who are funding digital entrepreneurs. Other developers—some still in college—are operating on a shoestring, soliciting funds via crowdfunding sites. Among them are WorryQuest, a gamified app for helping 20-somethings cope with anxiety, and Eliza, a mood-tracking tool that “listens” to users’ voice memos as they vent or reflect on their day. The app analyzes vocal tones for stress and emotional status and sends the results back to the user, along with suggestions for self-care, peer support, and/or psychotherapy.

Also in the works is a biosensing app for depression with the can-do name of Mobilyze! Now under testing by Northwestern University, it uses a smartphone’s built-in accelerometer and GPS to sense when a person may be sunk in despondency. It collects data on location and movement—for example, how much time you spend inside your house just lying around. The app also tracks some indicators of social activity, including how often you talk on the phone, text, and interact with people via social media. When it detects a sustained pattern of isolation, it sends you a text or an automated phone call urging you to call a friend, spend some time outside, or talk to a therapist online.

Over the next few years, clinicians can expect a steady stream of come-ons—via Facebook ads, mailings, therapy blogs, and conference exhibit booths—for a growing array of smartphone apps that can connect therapists to client information. A notable sign of the times: David Kupfer, the University of Pittsburgh psychiatrist who headed up the DSM-5 Task Force, has cofounded a startup called HealthRhythms, whose mission is to generate a comprehensive profile of an individual’s well-being “through continuous measurement.” One new product is MoodRhythm, a biosensing app that allows clinicians to chart a bipolar client’s emotional state between sessions. Other startups are developing apps that transmit data to therapists about clients’ daily symptoms of schizophrenia, as well as track the progress (or relapse) of those trying to stay clean and sober.

These digital entrepreneurs—and the venture capitalists backing them—are beginning to market to Big Health. The startup Ginger.io has supplied a smartphone package to 40 health insurers and hospital systems, and has already screened some 750,000 patients for depression, anxiety, and other common mood disorders. Another startup, Big White Wall, works with Kaiser Permanente Northwest and several community mental health systems to provide patients with instant support via smartphone apps. Many healthcare institutions find these apps attractive because they’re good at spotting early signs of psychological distress, allowing insurers and providers to intervene promptly and supply support groups, coaches, and in some cases, therapists. As the HealthRhythms website explains, this approach “reduces the financial strain insurance companies and health systems face” when emotional distress escalates and may require extensive psychotherapy, medication, or inpatient care. The strategic use of apps, in short, promotes a better bottom line.

“Totally Confidential” (Really?)

What are the potential hazards of behavioral health apps? Privacy is surely one. After all, these apps gather highly sensitive personal information. Steve Daviss, chair of the American Psychiatric Association’s committee on mental health information technology, recently observed in the online magazine UnDark, “While the idea of automatically giving clinicians information from cellphone data is good, it’s also a little Big Brotherish.” This is especially troubling in the wake of the increasing use of behavioral health apps by medical institutions. For instance, if a person’s struggles with depression or anxiety are transmitted to a health insurance company, might his or her premiums soar, or might the policy not be renewed? Kaiser Permanente West notes on its website that if you sign up for Big White Wall app via Kaiser, “your identity will be made known to KP under certain circumstances.”

Clearly, we can’t merely assume confidentiality. You may recall the backlash Fitbit faced five years ago, when the sexual activity level of 200 users was exposed to the public via Google search results. Many users didn’t understand that the company made users’ profiles and sexual activity public by default. (In the wake of that debacle, Fitbit changed the default setting to “private.”) On the smartphone front, some developers are testing apps that would allow financial institutions to conduct a kind of emotional surveillance of their employees. One program designed by the startup Behavox analyzes smartphone conversations to get a behavioral picture over time. Does this trader, once an even-tempered sort, now tend to shout at clients? Does that analyst, typically energetic, suddenly seem flat and lethargic? The results could signal the company to engage in further scrutiny of that employee.

Do Apps Even Help?

The short answer is that we don’t know yet. According to a 2015 report in the Wall Street Journal, fewer than one percent of mental health apps have been studied for effectiveness—and the apps’ developers have funded some of those trials. A handful of apps have submitted themselves to independent study, most of them pilot efforts. In 2014, the US Veteran Administration’s National Center for PTSD surveyed a small sample of veterans who used PTSD Coach, and found that 80 percent of the 45 subjects found the app to be “moderately” or “very” helpful in managing their symptoms. The good news is that larger independent studies are underway, some of them randomized and controlled. One of NIH’s websites, ClinicalTrials.gov, currently lists 152 funded studies on tech-assisted mental health interventions, many of them focused on the efficacy of smartphone apps.

For now, quality remains hard to judge. Anybody can roll out a mental health app and say it’s awesome. Although many apps I’ve looked at are reasonably modest in their claims, some bristle with promises. The website of the app Gratitude Journal asserts that “just five minutes daily is all it takes to rewire your brain and unleash everything great in your life.” Meanwhile, Joyable claims that “93 percent of our clients see their social anxiety decline,” and promises that if you complete the program, the benefits “can last for over 10 years.” (This assertion of enduring gains turns out to be based on a small study of people engaged in traditional psychotherapy.) A few programs may be outright hazardous. When a team of Australian researchers reviewed 82 apps for people with bipolar disorder, they discovered that one, iBipolar, advised sufferers to drink hard liquor to help them sleep. That app, which featured a section entitled “A Manic’s To-Do List,” no longer seems to be available.

In this digital cowboy culture, there’s no sheriff—or at best, only a part-time one. The US Food and Drug Administration plays a minimal role in assuring the safety or effectiveness of smartphone health apps, stating that it will evaluate only “the small subset of mobile apps that meet the regulatory definition of ‘device,’” that is, a mechanism that seeks to diagnose or cure a disease. The Federal Trade Commission has recently rolled out an online interactive tool to help health app developers figure out which FTC regulations might apply to them, including HIPPA privacy laws. While this is surely a useful step, it falls well short of oversight.

Will Apps Compete with Therapy?

For some clinicians, behavioral health apps may seem like a classic frenemy—a phenomenon that may support therapy while also stepping on its toes. On the one hand, if therapists or their clients can find high-quality apps—and they’re out there—they may be useful complements to therapy, helping clients to practice new behaviors and get immediate support, including crisis help. For example, Pacifica (the app I used to counter my belief system about the nature of entertaining) might well reinforce the work a client is already doing with a CBT-oriented therapist. For other people, apps may serve as gateways to therapy as they experience mood improvements via self-help activities but have trouble sustaining their gains. On their websites, some apps seem to support this gateway approach, stating clearly that they’re not a replacement for traditional therapy.

Yet some people almost surely use apps this way. In the more than half of US counties that lack any mental health services, a quality app that offers a suite of support—peer groups, self-help activities, coaches, therapists—might be the only option available for emotional ballast. In a truly catastrophic situation, such as a natural disaster or terror attack in which masses of people are traumatized and therapists aren’t immediately available, an app with a solid crisis-intervention feature could be a digital lifeline.

But even among those with ready access to therapists, mobile help may be more appealing than in-person treatment. PTSD Coach, a joint project of the US Department of Veterans Affairs and US Department of Defense, allows survivors who may feel stigmatized by psychotherapy to get instant, on-call support from friends, family members, coaches, and therapists. In psychologist-run focus groups, traumatized vets said they wanted something they could turn to the moment distress begins to rise—in the supermarket, say—while remaining anonymous. Other people might be glad to work face-to-face with a therapist, but simply can’t afford one. Virtually all mental health apps offer at least initial sustenance—via chat groups, self-help tools, and crisis help—at no cost.

One element of the app revolution that’s sure to affect the future of psychotherapy is young people’s fierce attachment to their smartphones. Judith Hoffman, who directs the national employee assistance program Coastline, observes a sea change in this regard. “A lot of the people we serve—especially teens and 20-somethings—won’t even use laptops anymore,” she says. “If they don’t get information directly through their smartphones, they don’t get it at all.”

While Hoffman and her staff of therapists regularly encourage troubled employees to seek counseling, Coastline recommends particular stress-management apps to give clients a resource they’re likelier to try. Her strategy may be a portent. As the youthful population ages and people increasingly rely on information and support from smartphones, digital devices may become first-line emotional support for many people.

Many perhaps, but not all. Numerous studies show that face-to-face connection is vital for fully engaging with, and healing, our struggles as humans. Clearly, we still need therapists to help us heal childhood pain—a father’s abandonment, a mother’s depression, torment by bullies, or simply growing up achingly lonely. A smartphone program isn’t sufficient to get us through major life crises like divorce, serious illness, or the loss of a loved one. Just as a physician is indispensable when a bone fractures—WebMD will never suffice—it’s hard to imagine a world in which therapists aren’t called upon to help restore emotional wholeness.

Therapists in the Age of Smartphones

Still, App-landia is here, and flourishing. We can resist it, feel defeated by it, or become a vital and judicious presence on its new frontier—not as sheriffs, certainly, but more as a kind of community watch, joining together to take a hard look at these apps and differentiating the good guys from the bad. Clients and others need help in hacking through the current thicket of choices. Which one might actually help to manage depression? Which to choose for anxiety? Which for life’s general stresses and strains? There are some terrific apps out there—and some terrible ones. Some take pains to protect your privacy, and a few will disregard it. Given the almost total lack of regulation in this realm, helping clients choose well is an important responsibility.

Guidance for clinicians is coming, but slowly. The American Psychiatric Association has taken the lead via its Smartphone App Evaluation Task Force, which is currently reviewing hundreds of mental health apps and will soon post them on its website, albeit behind a paywall. Meanwhile, the Anxiety and Depression Association of America, a nonprofit educational organization, has posted therapists’ ratings of 14 mental health apps, evaluating them for ease of use, features, and research evidence.

While awaiting more extensive evaluation, there’s nothing to stop therapists from getting into the act themselves. For example, Coastline’s Hoffman and her team of therapists have sifted through 30 popular stress management apps and come up with three “staff picks” to recommend to employees: CALM, Breathe2Relax, and SAM (Self-Help for Anxiety Management). A group practice, or even a solo practitioner, could feasibly do a version of this. Nonetheless, Hoffman acknowledges the basic inefficiency of this process. “Right now, individual therapists keep reinventing the wheel,” she says. “We need all the major therapy associations to do some screening and rating of apps, and get the results up on their websites.”

As more Americans use smartphones for mental health support, some clinicians will likely jump onto the app bus for business opportunities. In its 2016 report “Technology and the Future of Mental Health Treatment,” NIMH predicts that behavioral health apps will increasingly incorporate “face-to-face contact or remote counseling to provide a balance between technology and the ‘human touch.’” It’s already happening. Talkspace, which calls itself “the leading online therapy platform,” is offering psychotherapists the chance to earn “up to $3,000 per month” via counseling users by video, phone, and/or text messaging. Other apps offer similar moonlighting prospects, and more will inevitably arise. Of course, the possibilities for actually doing good therapy, at reasonable fees, will have to be determined by clinicians themselves.

Finally, some therapists may soon become cocreators of smartphone apps themselves. In a section of its recent report on mental health technology, NIMH urges therapists to join with app developers to provide everything a good app needs—an engaging digital interface dreamed up by a techie paired with the thoughtfulness and accuracy a clinician can provide. Once again, the American Psychiatric Association is off and running with this idea: its newly formed Collaboratory for Psychiatric App Development is encouraging clinicians to contact the committee if they have ideas for mental health apps and would like to get involved in creating them. These are not roles therapists customarily imagine themselves playing—app codeveloper, content consultant, smartphone savant. Not every clinician will get involved this way, of course. But some will, and perhaps sooner than we think.

What Apps Can Do—and What They Can’t

I now have 14 apps on my smartphone, and I find this new territory both enlivening and limited. Most of my experience has been positive, in part because I’ve chosen apps that have been subjected to at least some preliminary research. Some gains: I’ve managed to hold onto the belief that I don’t have to be a superhost (though I can still see my mother press her lips together at the mere idea of entertaining). On the creativity front, I’ve already made three simple collages. I’ve also stepped up and subscribed to Headspace, the mindfulness app. This daily timeout is restorative in itself, and it helps reinforce my two other app-fueled aims—to be easier on myself and to give myself some playful art time.

But my experience with mental health apps has been far from transformative. Mostly, they’ve worked as a space to brainstorm, a cheering committee for my goals. My self-awareness is a little sharper, my intention to make healthy shifts a bit stronger. But these apps are no proxy for face-to-face connection. To know that, all I have to do is imagine gazing at and talking with my husband, a good friend, one of my siblings, or the psychotherapist I recently worked with. For me, there’s no substitute—none at all—for the experience of sitting in a chair opposite someone who’s attuned, accepting, and utterly committed to helping me find a way forward. This in-person nourishment is the province and essence of therapy, and I value it beyond words.

As for smartphone apps, I’d call myself a cautious fan. They need tons of study, thoughtful evaluation and regulation, stringent privacy guarantees, and more. But to be fair, the app world is still in its infancy. By nature, infants are untidy and undisciplined—and also bursting with potential. There’s no telling how the app world will affect the mental health landscape in coming years, but clinicians may be able to influence that outcome. Maybe we can help this new kid on the block develop and mature. I think it deserves a chance to grow up.


Illustration © Oliver Burston/Getty Images

Marian Sandmaier

Marian Sandmaier is the author of two nonfiction books, Original Kin: The Search for Connection Among Adult Sisters and Brothers (Dutton-Penguin) and The Invisible Alcoholics: Women and Alcohol Abuse in America (McGraw-Hill). She is Features Editor at Psychotherapy Networker and has written for the New York Times Book Review, the Washington Post, and other publications. Sandmaier has discussed her work on the Oprah Winfrey Show, the Today Show, and NPR’s “All Things Considered” and “Fresh Air.” On several occasions, she has received recognition from the American Society of Journalists and Authors for magazine articles on psychology and behavior. Most recently, she won the ASJA first-person essay award for her article “Hanging Out with Dick Van Dyke” on her inconvenient attack of shyness while interviewing. You can learn more about her work at www.mariansandmaier.net.