The Therapy-App Fantasy
What can you really expect when your therapist is in the palm of your hand?
the summer of 2020, recalls Hillary Schieve, was hard. The pandemic was bearing down across the country, protests over racial injustice were erupting, and her sister’s breast cancer had become terminal. Schieve moved her sister into her house to take care of her; at night, she would watch the news and wonder how she was going to keep it together. Then her sister died, and a few weeks later, Schieve’s brother unexpectedly died too.
“When my brother died,” she said, “that’s when I fell apart.” She was having anxiety attacks; she was crying all the time. She wanted to find a therapist to talk to, so she started making calls but no one could fit her in for weeks. She was frustrated and unsure of what to do next. “I’m sitting at my counter, and a commercial comes on with Michael Phelps,” she remembered. It was an ad for the therapy app Talkspace. “I was like, I don’t know, maybe I should try that.”
Talkspace is part of a growing field of services that promise mental-health care via smartphone. And unlike many of the problems tech start-ups have set out to solve, this one actually exists: It’s hard to find a therapist. Maybe you have insurance, so you look up a list of in-network providers, start cold-calling, and hope to reach someone with an opening. Maybe you ask for recommendations from friends and hope someone they know takes your insurance or has out-of-pocket rates you can afford. Maybe you don’t know anybody with a therapist and the prospect of getting one yourself seems risky or shameful. Maybe you don’t know anyone with a therapist because there aren’t any therapists around to see—approximately 33 percent of counties have no records of licensed psychologists.
Geographic distribution is just one of the ways the mentalhealth profession fails to match the people in need of care: Doing so would also require more therapists who speak Spanish, more therapists of color, more therapists with LGBTQ expertise. Even in a therapist-rich environment like New York City, intangibles intervene. How do you find someone to whom you feel comfortable saying things you may feel uncomfortable saying at all? People seeking therapy face all these challenges even in the best of times, and these are not the best of times. According to a CDC report released last summer, 40 percent of American adults were dealing with mental-health or substance-abuse issues in late June, with younger adults, people of color, essential workers, and unpaid caregivers disproportionately hard-hit.
Therapists have long faced the question of how to provide their care to more people without diminishing its quality. In 1918, amid the catastrophe of the First World War, Sigmund Freud gave a lecture in which he proposed using free clinics for mass mentalhealth care—even as he acknowledged that doing so might require his fellow psychoanalysts to “alloy the pure gold” of their usual methods. “We’ve been in a crisis of access to mental-health care really since mental-health care professionalized,” said Hannah Zeavin, a professor at UC Berkeley whose forthcoming book, The Distance Cure, traces the history of remote therapy from Freud’s letters to crisis hotlines and up through today’s apps.
Accelerated by the pandemic, Zeavin’s subject has gone from an academic curiosity to a growth sector. Businesses in the “digital behavioral health” space raised $1.8 billion in venture-capital funding last year, compared to $609 million in 2019. In January, Talkspace announced plans to go public this year in a $1.4 billion spac deal. A presentation for investors managed to be simultaneously grim and upbeat in outlining the “enormous” market for its services: More than 70 million Americans suffer from mental illness, according to Talkspace, and the country has seen a 30 percent increase in the annual suicide rate since 2001. Talkspace says 60 percent of its users are in therapy for the first time.
Hillary Schieve, meanwhile, is not only one of the many Americans who have confronted mental-health concerns in the past year; she is also the mayor of Reno, Nevada. She knew plenty of other people in Reno were suffering from anxiety, depression, or grief. “Oh my God, if there’s one thing I could give as a gift to people in my city, it would be free therapy,” Schieve remembers thinking. “How do I do this?” Citywide therapy turned out to be one of the political fantasies the pandemic had brought within reach. After Schieve made her case before the City Council at a Zoom meeting in early December, the councilmembers voted unanimously to approve a contract for $1.3 million in cares Act funding: In 2021, all Reno residents over the age of 13 would have free access to Talkspace.
“We think the city of Reno has been really at the bleeding edge,” said Talkspace president Mark Hirschhorn. The martial spirit of corporate jargon is an uneasy match with care work. Even as pandemic news takes on a tentative note of hope, Talkspace foresees a longer-lasting shift in behavior, which bodes well for its business. “There is no vaccine for grief,” Hirschhorn said.
THERAPY EXISTS WHERE the placebo effect meets self-help meets a confession booth. I say this as someone who has been in and out of therapy for something approaching 30 years. Where would I be without therapy? I can’t know. Has it helped? I hope so.
When I was very young, the main solution I knew for what I would now call anxiety was to reserve all distressing thoughts I experienced in the course of the day and disgorge them to my mother before bed. I dreaded doing this, but it seemed to work. So probably I was favorably inclined to the idea of someone to talk to. The primary job of the therapists I’ve seen since then has been to notice what I didn’t. They told me if the things I was saying were cause for alarm or resembled other things I had said before or were otherwise revealing. The most effective tool I had acquired was Lexapro, which, after more than a decade, I chose to stop taking at the beginning of March 2020. A few weeks later—cruising on the adrenaline of a crisis in progress, wondering whether my husband was about to lose his livelihood—I decided I no longer needed therapy, either.
I remember my thought process here as matter-of-fact: My insurance had changed, then the world had shut down. The remote alternative to in-person therapy felt somehow flimsy. When I spoke to my therapist on the phone, I found myself in the conversational register of efficient factual updates; the ritual of going to a particular place at a particular time seemed to be what allowed me to escape the gravitational pull of small talk. Or so I thought. Within a few months, I discovered desperation would also do the trick. This was a discovery I was making at the same time as many other people. Prior to the pandemic, remote therapy—speaking to a therapist by video or phone— tended to be seen as better than nothing, a solution for limited situations. But then all therapy went remote, and, as I found when I began video sessions last summer, it was indeed better than nothing. (There were certain advantages, in fact: For the first time, I was reliably not late.)
Meanwhile, as the conventional therapy world adapted to this changed reality, the growing field of therapy apps had an opening to press its case. The customer demographic coveted by direct-to-consumer start-ups was now conducting its work life over Zoom, buying its groceries over Amazon Prime—why shouldn’t this logic apply to therapy? The tides of commerce
“Meet your matches,” Talkspace told me. “We’ve prioritized female providers who specialize in anxiety.” Beneath this message were three men.
are not new to the realm of mental health. In fact, the blurriness of categories like “wellness” and “self-care” can call to mind the 19th century, a time before psychotherapy had professionalized in any widespread way, when Americans turned to a teeming marketplace to treat their inchoate ills with tonics, phrenology, and rest cures. In the 20th century, the medical profession consolidated its authority over Americans’ mental well-being. Physicians did their best to run the less credentialed out of the marketplace, and psychoanalysis became the gold standard of expertise. This development gave a lasting shape to therapy in the popular imagination: a couch, your parents, your dreams, a cigar—the shorthand endures, even if almost no one is in analysis anymore.
By the end of the century, rival schools had emerged, including, most notably, cognitive behavioral therapy. Where psychoanalysis sought to plumb the depths of the past, CBT focused on present symptoms and quantified results. The goal was not to understand why you felt and thought what you did but to stop those thoughts and feelings from disrupting your life. Instead of a narrative, CBT produced data, with patients scored on symptom inventories for conditions like depression and anxiety. Data lent itself to clinical trials and scientific legitimacy; data (along with treatments that lasted weeks, not years) appealed to insurance companies. Today, in a therapist’s office, patients are more likely to encounter the principles of CBT than of Freud.
The British writer and psychoanalyst Adam Phillips reflected on this shift with some skepticism in 2006. “It would clearly be naïve for psychotherapists to turn a blind eye to science, or to be ‘against’ scientific methodology,” he wrote. “But the attempt to present psychotherapy as a hard science is merely an attempt to make it a convincing competitor in the marketplace. It is a sign, in other words, of a misguided wish to make psychotherapy both respectable and servile to the very consumerism it is supposed to help people deal with.” (Psychotherapy, he points out, emerges historically just as “traditional societies begin to break down and consumer capitalism begins to take hold.”)
The market-friendly mind-set that may worry a psychoanalyst beguiles a tech-company founder. And understanding psychotherapy in this way—as a matter of prescribed interventions and measurable results—makes it possible to imagine technological alternatives in the first place. An approach like CBT is “very friendly to computational modeling,” Zeavin, the Berkeley historian, explained; its practitioners already embrace manuals and workbooks.
Much of what appears if you search “therapy” in the App Store does not provide the services of a human therapist. Some of it does not address mental health at all, in the strict sense: It is the digital equivalent of a scented candle, wafting off into coloring apps and relaxation games. Many services occupy an area somewhere in between professional care and smartphone self-soothing. Reflectly, for example, bills itself as “the World’s First Intelligent Journal” and promises to use the principles of positive psychology, mindfulness, and cognitive behavioral therapy to help users track their moods and “invest in” self-care. “Just like a therapist!! But free!!” reads one review. (Reflectly costs $9.99 a month.) Sayana, an AI chatbot, is personified as a pastel illustration with a dark bob and cutoff jeans; she also tracks the user’s mood and offers tips (“Observe your thoughts as they flow, just like the river”) to guide users on a journey through “the world of you.” “This is like your own little therapist and I love it!” reads one five-star review. Youper (mood tracking, chatbot, lessons) sells “Self-Guided Therapy”; Bloom (mood tracking, chatbot, lessons) is “the world’s first digital therapist.”
But chatbots and mood scores aren’t generally what people are imagining when they say, for example, that their ex needs therapy. “Therapy” here conjures an intervention to fix the personality and save the soul. Different people want different things from therapy. They want to break bad habits, work through trauma, vent about their boss, their boyfriend, their mom. They want to feel better (always easier said than done). They want someone to talk to, and they want some tools. When I resumed seeing my longtime therapist over video, I wanted her to tell me whether the problem was my brain or the pandemic—I needed someone I trusted to judge the situation. That is to say, I wasn’t sure what I needed, but I wanted the help of someone who knew better. And this—expert counsel in the palm of your hand—is what the high end of an emerging class of therapy apps claims to deliver.
“In 2021, mental health is finally cool,” declares a podcast ad for BetterHelp, one of the apps promising access to trained therapists that has promoted itself to consumers most aggressively. “But therapy doesn’t have to be just sitting around talking about feelings. Therapy can be whatever you want it to be.”
With a therapy app, more blatantly than in most health-care transactions, the patient is a customer, and the customer is always right. But this assumes patients know what they want and need and that getting it will make them feel better. These are not expectations most therapists would necessarily share—nor are they ones therapy apps are reliably prepared to fulfill.
THE FORWARD MARCH of app-based progress has generally meant finding ways to speak to other people less, whether seeking takeout, a ride, or a date. Although this may seem like a strange mandate to bring to talk therapy, the first steps of seeking a therapist—sifting through referrals, leaving hit-ormiss voice-mails—are not experiences that make you cherish the complexities of human connection. On the Talkspace website, I completed an intake questionnaire (I’d prefer a female therapist, I felt somewhat anxious, I was sleeping well enough, I wasn’t considering self-harm) and watched as the kind of animation intended to convey a website’s diligent labor whirred away. Headshots cycled above a gradually completing checklist. “Calculating profile …” it read. “Searching for matches … Analyzing matches … Returning best matches …” And then, my results: “Meet your matches,” Talkspace told me. “We’ve prioritized female providers who specialize in anxiety.” Beneath this message were three men.
A D.C.-area Talkspace user named Cait remembered getting off to a more auspicious start. “I was so excited because they give you all these therapists,” she said. “It was almost like a dating app.” Cait had signed up for the service after talking to a satisfied friend with a supportive Talkspace therapist who texted her all the time. Cait had recently started medication for depression; it helped, but she wanted to speak with someone regularly, and even with her insurance, she was worried about cost. She saw that Talkspace was offering a New Year’s deal at the beginning of 2021. If she used that and paid for six months up front, she could get half a year of therapy for $700. This seemed to her like quite a deal—far cheaper than paying out of pocket for conventional therapy but also far cheaper than what Talkspace might otherwise have been. While mood trackers and mindfulness apps can cost $10 or $15 a month, therapy apps like Talkspace, BetterHelp, Brightside, and Calmerry—ones that connect users to an actual licensed human therapist—cost hundreds of dollars. Without discounts (or subscribing for months at a time), a one-month Talkspace plan that includes weekly video sessions runs nearly $400. Particularly because the standard length of these visits is just 30 minutes, users are paying hourly rates that can approach those of in-person care.
Of course, many users aren’t paying out of pocket because, for many apps, users aren’t the customer at all. These apps, like Ginger and Lyra, focus on selling their services to employers or insurance companies. For an institutional client, a therapy app checks the box of providing mental-health care. It also addresses employees’
unhappiness and stress without requiring any change to their actual work. Although Talkspace built its business marketing directly to consumers (their ads were, for a time, ubiquitous on the New York City subway), the company is now pursuing institutional clients as well—like employers or the City of Reno. My own workplace began offering Ginger last year; this year, it added Talkspace as an in-network provider on our insurance plan.
Bob, who works at a cybersecurity firm in Massachusetts, decided to try Talkspace after his employer started offering it as a benefit. He wanted help with anxiety, but he wasn’t sure about therapy. “It’s still that cliché thing, but it’s very true,” he said. “Most guys don’t talk about things, ever.” Talkspace seemed more approachable—he had heard ads on the podcasts he listened to—and besides, it was free. After submitting his questionnaire, he was surprised to see that none of his top matches had any availability for the next three weeks. Beyond that, he had no access to their schedules. His office’s plan included one video visit a month; now he wasn’t sure if he would even get a chance to use it. He decided to message the first match anyway. The therapist wrote back and told Bob that he currently had 210 clients in his Talkspace caseload—so, yes, he was unavailable. (Talkspace calls this “impossible” and says no therapist on the platform has an “active caseload” of that size.)
It took Cait longer to run into problems. After meeting with her first match and messaging for a couple of weeks, she wasn’t sure she had found the right fit. She wanted to find someone more suited to her, a practice Talkspace encourages. “The relationship drives outcomes,” said Neil Leibowitz, a psychiatrist and the chief medical officer at Talkspace. “We’re pretty big on giving people the choice of therapists that they like, and if they don’t like their therapist, they should switch.” The second therapist Cait was paired with didn’t respond, so after four more days, she moved on again. She exchanged a few messages with a third therapist, but the woman never followed up after Cait asked when they could schedule. At this point, she had been on the app for a month and had only a ten-minute introductory session. When she contacted customer service, a rep agreed to a few weeks’ worth of a refund (and assured her that she should be hearing from a therapist daily, five days a week), then paired her with a fourth therapist. Cait was excited about this one—when she explained that she’d had trouble finding someone who communicated regularly, her new therapist said she checked messages even on her off days. That was the last Cait heard from her. This time, customer service told her Talkspace was experiencing high demand as a result of the pandemic and offered to put her account on hold. (Talkspace says that experiences like this are “rare” and that the company works with clients who have an unresponsive therapist to find a new one.)
What had begun with a sense of bounty evocative of dating apps ended with a sense of frustrated disconnection evocative of dating apps. Like Tinder, a therapy app serves up a tantalizing array of faces and names with the promise of choice and agency. But even if some users get lucky, a satisfying relationship is hardly guaranteed.
AS ON A DATING APP, the therapy-app experience begins with texting: It is the staple of lower-priced plans; live video sessions tend to be added at a premium. Talkspace’s “Unlimited Messaging Therapy™” allows users to message their therapist “24/7,” sending text, audio, or video messages as they choose. The company is staunch in its commitment to describing this service as 24/7, although therapists are expected to respond only once a day, five days a week. (“It’s not 24/7 therapy; it’s 24/7 ability to communicate,” the company’s director of clinical effectiveness told the New York Times last year.) The experience is something like email—an asynchronous exchange of responses as opposed to an in-themoment conversation—though some services, like BetterHelp and Ginger, allow users to schedule live text chats.
Text messaging is perhaps the boldest innovation the therapy apps offer—from the standpoint of therapy, if not technology. It is the mechanism by which the apps attempt to widen a single therapist’s reach. And it appeals to many customers, too. The privacy-starved can text without anyone overhearing; the socially anxious can communicate without facing a stranger; people who are new to therapy can get their feet wet in a low-stakes way. When Hillary Schieve found her way to Talkspace after seeing that Michael Phelps ad, the texting (even as an email-like experience) was part of what she liked. After spending hours in City Council meetings on Zoom, it was nice not to be on-camera anymore. The person on the other end didn’t even have to know she was a mayor. The last time she had sought therapy, a few years before, the therapist kept wanting to talk politics; this time, secure in her anonymity, “I felt like I could be so open and honest,” she said.
Asynchronous texting is also a fundamental shift in the way therapists do their work. “As a therapist, all of your training is about how to have this conversation in the moment,” said Albert Thrower, a therapist on BetterHelp. “All of your skills and techniques are based around the idea that you are having a conversation.” Thrower joined BetterHelp after moving out of state so his partner could go to graduate school. Some of his clients said they had trouble putting their feelings into words—they liked having time to write things out, and Thrower appreciated the novel experience of taking time to sit with what they had written. It felt like writing letters. But it was harder to steer a conversation via text; clients would pick and choose what they responded to. And the long missives that evolved out of point-by-point replies to clients’ messages could become unwieldy as exchanges went on. Over time, he noticed that his textonly clients seemed not to be making as much progress as the ones he talked to on the phone.
An anonymous former BetterHelp therapist in Virginia said she noticed similar delays. Normally, it took her two or three in-person sessions to establish a baseline sense of trust and rapport, but over text, the process dragged on; there was no way to gauge body language or tone or to use pauses and silence to draw someone out. The difference might have had to do with the patients who were inclined to choose texting in the first place, she acknowledged. “I would rather a person do text-only therapy than not get the help they need at all,” she said. Still, it was a challenge as a clinician. She experienced the challenges of text therapy as a client when BetterHelp began offering its free service to its therapists. After sending an initial message to one therapist, introducing herself and what she was dealing with, she received “a very long—very long—very clearly copy-andpasted” response titled “What Is Depression?” It was followed shortly thereafter by “What Is Anxiety?” and “What Is Grief?” “Did you even read my message?” she remembers replying. “I’m a therapist. I know what depression and anxiety are.”
Over text, Cait unwound long monologues to her first Talkspace therapist, describing her past and her relationship problems, to which he did or did not reply. “Is there a method you recommend for how this goes to direct things and not just have this platform be like a weird journal into the universe?” she asked at one point. The answer, evidently, was no: He didn’t reply. His responses were sporadic and could include sensitive questions Cait found unnervingly abrupt. Mutual understanding seemed to elude them even on a basic mechanical level. After a Talkspace user sends a message, a button appears that says, “Let [your therapist] know you’re ready for them to reply”; this is the Guaranteed Response Time feature, which gives users an estimated window if they want to know when they can expect a reply. Cait thought she was supposed to hit the button to send each message. Her therapist said that he was receiving her messages already and that pushing the button made his
notifications pile up. It took a while for the two of them to sort this out or even to determine which buttons they were each talking about.
John Torous, a psychiatrist with a background in engineering, is the director of digital psychiatry at Beth
Israel Deaconess Medical Center and leads the American Psychiatric Association’s Health IT Committee; his work focuses on mobile mental-health technology. At this point, Torous says, the research on text therapy is very limited. A 2019 study showed “marginal evidence” to support text messaging as a treatment approach for depression and concluded that more research was needed. But in the context of therapy apps, texting is less a specific, coherent treatment regimen—the kind of protocol it may be possible to control and test—than a new attitude toward therapy altogether. Texting is what allows the fantasy of constant access.
Therapy-app users describe experiencing frustration when two or three days pass without a reply. Two or three days would not otherwise seem like an inappropriate wait time for what is essentially a nonemergency email. But the service they have been sold— and for which they’ve paid handsomely—promises something more, whatever the fine print about “five days a week.” Typical therapy-app promotional materials show texting in progress, with a therapist replying as soon as a message comes in. (An animated exchange from the Ginger website: “3:12 a.m. I’m having trouble sleeping.” “3:13 a.m. What’s on your mind?”) Leibowitz, the Talkspace chief medical officer, said the company encourages therapists to establish clear expectations with clients around communication, but doing this essentially means backtracking on the sales pitch. “They leave it to you to tell every client individually what your boundaries are,” said Alice Bentley, a therapist in Georgia who has practiced through both Talkspace and BetterHelp. “That is not fun,” especially when a client has just paid hundreds of dollars up front.
“It isn’t possible to sustain,” said Claire Lawrance, a therapist in Montana, of 24/7 therapy. “It’s a human on the other end of the app.” Lawrance saw clients through BetterHelp from 2019 to 2020 while she was working to build a new practice. The services all include disclaimers stressing that they aren’t appropriate for true psychiatric crises, but Lawrance found that difficulties arose on a more quotidian level. “I went through a breakup, it’s Sunday night, let me text my therapist while I’m on the couch with my ice cream— there is an expectation, I think, that therapists were available at that level of crisis, and that doesn’t foster good self-care and boundaries for clinicians, which doesn’t create good mental-health care.”
ONCE A MATCH HAS been made, once texts have been exchanged, a therapy-app user may at last find themselves face-to-face with a therapist. Video chat is the nearest substitute for an in-person session, the research to support its efficacy is robust, and—if you’re not too tired of staring directly into video-conferenced faces all day— the experience is pretty much fine. Peeking inside one another’s homes can be an unexpectedly intimate encounter. “I met people’s pets; people met my dog,” Lawrance said. “There’s a different human quality that I don’t quite have a word for.” One therapist told me about a client who had worked out a kind of ritual for remote therapy; she would light candles and play music so her roommates couldn’t overhear. Other clinicians were warier of domestic distractions. A former BetterHelp therapist in California remembers seeing one patient who folded laundry throughout their session. “It’s a less committed form of therapy,” he said, “less committed on both sides.” In his view, this difference in commitment had something to do with the structure of their transaction. Generally speaking, therapy apps are subscriptions; users pay to join and, as with a gym membership, often keep paying even if the service goes unused.
Names of clients they have barely met can linger on therapists’ caseloads as the company continues collecting its fee.
For therapists, the logic of compensation is more complicated. Instead of an hourly rate, the payment structures of the platforms attempt to quantify relationships that sprawl across media and time. In the past, Talkspace has said it pays therapists based on “engagement”; the company now says it uses multiple payment structures. BetterHelp uses an opaque formula that involves converting words (of texts exchanged) and minutes (of live interaction) into dollars. Thrower said he started tracking his work in a spreadsheet to figure out the hourly rates he was actually making; he topped out around $30 an hour, with a lot of time spent in the low $20s ($30 was the rough estimate most BetterHelp therapists I spoke to offered for their pay per session). Bentley joined BetterHelp in late 2016; that first December, she remembers working constantly, sending messages even on Christmas Day. It would be her highest-earning month ever on the app: She made $1,900. A typical full-time caseload for an offline therapist in private practice may be between 25 and 30 clients. At her peak on BetterHelp, Bentley had up to 55, although not all of them regularly showed up. Meanwhile, on Talkspace, she was seeing ten to 15 clients; she said of her monthly pay, “If I hit $1,000, I was doing great.” Insurance-reimbursement rates for an offline therapy session vary by region and insurer, but Bentley said the range in her area is between $70 and $120.
Comparing these figures raises the question of why therapists would choose to work with a service like Talkspace or BetterHelp at all. Many said they had come to the apps in moments of transition: Lawrance and Thrower were relocating, Bentley was moving from an institutional job into private practice, and others are juggling multiple jobs or child care. “I had the maximum amount that I could keep up with timewise, and it still wasn’t paying the bills,” Lawrance said. She had around 40 clients on her BetterHelp caseload. “You’ve got to make it sustainable for the people providing these services if you want to keep providing them.” Lawrance said she wished therapy apps could increase access to mental-health care; working as a therapist in the oil fields of North Dakota, she had seen the obstacles of scarcity and distance firsthand. But on the apps, as in the wider world, the sheer scale of demand seemed impossibly vast.
“The thing about BetterHelp is whenever you turn on the ‘Give me more clients’ button, you are going to get more clients. You’re going get as many clients as you possibly want. It’s like one of those Brazilian steakhouses,” Thrower said. “You flip the card this way, we’re just gonna keep coming with the meat.” Some therapists describe BetterHelp sending them new clients even after they had indicated their practices were already full.
The underlying problem of access—the fact that there simply aren’t as many therapists as there are people who need therapy— has not been solved by therapy apps so much as papered over. Dissatisfied therapy-app users sometimes speculate online that the services are scripted, being used to (Continued on page 100)
A former BetterHelp therapist in California remembers seeing one patient who folded laundry throughout their session. “It’s a less committed form of therapy.”