\Healthtech Analysis/

Is the “wild west” of online chat therapy doing more harm than good?

US-based ‘chat’ therapy services are dominating the global online therapy market, but there are doubts about their effectiveness.

By Simon Dumont

Like many people this year, Adriàn, who works in marketing at a tech company, has felt the weight of Covid-19 on his mental health.

“The company I was working for sold their New York office,” said Adriàn. “So I knew I had to move back to Europe. But Covid-19 was happening. There were just too many things going on.”

After some initial hesitation, Adriàn signed up for online therapy with TalkSpace, a leading US-based mental health startup with more than 1m users. While its premium plans do offer some video calls with therapists, TalkSpace specialises in therapy via text message. Its website claims that TalkSpace’s methods are more convenient than traditional therapy and just as effective, if not more.

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As it was Adriàn’s first time trying therapy, he didn’t really know what to expect. But after a few weeks, he felt like texting a therapist wasn’t really helping. If anything, it was adding to his mental health struggles.

“It was so much work to explain myself. It could be a good 30 minutes per day of writing, re-reading, then going back to working, then writing to my therapist again,” he explains. “I needed therapy because there was so much going on, but now I had this additional task to do. It was too much.”

“I felt like the advice never got very deep.”

The messages he received didn’t help matters, either. Adriàn always had to wait at least a few hours for a response. When it came, it was often generic and impersonal. “I felt like the advice never got very deep,” said Adriàn. “It was surface level.” 

Eventually, Adriàn switched to therapy via video call with another service, which he finds “more meaningful” and continues to attend. But his story is not unique.

The “wild west”

Sifted heard from numerous people who had similar chat therapy experiences with TalkSpace or Betterhelp, the other major US-based player in the online therapy market. 

While Betterhelp offers a mix of video calls and chat for a flat monthly subscription fee, one user, who preferred not to be named, told us that because her schedule clashed with her therapist’s, she ended up mostly paying for chat therapy — which made her anxiety worse.

Mental health startups have been booming during a pandemic that’s left people with declining mental wellbeing and no way to access traditional in-person therapy. Many have found online therapy to be a life-saver.

But for people who want to try therapy for the first time, the internet can be a minefield. The potential differences in effectiveness between in-person, video call, and chat therapy are rarely mentioned on most online therapy websites, despite the lack of solid research on the latter. 

Psychologist Maite Otero, who specialises in treating trauma, says that while therapy via text message is “doable,” it means therapists have to “do much more with much less,” which can make it harder to achieve meaningful results.

“Sometimes there’s misalignment between what we say and how we express it… body language gives you a lot of rich information.”

“Sometimes there’s misalignment between what we say and how we express it. When you’re looking at someone, their body language gives you a lot of rich information. With therapy through text, you don’t have that data source.”

And while others believe that therapy via text message can work very well for the right people, the lack of quality control is a major worry. “It’s the wild west out there,” says Kate Anthony, CEO of the Online Therapy Institute. “There’s no regulation of internet therapists.”

In Anthony’s opinion, the problem is simple: “It comes down to whether the company is client-led or money-led. The big American companies are looking for low-hanging fruit —the highest number of clients for the maximum money.” 

TalkSpace told Sifted that that research studies on the effectiveness of its online therapy platform have been published in numerous peer-reviewed journals. The company said that its therapists receive training and onboarding on the platform, and regularly conduct peer review and audits of their therapists.

Asked for comment, Betterhelp said that while the availability of its therapists varies, the mode of communication is entirely the client’s choice and they are able to easily switch to a different provider. It also said the effectiveness of text message therapy has been proven by their own experience and data, which is based on over a million people who used platform and validated by peer-reviewed studies.

Still, as demand for online therapy continues to sky-rocket and amid ongoing worries about chat therapy there have been a raft of European and international tech startups going against the grain of chat solutions and focusing on face-to-face online therapy.

“Meaningful” online therapy

After running her own practice for over 15 years, Covid-19 made therapist Ginnette Muñoz realise that online therapy is the future. “I serve others. And if the people who need me are online, I have to be there.”

So earlier this year, Muñoz became clinical lead of Oliva, a Barcelona-based online therapy startup, which operates in a similar space to startups such as My Online Therapy in the UK.

Founded in summer 2020, Oliva claims to offer “meaningful online therapy,” with a focus on personalised care, experienced therapists, and evidence-based techniques. This means delivering all their therapy via one-hour video calls — no chat therapy.

Therapy as on-demand, 24-7 chat risks stopping people from developing tools to handle their discomfort in the moment.”

Muñoz believes focused sessions talking with an experienced professional, followed by down-time to reflect between sessions, is key to clients’ progress. “You need the time between sessions to structure your feelings and think. Therapy as on-demand, 24-7 chat risks stopping people from developing tools to handle their discomfort in the moment.”

Of course, some people do find texting a therapist helpful, which Muñoz acknowledges. But she also believes online services should be more up-front about what they’re offering: “If organised in a focused way, chat therapy could be useful in specific cases. But we have to be very honest about which cases, how it will work, etc. People shouldn’t believe something will be effective for them when it won’t be.”

Anthony agrees that “clarity is everything in online work.” But she’s also a firm believer that the variety of approaches possible is a strength of online therapy, rather than a limitation — text messaging included.

“The appeal of written work is strong for many people. Narrative therapy and journaling come to the forefront during this process. Having a therapist encouraging you to write can reveal some really interesting aspects of yourself.”

For Anthony, chat therapy isn’t the problem — it’s that therapists aren’t trained on when and how to deliver it. As CEO of the Online Therapy Institute, she saw this problem coming when Covid-19 lockdowns began in March: “I realised that everyone was going to leap online. The ethics and legality are a minefield.”

So Anthony created a quick one-day course to train therapists how to give therapy online in various ways, including video calls, phone calls, and messaging. Since March, over 13,000 therapists have taken her course. Anthony has also helped set up a new UK-based online therapy platform that prioritises training its therapists for online work: ProblemShared.

“Find someone who’s done extra training to work online.”

Her advice for people searching online for a therapist? “Find someone who’s done extra training to work online. Whether it’s video, text, or telephone, if they’re trained it’s going to make everything much smoother, both for the client and the therapist.”

One thing’s for sure: with more and more people turning to the internet for mental health services, this is a unique moment for European startups to disrupt the online therapy space with a more client-centric approach — chat therapy or no chat therapy.

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