Uber, But for the Mirror Stage: How Mental-Health Apps Are Changing Therapy

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Photo: Hulton Archive/(c) Hulton Archive

Getting into therapy is a big deal. You have to confront your own internal turmoil. You have to research therapists and counselors and group sessions. You have to budget the money to pay for it. You figure out if you’re a “chair” or a “couch” person.

Or — a set of investors, app developers, and doctors are hoping — you just download and fire up an app on your phone.

If we were to design therapy today, we’d think about using technology today — because therapy is laborious,” says Glen Moriarty. Moriarty is the founder of 7 Cups of Tea, one of the most prominent apps in a burgeoning industry referred to by a host of neologisms nearly as unappealing as SSRI trademarks: online therapy, “telehealth,” “e-therapy” (one imagines “iShrink” is around the corner).

Some resemble social networks: 7 Cups of Tea and Koko group you anonymously with volunteer listeners for a group discussion on how, what, and why you’re feeling. Others are virtual exercises that provide a supplement — or in some cases, even an alternative — to in-person counseling: Talkspace and Joyable connect you directly to coaches or therapists for text sessions, thought exercises, and 1-1 messaging. As Talkspace co-founder Roni Frank told CNN: “It’s like WhatsApp, with a therapist.” (Points, we suppose, for not going with the far easier “Uber for therapy.”) Some charge by the month or by the session. Others are free to download.

The first question everyone asks, of course, is: Do any of them actually work? Silicon Valley has a history of offering (literally) press-button “solutions” to problems whose sources are systemic and intractable. Mental-health therapy can be a rigorous and taxing experience — not least because the problems it’s meant to address are by definition deep-seated.

The short answer, as usual, is “it’s complicated.” For some people, a few texts exchanged with volunteers can actually mimic the same emotional development as you see from an IRL relationship with a counselor. An October 2015 study in the Journal of Mental Health reported users viewed the volunteer “emotional support” programs like 7 Cups of Tea as “genuine” displays of empathy.

Moriarty compared it to the Alcoholics Anonymous model — an addict receives help from other addicts, and then turns around to assist others in recovery. “You’re essentially paying careful attention, you’re practicing empathy,” Moriarty said. “You’re imagining, ‘If I was this person, what would I be thinking and feeling?’ and you try to say that back to that person. The curative thing in therapy is called the therapeutic alliance — it’s that process, of feeling like the therapist cares about you.”

But for people dealing with mental-health issues involving addiction or abuse or self-harm, an app can’t make up for in-person check-ins. As one doctor told the New York Times, “If I’m treating an alcoholic, I can’t smell his breath over Skype.” And the American Psychological Association is still developing guidelines to uniform telehealth practice across states, and not all insurance programs offer reimbursement for online services.

The one particular problem that over-the-internet therapy seems primed to solve is the question of access. Before she started work with Talkspace as a telehealth therapist and then head of Clinical Development, Nicole Amesbury was working in psychiatry practice, hospital counseling, and acute psychiatric care. “I saw the common problems that were keeping people from getting therapy,” she said. “Stigma, affordability, or they just couldn’t get to the clinic, they couldn’t stay long enough because of the cost.”

Dr. April Foreman has been studying text-message-based or technologically assisted therapy for much of her career. As a psychiatrist working in rural Kansas, Foreman encountered numerous patients who had to drive long distances to make their appointments. That made it hard for her to build relationships with new patients while continuing to work with existing patients.

More than half of the counties in America are entirely without mental-health professionals, according to the director of the National Institute of Mental Health. “It’s a luxury service to get to my office,” Foreman told me. “It assumes you have transportation, spare time, no competing problems you would have to solve — how to get gas, how to drive in rural Kansas for two hours — and that only works for people who have disposable income and cars that work and lots of spare time.”  

That’s also spare time on the part of the provider. With the demand for mental-health professionals on the rise, Dr. Foreman predicts the conventional model of visit-the-office, lie-on-the-couch therapy could actually hold clinicians back from helping as many patients as possible. “If we took every licensed mental health professional, and we employed them at the top of their license, full-time, and they did nothing but high-risk care for adults, they would have to see 50 to 60 patients a year,” she said. “That would be your whole caseload.”

That sounds a bit like the sharing economy’s promise (or threat) to make more efficient use of  your time — as an Uber driver, or Taskrabbit worker, say — and it’s true that mental health, as a field, is experiencing the same kind of disruptive pressure other industries are. As more and more psychology schools incorporate “wired” programming into their curriculums, and more and more therapy app ads flood Facebook feeds with online therapy, it’s becoming an option the psychology community has to embrace.

For some people, this is great. After previous experiences with a life coach who charged $100 to talk about relationship issues, Katie Hart Morse wanted an option that offered her more time, more affordability, and most important, more control of the conversation. She turned to Talkspace.

When I’m in a therapy session, you get bogged down on one topic when you really also wanted to talk about one topic,” she said. “And then you’re like, ‘Shit, there went 100 bucks.’ So for me, it was definitely being able to get all my thoughts out and I also think more bang for my buck.”

But a better question than “do therapy apps work?” might be “what would ‘work’ mean?” These new apps and online therapy services are making big promises — 7 Cups offers free compassion, Koko bills itself as “a social network that actually calms your mind,” and Therapy calls its program “therapy how we live today.” But none of them can eradicate the larger structural problems destroying the system: the high cost of help, the crippling sense of stigma, and the critical shortage of mental-health professionals in rural areas.

If anything, the idea of a quick-fix, app-based solution could undermine the case for rigorous, consistent therapy for the people who need it. In-person therapy involves time. The therapist gets to know the patient, and gets to know the kind of therapy the patient prefers. The patient also needs time: time to warm up to the therapist, time to vocalize an issue or problem. And, even more important, time off from work and life to get to and from therapy appointments on a weekly basis.

But also the time to feel better. Online and off.