The rise of Counselling Apps - could they ever replace Face-to-Face therapy?
It’s no surprise that with NHS therapy waiting lists of up to two years, more of us are turning to digital healthcare. Last year, the NHS referred 1.4 million people to talking therapies such as counselling or cognitive behavioural therapy (CBT); 965,000 people actually began treatment, leaving over half a million still waiting. Twelve per cent of those referred waited longer than five months to see a counsellor. The situation is so unmanageable that the NHS website itself suggests that people in need of mental healthcare look into going private. Whatever the reason – political turmoil, young people feeling isolated at university, increase in hate crime – mental illness is on the rise, and people are seeking alternative sources of treatment where the government is failing to provide.
It’s against this backdrop that apps like BetterHelp and Talkspace are starting to appear on your Instagram feed, claiming they can “save” you, with big name ambassadors like Michael Phelps. There are several apps on the market that connect people to licensed therapists (for a fee, of course), and they’ve been growing in popularity over the last few years. Talkspace and BetterHelp are two of the largest, providing access to counsellors for text-based conversations, or phone/video calls. These apps are still fairly new in the world of mental health treatment, and they’re pretty controversial – some medical professionals have argued that there is not enough research to support the use of online therapy, which they believe to be less effective than face-to-face treatment.
Talkspace, an app with over a million active users, is US-based, but is increasingly popular in the UK and around the world. This app has become so integral to some people’s lives that it will soon be able to prescribe medications to its users – it could become the sole source of mental health treatment for millions globally. As convenient as this could be, it’s also kind of concerning.
Should we be comfortable relying fully on an app as a healthcare provider?
Though in practice they may be controversial, the concept of therapy apps has been a long time coming. For years, people have looked online for mental health information and support, whether that was because of a fear of stigma or lack of local resources. This is proven by the prevalence of websites like Muttr, where you can rant anonymously, 7 Cups which connects you to volunteer ‘listeners’ and trained therapists, and Pixel Thoughts, which allows you to type negative thoughts into a box and watch them disappear. These, along with the success of meditation apps like Headspace, have normalised the process of accessing mental healthcare online. It’s natural that people feel more comfortable now sharing their innermost thoughts and worries online than they do face-to-face. Unsurprisingly, most of Talkspace’s users fall into the mid 20s-30s bracket.
When I signed up to BetterHelp to test it out, I noticed that they included ‘non-binary’ as one of their gender options. Betterhelp’s therapy experience was more customisable than Talkspace’s: you could ask for a therapist who is sensitive to different faiths, or who identifies as a woman or LGBT+. You can also select therapist specialties, including ‘LGBT-related issues’, ‘trauma and abuse’, or ‘eating disorders’. When accessing therapy through the NHS, it’s very much a get-what-you’re-given situation – there is little, if any, option to ‘shop’ for the right therapist, or to ensure that your therapist will be understanding of your specific background or identities.
With Talkspace, you’re immediately assigned to a real person to chat to who’ll assess your needs. You give your details and explain why you want therapy. After chatting for a few minutes, you are told about the different payment plans, and from there, once you’ve paid, you’ll get to speak to an appropriate therapist. On the other hand, BetterHelp starts you off with a questionnaire about yourself and the problems you’re facing, before quickly assigning you a named therapist, who introduces themselves and starts a conversation. You have to make your first payment before you can reply, but it’s sort of comforting to see the face of the person you’re committing to talk to.
Courtney Brooke Davis, a Talkspace user of ten months, said having an online therapist has meant she can keep appointments when travelling for work. (Touring DJ The Black Madonna also recently wrote for Dazed about the benefits of having a CBT app she can use while she’s on the road for work.) Courtney said, “The big positive for me was getting diagnosed as having borderline personality disorder, which was something I had already suspected, but was relieved to get an actual diagnosis on”. She acknowledged that she’s been “lucky” with her assigned Talkspace therapist as some would refuse to work with personality disorders. On Talkspace’s Twitter, they emphasise that they have licensed therapists with a range of specialities, including training in dialectical behavioural therapy (DBT), the standard treatment for borderline personality disorder. Courtney occasionally sees a therapist offline, but only to be prescribed medication (which Talkspace will soon cover too). She plans to continue using Talkspace indefinitely.
“Talkspace just felt like a glorified expensive chatbot with some rigid predefined ‘mental healthcare’ answers and a vaguely antagonistic attitude”
However, Patrice Peck, a former Talkspace user, feels that these apps just don’t measure up. She downloaded Talkspace based on an endorsement from her favourite podcast hosts, Crissle and Kid Fury ofThe Read. As a black woman, Patrice was keen to find a therapist that had some understanding of “race, sexuality, and social justice”. The first therapist she was assigned failed on this front. Patrice said “our conversation waved a bunch of red flags in my face, and because I was gonna be doing the premium package, which costs about $400, I didn't wanna have any reservations or concerns.” She was next matched up with a younger black woman who she got along with really well. Unfortunately, Patrice felt “our dynamic seemed to be more like talking to a really supportive and encouraging friend, which isn't what I was looking for with therapy” – she was seeking a “goal-oriented” form of therapy like CBT, and didn’t feel the app could offer this. After quitting Talkspace and starting face-to-face CBT, Patrice also recognised that she was “more mentally present” when “physically present” rather than virtually.
33-year-old Fisher was one of the earlier users of therapy apps, having signed up for Talkspace in 2015. He joined out of desperation, despite a therapist friend telling him it was a “bad idea”. Fisher immediately felt that conversations with a Talkspace therapist were too similar to a “chatbot” and that their conversations existed in “some weird grey area between telesales and therapy”. When he challenged the more “impersonal” attitudes of the therapists, they would pass him on to someone else. Fisher says that after his experience with Talkspace, he quit therapy apps and doesn’t plan to go back. Though he sees the possible benefits of them, he argued there is “no comparison” with face-to-face therapies, and that there is “more measurable therapeutic value” to sharing anonymously online with “like-minded” people going through similar troubles to you. When asked about his final impression of therapy apps, Fisher said: “Talkspace just felt like a glorified expensive chatbot with some rigid predefined ‘mental healthcare’ answers and a vaguely antagonistic attitude that was like ‘talk to us about how you feel but not if it's too serious.’”
Chartered psychologist Dr. Jerry Kennard is one of a few professionals speaking out against therapy apps. Dr. Kennard lives and works in York, an area that has recently struggled with NHS funding for mental health. He believes “apps have their place for relatively simple tasks such as relaxation or even some cognitive treatments”, but can’t compare to the experience of working with a professional face-to-face. Dr. Kennard argues that the apps are limiting because there are “many different forms of psychotherapy, some of which are very open-ended, and with very different goals” – these therapy apps feel more like a drop-in experience, which doesn’t allow for variation in treatments.
Dr. Kennard believes that though apps will never provide the best experience, they are probably our future: he imagines that artificial intelligence will become “sophisticated” enough to overtake face-to-face therapies, and that our natural inclination toward self-help over asking for help will continue to draw us to online therapies. Despite his concerns about the impersonal and formulaic nature of therapy through an app, ultimately Dr. Kennard sees our need for convenience and simplicity overtaking the better practice of in-person therapy. This idea is in line with recent thinking from tech experts who see our society as increasingly a subscriber culture; we are much more likely to sign up for Netflix and Spotify than to go to a shop and buy a DVD. In this context, you could argue that using a therapy app is like torrenting the latest Marvel film – it’s easier to access, but the quality could be absolute shit.
Dr Carie Schuster also told Dazed that face-to-face therapy “is better (than apps) for the therapist in a lot of ways, as he/she can pick up on verbal, non-verbal, and other cues that are just lost when digital media is used”. Though she understands why the apps are becoming more popular, she raised concerns about how the apps almost allow a sort of “anonymity” for their users that might make the therapy process less personal.
Another major issue is that app users could easily become dependent on a therapist who is available almost constantly and indefinitely, as long as they continue to pay. The NHS offers limited blocks of one-hour sessions, not only because of pressure on the system, but also because therapy is supposed to make you a more independent and capable person. In a study published in the Journal of Counselling Psychology in 2001, it was concluded that patients made most improvement around the seven-to-ten session mark. Many more than that, and progress tended to stagnate. Aside from the minority, who will benefit from ongoing therapy for more complex mental health issues, most people don’t need to have a therapist on hand at all times. Encouraging people to view therapists in this way could ultimately change the way we view therapy, and not necessarily for the better.
Much like all the other apps we’ve integrated into our daily lives, therapy apps are probably here to stay. When the NHS is criminally underfunded – and funding isn’t even equally distributed across the country – and young people are feeling increasingly disconnected from their communities, therapy apps certainly seem like an obvious solution. They’re easy to use, and more flexible than a face-to-face appointment. But while online conversations can be an important lifeline, they should never be a crutch. As Dr Shuster and Dr Kennard explain, while our lives become busier and more complex, mental health apps could feature prominently in our future – but they’ll never totally replace in-person therapy.