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Is a Therapy App Ever as Good as the Real Thing?

Programs that allow you to text or video chat your therapist are more popular than ever. Here’s how to decide if one of them is right for your mental health needs.

Credit: Westend61/Getty

OfOf the tens of millions of Americans who suffer from a diagnosable mental health problem each year, only half will pursue treatment, for any number of reasons. Some can’t afford it, or struggle with accessibility. Others are deterred by the stigma still associated with mental illness. And that’s not even counting all the people without a clinical diagnosis who could still benefit from therapy, but are put off by the same challenges.

In recent years, a new type of therapy has positioned itself as a solution to all of the above. Text-based teletherapy apps, often with the option of phone and video sessions for a higher fee, are becoming an increasingly popular alternative to face-to-face sessions in a therapist’s office. Some of these apps claim hundreds of thousands of users; Talkspace, one of the bigger names, has said that it’s generating tens of millions of dollars in revenue.

It should be said that these apps do not and should not take the place of an in-person diagnosis or medication. When it comes to serious mental health issues, it’s important to consult your doctor before trying any new form of treatment. But with that in mind, therapy apps may be helpful for some people in treating a spectrum of problems, from depression and anxiety to career stress and relationship hurdles. Here’s what to know if you’re thinking about trying one.

Do they really work?

The research on app-based therapy isn’t exactly robust. There’s some evidence that it can be effective — one study, for example, argued that, in some cases, video-based teletherapy can help therapists cultivate their clients’ trust more easily, fostering a stronger, more intimate relationship than in-person therapy would. And some studies suggest that therapy apps can reduce symptoms of depression. But much of the other positive research has either been commissioned by the companies behind the apps themselves or done in concert with them, throwing the reliability of the conclusions into question.

Dr. John Torous, director of the digital psychiatry division at Beth Israel Deaconess Medical Center and head of the American Psychological Association (APA) group that studies therapy apps, has been investigating their effectiveness for years. In a recent study in the journal Nature, he and his colleagues analyzed 73 popular apps, and found that only one could support its claims of effectiveness with published academic research that stood up to peer review.

“They’ll say they’re evidence-based,” he says, but “when you actually dive into what that evidence really means, we found a lot of them are saying, ‘Therapy is an evidence-based practice, and we’re based off the principles of therapy. So therefore this app is evidence-based.’ Which really is just wrong.” Given the newness of app-based teletherapy, he says, potential users will likely need to wait several more years for long-term studies to examine how well it works.

In the meantime, though, some therapists argue that app-based treatment can still work for certain types of people, especially under the care of a qualified clinician.

Who’s a good candidate?

People who have trouble accessing traditional therapy are especially good candidates for teletherapy apps, advocates say. Barriers can be literal or psychological, says Haesue Jo, a licensed therapist and the clinical support lead at the app, BetterHelp.com. “Apps provide access for people that normally may never walk into the office of a therapist, whether that’s because they live in a rural community or because it’s a very small community, or maybe just because of the stigma that still surrounds the act of going to find a therapist,” she says.

Apps can also be useful for people who have physical disabilities that make transportation arduous, and young parents or busy professionals who don’t want to spend their limited free time commuting to therapy. And an app can be a good introduction to anyone who’s considering therapy, but wants to try it in a low-commitment way first.

Who’s better off with in-person therapy?

On the flip side, if you find it hard to express yourself through a digital connection, then an app might not meet your needs.

It can be extremely challenging to put into words the loss of a loved one or the bodily sensations of a PTSD flashback, and that much harder to try to put them into a text. It can also be difficult for a therapist to express herself and for the nuances of traditional communication to come across in a digital setting. So much of therapy is about gesture, emotion, and the other ineffable qualities of a face-to-face interaction, says Dr. Ellen Vora, a holistic psychiatrist based in New York City. “Good practitioners end up holding space for their patients in a way that’s an energetically therapeutic exchange,” she says. “A lot of the time, it’s not really what we’re saying; it’s the way we’re using micro gestures, reacting or not reacting to something that comes up in a conversation.”

It’s up to you and your doctor to decide whether you think the loss of that in-person connection is worth the trade-off. Across the board, though, therapy apps are not recommended for people in a crisis, those dealing with intense grief or trauma, those who need the closer supervision of outpatient care, or anyone struggling with severe depression or suicidal thoughts.

What should you be wary of?

Though therapy apps claim to be doing the same work as in-person therapists, one of the main differences comes down to supervision and emergency protocol. In many therapy apps, the counselors essentially act as freelancers who don’t have the same supervision or support network as they would offline. (Even traditional private practice therapists often work with a supervising clinician, who can offer additional insight on a given case and help the therapist figure out how best to approach the client’s care.)

Another major difference is that these apps do not have the same emergency protocols as in-person mental health care providers. If a traditional therapist hears that a patient is planning on harming himself or others, for instance, they are required to report it to local authorities. These apps will try to do to the same thing, but they often have limited options: some have first and last names and addresses of clients that they can provide to authorities, while others might only have the person’s first name and whatever emergency contact they provided when signing up. A representative from Talkspace said the company would provide police with the IP address of the user in case of an emergency, but a detailed report from The Verge in 2016 questioned the efficacy of this protocol.

How can you figure out where you fall?

Potential users should talk to a traditional healthcare practitioner before starting treatment online. Many licensed therapists are using apps in addition to their in-person therapy, and can often offer insight into which ones work best for a given person and situation.

The APA has also created a framework for evaluating mental health apps, taking into account privacy and safety, proven effectiveness, and ease of use, among other factors. But the APA’s system acknowledges that choosing an app often involves more gray area than patients or psychologists would like to admit: Much like choosing the right therapist, it requires some diligent legwork to find the right fit.

A journalist living between Brooklyn and Paris, she writes about women, history, and culture. @nytimes @wsj @time

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