Myra Altman Ph.D.

Evidence-Based Care


Why I’m Tentative on Text Therapy: A Clinician’s Perspective

Are apps missing the mark on helping clients build lasting skills?

Posted Nov 23, 2020

Apps offering therapy or coaching by text on-demand aim to deliver convenient care to a stressed-out world.
Source: ModernHealth/GettyImages

One of the deepest ironies in the field of psychology is that once an individual overcomes the social stigma surrounding mental health and decides to get care, it’s actually very difficult to find. We have an access problem for so many reasons; among them, there simply aren’t enough therapists to go around.

In the U.S., there is only one licensed therapist for every 3,000 people. Appointments fill up quickly, leaving no room for new patients, and therapists have little incentive to join the medical insurance networks whose reimbursement rates are disparagingly low. This makes the traditional therapeutic approach to care unaffordable to most Americans—so as a therapist, I believe my peers and I have a duty to innovate in our approach and delivery to increase access to care.

It’s in this spirit that I want to address the emerging format of text-based coaching and therapy. It’s marketed, smartly, as “on-demand” care, meant to address several patient pain points: 

  • People are busy and tired of scheduling appointments. 
  • They want help with tough problems in the moment. 
  • Conducting care by chat alleviates some of the stigma surrounding mental health by allowing for a degree of anonymity. 
  • And text-based care is generally available at a lower cost. 

While we all know that mental health sometimes demands attention at the least opportune moments, I think it’s crucial to discuss the underlying assumption that chat-based services are at their best in times of immediate need. As a therapist, I’m not sure they are.

There are two ways to define “immediate need” as I use it here. First, we are talking about a patient who’s actively experiencing distress and emotional overwhelm; they might describe feeling “flooded” by thoughts and emotions during a particularly triggering event and struggle to distract themselves or calm down. The second is a true mental health crisis—when someone is at risk of harming themselves or harming someone else. 

For the first category of need, an ample body of evidence demonstrates that individuals who experience this kind of distress will benefit from a well-established patient-provider relationship with a therapist or coach using evidence-based treatment. Through this relationship, the client will learn and practice skills enabling them to manage their emotions for the long term, ultimately becoming their own therapist and not needing my support at all. When people have 24/7 access to help, they may lose the opportunity to use their skills, to build confidence in their ability to navigate and tolerate distress, and to assess where they’ve made progress and where they could still work further. In my opinion, this client would be dramatically underserved by a texting app. 

In the event of a true emergency like a threat of suicide, other self-harm, or harming someone else, the distressed individual requires more help than asynchronous online chat can provide. Evidence tells us an emergency hotline is the best path forward. 

Not only does text-based therapy fail to help patients build skills to support themselves, but the evidence about its effectiveness is not where it needs to be. While the American Psychological Association (APA) "does not have an official position on text therapy as a standalone modality of treatment," it reports that "at this point, there is no research suggesting that texting alone is an effective modality for psychotherapy.” An APA review similarly noted that “there is insufficient empirical support for any one particular app to be considered evidence-based,” even when the tools reviewed were extensions of empirically supported treatments, like Cognitive Behavioral Therapy (CBT). 

There is promising preliminary research published by some of the app makers themselves (here’s one example), but we know that a single study is not enough. We more often read findings like that of a recent systematic review stating “there is limited research evidence regarding how effectively these [synchronous chat] services support mental health and well-being.” As a therapist, I struggle to see how texting could build the kind of therapeutic relationship that decades of research have shown to be effective. While the evidence isn’t there yet, I look forward to watching this space evolve. 

The last concern I’ll note here is that text-based therapy and coaching do not enable providers to do their best work. As clinicians and researchers, we know the most effective care network frameworks support providers by facilitating fulfilling and meaningful care interactions with clients. One reason I’m skeptical of on-demand care is that having top-quality providers available at all hours is not only unlikely, but there are also ethical concerns around subjecting providers to the stress and potential burnout associated with giving care 24/7 for low pay. I know that as a clinician, this wouldn’t lead to me doing my best work.

So, what do I propose instead? We need to innovate thoughtfully by using technology to deliver evidence-based care to more people. An ample body of peer-reviewed research on care modalities like CBT, Dialectical Behavior Therapy, and Acceptance and Commitment Therapy points to the effectiveness of well-established therapeutic relationships that feature regular interaction between client and provider and enable the client to practice skills on their own in-between sessions. A newer body of research suggests digital applications of these evidence-based methods (through video provider sessions and digital practice tools) can be as effective as in-person treatment. I am particularly excited about this blend of human care with a digital practicum component to empower clients to learn and practice skills. 

As a clinician, I know progress happens when I’ve established a trusting relationship with my client. We make strides when I read facial expressions and body language, when I ask follow-up questions, when I dig at the deeper meaning, and when we sit together in discomfort. Outside of the session, I know the skill-building happens when my client practices tools from therapy on their own. Therapy is often uncomfortable, and this discomfort is exactly what makes it effective. As the saying goes, “There is no way out but through.”

The truth is that no clinician can be on standby for any person forever. The aim of clinical care is to build each individual’s toolkit and emotional resilience so they can be their own therapist for life. My goal is quite the opposite of having me on-demand; I’m working hard to ensure they don’t even need me.

To find a therapist near you, visit the Psychology Today Therapy Directory.

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