- Teletherapy has frequently been escorted by a democratizing promise: therapy for all.
- The appification of mental healthcare is intertwined with the uberization of therapeutic labor.
- There is relatively little oversight in the burgeoning space of telehealth apps.
During the pandemic, much attention has been paid to the use of Zoom and FaceTime to deliver a continuity of clinical care over publicly mandated distance. Before the pandemic, therapy apps were already beginning to come under intense scrutiny as the future of mental health care, and as a litmus test for the promises and pitfalls of teletherapy generally. Perhaps because telehealth is being heralded as a growth industry due to the pandemic, and many people are seeking some form of mental health care after a year of pandemic conditions, or because many mental health clinicians are already debating (both hoping for and dreading) the return to their offices, there has been renewed interest in these digital interventions.
In my forthcoming book, The Distance Cure: A History of Teletherapy , I argue that the logic that licenses these apps is quite simple on the face of it. Teletherapy has frequently been escorted by a democratizing promise: There are too few clinicians to help all those in need of care, and much of mental healthcare is too expensive for the average American to purchase, if they can access it—a big if. Instead of addressing this underlying crisis by augmenting the number of clinicians trained via an overhaul of our educational debt system or, say, retooling the structure of insurance or socializing medicine and mental healthcare, private corporations have stepped in to “disrupt” the broken mental health care landscape and provide what they claim will be “Therapy for All”—easier, more efficient. Apps do this by turning referrals over to algorithms, moving the fee from the standard per session to a monthly all-inclusive, and making the bill auto-payable. That therapy, it is said, will be available to patients all the time—on demand, providing frictionless care.
This is, of course, a Silicon Valley-spun fantasy. In The Distance Cure, I argue that we can learn a lot about teletherapy apps by looking behind these promises to the lived reality of using and providing care on such platforms, starting with the slippage wherein these platforms suddenly call the patient a user or, perhaps worse, a consumer (even though, of course, therapy is consumed, so it’s also a blunt kind of honesty in marketing). The customer is promised a high level of care at a lower price, and one that is highly customizable. Don’t like your therapist? Switch. Don’t want to talk, only text? No problem. Yet there’s endless anecdotal evidence that whether it’s the promise of “on demand” texting (true for the client, not for the practitioner), a gender preference for a therapist, or a promise of tailored, customizable care, these things don’t come to fruition with any great frequency. Broken promises in mental healthcare and ever-shifting boundaries hurt everyone and may also prevent people from seeking care again.
Those who provide care on these applications have also begun to speak out about their experiences. There has been some wonderful reporting on this topic, most recently from Molly Fischer in New York Magazine , from Kashmir Hill and Aaron Krolik in The New York Times, and Dr. Todd Essig in Forbes about what it is these apps do to both sides of the therapeutic relationship they bridge. In my book, I look at the larger history of both radical and problematic devaluations of expert care, from 1940 onward. As the strictures on training have opened up, the fields that comprise mental healthcare have slowly become feminized. In tandem, the representations of techno-therapy have too almost always centered around avatars for algorithmic care that present as feminized. I argue that the feminization of the computerized therapy agent (like a medical-grade version of Siri or Alexa), and the feminization of (IRL) mental healthcare workers have walked hand in hand into our present, where the appification of mental healthcare is intertwined with the uberization of therapeutic labor. Dr. Elizabeth Cotton has great work on this, under the auspices of Surviving Work , and a special attention to therapeutic work in the U.K. context, while the Psychotherapy Action Network has provided crucial research and advocacy in the U.S. context.
Despite some direct marketing to individuals for many of these platforms, such apps are always thought at scale. By this I mean that the makers of the apps are interested in scaling up care not just because there is a dearth of it, but because they’re invested in market capture. To that end, many of these apps are marketed directly to employers, not to individuals, making their pitch not on the grounds of therapy for all, but by collapsing wellness and economic productivity—CEOs and COOs arguing for the necessity of these apps on the grounds of economic productivity loss from depression. These apps then, I argue, address themselves to the crisis that labor always is, but only just enough palliation for patients to resume, from their point of view, the right kind of labor.
There is relatively little oversight in the burgeoning “space” of telehealth apps, which often skirt the language of therapy for something vaguer instead in order to avoid regulation. In a gesture that parallels that of employer or university edicts to employees or students to take wellness into their own hands and perform #selfcare as a salve against the pandemic and widespread systemic failure, much of the positioning of these apps refuses a direct therapeutic claim. Instead, these interventions are called wellness, care, or even companionship, and coaching. These apps might do something—good or bad, or both—but it may not be a future we want for therapeutic care.
That’s not to say all teletherapy is hopeless, or necessarily lesser than in-person care. Long before the COVID-19 pandemic, the history of teletherapy has shown us that clinical work over distance can be powerful, competent, and almost always free—nearly the direct opposite of what corporate therapy apps currently offer under the same aegis.