THE DANGERS OF MOBILE THERAPY
MAY 07, 2019
Founded in 2012, the New York City based startup Talkspace promised an easy solution to a slew of complex mental health problems: mobile therapy. The app claimed its team of licensed freelance practitioners could provide therapy via text message that was comparable to if not better than the therapy provided in a traditional face to face setting.
For many users, that promise has yet to be held.
“I didn’t like the asynchronous texting,” says 28-year-old blogger Samantha Rogers. “Sometimes my therapists wouldn’t get back to me until after I already had to make a decision or decide how to feel.”
David D. Burns, Professor of Psychiatry and Behavioral Sciences at the Stanford University School of Medicine and author of the best-selling books Feeling Good: The New Mood Therapy and The Feeling Good Handbook says Roger’s experience is not unique.
“I was asked, begged really, to participate in a start up like this years ago – not this one – but refused due to serious concerns about the skill level of the therapists,” says Burns. “I think most mobile therapists aren’t very good.”
According to Burns, traditional face to face therapists measure symptoms such as severity of depression or tendency of suicidal thoughts before and after each session – a procedure not required of or routinely practiced by Talkspace therapists.
“It’s the only way to know how effective you are,” says Burns. “None or very few at best of these Talkspace therapists are doing that, which is like trying to run an emergency room without an x-ray machine, blood tests, and thermometer.”
Roger’s Talkspace experience included no such survey.
“Talkspace doesn’t systematically screen for suicide history or suicide ideation, which I now think is important for all therapists to do,” says Rogers.
But then again, Rogers was not suicidal when she first started using Talkspace back in 2017. She started using the app in order to treat relatively minor anxiety and depression brought on by a particularly rough patch in her life. A recent graduate, she had applied to 34 jobs and was rejected by all of them. Seeing no point in remaining stateside, Vogel packed up and moved to Thailand where she became a blogger. It wasn’t until she arrived in Thailand that Rogers realized she needed help working through her mental health issues. It also wasn’t until she arrived in Thailand that she realized just how hard it was to find a therapist abroad in a country where she didn’t speak the local language or have health insurance.
According to New Orleans based health care analyst Mary Cabell, the key words in describing Roger'’s mental health issues and Talkspace’s ability to treat them are “relatively minor.” Cabell, who has run the eponymous Cabell Consulting for three years, provides advice regarding best practice to therapists and psychiatric centers across the country.
“Mobile therapy apps like Talkspace while not ideal, can still work for relatively minor mental health issues,” says Cabell. “Think minor depression or minor anxiety. Where they do not work is in treating cases of major depression or major anxiety or severe mental illnesses like schizophrenia and bipolar disorder.”
Yet, Talkspace offers numerous articles on their website directing users on how to treat their bipolar disorder.
“People suffering from bipolar disorder need medication and should be regularly seen by a psychiatrist,” says Cabell. “To suggest anything different is downright dangerous.”
When asked to comment on Talkspace’s claims regarding the app’s ability to treat serious mental illnesses, Talkspace press team member Alana Cowan declined on behalf of the Talkspace corporate team due to their tight schedules.
The actual corporate structure of Talkspace is not that large and the app’s funding is surprisingly small. According to Crunchbase, Talkspace has secured $56.7 million in funding and employees 11 to 50 people corporately. The bulk of the people who work for Talkspace are therapists who operate as independent contractors. No official numbers are available as to just how many independent contractors supply Talkspace with therapy and once again Talkspace refused to comment when asked.
“Talkspace is on lockdown,” says Cabell. “Obviously their website doesn’t post anything they don’t want you to know and most of the research on the app is research Talkspace paid for. You can’t trust anything you find online about them.”
In a May 2018 Wirecutter article, Talkspace Vice President of Clinical Research and Development Derrick Hull claimed Talkspace is the research leader for asynchronous text therapy and further stated that no one but Talkspace and their partners had published research on mobile therapy thus far. It is almost a year later now and a quick google search reveals most articles written about Talkspace cite research originally produced by the app itself.
Consumers must then ask if they can trust the current literature on mobile therapy given the majority has been curated by mobile therapy’s leading provider.
Chicago based social worker Ellen Benjamin urges caution.
“I am of the opinion that any kind of therapy is good therapy and that people who need help should get the best help they possibly can get,” says Benjamin. “If that’s Talkspace, then that’s Talkspace. But if something seems too good to be true, then it usually is.”
Christina Marone, a 31-year-old American blogger living in the Netherlands corroborates Cabell’s and Benjamin’s reservations about the app. Like Rogers, Marone began using Talkspace during a time of mild depression and mild anxiety while living abroad. She also lacked health insurance and a fluent understanding of the native language making it hard for her to find a therapist in her new home.
Marone was matched with two therapists during her first round. Neither therapist seemed particularly interested in what she had to say and both failed to respond in what Marone would consider a timely manner.
“My first round with Talkspace was a failure,” says Marone. “You pay for a response once a day and days would go by without any response. It was very frustrating and, in the end, I canceled my subscription because of that.”
Three months later Marone decided to give Talkspace another try.
“Therapist number three was the right fit and I was able to walk away satisfied with the experience,” says Marone. “But while I managed to have a good experience in Round Two, the failure of Round One in such a fragile mindset shouldn't be treated as no big deal.”
Another problem users face are glitches that cause the app to shut down during pivotal therapy moments.
“Sometimes there are glitches with the app,” says 38-year-old Ontario resident and Talkspace user Nicole Sandoval. “Delayed messages or the app restarts on its own.”
33-year-old Minnesota based user A.M. Willette had a similar experience.
“I didn’t have a car so I thought Talkspace would be a good fix for my anxiety since I could use it from home,” says Willette. “But then it wasn’t live. I would need my therapist and it was just like she forgot about me. Or the app would shut completely down.”
Cabell claims such glitches and unresponsive therapists are more common – and dangerous – than Talkspace wants the public to know. She volunteers at the New Orleans branch of the National Alliance on Mental Illness crisis hotline and receives several calls a week from disgruntled and distraught Talkspace users who feel as though the app abandons them at their time of greatest need.
“I will say this until I am blue in the face,” says Cabell. “Too many Talkspace therapists are unreliable because they don’t answer to the same standards as traditional, non-mobile therapists. When was the last time you heard of a traditional therapist not showing up to a session? Talkspace creates an environment where tragedy is imminent. Someone who can’t reach their therapist who is supposed to be easily accessible in a time of crisis could very easily do something to harm themselves or others.”
Emory University neuroscientist Michael Davis agrees.
“One of the most effective pitches these days is the ability of virtual reality to do what reality can,” says Davis. “That is what Talkspace promises. A virtual therapist that can help you solve problems just as effectively as a real in-person therapist. The virtual reality pitch is fine when we’re talking about video games. But not when it comes to your mental health. Then the virtual reality pitch is dangerous.”
Davis has worked at Emory’s Center for Behavioral Neuroscience for over 30 years and has studied both old and new age therapy methods extensively and regularly provides consultations critiquing therapists’ methods. His videogame analogy seems perfect since Talkspace is now heavily marketing towards the demographic most likely to play videogames: adolescents.
On September 17, 2018, Talkspace introduced Talkspace for Teens. Whereas the app previously forbade those under the age of 18 from use, Talkspace for Teens is specifically created for ages 13-17. According to the FAQ section of the official Talkspace website, Talkspace took all legal requirements into consideration in their decision to offer therapy to minors. Namely, parental consent laws. Nearly all U.S. states require parental/guardian consent for a minor to enter into therapy and do not allow therapists to share information with a minor client’s parent/guardian without a signed release. A Review of State Laws Regarding Decision Making for Adolescent Drug Abuse and Mental Health Treatment, reveals these laws are not uniform and vary state by state. Some states like Alaska have no law regarding parental consent for therapy for minors while states like New York have a law specifically saying parental consent is not required for a minor seeking therapy. Still others like Minnesota require parental consent if the person seeking therapy is under the age of 16. Talkspace claims all of their therapists are familiar with the laws in their respective states.
Todd Essig is a clinical psychologist and psychoanalyst who has practiced in New York City for over 20 years and currently works as the training and supervising psychoanalyst at the William Alanson White Institute of Psychiatry, Psychoanalysis, and Psychology. Essig has researched extensively the application of mobile therapy and says he has never seen a version of therapy as dangerous – particularly, Talkspace for Teens.
“Any parent who legitimately expects their child has a diagnosable mental illness and is seeking treatment with Talkspace should be referred to Child Protective Services,” says Essig.
According to Essig, Talkspace provides more marketing than therapy and parents who allow their children access to the app are subjecting them to unsafe practices and potentially dangerous results.
“Talkspace is a marketing scheme, not a therapy provider,” says Essig. “They’re marketing to kids and giving them access to minimally qualified therapists practicing untested and untried but easily accessible methods. Commercially it is quite a seductive approach to therapy. Ethically? Not at all.”
Tamara Colucci, Betsy Rose, and Jade Fiedler, counselors at Rosemount Middle School (RMS) in Rosemount, Minn., have noticed an uptick in students using mobile therapy apps. The counselors share Essig’s sentiment with the exception that in the face of public-school budget cuts and ever-increasing caseloads, that access to counseling in any form is better than nothing.
Colucci believes Talkspace could be useful after school hours or when school counselors experience a heavy caseload and simply cannot get to every student.
“The app could never replace a school counselor but can act as another resource,” says Colucci. “We are accessible to the students from 7:00am to 3:00pm each day but after they leave the building they are on their own and during the day we have so many kids that we can’t meet with them all. If Talkspace can help fill that gap, then maybe something is better than nothing.”
Not every RMS counselor agrees with Colucci’s assessment of the app as a harmless and helpful additional resource.
“You can never replace the school counselor and face to face interaction,” says Rose. “Students need face to face interaction now more than ever since there is so much technology.”
Fiedler seconds Rose.
“Students are coming in here because they are so confused and frustrated and potentially depressed, mad, angry, resentful, and bitter because of things that have been texted to them because they are not able to differentiate and fully read the emotion of the text,” says Fiedler. “That’s why talking in person is so important because part of what they are working through is technology and not understanding all the nonverbal ques when it's just a text.”
Another problem arises in the fact a minor could conceivably use Talkspace without parental consent in a state that requires parental consent simply by saying they live in a different state that doesn’t require parental consent when they sign-up for the app. That’s what 14-year-old Brandon Bates did.
William signed up for Talkspace in March. His father, Mike Bates, only found out three weeks ago that Brandon was using the app.
“I was furious,” says Bates. “He is still a kid. It is my right to know what other adults are saying to him and what advice he is receiving.”
Both father and son live in Minnesota but during the school year Brandon boards two hours away from his childhood home at the prestigious Shattuck Saint Mary’s Hockey Academy. Brandon got around Minnesota’s parental consent law for minor’s seeking therapy by simply saying he lived in Alaska, a state with no parental consent requirement, when signing up for the app.
“The first time I signed up I said I lived in Minnesota and they said I needed to send a video of my dad saying it was ok for me to get therapy,” says Brandon. “I talked to my friend who uses it and he said that if I didn’t want to send a video, I should sign up again and say I live in Alaska.”
So that’s exactly what Brandon did. It worked. Talkspace never questioned how a 14-year-old who just the day before sought therapy from Minnesota suddenly lived in Alaska. William says he even used the same email address and identifying details. The only thing that changed was his state of residence.
“I just changed it,” says Brandon.
According to Fielder, the reasons William sought therapy were relatively minor in terms of the broad range of mental health issues children can suffer from.
“There are four different tiers of anxiety issues for kids,” says Fielder. “The lowest tier is a kid who is slightly anxious over a group project while the highest tier is a kid who is terrified of going to school.”
Fortunately, Brandon fell into the former category.
“I was really stressed out about school and hockey,” says Brandon. “I have Ds in all my classes. My teachers are always yelling at me and then my coaches yell at me too when I play bad and don’t pick up my feet.”
Brandon turned to Talkspace after hearing his classmates from the East Coast talk about it and discovering one of his idols claims to use the app.
“A lot of my friends use it and so does Michael Phelps,” says Brandon. “I like Michael Phelps because he shows how your past doesn’t define your future. He got into a lot of trouble but he still came back and won it all. I get into a lot of trouble too, not with drugs, but with my coaches and parents and teachers. So I thought if Talkspace could help Michael Phelps it could help me.”
Phelps, a swimmer and 23-time Olympic gold medalist, announced a partnership with Talkspace in May 2018 when he launched a national TV campaign addressing the stigma of mental illness. Since then, Phelps has become synonymous with Talkspace. His face is on billboards and commercials everywhere promoting the efficacy of the app.
According to William, sometimes his therapist forgets to text him or gets too busy.
“Most of the time I don’t care,” says William. “But sometimes if she forgets and I’ve had a bad day or practice it’s tough.”
It is this technological forgetfulness and the child’s reaction to it that most concerns Rose.
“What worries me is if the child were really thinking of harming themselves or others and needed attention,” says Rose. “Would that mean and trigger more of all that then this person actually doesn't get help and they're not responding again even though that something you know worrisome.”
Of course, there is room for parental error. Bates admits Brandon did sign up for Talkspace using a credit card his father gave him and upon reviewing his credit card statements Whitelaw discovered weekly payments had been made to Talkspace since March 3rd.
“I just don’t look at my statements that often,” says Bates.
Since discovering Brandon used the app, Bates cancelled Brandon’s subscription. He considered suing Talkspace but after several conversations with experts and his lawyer, decided against it.
“It’s wrong and it shouldn’t have happened,” says Bates. “A therapist should not be able to talk to your minor child in a state where parental consent is required no matter where the child says he lives. They should have a check in place. But my lawyer says I would never win the lawsuit and legal action just isn’t worth it.”
Essig has heard dozens of stories like Bates’ before.
“People don’t sue Talkspace for a couple of reasons,” says Essig. “First is that a lawsuit is expensive with no guarantee of winning. The second is that in their Terms of Service Talkspace provides themselves with the legal protections they need not to be able to be on the receiving end of any kind of large-scale malpractices in terms of the first issue.”
Ultimately, most people just want to move on following a bad experience with the app.
“I mean they could be subject to lawsuits that have to do with consumer fraud because they market one thing and do another,” says Essig. “I've gotten lots of calls from people who have had unhappy and difficult experiences with Talkspace and without exception just want to move on. They don't want to try and get revenge in a lawsuit.”
Regarding his experience with the app, Brandon thinks it neither helped nor hurt him.
“I’m still stressed,” says Brandon. “My grades are still bad and sometimes I have bad practices. But it’s not like anything got worst. The most frustrating thing was not getting texted back.”
Fiedler thinks Brandon should count himself lucky in his ability to cope with a sometime unresponsive therapist.
“A lot of kids come to me saying this person never texted me back and then they go into a tailspin,” says Fiedler.
Rose says she has had similar experiences with her students.
“You always want more resources for kids,” says Rose. “But if one of those resources is unreliable, then is it really an effective and more importantly, safe resource for kids to use?”
Chicago based psychotherapist Susan Lipson agrees – especially when it comes to Talkspace’s claim the app is a suitable therapy option for those with severe mental illness.
“I would never recommend it to someone with a serious mental disorder instead of an in-person evaluation and follow up,” says Lipson.
Although she supports the idea of mobile therapy, Colucci also agrees that serious mental disorders need serious face to face time with a therapist.
“There is a time when they really truly need to come in and talk whatever it is, they are going through out,” says Colucci.
Fiedler elaborates on how collaborative therapy processes can transform students lives if and only if all therapy is consistent.
“Some of our best work done in transforming a student’s life to having more hope and healing is when we as counselors are involved, their parents are involved, and their teachers are involved,” says Fiedler. “Many people from the outside and inside or different fields are all supporting the kid in their own fields attached to the school.”
Essig concedes Talkspace can be helpful in some ways – but not therapeutically.
“If they were marketing themselves as interactive self-help, I would be supporting the and I would be sending people to them,” says Essig. “But what Talkspace is doing is dangerous because they are not able to access the information that a therapist needs to have to make sure that patients are safe.”
He equates the effects of Talkspace on the human mind to those of yoga and exercise.
“There are lots of anecdotes of people saying it was very helpful and I think that’s wonderful,” says Essig. “The first is the plural of anecdote is not data just more anecdotes and lots of things can be helpful. Yoga can be helpful. Your mood can be elevated by regular exercise. Expressive writing where you’re simply writing about yourself in an autobiographical narrative with mood can help. A lot of things can be helpful. But that doesn’t mean that what they’re doing is functionally equivalent to face to face therapy.”
Talkspace therapist Melissa Moreno is featured heavily on the app’s website. Moreno agreed to an interview concerning this article but did not answer when called at the scheduled interview time. Several more calls failed to produce a pickup. When contacted – repeatedly – to reschedule, she did not reply. A similar situation occurred with Talkspace press team member Alana Cowan. Originally eager to provide a comment for this article, Cowan proceeded to decline an interview request but promised to answer any questions via email. An email asking for the exact number of therapists employed by Talkspace and clarification regarding the app’s advertisement as a therapy catch all and if the app considered the high-risk status of teens when launching Talkspace for Teens and a comment on Brandon Bates’ experience went unanswered – as did several follow-up emails.
On July 23, 2018, the American Psychological Association (APA) ceased posting advertisements for Talkspace in their monthly flagship publication Monitor on Psychology citing possible false advertising on the part of the app. The APA did not return a request for comment.