Will Your Therapist’s Office Disappear Soon?
Harvey is a successful executive with a loving wife and two adorable kids. He is a model dad and husband, prosperous in business, makes time to enjoy recreation and is active in community causes. In many ways, he personifies the American dream.
When Harvey reached his fortieth birthday, he did some introspection in the stillness of his own mind. He noticed that his relationship with his wife was cordial, but lukewarm. They did not connect emotionally and were missing excitement and passion. Harvey also observed that he was an adequate father, but he felt distant from his children. He began to question who he was and if he was a successful in the different arenas of his life.
Then Harvey began to feel frustrated, unappreciated, and sometimes downright miserable. He started to have mood swings throughout the week. On a good day, he experienced a surge of energy and he was able to overcome life’s hurdles. But on most days, Harvey trudged through the hours, from bed to work, from work to home, from home to dinner, from dinner to some “down time,” and then to bed. Then the cycle started again. He felt like he was going through the motions, but not really “living.” His moods spiraled downward until it was sometimes hard to get up. The lower moods also impacted his relationships. His tepid connection with his wife declined. He felt more insecure about his parenting. He started muddling through his prominent job. Harvey also started losing patience with himself, his wife and his kids.
Several months ago, Harvey made a change. Now, he feels more positive and confident than ever. Harvey’s mood is generally up, he has a closer relationship with his wife, and he feels engaged in parenting his kids.
What is Harvey’s secret?
Harvey started working with a seasoned, master therapist. He shares what is on his mind with her, and she responds with empathy, support, and insight. She is there for him and they explore his thoughts, feelings, and ideas together. Since Harvey started working with his therapist, he noticed that his mood and interpersonal relationships greatly improved. He also started being more successful financially.
Situations similar to Harvey’s repeat themselves in many therapist’s offices. But Harvey’s growth did not take place in an office. He never even met his therapist. Their entire relationship took form through Harvey’s computer. Harvey is one of a growing number of people that use text based therapy to improve their lives.
What is text therapy?
When most people hear about text based therapy, the first question they ask is, “really, just through texting?” Yes…and no. Text based therapy, also called text therapy, is a bit of a misnomer. The word text does not refer to typical text messages. “Text” in this context means written, as opposed to verbal. The therapist and her client communicate through messages instead of talking to each other. Messages can be long or short. Therapists and clients build deep, meaningful relationships through their written communication.
Text therapy is the wave of the future in psychotherapy. It is more affordable and convenient than office therapy. Text therapy has begun to revolutionize mental health. According to reports, the three major sites that offer text based therapy, BetterHelp.com, Lisning.com, and Talkspace.com, have totaled well over a million subscribers. That’s a significant vote of confidence for text therapy.
Is text based therapy going to make brick and mortar offices obsolete? Text therapy has both advantages and disadvantages.
Advantages of text therapy
1) Price of text therapy
Psychotherapy with a licensed, veteran therapist can run $300.00 a session in metropolitan areas. Since most therapy consists of more than one meeting, the number of sessions that you meet multiplies that cost. Many therapists are “out of network,” which means that insurance companies do not cover therapy or only reimburse a small amount for each session.
Psychotherapists invest a tremendous amount of time, effort and energy in their education, developing their expertise, and working with their clients. The money paid for sessions is often well spent. At the same time, that steep price can hold people back from therapy.
In contrast, text therapy is economical. Therapy on those three sites ranges from less than $30.00 to $80.00 a week, depending on the site and the subscription. If you sign up for text based therapy, what can you expect for that price? Text therapy sites usually use asynchronous messaging. That means that you and your therapist do not connect at the same time. You write to your therapist when you want to and your therapist replies within a reasonable period. You can message your therapist as often as you would like to, for as long or as short as you desire. Send a quick text when an idea or thought strikes you. Compose an entire page when you are in the mood. Your therapist responds to you frequently. Exactly how often your therapist writes back usually depends on your subscription level. For example, with Lisning’s basic subscription, your therapist writes a significant message back to you at least every other day.
2) Frequent connection with a therapist
The standard psychotherapy session lasts 45 minutes, once a week. There are times that you meet more often, and sometimes less. It always involves a time commitment. You also need to compute the time it takes to get there and back. If you are meeting your therapist week after week, it takes a lot of time. If you are working, you need to find someone right near your job, or open at night or on weekends.
Text based therapy uses a different model. Your therapist responds to your messages frequently, on a reliable schedule. It can fit your lifestyle, no matter how busy it is. You can write on your own time, read on your own time, and think on your own time.
There is another significant advantage to text therapy’s frequent communication. Clients report that corresponding with their therapists several times a week (or more) helps the therapeutic relationship develop quickly. The messages are consistent and dependable. They work to help create a deep, caring, connecting relationship, often in a shorter amount of time than therapy in person.
3) Anonymity in text therapy
The world has made major strides in appreciating therapy and mental health. Society has been educated not to look down on people that go for therapy or to see mental illness as any different than physical illness. “Depression is like the flu,” we are often told. Yet, seeking psychotherapy still has a stigma associated with it. The level of shame and indignity can vary in different cultures and communities, but can be found almost anywhere. The self-consciousness associated with going for therapy can make many people refrain from addressing their mental health.
In addition, many people find it hard to reach for help for anything. Some quip that the biggest advantage of Waze is not that you can find out how to go, but that you can do it without asking for directions! Asking for assistance with mental health is even harder. It takes a lot of strength and courage to reach out to someone to help deal with a problem, issue, or disorder.
When you use text therapy, your therapist does not need to know anything about you. You can send messages with complete anonymity. As the therapy progresses, you might want to tell your therapist more about yourself, including your name. You are welcome to, but you do not have to. Anonymity is unusual for in person therapy, but it is the way text therapy works.
Dr. Irvin Yalom, the renowned professor emeritus of psychiatry at Stanford University, became an outspoken advocate for text therapy in the past several years. One of the things he likes most about text therapy is the anonymity it provides. He noticed that it can allow a client to feel more comfortable sharing deeply with his therapist. Yalom explains that he supervised a therapist who was using text therapy, and he was astonished at how her clients revealed personal information more easily than they did in office therapy. In an interview conducted by Talkspace, he reports:
What has astounded me is – several times I’ve heard her say – the patients have said that they reveal things to her they never revealed to their face to face therapist. That’s quite remarkable. One of the things is, of course, the anonymity… here they work with a face to face therapist for a year or two, and never revealed certain of these things that were very shameful.
(You can watch that video here.)
4) Indirectness like Freud’s couch
Text based therapy uses indirect communication, which helps people overcome normal inhibitions they could feel with a therapist. It is close to the technique developed by Sigmund Freud, the father of psychoanalysis and talk therapy. Freud conducted sessions with his patients laying down on a couch. He sat behind them and out of view. The patient spoke and Freud listened, but the patient did not look at Freud. With that posture, a patient felt that he was more free to express himself. Since he was not directly addressing someone, he had less inhibition to talking.
Text based therapy mimics Freud’s couch. You do not talk face to face with your therapist. You know that your therapist is there, but you do not see him and do not talk directly to him. It allows you to be yourself and share yourself in an easier way than you can with traditional talk therapy.
5) Accessibility to therapy
Therapy is both an art and a science. Not every licensed therapist is going to “get you.” You have your own rhythm and tune and your therapist needs to be in sync with that. If you are restricted by your location, it might be even harder to find someone to work with.
Text therapy allows you to find a therapist that you want to work with, anywhere. Since it goes through your phone or computer and is asynchronous, you do not even need to be in the same time zone.
The three major sites have slightly different ways of allowing clients to find a therapist. Lisning gives you the freedom to select your own. Each therapist fills out a detailed, accessible profile. You get to read about each therapist’s training, education, and expertise. You can sense their personality and get a feel for who you would like to work with. There is also a robust search feature where you can narrow down your search by criteria such as expertise, practice specialty, age group focus, or faith. BetterHelp works differently. After you sign up, you are asked specific questions so their team can match you with a therapist. There is also an option to manually browse the names and pictures of their therapists. Since most people are matched by BetterHelp staff, they do not have a search feature to assist with your own selection. Talkspace favors the match model alone. They ask you detailed questions and then Talkspace selects your therapist for you. All three sites allow you to switch to another therapist, even after you began working with one.
Yalom adds another angle to the accessibility provided by text therapy. Not only can you find a therapist anywhere, you can contact him whenever you want, in real time. He points out that:
A patient can have a panic attack in the middle of the night and immediately text the therapist. Now the therapist is not going to be reading that text, of course, he may not be reading it for some hours, and responding for some hours, but still, there is a sense that they can convey what they’re feeling much better than if they reveal [it] several hours later, and try to recall what’s happening to them. So that [is] another kind of intimacy that occurs, too.
6) Therapy sessions are recorded
Therapy includes a mix of experience, relationship, and psychoeducation. Often therapists share ideas, information, and techniques during a session. It can be hard to remember all of those things after the meeting. In addition, it might be difficult to notice your progress in therapy over time.
Text therapy uses private, virtual rooms. Each client has his own secure space to write to his therapist. Those conversations are password protected and saved. They are always there to be reread, referenced, or studied. You can see how far you have come by looking back at your previous conversations. You can also find an idea you wanted to contemplate more or revisit the experience.
7) Therapy for loneliness
The world can feel like a very lonely place. Loneliness can surround you, even if you have many friends and good relationships. You can navigate your day and feel like you have no person in the world that understands you. There is no one in whom you can confide in and share your deep thoughts and feelings with.
Aside from addressing mental health issues, text therapists can help alleviate that feeling of loneliness. The frequency and regularity of text therapy offers an opportunity to develop a deep and meaningful relationship with a caring person. Even if you don’t have a pressing mental health concern, you can share your vulnerable thoughts and feelings daily, knowing your therapist will reliably respond to you.
Disadvantages of text therapy
1) Significant disorders and emergencies
There are some mental health disorders that require hospitalization or medication in conjunction with therapy. Text messaging therapists do not prescribe medication. That means that if someone does need meds, he has to consult with a psychiatrist that he can meet in person or on video.
In addition, all three sites do not see their site as the sole support for someone struggling with a significant mental health disorder. For example, BetterHelp makes a strong statement on their website:
BetterHelp is not the right solution for you if any of the following is true:
- You have thoughts of hurting yourself or others
- You are in an urgent crisis or an emergency situation
- You have been diagnosed with a severe mental illness, or if you have been advised to be in psychological supervision or psychiatric care
This is echoed by Lynn Bufka, PhD, associate executive director for practice research and policy at the American Psychological Association (APA). In the APA published Monitor on Psychology, she cautions that using text therapy is questionable when counseling “a patient who may seem suicidal in his or her messaging responses.” “If you’re using an online therapy platform and you ask someone if they’re suicidal and they say no, is that it?” Bufka says. “Those kinds of clinical issues come up,” she explains.
2) Office therapy includes an in person relationship
One of the beautiful things about psychotherapy in an office is that it allows an interpersonal relationship to take root, sprout, bud, and flower. There is a melodious rhythm to meeting with someone in person who is deeply interested in knowing about you. It can help the discussions that take place become profound, insightful, and exploratory.
In addition, a face to face relationship in therapy can sometimes recreate past relationships, such as with parents or significant others, and work to restore them. When your earlier relationships went sour or had something that was missing, you can sometimes develop a relationship that mimics that in therapy. You can discuss it, examine it, and sometimes repair it in the therapy room. Some clients might do best when that insight and improvement is done in person.
3) Office therapy has synchronous discussions
Conversations bring something else to the table – instant responses. When you talk to your therapist in person, she responds during the conversation. On the other hand, text therapy has a delay. Your therapist is not expected to respond right away. For Astha Sexana, a client who tried BetterHelp.com, the gap was not ideal. In her review, she describes that, “as wonderful as my therapist at Betterhelp was, it usually took anywhere from four to 10 hours to receive a response, which can be frustrating to some.” Those time lapses are to be expected across the board at all three portals. Therapists try to respond quickly, but not in a specific time frame.
4) Expressing yourself in writing
In office therapy, you can talk and share what’s on your mind. You might find it challenging to type on your computer instead of speaking. It is important to note that text therapy is really a conversation in written form and not comparable to school composition assignments. Yet, you might prefer to speak directly to a therapist instead of writing your thoughts down.
5) Body language is missing
A large part of the way we communicate is through non-verbal methods. Body language, affect, voice modulation, and eye movements all take part in communicating what we want (or do not want!) to say. In text therapy, those non-verbals are not there. There might be other cues, such as message lengths, punctuation, and sentence structure. Yet, traditional clues are missing. That bothered Astha, the client who tried BetterHelp. “Traditional face-to-face therapy definitely has some advantages over e-counseling. There is nothing like being able to sit in front of a person and interact with their body language, facial expressions, and even simply their physical human presence,” she reported.
Combining text therapy and office therapy
Some respected voices in the mental health arena suggest that a combination of text and in person therapies might be the way to go. That is how Bufka sees it. She maintains, “I think most psychologists seem to feel much more comfortable integrating technology into an ongoing face-to-face or video/teleconferencing relationship versus using only messaging.” In a similar vein, my clinical experience has demonstrated that many experienced therapists are reluctant to embrace the efficacy of text therapy alone.
Megan Jones, PsyD, adjunct clinical assistant professor of psychiatry and behavioral sciences at Stanford University School of Medicine, adds another point in the APA Monitor. She sees text therapy as a great first step, “even more encouraging is that when digital interventions are positive, effective experiences for patients, they may go on to seek face-to-face therapy.” Interestingly, some portals afford clients that option. They can search for a text therapist by location. That allows you to work with your therapist through text first, then transition or supplement with office visits, too.
Bufka expresses another issue to consider. She remarks, “my concern is that some of these models are probably start-ups that are launched by people in technology, who have good intentions but haven’t fully investigated all the nuances in what’s involved in providing health services,” she says. She is partially correct. BetterHelp was started by Alon Matas, an entrepreneur who was looking to create a startup (as he discusses in an interview available here). Oren and Roni Frank, the founders of Talkspace, are entrepreneurs who founded their company after they gained from counseling for their own marriage (as reported here). They were eager to make that type of counseling accessible to others. Despite not having origins in mental health, those creators already significantly impacted the practice of psychotherapy. Lisning.com had a different start. I developed it after a decade and a half of my practicing psychotherapy as a licensed clinical social worker, relationship coach, and rabbi. Based on my experience as a therapist, I contemplated and researched ways to create the ideal text therapy platform. My goals were to bring the therapeutic relationship and insightful conversations that take place in offices to more people for less cost, and to allow therapy and coaching to become both normal and accessible for the whole population.
The bottom line about text therapy
Is text therapy for you? Many of the mental health issues that people struggle with can find significant relief through text therapy. It can be extremely helpful for difficulties including: anxiety, low moods, obsessive thoughts, loneliness, and difficulties in relationships. Text therapy also can foster a caring and genuine therapeutic relationship. On the other hand, if you think that your issue is very serious and acute, it might make the most sense to look for help in person.
Will text therapy eventually close the doors on therapist’s offices? Mental health is an important international priority. There seems to be plenty of room for both methods of therapy as the world spins toward improved mental health, positivity, and happiness.
Shmuel Maybruch, LCSW is a psychotherapist in private practice and Clinical Director of Lisning.com
- Feb 28, 2019
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