Does text therapy really work?

Source – Illustration by TIME

MMore than a decade ago, Thomas Derrick Hull, a clinical psychologist who studies digital health, had something that seemed crazy: What if therapists, struggling to keep up with the demand for mental health care in the U.S., started texting their patients instead of having them come into the office?

At the time, even to Hull, it seemed unlikely that patients and providers could use a screen to create the kind of connection and meaningful conversations that thrive in person. But the benefits were enticing: Texting is cheap, fast, accessible, and easy to do on the fly, potentially allowing therapists to interact with patients on a regular basis rather than waiting for a weekly session. So Hull began researching the effectiveness of text-based care, eventually landing a job as an executive at online therapy provider Talkspace. (He left the company in 2020 and now works for a digital health startup.)

Even if texting were only 60% or 70% as effective as traditional therapy, the convenience and accessibility might make it a better option than nothing, Hull thought. “It seemed like a fair trade-off,” Hull says. “But once we started looking at the data, they were just as effective.”

Recent studies—some of them funded by text-based therapy providers like Talkspace—continue to suggest that texting is a legitimate and effective way to deliver mental health care to people of all ages. For example, in a study published in July, Hull and other researchers found that text-based or voice-note therapy was just as good as teletherapy—which itself was found to be about as effective as face-to-face therapy—in reducing symptoms of anxiety and depression over three months.

That means people who like the idea of ​​texting a therapist should feel confident that they’re getting the same quality of care as those who opt for video visits, says senior author Michael Pullmann, who conducted the study while a research professor at the University of Washington School of Medicine.

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How is that possible, when the bond between patient and therapist is considered one of the best predictors of therapy success? Can such a bond develop over text? The American Psychological Association didn’t take an official position on text therapy until 2015, and some therapists remain skeptical of the idea. But a 2021 review of research suggests that strong bonds can develop over text or email, just as they do in person. Other studies even show that people can “bond” with AI chatbots.

Some research suggests that face-to-face relationships yield better outcomes than online connections — but Adrian Aguilera, an assistant professor at the University of California, Berkeley, who studies digital health, isn’t too worried about that. Aguilera says he’s less concerned about whether text-based therapy is as effective as face-to-face therapy and more about whether it’s better than nothing — because that’s the mental health care most people in the U.S. get today. “Is it the best? Probably not,” he says. “The better question would be, ‘Can it fill an unmet need?’”

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The response seems to be positive. During the pandemic, Aguilera tested a system in which people received daily automated text messages aimed at improving their mental health. (Example: “Self-soothing is an important coping skill. What are two ways you can use your senses (e.g., smell, taste, touch) that will be calming?”) Overall, those who received the text messages reported improved symptoms of anxiety and depression after 60 days. But the program seemed to be particularly beneficial for Latino users, who reported learning new information from the messages, perhaps because they were less likely than white participants to have sought mental health care sooner.

Aguilera’s other research also found that patients tend to stay in therapy longer when it includes a texting component. And maybe that’s not so surprising, considering that almost all of us are glued to our phones these days. “Have you ever texted a friend when you were upset or worried about something?” Pullmann asks. The answer is almost certainly yes.

As with regular conversation, Pullmann says, texting with a therapist offers the benefits of both immediacy (you can send a message as soon as a difficult feeling comes up) and asynchrony (the person on the other end can take the time to prepare a thoughtful response).

Some people may also find it easier to express dark, embarrassing, or vulnerable thoughts in writing—and research consistently shows that people benefit from putting their thoughts into written words, Hull notes. In addition, she says, text therapy may offer the benefits of “state-based learning,” the old psychological principle that it’s best to study for a test in the room where you’ll be taking it. In other words, it’s possible that therapeutic principles are more memorable when they’re delivered in environments where people will actually need those insights, such as at home or at work.

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Text therapy isn’t perfect. Two of the largest online providers, Talkspace and BetterHelp, have faced criticism, and Talkspace is the subject of a class action lawsuit alleging that it charges users fees even when therapists aren’t available to meet with them. (All of the claims in the lawsuit have since been dismissed or settled, according to a statement from Talkspace.) In 2022, Wall Street Journal In the article, healthcare providers who worked with Talkspace also criticized the quality of care offered on the platform.

In a statement to TIME, Dr. Nikole Benders-Hadi, medical director of Talkspace, said the platform’s therapists are vetted and licensed, and research suggests text-based therapy is effective. “Imagine having an always-on, open option for communication with therapists, instead of having to bottle everything up and wait for the next session,” Benders-Hadi said in a statement. “Ultimately, meeting members where they are and empowering them to choose the way that best suits their therapy needs is what matters most.”

BetterHelp, meanwhile, last year agreed to pay nearly $8 million to settle Federal Trade Commission allegations of improper data-sharing practices. In a public statement after the settlement, the company said its “technology, policies and procedures are designed to protect and secure our members’ information so it is not used or shared without their consent.”

BetterHelp has also recently faced negative social media backlash from customers who say its clinicians have given bad advice or behaved inappropriately. In a statement to TIME, a BetterHelp spokesperson did not directly address those allegations, but emphasized that the company provides customers with “multiple ways” to connect with therapists, including phone and video calls, and said it’s “very rare” for members to rely solely on text messaging.

Quality control is an issue in any form of therapy, Hull says. There will always be good and bad therapists, good and bad patients, whether the visits are conducted in a private practice or via iPhone.

“I don’t think there’s anything about news-based care that reduces quality,” he says. Increasingly, the data is on his side.

Write to Jamie Ducharme at [email protected].