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1 Question, 5 Answers: When Is Online Therapy the Right Choice?

Mental healthcare has jumped on the mobile bandwagon. Text message-based treatment has surged in popularity since the 2012 introduction of the therapy app Talkspace. While the practice is still new, early research suggests that texting with a therapist can be as effective as sitting down for in-person sessions. But that doesn’t mean it’s the right choice for everyone or every issue. We asked five mental health providers which types of patients get the most out of text-based therapy, and how virtual and in-person sessions should be combined — or not. Here’s what they said.

Jor-El Caraballo, LMHC

Therapist and founder of the holistic health practice Viva Wellness

I think that people who do well in text-based support tend to be highly motivated, verbal and self-starters. That is, they can work on holding themselves accountable to a text-based interaction with a therapist regularly to keep the process moving forward. As an alternative, those who find it difficult to type or write online (or use voice dictation) aren’t well-served by text-based support. In those instances, it also becomes another barrier to effective treatment. Those who are also regularly in crisis or suicidal would be better served, in my experience, with traditional face-to-face therapy or some combination thereof.

I think that issues related to anxiety are generally well-treated through online formats, such as text-based therapy. Additionally, in my experience, issues related to gender, sex or sexuality can be served well through text-based support, as there tends to be a lot of personal shame associated with some of those concerns. For many, talking through the format of text can be an important, and safer, first step in exploring those issues on their path to healing.

People who have severe depression, anxiety or psychosis-related disorders are best served by in-person services. I don’t think we yet have a good model for supporting folks with these conditions in a virtual format. Additionally, it’s also been my experience that primarily relational concerns, like personality conditions or communication issues, are better served with face-to-face therapy, as the therapist can better use the energy of the room to provide complex interpersonal feedback due to cues that aren’t readily available in text-based conversations.

Unfortunately, insurance hasn’t quite gotten on board with text-based therapy. The mental health industry, as a whole, is still in the infancy stage of seeing live video sessions as valuable therapy, despite ongoing evidence of their benefits.

David J. Austern, PsyD

Clinical instructor, NYU Langone Department of Psychiatry
New York City

Not enough well-controlled research has been done to answer [who the best candidates for text therapy are]. However, based on the data we have from two recent studies, it seems that younger people may be more interested in this form of therapy. The average age of participants in both studies was 34 years old.

While many people experience stress, anxiety and depressive symptoms, they may not necessarily have a clinical anxiety disorder or depressive disorder. Often people struggle with adjustment issues when jobs or relationships change. These may be the best type of problems for people to seek online therapy for at this time. A recent study included a case illustration of a Talkspace client-therapist interaction and suggested that the therapist often provided “basic empathic statements.” Similarly, that study asked patients what theoretical orientation the therapist was operating from. The most common response was that they didn’t know.

It is possible that many Talkspace therapists are providing supportive psychotherapy, which might be a fine option for both new and longstanding patients with lower-severity problems wanting lower-intensity interventions. It’s not likely to be sufficient many higher-intensity clinical problems.

We currently have a gap between the supply of psychotherapists and the demand for psychotherapeutic services. Apps could potentially function in a stepped-care service delivery model, where if patients try an app first before seeking in-person therapy, they may benefit sufficiently from the app and never need to see the live therapist. Similarly, after a patient has successfully completed a course of in-person therapy, they may step down to a therapy app for maintenance check-ins. This would best allocate resources so clinical providers who specialize in the treatment of more challenging disorders would primarily see patients truly needing their expertise.

Online therapy apps like Talkspace can stand alone. They don’t need to be combined with in-person therapy. Patients are assigned a licensed therapist, so if they are also seeking in-person therapy, they would have two therapists. This is generally frowned upon, although there are some circumstances where it may make sense. For example, if a patient is experiencing relationship stress and also wants to work on a flying phobia, they may want to see an in-person [cognitive behavior therapy] therapist to engage in exposure therapy for flying while also receiving supportive psychotherapy via Talkspace. The CBT therapy would be specifically focused on the flying phobia, so this could make sense on a short-term basis. If the content discussed overlapped too much, it would not be ideal.

Amanda Frey, LCSW

Social worker in private practice
New York City

I honestly think that most people would benefit most from in-person therapy. This is because it is very easy to misinterpret tone over text, leading to misunderstandings. The ideal client for online text therapy is someone who is looking for something short term, to deal with a temporary adjustment or stressful situation. For example, maybe you’ve just started a new job and need help managing the transition and the anxiety that comes with it. Maybe you’re about to graduate college and are freaking out about your future. These are people who are able to function and don’t normally experience mental health symptoms.

If someone is anxious of the unknown and isn’t sure what they might get out of therapy, then pursuing online therapy may be worthwhile. Online therapy should be a jumping-off point, or a tool in larger arsenal of mental health treatment. It can be combined with in-person therapy if done in a thoughtful way that respects the boundaries of both patient and clinician. For example, a depressed person in crisis who is going through an episode and can’t get out of bed may benefit from text therapy as opposed to nothing at all.

I would strongly recommend against pursuing online therapy as your primary mental health treatment if you have been diagnosed with an episode of psychosis at any time, or if you are diagnosed with a thought disorder. Additionally, any severe, persistent mood disorder would not be well served by online therapy alone.

Many subscription-based online therapy services operate outside the realm of health insurance, which means that patients are on their own to seek reimbursement for their sessions. However, more and more therapists are able to offer, for example, Skype (or another HIPAA-secure video chat) sessions and charge them to your insurance company.

Dr. Graham Mitchell, MD

Los Angeles

I think a format like [text-based therapy] is going to work best for cognitive behavioral therapy, which doesn’t require a whole lot of talking. It requires a lot more doing. Patients would come into a session to get some guidance and advice, but most of the meat and potatoes of the treatment and where you get the benefit is at home doing homework and exercises. You might be asked to do something uncomfortable. [The patient] needs to be a very highly motivated person who gets it, and a person who has a history of being self-directed.

Anxiety and depression are good options for online therapy, because 90 percent of it is up to you. It’s self-motivated and it’s very procedurally based. You challenge your own thoughts and assess them. Anxiety is kind of like a muscle in that the more that you practice your skills for squashing it, the easier it’s going to get. If you don’t keep up with it, it will get worse. These are skill-based, and you can learn these skills inside or outside an office. Smoking cessation works as well; there’s a program specifically for that. I would not recommend online therapy for anybody with any psychotic symptoms.

Insurance coverage is going to be state and carrier specific.

Annette Lee, LMHC

Therapist at Beacon Mental Health Counseling Services
Pittsford, New York

Online therapy can definitely be combined with in-person therapy, but it works great as a stand-alone option.  

I believe anyone can benefit from online text therapy, but specifically people with very busy schedules or who travel a lot are great candidates, since they can benefit from having their therapist literally at their fingertips. Some other good candidates are first-timers to therapy who are nervous. Along those lines, people seeking help with sensitive topics like sex or gender issues can benefit from text therapy, as it can be a more comfortable setting.

Most issues can be treated via online therapy. I’ve helped clients [online] with all kinds of things, from anxiety disorders and depression to sexual dysfunction, relationship issues, grief and loss, and adjustment disorders.

I do think that something like an emergent substance-use issue should be treated face to face. There are so many complicated factors to recovery, and it can actually be physically dangerous for someone who is in active use, which an online therapist can’t always effectively monitor. Also, someone who has an active suicidal plan with intent should be seen by someone in person or call a suicide hotline so that they can be helped immediately. That being said, online therapy can be a good supplement to any kind of treatment if someone is looking for extra support.  

A lot of insurances and employee assistance plans (EAPs) are now covering online therapy as an option for the people they serve, which is a great thing, since online therapy brings treatment to many people who might not otherwise seek it.

Responses have been condensed and lightly edited.

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