The Perils of Text Therapy

Online therapy seems to be everywhere these days – in our Google search results, news feeds, on the lips of our friends and colleagues. An ever-growing number of companies are marketing platforms that connect potential therapy consumers to qualified clinicians in their state. The marketing rhetoric deployed by these companies is Pollyanna: one BetterHelp ad I saw in my Facebook news feed promises professional, personalized, unlimited therapy for $35 per week, without the hassle of having to drive to an office and pay over $100/hour.

Like many therapists, I was both intrigued by and skeptical of how technology might create better access to therapeutic services for those who need it. I began to investigate these platforms. Many companies, such as Breakthrough, offer therapy video conferencing, the efficacy of which is well-supported by research. Many others, however, offer text and phone-based therapy only, and when I signed up for a trial with them I was appalled by what I found.

Misrepresentation of Therapy

The average consumer who searches for “online therapy” probably envisions finding a therapist with whom they can talk through a video interface. So when their search results pull up services that limit their therapeutic interactions to text and phone— with pricing models that incentivize text-based communication only—they might conclude that this is just as effective. They would be wrong.

Let’s get one thing clear: psychotherapy is, at its core, about human connection. Humans have bodies. When you remove the bodies from the equation, you’ve amputated a critical aspect of the human connection. Here’s why: all available social science and psychological research into the subject finds that a large majority of communication is nonverbal.

A large part of what makes psychotherapy effective is that therapists are trained to notice all aspects of a client’s presentation: their speech (including tone, volume, and pace), appearance, body language, and affect (expressed emotion), among other things. This nonverbal information provides important clues about the client’s psychological condition as well as what therapeutic interventions could be most useful. This nonverbal communication is unconscious (outside of the client’s awareness), and even pointing it out to them can have immensely positive impact on the development of self-awareness and feeling of being deeply witnessed. Occupying the same physical space allows the client to utilize the therapist as a second nervous system, which helps them regulate and process their feelings in real time; such resonance is not possible through text. Most importantly, in-person therapy allows the therapist to connect to the client as a whole person, which is essential for fostering perhaps the most important element in therapy: empathy.

To remove the ability to see one another is to eliminate the possibility of real psychotherapy; it reduces the therapeutic interaction to “Dear Abby”-type advice giving, or at best, life coaching.

Another significant problem is intrinsic to text as medium of complex communication. Studies show that, in the absence of nonverbal contextual cues such as tone of voice, text communications are almost always read more negatively than intended. Positive emails are read as neutral in tone, and neutral emails are read as negative in tone. This is why a cardinal rule of couples therapy is to avoid communicating about important topics over text-messaging. In the context of online text therapy, a psycho-educational comment or gentle challenge to a client can easily be interpreted as condescending or critical.

If clients want advice, there is already an abundance of generic mental health advice and information on the internet, available free of charge.

Ethical Problems

By suggesting that text-based “therapy” is an adequate substitute for face-to-face interactions, these companies irresponsibly perpetuate the notion that improving complex mental health issues can be done quickly, conveniently, cheaply, on-demand and on-the-go. In this attitude we see reflected the sinister confluence of two major forces shaping our culture: the overmedicalization of mental health, and the misguided utopian fantasy that technology can only benefit us.

Primed to believe something that is, in fact, too good to be true, potential clients are all too eager to sign up . These text-based therapy platforms prey on people who are suffering, vulnerable, lost, isolated, economically disadvantaged, and do not have an adequate understanding of what therapy actually is. And there is no shortage of them: the abundant stream of new potential clients is part of how these platforms seduce therapists to work for them at a pay rate significantly lower than even the stingiest insurance companies.

Suddenly they’re roped in, having been promised impossible-to-deliver fast relief, when they could be seeking higher quality professional help. BetterHelp’s Terms of Service for providers even states: “The Provider agrees that the Provider Services, advice and or information that he or she provides to a User, aren't in any way to be considered a substitute for a face-to-face interaction between the User and the Provider (or any other professional)[emphasis mine].” Yet it is precisely the idea that texting is a substitute for face-to-face therapy—implied everywhere in their marketing materials—that hooks new customers. All of my clients seemed surprised when I suggested otherwise.

Bad for Clients, Bad for Therapists

Many argue that there is a healthy market of consumers who want this service and feel they benefit from it. And if this indeed offers true benefit for some, then I support it. But consider the clients in crisis or whose difficulties are complex and severe; in my anecdotal experience, they comprise at least 75% of the clients using these services. I don’t know any therapist of professional mental health organization that would condone addressing these situations through a series of emails, and yet when I suggested to these clients that phone sessions—which cost more—would be necessary to provide them with at least the minimum clinical standard of care, they say they cannot afford it. This financial reality is real, but text-therapy platforms that promise an artificially low cost of treatment do nothing to meaningfully address it.

Therapists similarly do not benefit from this arrangement. They devalue themselves monetarily, accepting rock-bottom reimbursement rates that contribute to demoralization, burnout and high turnover; they suspend their professional integrity reinforcing unrealistic expectations for clients; and they cheapen the public’s perception of psychotherapy by caving to Big Tech.

To be clear, online therapy via video conferencing is promising and has already showing great results. Though not ideal, the overall gains in terms of access and convenience outweigh the some of drawbacks it shares with text-based therapy. So let us as a culture stop trying to find cheap shortcuts for the most important and sacred goals in our lives: the enhancement of our well-being and relationships. We deserve better.