Dos and Don’ts of Therapy on the Go: Navigating the use of apps for mental health care

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It might be sur­pris­ing to think about brows­ing for ther­a­pists and order­ing up men­tal health care the way you can peruse a menu on Grub­hub or sum­mon a car on Lyft.

But over the last decade, dig­i­tal access to ther­a­py has become increas­ing­ly com­mon, in some cas­es replac­ing the tra­di­tion­al mod­el of in-per­son week­ly ses­sions between a ther­a­pist and client.

Apps for men­tal health and well­ness range from mood track­ers, med­i­ta­tion tools and jour­nals to ther­a­py apps that match users to a licensed pro­fes­sion­al. My team’s research focus­es on ther­a­py apps that work by match­ing clients to a licensed professional.

As a social work researcher, I am inter­est­ed in under­stand­ing how these apps affect clients and prac­ti­tion­ers. My research team has stud­ied the care that app users receive. We have talked to ther­a­pists who use apps to reach new clients. We’ve also ana­lyzed app con­tracts that men­tal health pro­fes­sion­als sign, as well as the agree­ments clients accept by using the apps.

Real ques­tions per­sist about how apps are reg­u­lat­ed, how to ensure user pri­va­cy and care qual­i­ty and how remote ther­a­py can be reim­bursed by insur­ance. While those debates con­tin­ue, peo­ple are reg­u­lar­ly using apps to con­nect to ther­a­pists for help with emo­tion­al and men­tal strug­gles. And through these apps, ther­a­pists are inter­act­ing with peo­ple who may nev­er have con­sid­ered ther­a­py before.

A ready-made market:

In the first year of the pan­dem­ic, rates of depres­sion and anx­i­ety increased by 25% world­wide. In a June 2020 sur­vey from the Cen­ters for Dis­ease Con­trol and Pre­ven­tion, 40.9% of respon­dents report­ed at least one adverse men­tal or behav­ioral health con­di­tion, com­pared to only 19% in 2018.

The old mod­el of ther­a­py, in which ther­a­pists and patients sat face to face, was already out of reach for many. In fact, men­tal health apps are a response to the demand from clients seek­ing more acces­si­ble ther­a­py services.

The COVID-19 pan­dem­ic tur­bocharged both trends – the grow­ing need for men­tal health care and using tech­nol­o­gy to access it. For exist­ing men­tal health clients, stay-at-home orders closed clin­ics and ther­a­pists’ offices to in-per­son vis­its, result­ing in an unprece­dent­ed shift to online access to therapy.

How matching apps work:

Con­sumer men­tal health plat­forms like Bet­ter Help, Alma and Talk­Space match clients to licensed ther­a­py providers. With adver­tis­ing on tele­vi­sion, across social media chan­nels and on high­way bill­boards, the apps pro­mote flex­i­bil­i­ty, con­ve­nience and the poten­tial to receive sup­port with slo­gans like “You deserve to be hap­py” or “Feel­ing bet­ter starts with a sin­gle call.”

When app users enter a platform’s online space, its pro­pri­etary soft­ware offers a dig­i­tal dash­board and com­mu­ni­ca­tion tools. These plat­forms also promise instant access to a pro­fes­sion­al ther­a­pist, imme­di­ate respon­sive­ness from them as well as anonymity.

App users choose a ther­a­pist by review­ing a list of providers accom­pa­nied by thumb­nail pho­tos, resume-like bios and con­sumer reviews. Users also choose how they’ll con­nect with ther­a­pists – phone or video calls, email, text or some com­bi­na­tion. The apps also let clients change ther­a­pists at any time.

As the client and their cho­sen ther­a­pist con­nect and com­mu­ni­cate, behind the scenes the app col­lects and main­tains records, lat­er cal­cu­lat­ing the cho­sen therapist’s pay­ment and billing the app user.

Apps and their risks:

Curi­ous­ly, while men­tal health app plat­forms pro­mote them­selves as providers of men­tal health ser­vices, they actu­al­ly don’t take respon­si­bil­i­ty for the coun­sel­ing ser­vices they are pro­vid­ing. The apps con­sid­er ther­a­pists to be inde­pen­dent con­trac­tors, with the plat­form act­ing as a match­ing ser­vice. And the apps can help users find a more suit­able fit if they request it.

But no law or prece­dent pro­tects con­sumers or clar­i­fies app users’ rights. This dif­fers from face-to-face ther­a­py, in which prac­ti­tion­ers work under the over­sight of state licens­ing boards and fed­er­al law. Some of the major ther­a­py apps have been accused of min­ing client data and being at risk for data breaches.

Like oth­er vir­tu­al spaces, online men­tal health ser­vice domains oper­ate under ever-evolv­ing and local­ized regulations.

Who benefits from these apps?

The social work­ers our team inter­viewed talked a lot about who can ben­e­fit from this kind of app-based ther­a­py and – impor­tant­ly – who can’t. For exam­ple, the plat­forms are not set up to treat peo­ple with seri­ous men­tal ill­ness or men­tal dis­or­ders that sub­stan­tial­ly inter­fere with a person’s life, activ­i­ties and abil­i­ty to func­tion independently.

Sim­i­lar­ly, app-based psy­chother­a­py is not suit­able for those hav­ing sui­ci­dal thoughts. The plat­forms screen users for risk of self-harm when they sign up. If a client ever pos­es harm to them­selves or some­one else, user anonymi­ty on the apps makes it almost impos­si­ble for a ther­a­pist to send a cri­sis response team. App-based prac­ti­tion­ers told our research team that they some­times end up mon­i­tor­ing their clients for signs of cri­sis by con­tact­ing them through the app more fre­quent­ly. It’s one rea­son app ther­a­pists, who also screen users, some­times reject poten­tial clients who may need a high­er lev­el of care.

For those with­out severe men­tal ill­ness, app-based ther­a­py may be help­ful in match­ing clients with a pro­fes­sion­al famil­iar with a range of prob­lems and stres­sors. This makes apps attrac­tive to those with anx­i­ety and mild to mod­er­ate depres­sion. They also appeal to peo­ple who wouldn’t ordi­nar­i­ly seek out office-based ther­a­py, but who want help with life issues such as mar­i­tal prob­lems and work-relat­ed stress.

The apps could also be prac­ti­cal and con­ve­nient for those who can’t or won’t get for­mal ther­a­py, even remote­ly, from a men­tal health clin­ic or office. For instance, the anonymi­ty of apps might appeal to peo­ple suf­fer­ing from con­di­tions like social anx­i­ety or ago­ra­pho­bia, or for those indi­vid­u­als who can’t or won’t appear on a video call.

Ther­a­py apps have helped to nor­mal­ize the idea that it’s OK to pur­sue men­tal health treat­ment through non­tra­di­tion­al routes. And with high-pro­file peo­ple such as Michael Phelps and Ari­ana Grande part­ner­ing with these apps, they might even be on their way to mak­ing men­tal health treat­ment cool.

– Lau­ri Gold­kind is an asso­ciate pro­fes­sor at Fordham’s Grad­u­ate School of Social Ser­vice and the Edi­tor in Chief of the Jour­nal of Tech­nol­o­gy in Human Ser­vices. This arti­cle was orig­i­nal­ly pub­lished on The Con­ver­sa­tion.

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