Open up your phone at any time and vent to a mental health professional about your issues—that’s the promise of text-based therapy. But the experience isn’t quite that seamless, and it’s backed by a limited amount of peer-reviewed research. If you choose to use one of these services, you should do so with the knowledge that you’re participating in an ongoing experiment in a form of therapy whose benefits may or may not be supported by future science.
“Text therapy is really unknown,” said John Torous, who leads the American Psychiatric Association’s working group on apps. “There are a lot of assumptions being made.” In this new form of therapy, you can message your therapist anytime in a secure chat window on your computer or phone, and they respond once or twice a day (or so). Although you can schedule a “live text” session with therapists on some platforms, this is not the primary use. As I discovered when I did a free trial of BetterHelp while researching for Wirecutter’s guide to online therapy, text therapy is more akin to an email exchange. (See my companion piece “What Is It Like to Use Online Therapy?”)
Because of the time lag in communication—it’s asynchronous—text-based therapy is different from both traditional in-person therapy and video therapy, which in comparison are rather close to each other.
Text strips away visual cues, noted Sheila Addison, a California-based therapist who offers video sessions. Being face-to-face in a conversation with someone can help them open up because you are there with them. With a text-based app, “you don’t have that leverage to say, ‘I want you to go to a scary place, and I’m going to go there with you,’” Addison explained.
Although video therapy is well-studied—nearly 100,000 people participated in one trial for such services—peer-reviewed studies on text therapy are small.
In one 2006 study, participants experiencing a severe form of grief who received counseling over email improved significantly, but that study included just 55 people.
Or take a peer-reviewed study from 2013, which suggests that contrary to Addison’s concerns some patients may form a strong relationship with their text-based therapist. That trial included 30 people and lacked a control group, making it hard to tell whether the effect was due to the kind of therapy or, say, how soothing the patients found the very act of participating in the study. Given those limitations, this study is an interesting peek into what text-based therapy may be capable of, not clear evidence that it will work on a real-world scale.
Although video therapy is well-studied—nearly 100,000 people participated in one trial for such services—peer-reviewed studies on text therapy are small.There are good reasons why text therapy may work, said D’Arcy Reynolds, assistant professor of psychology at Southeast Missouri State University and an author of the 2013 study. Writing in a chat window may be a calmer experience than telling someone your problems aloud. The act of writing itself can provide relief. “It might be a different way of doing psychotherapy that has advantages hardwired in,” he said.
Reynolds told us he saw no huge problem with people trying it out, especially if those qualities made therapy seem more appealing. But even he was quick to note that there’s a lot more to learn: “Does it have the critical mass of research so that I can say without hesitation that it can be efficacious? No.”
The folks selling the therapy don’t convey that uncertainty. The website for text-therapy company BetterHelp notes that the service “may be right for you if you're looking to improve the quality of your life.” The FAQ page for Talkspace states that online therapy is “absolutely” effective. (The caveat these companies are clear on: Their services aren’t for people in emergencies, or people with a severe diagnosis.)
Those companies have some additional evidence, gathered after they started selling text therapy, including a couple of white papers (PDF) on the effectiveness (PDF) of their services, complete with analysis and charts. A forthcoming study funded by Talkspace will be published in May in the peer-reviewed Journal of Clinical Psychology. The Columbia researchers who conducted the study looked at 267 Talkspace clients with anxiety or depression (there was no control group). After 90 days on the platform, two-thirds had recovered or improved.
Text-based services aren’t for people in emergencies, or people with a severe diagnosis.Take those results with a helping of salt. Although the scientists were allowed to publish the results even if they didn’t shine a positive light on Talkspace, the fact that Talkspace was sponsoring their work means that they still could have harbored an unconscious bias in favor of the platform. (If a company paid you to review a new candy bar and said that you were allowed to say whatever you wanted about it, well, you still might be subtly inclined to give a nice review. Talkspace, unsurprisingly, argues that this bias is negated by peer review and Ivy League reputations.) So even though we don’t need to throw out these results entirely, there is no other substantial work on text-based therapy to bolster them or put them in context.
“Talkspace is the research leader for asynchronous text, as no one else has published research on this modality except for us and our partners so far,” Talkspace VP of clinical research and development Derrick Hull said in an email. Still, he said in a follow-up phone call that he took it as a given at this point that text-based therapy was effective, arguing that the studies with smaller sample sizes were robust enough support (contrary to what D’Arcy Reynolds, the very author of one such study, told me). “The research that we’re doing on our modality now is really out of due diligence,” Hull said.
“You don't need a study to know that texting is now the preferred mode of communication of essentially everybody,” wrote Alon Matas, the founder of BetterHelp, in an email. Although Matas noted that he welcomed more studies, he didn’t seem to see BetterHelp as treatment so much as something to buy, a product that could be bolstered by customer reviews in place of peer-reviewed data. In an email exchange, I referred to people seeking assistance on BetterHelp as “patients.” He corrected me: “We call them ‘members’ or ‘customers.’”
If you try it, read the pricing carefully: Services commonly advertise weekly rates, whereas they actually bill on a monthly basis.Even given text-based therapy’s potential for some people, there are a few quirks of the platforms themselves that further make the format less than ideal. They match you with a therapist based on a survey, rather than allowing you to select your own. Even though you can switch therapists, it’s better to have a clear view of all your options before you pay for the service, especially because the choices can be quite limited (therapists can see patients only in states where they are licensed). Text-based startups frequently advertise their affordability, but their services are not necessarily a good deal. With text-based therapy, you might spend less money per month compared with the fees for seeing a therapist in person every week (at least if you’re paying out of pocket; these companies do not accept insurance). But considering the lack of evidence, the value of the therapy is unclear. Companies that offer text therapy typically run on a subscription model, bundling in an option for one or more video sessions per month, along with the ability to contact your therapist at any time. But those video sessions may be shorter than a traditional 45-minute (or so) session you’d find with in-person therapy or video-therapy platforms. Although one company, BetterHelp, technically offers unlimited video sessions for a $65-per-week fee, the limiting factor remains how often your therapist can meet with you, and when your schedules sync up. You’re assigned a therapist without any questions about what your schedule is like. BetterHelp's Alon Matas noted that if availability didn’t work out, you could always switch; at best, this seems like a hassle. If you try it, read the pricing carefully: Services commonly advertise weekly rates, whereas they actually bill on a monthly basis. Call customer service or communicate with your therapist to know the number and length of video sessions you’ll be getting for your money. And watch out for the auto-renew feature. Ultimately, the main harm in trying text-based therapy is spending the time and money you could have instead applied toward in-person or online therapy—treatments backed by more robust research and experience.