Is Text-Based Therapy Effective?

Is Text-Based Therapy Effective?
Illustration: Benjamin Currie

Living with mental illness looks different for everyone, but for many people, there are periods of time when your anxiety and/or depression symptoms are worse than others. One minute I’ll be typing away feeling neutral, and then the feelings start trickling in. (I picture it being like that older couple in bed together in Titanic who are stuck there, just watching the room fill with water, knowing they’re going to die…which probably doesn’t help with the depression.)

Even coming from a place of privilege when it comes to mental health, where I get the therapy and medication I need, there are still times when everything feels too overwhelming and I wish I could text my therapist right then and there (but I don’t). Sometimes, though, I use free online text/chat therapy services, and whether or not it was a licensed human therapist on the other end or some type of AI chatbot, it has helped.

But what about having regular therapy appointments via text or chat? Is that effective, or even a good idea? Could it be an option for the many people who are dealing with mental health issues for the first time during the pandemic and are new to navigating all of this? We spoke with several mental health experts to find out.

What is text- and chat-based therapy?

First of all, the term “therapy” can mean many different things for people. The kind we’ll be discussing here involves having a conversation with a trained professional (or computer) regarding your mental health. Instead of seeing a therapist face-to-face (either in-person, or through teletherapy), the client and therapist exchange messages through text or online chat. We’ll touch on both text/chat-based therapy with an actual licensed human therapist on the other end, as well as the kind where the “therapist” is an AI-operated chatbot.

What are the potential benefits?

Before we get into the risks and limitations of this form of therapy, let’s look at some of the potential ways it can help.

Accessibility and convenience

The biggest benefit of text- and chat-based therapy (with both humans and chatbots) is accessibility. “Text-based therapy may reach more patients because of reduced constraints on time, money, and location,” Dr. Sabrina Romanoff, a clinical psychologist at Lenox Hill Hospital in New York City, tells Lifehacker.

This is especially true now during the pandemic, because you don’t need to leave your home or find a local therapist who accepts your insurance (or has sliding-scale payments) and is currently taking new patients. Pandemic or not, it’s also useful for those who live in an area where therapy is simply not available. And, as Romanoff points out, in cases involving a chatbot, the service is available around the clock when you need it.

Affordability

Text- and chat-based therapy can be a way to access mental health support for those who otherwise wouldn’t be able to afford it. “Apps and chats are fairly inexpensive with low monthly fees or unlimited messaging,” Dr. Scott Guerin, a developmental psychologist and adjunct professor in psychology at Kean University, tells Lifehacker. “Even with copays, live sessions can be costly.”

Intro to therapy

If you’ve been curious about therapy in general and want to get a feel for having those types of conversations, text- and chat-based therapy could be a way to do that. “It can be an opportunity for individuals to dip their toes into the therapy pool, and motivate them to seek out the real thing,” Romanoff says.

Some people prefer writing/typing

We’ve reached a point where, for many people, communicating through text message, email, or online chat has become the norm. Even if you didn’t grow up learning how to process your feelings via texting and typing, you may have gotten so used to it that you’re now more comfortable over text than you are on a phone call. In fact, for some people, phone calls themselves are sources of anxiety. Those in that category might prefer to do therapy in the same way.

Along the same lines, Romanoff explains that some people are better able to process their emotions by writing (or in this case, typing) them out. But if that’s the aspect that helps you the most, she says that writing in a journal may be more effective.

What are the potential risks or limitations?

When making any kind of decision about your mental or physical health, it’s helpful to weigh both the possible pros and cons of your options to see which come out on top. These risks and limitations of text- and chat-based therapy aren’t another way of saying “this is dangerous, don’t do this,” but some things to consider while you’re deciding.

Developing a specific care plan

Before starting in-person therapy sessions, you’ll likely have some type of intake evaluation to help both you and the mental health professional you’re working with identify the areas you need to focus on, and then develop a care plan specific to your needs.

“There are many types of therapy and the only way to know which one would be right for you would be to speak with a mental health professional who can ascertain what could be most helpful,” Dr. Georgia Gaveras, co-founder and chief psychiatrist for Talkiatry, tells Lifehacker. “This may very well be a chat-based service, but for many others, it might not be enough.”

Lack of facial cues and tone

Like any form of written communication, things can get lost in translation during text- and chat-based therapy, given that it doesn’t provide the opportunity to pick up on facial cues and someone’s tone.

“It is critical to understand that even in these times where digital communication is the norm, it is still estimated that 70 to 93 per cent of in-person communication is non-verbal,” Guerin says. “That is, reading the client’s body language, glances, frown, furrowed brow, smile, hand gestures, and eye contact provides an enormous amount of information to the clinician as they assess the client, their issue and develop a therapeutic plan.”

The lack of these cues can be particularly problematic when someone’s words do not match up with their thoughts, according to Romanoff. This could happen in situations when patients are concealing important information — a difference Romanoff says therapists can more likely discern in person, but not through text. “This is especially true for high-risk populations, like individuals struggling with suicide, abuse, or substances.”

And, as Gaveras points out, it’s not only the absence of the facial cues and tone people use when describing a situation — there are also other physical clues therapists use to assess how a patient is doing overall. “For example, if you cut your arm but the doctor couldn’t see it, it would be incredibly difficult for the doctor to determine how bad it is,” she explains. “Similarly, in psychiatry, we learn a lot about someone through body language and facial expressions. We can see how someone has been able to care for him- or herself physically, if they are biting their nails, talking to themselves, or welling up with tears.”

It can also make a difference to the person on the receiving end of therapy. “Either during a scheduled session or a crisis contact, how someone says something is as important as what they say, and this can be difficult to ascertain through a text, and certainly using only AI,” Gaveras explains.

For example, someone with anxiety who catastrophizes everything might see a period at the end of a message from their therapist and read it as being aggressive (when that’s very unlikely the case), which could make them feel even more anxious and worry about whether they’ve offended the therapist or chatbot (don’t judge if you haven’t been there).

Authenticity

For Romanoff, there’s also the issue of authenticity. “In in-person therapy, we encourage patients to engage in free association — to open the gates of the mind without filters — and editing that goes into other types of communications,” she explains. “Texting brings those walls right up. The mechanism of thinking out a response, typing it, viewing it on the screen contextualized by the earlier conversation leaves very little authentic reaction, [and] instead, more self-editing and censoring processes are at work than if those same thoughts were communicated by speech.”

The missing human connection

In therapy involving AI-operated chatbots, not only are you dealing with all of the above, but there are also challenges that could come from the fact that you’re communicating with a computer, rather than a human person. “It takes a lot of vulnerability and effort to begin the process of therapy,” Romanoff says. “It is not easy to inhabit the patient role.”

For some people, therapy includes opening up about parts of their past that haunt them the most — things they may not have even discussed with those closest to them. This is another case of people needing and wanting different things out of therapy. For some people, telling their deepest secrets and fears to a computer program instead of a human therapist might make the process easier. Similarly, there may be individuals who find simply letting go of something the most useful part of therapy — regardless of who is or isn’t on the other end of the conversation.

But for others, human connection — even just over text or chat — is a crucial part of the process. “Being fully seen, heard, and withstanding that pain in the presence of another person is one of the most curative and comforting aspects of therapy,” Romanoff explains. “There is a great loss when considering the conduct of therapy among humans and robots. Robots cannot take in our experiences the way we need them to.”

The time lag in communication

For some, text- or chat-based therapy may not be as effective as in-person sessions because of the time lag in communication, which Romanoff says can disrupt the flow of the work. “Part of what makes therapy so effective is the emotional intensity that corresponds with the words. This is missing through text,” she explains.

And while most people go into this type of therapy expecting it to feel like a text conversation, according to Romanoff, in reality it usually tends to feel like an email correspondence. “This prolonged time gap between responses loses the emotional tone and salience that was present in the moment,” she says. “Therefore, the person is reading the response through a completely different lens, midpoint, and perspective when there is a delay, compared to when the message was originally sent.”

It requires trust

With everything we know about data and privacy, it’s understandable if you feel hesitant — maybe even suspicious — of therapy where you have to trust that the person (or bot) on the other end is who they say they are, including having all the necessary qualifications.

“Ethically, I think that anyone entering any type of therapeutic relationship should be confident that the space will be safe, and their privacy will be protected,” Gaveras says. “Any chat-based service should go above and beyond to ensure that it offers the highest level of security to its clients.” This means doing a little homework before selecting a site or provider (we’ll get to that in a minute).

Is text- and chat-based therapy effective?

At this point, you’ve probably figured out that it all depends on a person’s individual needs, and how they’re best able to express themselves and experience the benefits of therapy.

According to Guerin, text- and chat-based therapy can work well for people with mild symptoms, or with those who have been through in-depth counseling sessions and can use them as maintenance or supportive sessions. Similarly, Gaveras says that she can see text- and chat-based therapy being a useful supplement for those who are also in more traditional forms of therapy, especially for those engaged in certain treatments for anxiety and obsessive-compulsive disorder (OCD).

But Guerin says that doesn’t mean that text- and chat-based therapy is a good option for everyone. “I do not think this type of therapy is appropriate for those with serious or long-term issues, for people who have been hospitalized in the past for behavioural/emotional problems, or for those who require regular medication in order to maintain a stable life,” he notes.

This is especially a concern for people with more complex diagnoses or symptoms who opt for chatbot therapy, Romanoff says. That’s because it is often provided in the form of cognitive behavioural therapy (CBT) interventions — which may not be the best option for everyone.

“These are treatments guided through manuals, and have been found to be most effective for folks with ‘cookie-cutter’ clinical presentations,” she explains. “That means individuals with no preexisting conditions, premorbid or co-existing disorders, and relatively straightforward clinical cases. The reality is that no one is that simple, and there lies the beauty of the work. This is the main drawback of CBT, and is only further exacerbated online.”

Ultimately, Gaveras is optimistic about the possibilities for text- and chat-based therapy, but says we have to get a better understanding of it first. “There have been some studies on these chat-based services which have had their limitations in size and scope, but they are promising,” she says, “and it is absolutely something that should be explored further.”

How to pick a text-or chat-based service provider

If you’re interested in text- or chat-based therapy but aren’t sure where or how to find a provider that fits your needs, Guerin offers the following tips:

  • Look for a provider that uses licensed therapists with at least a masters degree or PhD. Make sure they are affiliated with an established and reputable company. Check out their academic background to verify their degree is from an accredited college or university.
  • Look for a service or provider that has experience with what you are looking to address — depression, anxiety, sleep disorders, etc. — and has experience with people like you: younger, older, college students, retired, etc.
  • Understand how the service works, including their scheduled times for interactions, whether a monthly plan is limited or unlimited, its cost, and the length of sessions.
  • Beware of any long-term contracts or financial commitments.
  • Make sure providers and services have a clearly stated confidentiality agreement and statement, and that they do not to use your information for anything else or give it to anyone. This is a must, to protect your privacy.
  • Look for how they support people who have serious problems. Do they offer emergency phone consultations or services? What does someone do if they have feelings about harming themselves or others?

Like in-person therapy, it may take a bit of trial and error to find a service or provider that’s a good fit for you.

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