Is App-Based Therapy "Real" Therapy?

Written by Danielle L. Currin, MA, and Erica D. Marshall-Lee, Ph.D., ABPP on behalf of the Atlanta Behavioral Health Advocates

For several months, I co-led a group within a state-funded hospital’s outpatient clinic. One member, whom I will call Bill, often stated that he had been waiting for individual therapy for months and desperately needed extra support. He was encouraged to continue attending group sessions, and his frustration regarding the waitlist was validated.

Bill signed up for a popular online therapy app; however, no change was noted in his presentation. He indicated that despite reaching out to his app-based therapist for support, the suggestion was that he procure “actual” therapy, furthering his frustration and distress.

Eventually, Bill obtained individual therapy services within the outpatient clinic, but his journey sparked a question for me: What makes therapy “actual” therapy?

The United States has been facing a growing mental health crisis combined with a widening treatment gap over the past several years. From 2015 to 2019, the prevalence of a major depressive episode in the past 12 months increased among Americans at least 12 years old, from 7.3 percent to 8.6 percent, but the rate of speaking with a professional or receiving psychopharmacological treatment remained constant (Goodwin et al., 2022).

Since the COVID-19 pandemic, access to telehealth services and app- and web-based interventions has surged as more individuals have sought mental healthcare and in-person therapy has fluctuated in availability. These services have shown considerable promise as ways to increase access to mental healthcare, though they do not always employ evidence-based psychotherapy approaches (Li, 2023).

Utilizing digital technologies alongside traditional psychotherapy is not new. Phone-based apps, particularly mindfulness-focused ones, have existed for years as simple resources to incorporate daily mindfulness routines and home practice outside therapy. A recent meta-analysis highlights the utility of self-guided mindfulness training in both clinical and non-clinical samples (Taylor et al., 2021).

With dozens of apps available and research supporting their positive impact on individuals’ well-being, what makes these self-guided programs different than “actual” therapy? Is it the involvement of a mental health professional in real time?

Consider the use of chat-based crisis lines. Research on the National Suicide Prevention Lifeline’s crisis chat service has pointed to the significant efficacy of this brief intervention in decreasing suicidality (Gould et al., 2021). While not cure-alls or perfect interventions, the research backing the use of self-help mindfulness apps and crisis chat services makes an argument for the effectiveness of easy-access, low-commitment therapy-adjacent services.

In the service of increased accessibility, therapy apps seem to be a logical next step. The rationale for these apps is hugely appealing to the consumer considering mental health support but reticent to visit a therapist’s office. For a person who could benefit from mental health support, is it not better to have more access, more options, and more freedom to choose?

Robert Cohen's recent Mad in America article shines an unforgiving light on receiving and providing therapy by way of an app (Cohen 2024). Cohen highlights numerous considerations around app use—from a lack of evidence of efficacy to privacy concerns to the drawbacks of having 24-hour access to providers. But for the “what makes therapy, therapy?” question, I will focus on the flexibility of obtaining and changing providers at the consumer’s whim.

Recent reviews confirm that there is no one “right answer” for the number of sessions needed to achieve significant change (Nordmo et al., 2021, Robinson et al., 2020); rather, having the time and opportunity to develop a therapeutic relationship significantly impacts the effectiveness of psychotherapy, whether in person or virtually (Falkenström et al., 2014, Zech et al., 2023). Different providers, particularly on apps, may have vastly different approaches to therapy in terms of theoretical orientation, clinical focus, or personality.

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While “shopping around” for an appropriate provider is a practice to be encouraged, doing so repeatedly has the potential to hamper the opportunity to build an alliance with any one therapist, or may encourage consumers to seek out a provider who specifically says what they want, but may not need, to hear.

Additionally, communication encouraged by therapy apps is quick, informal, and in some ways, impersonal. The consumer and provider are disadvantaged, especially if a significant or early portion of the work is via chat. A consumer may expect a provider to respond to a text much more quickly than the provider is accustomed to or communicate in a way that crosses professional or ethical boundaries.

Small missteps or misunderstandings, particularly related to missing nonverbals like body language or tone, may result in the choice to switch providers, forgoing a “rupture and repair” experience, which can have a significant impact on therapeutic alliance and treatment outcomes (Eubanks et al., 2018). When consumers can leave without warning, the opportunity to closely examine a unique and rich relationship is missed, potentially encouraging one of the very behaviors the consumer may be hoping to address: avoidance.

How can mental health professionals attend to this issue? Two primary behaviors may prove to be essential: education and network development.

Providers and consumers alike can educate themselves and each other about how we can best utilize technology in mental healthcare without leaning on it entirely. As providers, we can build and maintain professional networks to ensure continuity of care in limited access spaces by identifying sustaining resources (e.g., groups, social workers, crisis lines, and apps) until consistent individual therapy can be provided.

Back to Bill. I do not know what he found beneficial or not about the digital platform. Given our knowledge of the therapeutic process, I have a sense that, while the app he chose afforded a level of attention that suited his preferences, it did not provide the depth of connection that Bill eventually received from a long-term individual therapist.

This is not to minimize the benefit of digital platforms; therapy-adjacent work (self-guided mindfulness apps, brief crisis interventions) can have a huge impact on a person’s mental well-being. However, for many individuals who need more support than one-time text conversations or daily mindfulness reminders, such apps may present an alluring but incomplete intervention. Working directly with a mental health professional may provide the missing piece.