The Trouble With Instant Therapy

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If you’re a habitual podcast listener, you’ve probably heard — or passed over, with the skip button — an ad for an online counseling service. These so-called “direct-to-consumer" therapy services are pretty thick on the ground these days; a quick search reveals no fewer than 12 of them. You’ve probably been advised, repeatedly, just how convenient these services are, how easy it is to switch therapists if you choose, and how much money you might be able to save with an instant-therapy service over traditional face-to-face treatment. It certainly does seem easy: Just turn on your phone (or computer, or tablet) and you could be chatting with a therapist in moments — or instead, try therapy-by-text, and take advantage of your unlimited ability to message your counselor at any time of day or night. It certainly sounds terrific — but is it?

Although your average therapy-goer might not be committed to the traditional face-to-face treatment style, plenty of people who need therapy might need more help than an instant service can provide.** Those who suffer from suicidal ideation, and are at risk of harming themselves (or others), certainly need a higher level of care; so do people with disorganized thinking, or with the delusions or hallucinations found in some psychotic disorders. And some patients need more careful medical monitoring, and tighter coordination between psychotherapy and physical medicine, than a more casual, switch-whenever-you-want therapy service can provide. Lastly, some conditions — like borderline personality disorder — may cause disturbances of relationships themselves; in those cases, the light touch of an online therapy service, or a text-based connection with a therapist, won’t be enough.

Other, more general problems with virtual therapy services have been well publicized. A 2015 article released by the American Psychological Association summed up their concerns over online mental health treatment: Some providers, they reported, might not be fully licensed, or unlicensed in the states where their patients live; also, the technology in use can compromise a patient's confidentiality, if an app or website isn’t made completely secure.

Several online providers tout the advantages, in their view, of being able to switch therapists whenever you choose, but this might not actually be a benefit. A long-understood perspective on psychotherapy holds that a few “common factors” across all types of treatment account for most of its benefit. High up on the list of these common factors is the therapeutic alliance — the unique, empathic connection between therapist and client. This relationship may go through its ups and downs over a course of treatment, but — according to Bruce Wampold in World Psychiatry (2015), the “real relationship” between patient and therapist continues to deeply affect a treatment’s outcome. Choosing to swap out one therapist for a new one, whenever a given moment appears to present the need, does not contribute to this kind of genuine connection, and can prevent online therapies from benefiting from this powerful and consistent curative factor.

App-based and web-based therapies have another major problem: upholding users’ trust. One player in this marketplace, BetterHelp, assured customers that their data would remain confidential, but later shared the private information of over 7 million customers with social media platforms like Facebook, Pinterest, and Snapchat. According to the Federal Trade Commission: “In 2017, BetterHelp allegedly uploaded the email addresses of all current and former clients to Facebook – nearly 2 million in total – to target them with ads to refer their Facebook friends to BetterHelp for mental health services.” Later, BetterHelp released information to Facebook about customers who had previously been in therapy — which they’d learned by directly asking customers if they’d ever been in counseling or therapy before. Essentially, BetterHelp made private disclosures like this a condition of using their service, and then sold that information without their customers’ consent.

There are other concerns: A TikTok thread called “BetterHelp Horror Stories,” and a plethora of “Worst Experience Ever” posts on Reddit, suggest that not every consumer of online therapy winds up satisfied. Others allege that some online therapists hold sessions that are too short; suddenly discontinue treatment without explanation, conduct virtual therapy sessions while in public, or fail to understand the conditions with which their patients have been diagnosed.

To be clear, plenty of people can do well in online therapy. College campuses offer it to students, and psychology doctoral programs often provide it for other students at their universities. There is a real need for barrier-free online therapy, and many such organizations fill that need admirably. But for most people seeking mental health care today, no matter how cheap or fungible an instant virtual therapist might be, the results may still not approach the potential of old-school psychotherapy (whether in person or online). Instant therapy might be easy to initiate, and it might offer you the chance to text a stranger at any time of day or night, but there’s not yet enough evidence that these qualities really help. Developing a real relationship with your therapist — that is to say, finding a person who understands what you’re going through, and learning to trust that person with your feelings — is still the most relaible way to restore your mental health.

In this post, when I say “instant therapy” or “virtual therapy,” I’m referring to services that aim to immediately connect you with a therapist, and not to the now-common style of conducting therapy through a video link.

To find a therapist, visit the Psychology Today Therapy Directory.