“When my brother died,” she said, “that’s when I fell apart.” She was having anxiety attacks; she was crying all the time. She wanted to find a therapist to talk to, so she started making calls but no one could fit her in for weeks. She was frustrated and unsure of what to do next. “I’m sitting at my counter, and a commercial comes on with Michael Phelps,” she remembered. It was an ad for the therapy app Talkspace. “I was like, I don’t know, maybe I should try that.”
Talkspace is part of a growing field of services that promise mental-health care via smartphone. And unlike many of the problems tech start-ups have set out to solve, this one actually exists: It’s hard to find a therapist. Maybe you have insurance, so you look up a list of in-network providers, start cold-calling, and hope to reach someone with an opening. Maybe you ask for recommendations from friends and hope someone they know takes your insurance or has out-of-pocket rates you can afford. Maybe you don’t know anybody with a therapist and the prospect of getting one yourself seems risky or shameful. Maybe you don’t know anyone with a therapist because there aren’t any therapists around to see—approximately 33 percent of counties have no records of licensed psychologists.
Geographic distribution is just one of the ways the mentalhealth profession fails to match the people in need of care: Doing so would also require more therapists who speak Spanish, more therapists of color, more therapists with LGBTQ expertise. Even in a therapist-rich environment like New York City, intangibles intervene. How do you find someone to whom you feel comfortable saying things you may feel uncomfortable saying at all? People seeking therapy face all these challenges even in the best of times, and these are not the best of times. According to a CDC report released last summer, 40 percent of American adults were dealing with mental-health or substance-abuse issues in late June, with younger adults, people of color, essential workers, and unpaid caregivers disproportionately hard-hit.
Therapists have long faced the question of how to provide their care to more people without diminishing its quality. In 1918, amid the catastrophe of the First World War, Sigmund Freud gave a lecture in which he proposed using free clinics for mass mentalhealth care—even as he acknowledged that doing so might require his fellow psychoanalysts to “alloy the pure gold” of their usual methods. “We’ve been in a crisis of access to mental-health care really since mental-health care professionalized,” said Hannah Zeavin, a professor at UC Berkeley whose forthcoming book, The Distance Cure, traces the history of remote therapy from Freud’s letters to crisis hotlines and up through today’s apps.
Accelerated by the pandemic, Zeavin’s subject has gone from an academic curiosity to a growth sector. Businesses in the “digital behavioral health” space raised $1.8 billion in venture-capital funding last year, compared to $609 million in 2019. In January, Talkspace announced plans to go public this year in a $1.4 billion spac deal. A presentation for investors managed to be simultaneously grim and upbeat in outlining the “enormous” market for its services: More than 70 million Americans suffer from mental illness, according to Talkspace, and the country has seen a 30 percent increase in the annual suicide rate since 2001. Talkspace says 60 percent of its users are in therapy for the first time.
Hillary Schieve, meanwhile, is not only one of the many Americans who have confronted mental-health concerns in the past year; she is also the mayor of Reno, Nevada. She knew plenty of other people in Reno were suffering from anxiety, depression, or grief. “Oh my God, if there’s one thing I could give as a gift to people in my city, it would be free therapy,” Schieve remembers thinking. “How do I do this?” Citywide therapy turned out to be one of the political fantasies the pandemic had brought within reach. After Schieve made her case before the City Council at a Zoom meeting in early December, the councilmembers voted unanimously to approve a contract for $1.3 million in cares Act funding: In 2021, all Reno residents over the age of 13 would have free access to Talkspace.
“We think the city of Reno has been really at the bleeding edge,” said Talkspace president Mark Hirschhorn. The martial spirit of corporate jargon is an uneasy match with care work. Even as pandemic news takes on a tentative note of hope, Talkspace foresees a longer-lasting shift in behavior, which bodes well for its business. “There is no vaccine for grief,” Hirschhorn said.
Therapy exists where the placebo effect meets self-help meets a confession booth. I say this as someone who has been in and out of therapy for something approaching 30 years. Where would I be without therapy? I can’t know. Has it helped? I hope so.
When I was very young, the main solution I knew for what I would now call anxiety was to reserve all distressing thoughts I experienced in the course of the day and disgorge them to my mother before bed. I dreaded doing this, but it seemed to work. So probably I was favorably inclined to the idea of someone to talk to. The primary job of the therapists I’ve seen since then has been to notice what I didn’t. They told me if the things I was saying were cause for alarm or resembled other things I had said before or were otherwise revealing. The most effective tool I had acquired was Lexapro, which, after more than a decade, I chose to stop taking at the beginning of March 2020. A few weeks later—cruising on the adrenaline of a crisis in progress, wondering whether my husband was about to lose his livelihood—I decided I no longer needed therapy, either.
I remember my thought process here as matter-of-fact: My insurance had changed, then the world had shut down. The remote alternative to in-person therapy felt somehow flimsy. When I spoke to my therapist on the phone, I found myself in the conversational register of efficient factual updates; the ritual of going to a particular place at a particular time seemed to be what allowed me to escape the gravitational pull of small talk. Or so I thought. Within a few months, I discovered desperation would also do the trick. This was a discovery I was making at the same time as many other people. Prior to the pandemic, remote therapy—speaking to a therapist by video or phone— tended to be seen as better than nothing, a solution for limited situations. But then all therapy went remote, and, as I found when I began video sessions last summer, it was indeed better than nothing. (There were certain advantages, in fact: For the first time, I was reliably not late.)
Meanwhile, as the conventional therapy world adapted to this changed reality, the growing field of therapy apps had an opening to press its case. The customer demographic coveted by direct-to-consumer start-ups was now conducting its work life over Zoom, buying its groceries over Amazon Prime—why shouldn’t this logic apply to therapy? The tides of commerce are not new to the realm of mental health. In fact, the blurriness of categories like “wellness” and “self-care” can call to mind the 19th century, a time before psychotherapy had professionalized in any widespread way, when Americans turned to a teeming marketplace to treat their inchoate ills with tonics, phrenology, and rest cures. In the 20th century, the medical profession consolidated its authority over Americans’ mental well-being. Physicians did their best to run the less credentialed out of the marketplace, and psychoanalysis became the gold standard of expertise. This development gave a lasting shape to therapy in the popular imagination: a couch, your parents, your dreams, a cigar—the shorthand endures, even if almost no one is in analysis anymore.
By the end of the century, rival schools had emerged, including, most notably, cognitive behavioral therapy. Where psychoanalysis sought to plumb the depths of the past, CBT focused on present symptoms and quantified results. The goal was not to understand why you felt and thought what you did but to stop those thoughts and feelings from disrupting your life. Instead of a narrative, CBT produced data, with patients scored on symptom inventories for conditions like depression and anxiety. Data lent itself to clinical trials and scientific legitimacy; data (along with treatments that lasted weeks, not years) appealed to insurance companies. Today, in a therapist’s office, patients are more likely to encounter the principles of CBT than of Freud.
The British writer and psychoanalyst Adam Phillips reflected on this shift with some skepticism in 2006. “It would clearly be naïve for psychotherapists to turn a blind eye to science, or to be ‘against’ scientific methodology,” he wrote. “But the attempt to present psychotherapy as a hard science is merely an attempt to make it a convincing competitor in the marketplace. It is a sign, in other words, of a misguided wish to make psychotherapy both respectable and servile to the very consumerism it is supposed to help people deal with.” (Psychotherapy, he points out, emerges historically just as “traditional societies begin to break down and consumer capitalism begins to take hold.”)
The market-friendly mind-set that may worry a psychoanalyst beguiles a tech-company founder. And understanding psychotherapy in this way—as a matter of prescribed interventions and measurable results—makes it possible to imagine technological alternatives in the first place. An approach like CBT is “very friendly to computational modeling,” Zeavin, the Berkeley historian, explained; its practitioners already embrace manuals and workbooks.
Much of what appears if you search “therapy” in the App Store does not provide the services of a human therapist. Some of it does not address mental health at all, in the strict sense: It is the digital equivalent of a scented candle, wafting off into coloring apps and relaxation games. Many services occupy an area somewhere in between professional care and smartphone self-soothing. Reflectly, for example, bills itself as “the World’s First Intelligent Journal” and promises to use the principles of positive psychology, mindfulness, and cognitive behavioral therapy to help users track their moods and “invest in” self-care. “Just like a therapist!! But free!!” reads one review. (Reflectly costs $9.99 a month.) Sayana, an AI chatbot, is personified as a pastel illustration with a dark bob and cutoff jeans; she also tracks the user’s mood and offers tips (“Observe your thoughts as they flow, just like the river”) to guide users on a journey through “the world of you.” “This is like your own little therapist and I love it!” reads one five-star review. Youper (mood tracking, chatbot, lessons) sells “Self-Guided Therapy”; Bloom (mood tracking, chatbot, lessons) is “the world’s first digital therapist.”
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