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The Myth of Unlimited Text Therapy

 

The Hype

The success of companies such as Talkspace and Betterhelp in the new field of behavioral therapy chat created a hype which the telehealth company I worked for wanted to capitalize on. We already had a nationwide network of regionally licensed behavioral therapists taking video calls, so therapy chat appeared to be within reach: we just needed to develop a messaging app. I was asked to study “text therapy” services and evaluate what it would take to enter this new market.

Unlimited Therapy?

Talkspace and other similar companies very successfully surfed on the association that people made between text messaging’s “unlimited” characteristics and behavioral therapy. Therapy chat appeared to be much cheaper than a series of in-person sessions, and gave the appearance of the therapist being “always available”.

But according to therapists we met with who had worked with text messaging as a means of treatment, the medium lacked efficiency and was terribly time-consuming. This raised a big redflag: how were these companies successful when the question of how to make “text therapy” sustainable had not been addressed?

Text App Limitations

I built a team of volunteers to test Talkspace and Betterhelp products. We had three weeks to engage in-depth with this type of therapy, report on the experience, and evaluate the differences with regular “talk therapy”.

We found that text interactions with therapists were highly rated by testers. The service engaged patients with dealing with their issues and pushed them to want to pursue a behavioral treatment; the casual format of text messaging appeared to lower the stigma associated with getting help. However, reproducing “talk therapy” via the messaging medium proved to be difficult—using this interface presented various challenges to both patients and therapists, at the core of which were the efficiency concerns first raised by the therapists during pre-test interviews.  
 

 
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Seeking Sustainability

We needed to look into the efficiency concerns voiced by these therapists. So we used a standard messaging app to simulate a work interaction between a therapist and multiple patients.

We counted time for redacting, understanding, and answering text, as well as the average delays between each exchange. Then we role-played the same content as if it were a live interaction.

We estimated the messaging medium took up to triple the time “talk therapy” would take to reach an equivalent outcome. The culprits for this inefficiency were:

  • the asynchronous nature of the interactions

  • the lack of immediate prompting by the therapist

  • issues related to written expression, and

  • lags and delays between exchanges.

These findings confirmed that a behavioral treatment engages vastly different communication behaviors than those for sending a text message; as such, a texting app is much more limited when it comes to introspective work.

Through discussions with therapists, we also realized that there was no established clinical methodology regarding delivering a treatment via text messages. Consequently, they didn’t see any value in using this medium as an alternative to “talk therapy.”
 

Value: User Acquisition

We noticed a pattern with both Talkspace and BetterHelp therapists: after initially attracting patients through the messaging app, they were quick to push the benefits of live interactions such as in-person visits, phone or video calls—all of which were upgrades or involved extra fees. These offers were appealing to patients, who had experienced difficulties within the messaging app but who by that point had already become invested in the process. Text therapy,” in this instance, seemed to be less of a meaningful alternative to “talk therapy” and more likely a viable tool for user acquisition and lead generation.

We also noticed how both applications would attempt to retain their users by exploiting their vulnerability and making them feel irresponsible for unsubscribing. Seen through this lens, Talkspace’s astonishing user base made more sense.

 

Not “Just” A Messaging App

The inquiry into “text therapy” concluded with two main assertions: that entering this field wasn’t as simple as “just” developing a messaging app; and that messaging was primarily an entry point to more conventional means of therapy. Our company had various assets to its advantage that showed we could clearly offer more value than anyone else in the “therapy app” field:

  • a significant network of licensed therapists

  • the ability to give prescriptions

  • the phone and video technology, as well as supporting infrastructure, to process insurance claims, perform customer service, and other administrative tasks.

I followed up with a set of recommendations and design challenges:

Primary challenge: Convince members of our existing provider network to work with messaging, and to do so by designing a competitive compensation scheme that would attract experienced professionals. Then, organize a trial to understand how to best balance messaging interactions with live interactions.

Secondary challenge: Design an application that addresses the blatant usability issues we observed during our inquiry. Providers need a tool—a browser-based app—for aggregating their stream of messages coming from many patients, and for optimizing the time spent recalling cases, identifying issues, and redacting answers. A significant design and development effort is needed to create a messaging app for care professionals.


Tertiary challenge: Make our patient-facing messaging mobile app more conducive to sustained writing than the standard messaging app.