Mental health care has become an increasingly common and de-stigmatized imperative, thanks in most part to a continuum of campaigning that includes everyone from grassroots activists to the Royal Family. But what does the therapist’s couch look like in the digital age? And how has our access to it changed over the years?
“Therapy culture in the UK is very conservative around technology,” says Dr Charlotte Cooper, a London based psychotherapist. “Having a website is still seen as somewhat daring.” There are a number of reasons for this, she explains.
“Therapy is one of the few professions in which older women can thrive as practitioners. This means that many therapists are not digital natives or early adopters of computers and the internet and are much more comfortable communicating offline.”
A lack of confidence or skill in using technology reflects the lack of investment in women in tech more broadly, says Cooper. “Plus, therapy training is not geared towards the working life of a therapist, and many practitioners are relatively unskilled in using social media or online resources to build a practice. This stale thinking also makes practitioners vulnerable to duff services.
“For example, I pay an extortionate £76 per year – on top of my other membership fees – to be listed in my professional body’s online database of therapists. For this I get a page that barely reflects the values and qualities of my practice, that I cannot customise, improve SEO, edit very easily and for which my returns are minimal compared to my own marketing elsewhere.”
Practitioners will do all they can to preserve the integrity of therapy’s relational nature, says Cooper. “For example, some practitioners refuse to use email; they insist on speaking on the phone to arrange things because they believe it is essential to hear a client’s voice in order to build a sound therapeutic relationship. Professional bodies are very cautious about causing no harm, and rightly so, but they’re not necessarily in sync with therapy clients, who are getting increasingly younger, and for whom internet technology is a fact of life.”
As studies show, anxiety has been at epidemic levels for some time, particularly across Generation Y. There are numerous factors behind this spike in distress; chief among these includes the 24-hour newsfeed. In the UK, the Mental Health Foundation have recently reported receiving a five-fold increase in traffic to their online anxiety page, a surge that began last July: the month following the EU referendum vote.
“Phones and social media keep us connected to the shifting currents of world and home political affairs, making it much harder to maintain boundaries and take healthy time out from anxiety-inducing news,” explains the charity’s senior media officer, Carl Strode.
While many in the therapy industry are asking us to rethink the way we use smartphones, others are hoping our devices may, ironically, offer a solution. Talkspace, a US-based online counselling app that launched in 2012, is reaping lucrative rewards out of American anxiety.
National distress around the 2016 presidential campaign and inauguration of Trump saw the start-up – which charges uses a monthly fee to connect with therapists via texts and video sessions – growing 70-80% faster than projected, according to CEO and co-founder Oren Frank, a swell made up mostly of millennials in the 33-34 year-old age bracket. LGBT people, Jewish people, Muslim Americans and women make up the lion’s share of Talkspace’s traffic.
“We think psychotherapy is something everyone and anyone should have access to,” says Frank. But are apps like Talkspace truly beneficial to their users, and the therapists they employ? Cooper thinks not. “They offer very low rates of pay and practitioners have to be available at all hours. Plus, texting is so limited. Apps like this are the Uberification of therapy.”
Digital stand-ins: help or hinder?
Apps like Talkspace are proving big business in the UK. In April, NHS England announced plans to invest £70m in digital mental health services. Online CBT programs, used to treat depression, anxiety and panic disorders, are an increasingly common feature on the NHS App Library. Some of these are free, while others are fee-based, and while some allow users to connect with a human, most do not.
Browse the NHS site and you’ll find apps like Big White Wall, a Facebook-slash-study-course style platfom for people with depression and anxiety, overseen by human ‘guides’; Buddy, a diary-like app to help spot patterns in mood and behaviour; Fearfighter, a CBT-based self-help course for panic and phobias; Leso, a live, confidential, IM-assisted CBT course for depression, pain management, OCD and stress management and Sleepio, a module-based tracker-style course for sleep issues such as insomnia.
There’s little-to-no proof that the majority of these digital stand-ins actually work
While apps like the aforementioned proliferate, encouraged into life by large, profitable NHS contracts, demographics that might have troubling accessing these technologies – the elderly, the neurodiverse and second-language English patients – seem conveniently forgotten. There’s also little-to-no proof that the majority of these digital stand-ins actually work. And after the recent ransomware attack on the NHS, concerns around confidentiality and government data protection seem particularly salient.
Even the most benevolent, non-profit therapy apps can fail – and even harm, as the Samartians found out in 2014. Their app, Radar, was designed to read Twitter users’ content for evidence of suicidal thoughts, and then alert the user’s friends and family. On paper, Radar was a way of turning “your social net into a safety net”; in reality, the app felt to many like an invasion of privacy, and a chance for bullies and stalkers to weaponize sensitive information against their targets. After heavy criticism, the charity abandoned the app.
Plugging the funding gap
Many experts, including Emma Broglia, a PhD student at the University of Sheffield, are voicing concerns around this wave of e-therapy business. “The issue is that these apps are designed by developers who do not have a therapeutic or clinical background, and very few have been the subject of clinical trials,” she points out in industry publication, Therapy Today.
What is clear is that the NHS is operating under increasingly untenable means, decimated by underfunding, mismanagement and privatisation. The annual estimated cost of mental health care in the UK is around £100bn per year, and since that extra £3.5m we were promised by the Brexit camp seems unlikely to materialise, crude tech stand-ins are being used to plug the gaps that record waiting times are creating.
They herald poor working conditions for therapists, says Cooper, which in turn means poor services for clients. The premise – that apps can adequately replace in-person therapies – is “total neoliberal nonsense in an austerity climate that is trying to de-fund health services and palm off cheap useless interventions on poor people. The rich still get their four-times-a-week, years-long psychoanalysis in Hampstead, of course.”
Developers and providers tell us these apps are indispensible because they’re available around the clock, on any device; that they make travel unnecessary, a boon for people who are ill, immobile or unable to travel due to financial, geopgraphical and/or mental health reasons. Cooper sees some of her clients via Skype, and while screen-based therapy may be a boon for some, it should never be the only available option.
The value of spontaneity
While some feel liberated by the mask of an avatar, others find them a real barrier. Evidence proves that screens can seriously impede the therapy process. As psychoanalyst and author Dr Gillian Isaacs Russell points out, 60% of communication is non-verbal.
“That implicit, non-verbal communication that is central to what you do in the consulting room isn’t going to happen in the same way online,” she warns. “Presence is a core neuropsychological phenomenon – it’s an organism’s capacity to locate itself in the external world, and the ability to interact with another in a shared physical environment enables the nervous system to recognise that it is in an environment outside of itself that is not a dream state or a product of its mind. The experience of embodiment in a shared environment is essential to our experience of being.”
In mediating the care of our pain via a screen, we’re often attempting to avoid what clinical psychologist Sherry Turkle calls the “messiness” of spontaneous conversation – the very thing that, in talking therapies, can yield the most healing, breakthrough dialogues. We also know that the presence of a phone in social situations, even a switched-off device, can disrupt our capacity to both open up and empathise with others.
How then, given these barriers, can phones and screens truly serve us in a therapeutic context? How much nuanced, holistic care is lost when we attempt to map our complex, unique and frequently unquantifiable needs over modules, scales and multiple choice-style box-ticking exercises? An app in itself isn’t a problem, says Cooper, but as the only accessible source of support for someone in distress, its next to useless.
“Technology that has a better chance of helping people are tools that enable people to think things through collaboratively, in a context where they feel emotionally secure and cared for by another real live person whom they have got to know over time. Skype and instant messaging can be very effective, but they need that human quality of relating behind them; they can’t be treated as a cut and paste job. I also think it’s fine to use things in conjunction with a pre-existing therapeutic alliance.
“Clients might want to talk about their use of therapeutic apps, practitioners might use a tablet in session to draw things or create mind maps. Digital pictures, video and sound can prompt useful therapeutic conversations. Sometimes clients have read emails and texts to me in sessions and we have discussed them together.”
There is a place for technology in therapy, says Cooper, but it must serve clients and therapist alike, and be grounded in evidence and practitioner-based knowledge. Only that kind of technology can truly enrich our mental health care.