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LCSWs and the Use of Texting in Mental Health Treatment: Responsibilities of the LCSW Providing Text Therapy

Laura Groshong, AM, LICSW, the Policy & Practice Director of the Clinical Social Work Association (CSWA), wrote an article entitled, LCSWs and the Use of Texting in Mental Health Treatment, with co-author Margot Aronson, LICSW, CSWA’s Policy & Practice Deputy Director. The article explained the responsibilities of the LCSW providing text therapy. They allowed Telebehavioral Health Institute (TBHI) to obtain a copy of the article and share to the TBHI Blog.

Text Therapy – Start Feeling Better Today with Talkspace Online Therapy. A Convenient and Affordable Solution That Provides Access to Therapy Whenever You Need. 100% Private & Secure. Secure & Confidential. 1 Million Happy Users. 2000+ Licensed Therapists. As Low As $49/Week. (Talkspace Website, https://help.talkspace.com/hc/en-us )

Texts are primarily used for social purposes: short missives conveying limited information. Much has been written about the negative impact of reliance on this mode of communication (Turkle, 2012), but the popularity of texting is obvious, particularly among those under the age of 30 who have texted regularly throughout their lives. Therefore, the increasing use of texting in the context of therapy cannot be ignored.

While there is no definitive research as yet, it appears that texting can play a useful role in some mental health treatment. Certainly for anyone who is most comfortable with texting as the preferred form of communication, this may be where a treatment relationship can best begin.

Responsibilities of the LCSW Providing Text Therapy

Clinical social workers should be knowledgeable both about the promise of digital innovations in treatment, and equally about the potential downside. LCSWs who choose to engage in providing text therapy must be willing to explore ethical complications, perhaps even license violations, in the terms of agreement with client and/or texting platform.

The first issue: is “text therapy” really psychotherapy?

Psychotherapy — also called “talk therapy” or just plain therapy — is a process whereby psychological problems are treated through communication and relationship factors between an individual and a trained mental health professional. Modern psychotherapy is time-limited, focused, and usually occurs once or twice a week for 45-50 minutes per session (Herkov, M., “What is Psychotherapy?”, PsychCentral, October 8, 2018.)

This simple definition of psychotherapy, paired with the quoted Talkspace web advertisement at the top, illustrate the very real differences that exist between psychotherapy and text therapy. Psychotherapy (whether in person or through synchronous videoconferencing) is a continuous process based on an established emotional relationship, an ongoing dialogue between two people in real time about complex issues with deep emotional content.

Texting is by its nature short, often with a gap in the timing of communications between client and therapist; it is not consistent with a dialogue based on emotional meaning, as with psychotherapy. This fact is acknowledged in the Talkspace User Agreement below:

Talkspace User Agreement – This Site Does Not Provide Therapy. It provides Therapeutic conversation with a licensed therapist (Essig, T., “APA Cancels Talkspace Ads Moving Forward”, Forbes Magazine, July 29, 2018.)

It is in the small print of User Agreements that some text therapy platforms (platforms and companies are used interchangeably) emphasize to clients that the services provided are not psychotherapy. Meanwhile, the term “text therapy” continues to appear prominently in the ads, potentially creating confusion for those seeking psychotherapy, and giving an appearance of misleading advertisement.

How, then, do we as LCSWs conceptualize and engage in text therapy? Perhaps “text therapy” might more accurately be called “text assessment” or “text coaching”. Texting might also be the means for starting the therapeutic process, to be converted to an in-person or videoconferencing process if it becomes an ongoing psychotherapy.

Reading any contract with care is essential, and this is most certainly true for contracts offered by text therapy platforms. Does the contract address issues such as diagnosis, HIPAA compliance, state-to-state licensing laws, and dual relationships? Does the company set limitations on helping a client understand the differences between in-person treatment and text therapy, or on recommending in-person therapy when such treatment is indicated? LCSWs who sign on as providers should be aware that our ethics and standards of practice may not be supported by these companies.

 

This is Part 1 of the 3-part blog series. You can also read Parts 2 and 3 below:

 

Is Text Therapy Good For Your Practice?

Therapists are finding that clients are increasingly asking for text messaging in therapy. TBHI’s online training event is entitled, “Is Text Therapy For You? Telehealth Legal/Ethical Requirements. Join Dr. Marlene Maheu and Guest Laura Groshong, AM, LICSW on September 5th, Wednesday, at 11 pm – 12 pm, Pacific Standard Time. In the discussion, basic risk management approaches to using text messaging will be reviewed. The popular choice of using text messaging as the basis for clinical care will be examined from the perspective of legal and ethical requirements. This discussion will also clarify considerations for accepting employment from online text therapy companies. The online training will be recorded for your convenience.

 

Disclaimer: The views and opinions expressed in the article and on this blog post are those of the authors. These do not necessarily reflect the views, opinions, and position of the Telebehavioral Health Institute (TBHI). Any content written by the authors are their opinion and are not intended to malign any organization, company or individuals.

 

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2 comments on “LCSWs and the Use of Texting in Mental Health Treatment: Responsibilities of the LCSW Providing Text Therapy

  1. I’m curious whether this article is based on any research or evidence. The reference to Talkspace is a misquote from a hostile and potentially libelous (not to mention old) unvetted contributor piece by Todd Essig. I encourage readers to take a look at the actual and relevant Talkspace Terms of Use (https://www.talkspace.com/public/terms), and invite both readers and the TBHI to reach out to Talkspace to learn what we do, how therapy on our platform is different from and similar to in-person therapy, and about the overwhelmingly positive evidence-based clinical outcomes we are seeing in our patient care. Talkspace has over 4,000 licensed therapists who are helping hundreds of thousands of patients who have never had access to therapy before, and we are hearing on a daily basis how this increased access and being able to finally get help is changing people’s lives. It’s real therapy, and it’s proven to be effective.

    • Shannon,

      Thank you for your comment. I take it that you are addressing us as a Talkspace employee, correct? If yes, there are a couple things that I’d like to ask you to provide for us after I make it clear that we do not accept responsibility for the opinions of our guest authors. Please see our disclaimer at the bottom of all our guest posts.

      On to my questions of you:

      1) If indeed the article referenced by Ms. Groshong is indeed, and “potentially libelous”, please let us know if Talkspace has indeed sought legal remedies for this “unvetted contributor piece by Todd Essig”. I would think that after all this time if the previous publication is libelous, it would have been removed from public view.
      2) A quick Internet search for the Forbes contributor and psychologist Todd Essig, PhD shows not only one but several Forbes articles that are critical of Forbes. One of the more remarkable ones reports that the American Psychological Association has banned Talkspace from advertising and exhibits from Talkspace. See APA Cancels Talkspace Ads Going Forward. Is that more recent Essig report true?
      3) And to respond to your question more directly, yes, we do research not only our information but also that rep[orted by our guests. We do not decide whether they are libelous, though. We assume the injured compmnay would do that is needed. However, when I looked at your FAQ page today (7-22-19), I saw a heading that reads “Is online therapy really effective?” followed by a list of research that seems to be much less than “overwhelmingly positive.” In fact, your list of articles not only includes outdated journal articles (Azy Barak, 2008) and several older ones, but most of them do not relate directly to text-messaging. More specifically, Azy’s work is about internet therapy – not text messaging as we know it is in 2019. In fact, none of the articles have a date posted that is in the current decade, and none of them specifically mention texting therapy. Rather the majority mention “Internet therapy or some such term.” I invite our readers to carefully review the Talkspace “Top Questions” page for themselves. I will also paste the relevant contents of the outcomes evidence supplied on your site to support your claim of overwhelmingly positive outcomes evidence:

      “Internet-based versus face-to-face cognitive-behavioral intervention for depression: A randomized controlled non-inferiority trial”
      http://www.jad-journal.com/article/S0165-0327(13)00512-0/pdf

      Linda Godleski, M.D.; Adam Darkins, M.D., M.P.H.; John Peters, M.S. (2014) “Outcomes of 98,609
      U.S. Department of Veterans Affairs Patients Enrolled in Telemental Health Services,
      2006–2010”
      http://dx.doi.org/10.1176/appi.ps.201100206

      Andersson, G., & Cuijpers, P. (2009). “Internet-based and other computerized psychological treatments for adult depression: A meta-analysis.” Cognitive Behaviour Therapy, 38(4), 196-205.
      http://www.ncbi.nlm.nih.gov/pubmed/20183695

      Barak, Azy, et al. (2008). “A comprehensive review and a meta-analysis of the effectiveness of internet-based psychotherapeutic interventions.” Journal of Technology in Human Services, 26.2-4: 109-160.
      http://www.tandfonline.com/doi/abs/10.1080/15228830802094429#.VI8vaCvF_hs

      Wantland, D. J., Portillo, C. J., Holzemer, W. L., Slaughter, R., & McGhee, E. M. (2004). “The effectiveness of Web-based vs. non-Web-based interventions: a meta-analysis of behavioral change outcomes.” Journal of Medical Internet Research, 6(4).
      http://www.jmir.org/2004/4/e40/

      “Internet-versus group-administered cognitive behaviour therapy for panic disorder in a psychiatric setting: a randomised trial”
      http://www.biomedcentral.com/1471-244X/10/54

      “Home telemental health implementation and outcomes using electronic messaging.”
      http://www.ncbi.nlm.nih.gov/pubmed/22052966

      “Mobile Assessment and Treatment for Schizophrenia (MATS): a pilot trial of an interactive text-messaging intervention for medication adherence, socialization, and auditory hallucinations.”
      http://www.ncbi.nlm.nih.gov/pubmed/22080492

      Antiretroviral Medication Adherence for HIV/Aids:
      http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3718389/
      http://www.biomedcentral.com/content/pdf/1745-6215-12-5.pdf

      “Distance Therapy Comes of Age.” Scientific American.
      http://www.scientificamerican.com/article/distance-therapy-comes-of-age/

      Shannon, I invite you to paste any current and overwhelmingly relevant articles supporting your company’s specific approach here in our blog. Please note that if you do, I sincerely hope to see actual outcomes research, published in the last 5 years for a ~specific population~ to be tested using your specific use of ~text messaging~ as the only mode of communication supporting a therapeutic relationship with a licensed behavioral health professional. General populations and general statements do not qualify “overwhelmingly positive evidence-based clinical outcomes.”

      Also, some of my own research over the last two decades has shown that more than 1/3 of all licensed professionals that we polled are unaware of legal and ethical regulations that control telehealth. They operate online as unwitting professionals who work for a variety of companies as well as privately in their own private or group practices. My point is that the fact that 4,000 professionals currently work for Talkspace (or any other large site) is not a reason for other licensed professionals to follow suit.

      If you can show us real outcomes research tied to your specific model, please do so by listing your supporting research. I invite the researchers in the telehealth community, as well as those with a solid grasp of behavioral research to keep an eye on this blog and weigh in on any research presented. And Shannon, I also invite you to explain some of the clinical/legal issues, such as how informed consent is conducted through text messaging on your platform.

      Let’s talk. Maybe we’ll all learn someone thing worthwhile?

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