Talkspace Therapy Is Questioned Again

Talkspace text therapy appTalkspace Therapy Is Questioned Again

Talkspace therapy claims were challenged in an August 7, 2020 article published in the New York Times. Writers Kashmir Hill and Aaron Krolik raised several concerns about “text therapy” as offered by the online employer of behavioral professionals called Talkspace.  Issues of concern outlined in At Talkspace, Start-Up Culture Collides With Mental Health Concerns include:

  • Whether or not text therapy is therapy as claimed by Talkspace 
  • Whether the Talkspace therapy model has clinical effectiveness
  • Confidentiality issues within the company
  • Examination of the content of therapist/client text conversations to develop marketing strategies and unethical marketing practices

Is Talkspace Therapy Really Psychotherapy?

The free-flowing format of text therapy is at odds with the traditional “frame” of psychotherapy with its regular, scheduled meetings that have a clear beginning and ending with which to measure progress. Texting historically has been used primarily for social purposes, is short, and often has a time gap between responses. Up to 2018, the Talkspace user agreement stated: “This Site Does Not Provide Therapy. It provides Therapeutic conversation with a licensed therapist.” Although that statement has since been dropped, the services are still advertised as “ text therapy.” The evidence base related to the clinical benefit of text-based therapy is sparse. Much of what exists is based on client satisfaction surveys, according to a representative from the American Psychological Association.

The Clinical Social Work Association (CSWA) has also made a number of observations that question the types of interactions offered by the Talkspace text therapy app. In her article, LCSWs and the Use of Texting in Mental Health Treatment: Responsibilities of the LCSW Providing Text Therapy, Laura Groshong, AM, LICSW, Policy and Practice Director of CSWA, discussed the question of whether or not text therapy is actually psychotherapy given that psychotherapy is “a continuous process based on an established emotional relationship and ongoing dialogue between two people in real-time about complex issues with deep emotional content.” She asserts that texting is not consistent with a dialogue based on emotional meaning. She suggests that texting can be useful because it is highly popular with a large part of the population, but it might be better conceptualized as “text assessment or text coaching.” She stated that it might also be a way to start an ongoing relationship that could be converted to in-person video sessions if continued therapy is warranted.

Talkspace Text Therapy’s Corporate Use of Client’s Confidential Information

The New York Times article questions the services offered by the Talkspace text therapy app,  and asks if those services are more driven by profit than clinical assistance. More specifically, concerns are raised about the confidentiality of client information contained in text conversations with therapists and  Talkspace’s use of the information to drive marketing practices. The article’s authors point out that some employees told them of the company engaging in “questionable marketing practices and regard treatment scripts as another data source to be mined.” An employee reported that he used the text therapy app service and was asked by the company to use transcripts of his messages to share at a staff meeting, with the understanding that his identity would not be revealed. He agreed, and somehow other employees did find out the shared information was from his own text therapy.

While users of Talkspace therapy app are promised their conversations will be safe and confidential, “users can’t delete their transcripts and the privacy policy states the information may be used by the company for the design of the website and in research and analysis.” Former employees and therapists reported to the article’s authors that individual user’s conversations were reviewed and scrutinized for “insights.” A former therapist reported she was surprised that the company contacted her after she gave a client a resource link outside of Talkspace and was told to keep clients within the app. Clearly her conversation was being viewed. 

Questionable Marketing: Mixed Messages to Therapists and Clients?

Talkspace offers a service that allows clients to demand a response to their text-based question within a specified amount of time. In essence, a therapist is on call throughout the day, and their pay can be docked if they don’t respond in a timely manner. Former employees contributing to the New York Times article reported that they were not informed of such penalties ahead of time.

Further, several employees stated that in 2015 and 2016 the company asked its employees to write positive reviews, and in fact, one employee was asked to compile “100 fake reviews” so that other employees could submit them to app stores. Supposedly employees were given “burner phones” to use to submit the reviews or to give 5-star ratings. Talkspace lawyer Mr. Riley was cited by the New York Times article as stating “To be clear: We have never used fake identities or encouraged anybody to do so. There is no event involving burner phones….”

Talkspace Therapy App Founders Respond

The founders of Talkspace, Roni and Oren Frank apparently responded to the above-mentioned article. In Talkspace Founders Respond to a New York Times Article, the founders claimed that the employee whose chats were the basis of the dramatic reading in a staff meeting gave explicit permission for it to be shared, and he revealed his identity to many others. Further, they deny the existence of  “ burner phones “ for faking reviews, although they acknowledge that they did ask their employees to review Talkspace since the service is offered to employees. The Franks also confirmed that they analyze encrypted and de-identified data to look for risk-related language or inappropriate behavior. They acknowledged that there are other keywords or phrases that are searched, for example, to identify therapists who may be trying to solicit clients away from Talkspace. 

Questions to Ponder

  1. How confidential are messages sent between clients and therapists during text sessions? 
  2. How is client/therapist information used by companies offering this service…. for improving company profits through marketing strategies or enhancement of client service? 
  3. Is texting an adequate mechanism for delivering ongoing therapeutic services given its nature of being short and intermittent communication between a client and therapist? Where’s the research?

Talkspace Validity Studies?

From our perspective at the Telebehavioral Health Institute, despite our best efforts to carefully consider the few journal articles published about the Talkspace model, or to speak with Talkspace staff directly about the veracity of their claims regarding the efficacy of their text therapy app, we found their claims to be suspect. When speaking with the Talkspace Quality Control Managers about an invitation to moderate a panel featuring one of the Clinical Directors of Talkspace at an American Psychological Association convention, the Quality Control Manager was unable to explain how Talkspace clinicians are trained to collect informed consent. To be clear, the definition of legal informed consent is that it is a discussion that leaves the clinician reasonably assured that the client/patient understands the risks and benefits of the treatment being undertaken. Any paperwork exchanged simply documents that the discussion took place, and is not a replacement for that essential discussion.

Furthermore, we found the Talkspace staff to be defensive in multiple conversations, and unwilling to give details of, for example, how many of their clinicians actually use the video options claimed to be at the clinician’s disposal. Our position is that if such is the case, the natural next question would be how many of the clinicians are actually using video vs texting. Answers to this question were not available.

Last we looked, in 2019, we found three published articles related to Talkspace text therapy app’s model. Two described their populations as “mixed.” Definitions of “mixed” were missing. While these feasibility studies exist, we have been unable to find any validity studies. However, being open-minded, we now formally are extending an invitation to anyone more familiar with their studies to provide citations for validity studies in support of the Talkspace claims. Also of interest are the models offered by Better Help or other such text-based behavioral companies offering their interventions to consumers and employers through the Internet. If anyone has supporting evidence for either of these models, please paste in the comment box below for community review.

Let’s have a community discussion of the literature.

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6 comments on “Talkspace Therapy Is Questioned Again

  1. There are multiple text-based therapies on the market, some with good evidence to indicate that they produce outcomes comparable to traditonal face to face treatment. A basic internet search can reveal the research, not all of which is generated from the companies themselves. Talkspace has a history of problems with regard to the way it handles its business. I don’t think it is helpful to generalize from Talkspace to all of text therapy as a modality. My concern with even well-run, evidence based and ethical text therapies has been the privacy protection of the verbatim transcripts. HIPAA and 42 CFR Pt 2 of course did not anticipate digital transcripts and the manner in which they could be used. I don’t think that most patients think of this issue either. Yet verbatim transcripts pose the same privacy risks to patients that “psychotherapy notes” can– i.e. a level of detail that if exploited could be very embarrassing and/or in a legal proceeding (for example, a custody dispute) could really disadvantage a patient. For this reason, my position is that these verbatim transcripts should be treated as “psychotherapy notes” under HIPAA and hold the same level of privacy protection.

    • Deborah,

      Thank you for your reply to our article. Please note that we are not condemning all text-based therapies by any means. We are only highlighting that some notable groups are questioning some text-based services that make claims about replacing in-person care with text-based alone; typically without the benefit of a traditional referral from other trained and licensed professionals; that seem to make it difficult to understand all of their practices, be they clinical or business; that have been banned from advertising with some professional associations; who only offer home-grown training rather than using well-known and respected training models; and who may be duping their clinicians into believing that they are legitimate.

      Again, if supportive articles for what we described in our article are plentiful, please post a few references that are germane to the position taken, and not to the field of text-based interventions in general. I am sincere about my request to be educated. Please show us the science behind what is happening not only with Talkspace, but with other online services who engage licensed professionals to do intakes, informed consent, treatment and termination 100% through text-messaging alone. I for one invite a collegial discussion of whether any relevant, supportive research has scientific merit.

  2. I have been a contract therapist for Talkspace since 2017, and absolutely consider what I do to be therapy. My caseload contains, on average, about 40 people, including doctors, teachers, performers, homemakers, politicians, and corporate executives. Many clients have been with me for over a year.
    I make use of all available resources including the audio and video features, Talkspace psychiatric services, peer counselors, and provider support.
    Clients are encouraged to leave written reviews of the service they’ve received, and the large percentages of positive statements are all the evidence I need to confirm that this platform is a viable and valuable therapeutic provider.

    • Pat, While many clinicians working for professionals in digital environments of all sorts may consider what they do to be therapy, I want to encourage anyone involved in “disruptive” or non-evidence-based care to write to their licensing boards to see if the boards will consider their practices to be legal. Emotional reasoning has no place in professional practice.

      The very fact that you allow people to give you positive ratings on a public website is in a way asking for testimonials – which is illegal and unethical in many states as well as professional associations.

      I strongly want to encourage you to get the facts in writing from your licensing board and professional association ethical board(s). If those groups agree with you, please come back and post their decisions with the names of the board members so we all can be educated. Short of that, I would encourage you to be careful about challenging anyone who questions the appropriateness of some online employers by posting admissions such as your on public websites. It would be disconcerting to all of us to have disgruntled clients referred to you through some of these online platforms choose to avoid rating you on the website where they obtained your services, but nonetheless be looking around to find your name online. They, of course, upon reading your comments here, would then be in their rights to report you to your board who may feel compelled to investigate your public admissions.

      Please be careful. If you want to challenge us here or elsewhere, or anyone else who raises questions about any aspect of digital care, feel free to do so — but be smart about it and give yourself another name.

      And please do not shoot the messenger. We at TBHI did not make up the rules. We just report them to help educate our colleagues, many of whom have been led to believe things that simply are not true.

  3. I was a Talk Space therapist for about six months. I wanted to learn about remote therapy so although I am successful in my private practice I saw it as a way to expand my tool kit. It took a long time to on-board, the training materials were frustrating.. as if they started with a reasonable training program and kept adding onto it so it became… ridiculous. Once on the platform, I was astounded how little input and feedback the platform asked from it’s therapists. It had a completely top down structure that reminded me of my clinic days and often is the reason, that service to patients is the last factor prioritized. The platform ignores very basic principals of therapist/patient perimeters, often moving clients around with no explanation to the therapists. It took about four months for me to figure out that working as a TS therapist was completely untenable unless I wanted to be sitting at my computer every possible free moment of my day. I also found it was impossible for me to get through the reams of texts, emails and voicemails that clients would leave. Because of this I came to the conclusion I could not provide quality service to my clients and this did not feel ethical or safe for the clients. In short although I believe patients can benefit from quality remote therapy, the TS platform was not providing that.

    • ST,

      Thank you for commenting. Your insider view is valuable information for other clinicians who may be enticed by any online platforms. Always look to your training, your law and ethical codes for guidance. If you cannot follow each and every requirement, move on to other telehealth opportunities.

      They are plentiful. We are developing several here at TBHI. Stay tuned to our newsletter for details: https://telehealth.org/signup. Our graduates will have a significant advantage in everything we develop because we believe in educating clinicians about legal and ethical issues first, then offering them tools – not the other way around.

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