Text Messaging for Counseling, Therapy & Crisis Intervention?

Text Messaging Webinar

Over the last six months, we’ve seen a variety of new text messaging therapy sites that promise to bring the convenience of no-nonsense, 24/7 “therapy” to the consumer. Type your problem, get an answer —  and move on. What could be better?


In October, the New York Times did an expose of All-You-Can-Text Therapy Services, wherein a service called BetterHelp connects licensed mental health professionals to consumers after completion of a simple questionnaire and a $40 credit-card charge. With a tag line of “You Deserve to Be Happy,” the service touts its advantages by stating, “Online Counseling is effective, affordable, and discreet.” In his description of the site’s service, the NYT journalist states, 

My BetterHelp therapist asked the same kinds of thought-provoking questions as the traditional therapists I worked with in the past. (What is it about your future that you’re unsure of? Can you tell me about your old life and what is different now?) Because of the continuing, open-ended nature of the text chat, however, she helped me identify anxiety triggers and coping mechanisms much faster than it would have taken had we met only once a week. What’s more, I came to find that launching the BetterHelp site on my smartphone or laptop and writing out my thoughts became therapeutic in itself.


The same NYT article described Talkspace, which offers unlimited text-chat with a licensed therapist, “but it costs just $25 a week and gets you up and running faster.” What was the author’s experience? Here’s a glimpse:

My Talkspace therapist wrote long, thoughtful responses to my meandering journal entries, pulling apart the elements and dissecting them as only a true professional therapist can do. He asked me to expound on and reflect on my entries, always checking if I felt that we were making progress, and assuring me that what we were doing had a positive end in sight. The process was identical to what I had experienced in traditional therapy, except I had access to it any time I pulled out my iPhone.

The article went on to describe yet more services available at Talkspace, “The site allows you to change therapists (currently 90 are registered with the site) at any point. Should you want to go with a more traditional talk-therapy route, you can sign up for a 30-minute live-video session, which costs $29.” In November, CNN Money also commented on Talkspace in an article called, Does text therapy actually work? The NCC journalist seemed to be impressed with the efficacy of text-treatment, evidenced by this statement:

I was surprised by how much she was able to read between the lines, as she encouraged me to expand on certain issues or return to something I’d mentioned before. Despite not having much background on me, simple questions in response to my dating distresses (“[Why aren’t you] allowing yourself any more options?”) caused me to reflect on my own relationship history, and why I was viewing my current situations through a black-and-white lens.

The CNN article drew on the expertise of Dr. George Nitzburg, a psychological researcher from Columbia University, to conclude that online therapy solutions like TalkSpace (which raised $2.5 million in funding in May) are only effective for a subset of patients. According to Dr. Nizburg, those with serious addictions or risk-taking tendencies (like self-mutilation or reckless driving) need more treatment than digital therapy can provide. Tools to be used to differentiate both groups were not mentioned in the NYT article, however. Dr. Nitzburg is quoted at the end of the article as saying, Most online or texting therapy forms don’t offer crisis counseling or emergency services.

R U There?

This week’s R U There? – The New Yorker‘s expose outlines the newest company to fill the text-messaging opportunity — only to defy Dr. Nizburg’s warning about text messaging therapy and crisis services.  A non-profit called DoSomething.org has apparently given birth to a new company called, Crisis Text Line, described by the New Yorker article as:

…the first and only national, 24/7 crisis-intervention hotline to conduct its conversations (the majority of which are with teen-agers) exclusively by text message.

What about You?

Perhaps it would be useful to consider this discussion in light of a more personal angle.  Those of us who send and receive text messages know how convenient and yes, helpful they can be. As depicted in the image above, many people sleep with their mobile phones and check them first thing in the morning, sometimes before making any other human contact.  Let’s think about text messaging for therapy, though.Would there be any use for this kind of service in your life? If your 19 year-old daughter, niece or mother wanted to receive such a service from a licensed therapist, would you support it? Why? 


For a recent TMHI webinar recording addressing the legal and ethical side of these issues, see Text Messaging: 12 Risk Management Considerations To Keep You Out Of Hot Water.

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3 comments on “Text Messaging for Counseling, Therapy & Crisis Intervention?

  1. Thanks for this timely post. I am one of your students in the advanced distance counseling training, just starting out. I have been interviewed by Talkspace to possibly work for them and tried to get info from Betterhelp abut signing up. My concern is about practicing across state lines. You probably address this in your webinar about texting but I am wondering about this because both of these services give their therapists referrals from all over the country. When I asked about this, Talkspace told me it was not a problem and I should not worry about it and Betterhelp never responded to my question about it. Both of them seem to put all the liability for anything on their therapists in their terms of agreement so maybe that is how they deal with it? I decided not to sign up with either one for a number of reasons (aside from the legal issue they pay pretty low and I am not sure I want to be so “available” to my clients all the time). What do you think about the licensing issue when it comes to texting services such as these? I would hope that they’ve consulted a lawyer before going into business but maybe not? In your opinion, would this be treated the same way as any other kind of therapy as far as licensing goes? Why or why not?
    Thanks for all your work and your expertise!

    • Thank you for your question. Text messaging, telephone calls, email, videoconferencing — all telecommunication technology is simply an extension of the professional services offered by licensed professionals. When using these technologies, we are bound by all state and federal laws and professional ethics codes. The same exact rules apply to online and offline, in-person practice. We are therefore accountable for all contact with clients and patients regardless of communication channel used.

      Before I make any further comments, please let me be clear that I have not investigated the services of the companies listed in my blog post above. I simply have recently seen a number of articles about text-messaging services in the news and quoted and linked to them above for your consideration.

      As a service to our readers, we summarize such news and make it available every week through this blog and our newsletter. Now that I’ve stated my intent with this blog, I will answer your question as best I can.

      At the institute, we advise caution and thorough investigation with regard to your liabilities when engaged by any online employers. We have seen many start-up, Internet companies operate legally — and many others who either choose to ignore the law and our ethical mandates or haven’t bothered to understand them.

      The latter group seeks unwitting, licensed professionals who will sign their contracts and offer services to unknown, un-assessed, uninformed consumers who simply need help, have a credit card and trust licensed professionals. They accept payment from any consumer, with any problem, and from anywhere. They don’t offer their licensed professionals the ability to conduct a full intake, use validated assessment tools, conduct an informed consent processes or operate within the bounds of their state-limited licensure. They don’t provide traditional telehealth systems and models for emergency backup in the consumer’s community if the client or patient suddenly becomes unmanageable. All these processes are indeed available online (and with traditional telemental health models), but they take time, and clinicians have to be trained so as to use them properly. Training also takes time.

      By seeking licensed professionals, some startups may believe that they are being “innovative” and that they are not responsible for harm that may come to the consumers they serve. After all, licensed professionals are fully responsible for what they do, right? They have been trained in how to work with all kinds of issues, both online and offline, right?

      Most often, they don’t. Many clinical professionals haven’t yet learned how to deal with the complications involved with technology. For instance, many don’t realize that their professional ethics codes require them to have obtained training to establish “competency” prior to delivering online service to vulnerable, unsuspecting consumers.

      Again, you are wise to ask questions. I urge all professionals to communicate with their licensing board directly before believing any employer about licensure, intakes, informed consent, handling emergencies and the host of issues involved in the legal and ethical use of any technology, from text messaging to email to video and telephone. The good news is that models have been developed for using all these technologies responsibly.

      I hope this helps.

  2. I like this article. We are a technology nation and to be able to provide and utilize these services from companies integrity and honesty is a great idea.

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