Protocol Manual: Health Care

Talkspace was built for a moment like this pandemic

The teletherapy app is one of a growing number of services trying to reinvent the way therapy is delivered in the middle of a pandemic.

Talkspace app

Talkspace's app gives patients as many ways to communicate with their therapists as they need.

Image: Talkspace

The last few months have proven Talkspace right about a lot of things. Video, for one: When Talkspace launched in 2012, it was primarily designed to be a tool for therapy by video chat, but the company realized quickly that what was really clicking for people was being able to text with their therapist. That was fine with Talkspace — its goal, CEO Oren Frank said, was simply to make therapy more accessible to people, however they wanted it. Messaging became Talkspace's primary thing and remained so for years.

Recently, though, video's making a comeback. Blame the pandemic, and the fact that everyone's suddenly used to staring into a Zoom or Teams window all day. "I think we've all been Zoomified because of the situation," Frank said, "so there's been higher demand for video sessions." That's fine with Talkspace, too. It offers video, audio and text, for clients and therapists to use however they'd like. Every patient-therapist relationship is different, which is exactly the idea.

The more pressing change for Talkspace is the sheer number of people who need something like it. Thanks to COVID-19, many people who already go to therapy have been forced to find new ways to do so. The pandemic has also caused a spike in mental health issues: a Kaiser Family Foundation poll found that 45% of adults in the United States said "their mental health has been negatively impacted due to worry and stress over the virus." A CDC survey found that the number of people reporting symptoms of anxiety or depression is nearly triple a year ago. Combine that with unprecedented levels of unemployment, the fight over racial injustice and the ongoing rise in social media-induced anxiety, and therapy's never been more essential to more people.

The ongoing mental-health crisis has forced Talkspace and other virtual-care services, like BetterHealth and MDLive, to rethink how they work and whether they can scale. Turning therapy from a weekly hour in a building somewhere to an ongoing text-based conversation certainly opens it up to more people, but it's still a one-on-one process that requires time and individualized care. Making it cheaper — Talkspace starts at $65 a week and goes up to $99 when you include a weekly live session, while in-person weekly therapy sessions can cost nearly double that — brings in more people, but many still can't afford it. So Talkspace and others are working with insurance companies and regulators, experimenting with AI tools and social media strategies, and generally trying to find every possible way to scale their business. (Talkspace isn't currently profitable.) Both because now is an unprecedented business opportunity for these apps, many of which have raised millions in venture capital, and because it simply feels like the right thing to do.

Talkspace is the largest player in the virtual-therapy space. It's raised $106.7 million in funding, according to Crunchbase, and says it has more than 1 million users and thousands of therapists on board. It doesn't actually employ therapists, but rather runs a marketplace similar to Uber, with Talkspace in the middle keeping everything running and taking a cut. And just as drivers have felt mistreated by ride-sharing companies, therapists have said they feel underpaid and overworked by a platform that promises them more flexibility and money but often doesn't follow through. Talkspace therapists are paid by the word, given strict requirements about when and how to respond, and typically make far less per hour than they would on their own. The company has spent much time in recent years trying to figure out a way to make the system work for everyone. And it's still working on it.

But the fundamental idea — that virtual therapy can be effective therapy — works. Some studies show that it's just as effective as in-person treatment, whereas others say it's at worst slightly less productive, but all agree that virtual therapy works. As health agencies around the world shift to doing more care in people's homes and less in hospitals and doctor's offices, Talkspace's methods seem likely to be part of it.

Like remote work, remote therapy is a longstanding trend suddenly thrown into hyperdrive by the pandemic. And tech is seeping into every part of the process. The Oxford University Centre for Anxiety Disorders and Trauma's COVID-inspired guidelines for remote therapists include using Google Street View to visit traumatic places for patients with PTSD. It also offers recommendations on how to make video more palatable, like having patients hide their view of their own video. And it encourages sharing your screen and writing a narrative together with patients.

There are two types of patients right now: those who are used to in-person therapy and are switching to remote, and those who are receiving care for the first time. In the latter case, one key measure of success, Talkspace Chief Medical Officer Neil Leibowitz told Protocol, is how quickly people bond with their therapist. "Do you like them? On day one, that's more important than their ability to treat," Leibowitz said. "Over time, their ability to treat becomes very important, but if you don't like them, you never go back." Studies have shown that people can bond with therapists without ever seeing their face or hearing their voice.

One challenge for Talkspace and other virtual therapy services has long been that insurance companies didn't really know what to make of them. "I always say telehealth has been around for over a century," Leibowitz said. "Doctors talked on the telephone. We just never figured out how to pay for it." But now that therapists are experimenting with the tech, and patients are finding services like Talkspace, insurance providers are coming around.

Eva Borden, Cigna's managing director for behavioral and medical solutions, said she's been watching Talkspace for a while. Cigna began reimbursing patients for virtual sessions with their otherwise in-person therapists a couple of years ago. But in May, it added Talkspace as a clinical provider. For Borden, too, it's about access to care. With Talkspace, she said, "it stops being so much about when the clock told you you needed to get help. It's there when you need it. That was a really major part for us." Many insurers still don't cover Talkspace, but Leibowitz said that's changing quickly.

Regulation may be an even bigger hurdle for Talkspace's growth. State regulations typically require that a therapist be licensed in the state in which they practice, which is simple for someone in a brick-and-mortar setting but complex when one therapist could theoretically have virtual clients all over the world. In the past, regulators have even suggested that patients who are traveling out of state might not be able to get treatment from their usual therapist. This has been changing for a while, thanks to rules like the Psychology Interjurisdictional Compact (known as PSYPACT), a group set up by a number of psychology boards to create interstate systems for practicing teletherapy. COVID has also prompted states to ease their restrictions temporarily. But change happens slowly.

As those regulations change, one reason Borden said she's excited about teletherapy in general is that it can help patients find the right therapist, wherever they may be. "There's a shortage of behavioral health providers, particularly in rural areas," she said. Helping people find someone who understands them and their issues, she said, can be far more useful than just walking into the nearest door. (Talkspace has recently been making an effort to help Black patients find therapists who better understand their backgrounds.)

Borden said the future isn't just virtual, but nor will the world go back to only face-to-face interactions when the pandemic ends. "My goal is to provide optionality so that people get care in the way they want to get care," she said. Whatever patients need, however they need it.

Talkspace CEO Oren FrankPhoto: Courtesy of Talkspace

The one thing all these modalities and options still have in common, though, is that they're a one-on-one experience — therapists often have many clients, but they're only working with one at a time. When the pandemic hit, Talkspace donated therapy hours to frontline workers, and Frank said he looked at ways to get more free services to people who needed it. But because every new client requires a therapist's time and attention, that approach just doesn't scale.

So Talkspace came back to its basic goal: access. What better way to reach lots of people than on the most popular social platform on the planet? In March, Talkspace set up a number of Facebook groups. The most popular is "Free Public Support Group to Manage Coronavirus Anxiety," with nearly 3,000 members. They're frequently moderated by Talkspace therapists, who are paid for their time moderating the groups, but they're not therapy. The long disclaimer at the top of every group makes that very clear. Instead, they're a place for a lot more people to talk to each other and sometimes to a professional.

The groups are filled with people looking for information or checking to make sure they're not alone in being totally unable to work or think or focus during these crazy times. The comments are, with rare exceptions, positive, helpful and kind. And while Talkspace therapists aren't paid to be there, they're often posting tips and asking questions.

Talkspace's blog, and its Instagram and Twitter pages, have come to serve a similar purpose. Talkspace posts "Quick Ways to Reduce Stress" on Instagram, and people start chiming in with their own; it posts "Signs of PTSD" and people comment, "This is me." The company has hosted Q&As on Instagram, runs a series called "Talkspace Therapist Diaries," and has millions of blog readers every month.

All that is well and good, but if Talkspace wanted to hit true scale, to give absolutely everyone access to virtual therapy, there's only one way forward: remove the human therapists from the equation entirely and replace them with AI chatbots. Therapy bots are very much becoming a thing. Frank dismisses the whole idea out of hand. "People that talk about AI with regards to therapy or many other forms of health care," he said, "I think they're 50 years too early for that discussion — if at all."

Talkspace has run some tests and tried some things around AI, Frank said, but the goal is to help the therapists, not replace them. Frank wants to use data to help train therapists on when to use video versus audio, or help psychaitrists figure out which medications to prescribe and when. Talkspace also has a risk algorithm it uses to flag particularly worrisome moments or messages so therapists can respond more quickly and correctly.

AI can be a way to get more people more help, but Talkspace is mostly focused on how to make things easier on the therapists, many of whom are also still figuring out how to operate in this new multiplatform therapy space. "Our strategy and our belief is that the human is a far, far superior technology for the foreseeable future," Frank said. But humans and scale don't always mix. Talkspace recently relaxed its "guaranteed response time" guidelines, which tell therapists how quickly they need to respond to a patient's messages, to give therapists more time without getting in trouble.

Demand for Talkspace, and across the virtual therapy industry, continues to grow. Leibowitz said that one shortcut for tracking therapy needs is to track the economy — and as the U.S. heads into a recession, that need continues to go up. Within Talkspace, Frank said, the current system feels like it's working. Or, at least, it feels like the most Talkspace can do. "The network is stressed, our customer service is stressed," he said.

Eventually, everyone seems to hope brick-and-mortar therapy comes back for those who need it. "My whole goal is to get everyone the kind of care they need, whatever that is," Cigna's Borden said. But with all those physical locations closed, the last few months have been a stress test for everything Talkspace, BetterHealth and the rest of the tech-forward therapy companies wanted to be — the kind of flexible, multiplatform therapy that felt like the future. "We've held up pretty well considering all the factors," Leibowitz said, "and I'm pretty proud we've been able to help people."

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