Therapy via Text Message

This week we have a choice between major magazine articles about therapy. Naturally, we feel compelled to say something about them, and we choose to comment on Molly Fischer’s New York Magazine article about therapy via texting. We find the Katy Waldman article in The New Yorker to be less interesting and less salient.

Can you do therapy via text messaging? Fischer reports on the data, which I will spare you, and concludes that you cannot. Apparently, this gives the lie to the empty protestations of French philosophers, especially Jacques Derrida, that writing should always prevail over speech and that you cannot reduce it to speech.

One has noted that there are currently some new articles about Derrida, corresponding to the appearance of some massive biographies. As it happened, by my reading, none of them addressed the most salient question-- how did such a bright man get suckered into being a carrier for Nazi thought and practice. Derrida was like Typhoid Mary-- he happily transmitted the essence of the Nazi thinking of one Martin Heidegger, while imagining that he was a leftist intellectual.

Anyway, Derrida considered post-Socratic thought to be a massive conspiracy to repress writing in favor of speech. He believed that speech was a mere and unnecessary appendage to writing. For the record, I met with Derrida once, and the 0nly lasting impression I gleaned was that he did not know how to engage a conversation.

Anyway, if therapy is based on a conversation-- which it certainly is-- then texting should not work as well as in-person meetings or even televideo or telephone sessions. I am going to defer to Fischer’s expertise here, because I do not and have never texted. You see, I am the last living human who does not own or use a smart phone.  

Anyway, the important question, the center of Fischer’s essay, involves whether or not any of it works. If you cannot connect with your therapist can the treatment be any good. Or else, considering that most text based therapy is very low priced, is the patient simply getting what he is paying for. 

As it happens, it does not seem to matter. It’s a new business opportunity, a new way to sell the public on snake oil, so it has created its own market, with stock.

Fischer opens thusly:

Businesses in the “digital behavioral health” space raised $1.8 billion in venture-capital funding last year, compared to $609 million in 2019. In January, Talkspace announced plans to go public this year in a $1.4 billion SPAC deal. A presentation for investors managed to be simultaneously grim and upbeat in outlining the “enormous” market for its services: More than 70 million Americans suffer from mental illness, according to Talkspace, and the country has seen a 30 percent increase in the annual suicide rate since 2001. Talkspace says 60 percent of its users are in therapy for the first time.

In the meantime Fischer tells of her own experience with therapy, which mostly involved sharing her distress with her mother. It was, dare we say, better than nothing. It mitigates the sense of loneliness. And besides, it seemed to work for her:

When I was very young, the main solution I knew for what I would now call anxiety was to reserve all distressing thoughts I experienced in the course of the day and disgorge them to my mother before bed. I dreaded doing this, but it seemed to work. So probably I was favorably inclined to the idea of someone to talk to. The primary job of the therapists I’ve seen since then has been to notice what I didn’t. They told me if the things I was saying were cause for alarm or resembled other things I had said before or were otherwise revealing. The most effective tool I had acquired was Lexapro, which, after more than a decade, I chose to stop taking at the beginning of March 2020. A few weeks later — cruising on the adrenaline of a crisis in progress, wondering whether my husband was about to lose his livelihood — I decided I no longer needed therapy, either.

One remarks that she did not seem to engage or connect with her therapists. She did not interact with them. They seemed mostly to tell her what she would have been saying if she had been as savvy as they were. It is, dare we say, grossly disrespectful.

Better yet, you probably noticed that she considered medication the most effective tool for managing her anxiety. Not a ringing endorsement of therapy, though surely the advent of new classes of medications has been a godsend for many patients.

Within the therapy world a split occurred, between the old Freudian and insight laden forms of treatment, which were based on storytelling and the new cognitive behavioral treatments that were less about meaning and more about results.

By the end of the century, rival schools had emerged, including, most notably, cognitive behavioral therapy. Where psychoanalysis sought to plumb the depths of the past, CBT focused on present symptoms and quantified results. The goal was not to understand why you felt and thought what you did but to stop those thoughts and feelings from disrupting your life. Instead of a narrative, CBT produced data, with patients scored on symptom inventories for conditions like depression and anxiety.

And yet, when you move into the world of apps you find a panoply of New Age nostrums, most of which are not exactly designed to do anything more than separate you from your money:

Much of what appears if you search “therapy” in the App Store does not provide the services of a human therapist. Some of it does not address mental health at all, in the strict sense: It is the digital equivalent of a scented candle, wafting off into coloring apps and relaxation games. Many services occupy an area somewhere in between professional care and smartphone self-soothing. Reflectly, for example, bills itself as “the World’s First Intelligent Journal” and promises to use the principles of positive psychology, mindfulness, and cognitive behavioral therapy to help users track their moods and “invest in” self-care. “Just like a therapist!! But free!!” reads one review. (Reflectly costs $9.99 a month.) Sayana, an AI chatbot, is personified as a pastel illustration with a dark bob and cutoff jeans; she also tracks the user’s mood and offers tips (“Observe your thoughts as they flow, just like the river”) to guide users on a journey through “the world of you.” “This is like your own little therapist and I love it!” reads one five-star review. Youper (mood tracking, chatbot, lessons) sells “Self-Guided Therapy”; Bloom (mood tracking, chatbot, lessons) is “the world’s first digital therapist.”

Can an app or a text message provide what patients really need?

Different people want different things from therapy. They want to break bad habits, work through trauma, vent about their boss, their boyfriend, their mom. They want to feel better (always easier said than done). They want someone to talk to, and they want some tools.

But, what about text messaging:

Text messaging is perhaps the boldest innovation the therapy apps offer — from the standpoint of therapy, if not technology. It is the mechanism by which the apps attempt to widen a single therapist’s reach. And it appeals to many customers, too. The privacy-starved can text without anyone overhearing; the socially anxious can communicate without facing a stranger; people who are new to therapy can get their feet wet in a low-stakes way. 

Of course, if you are texting you do not have a synchronous exchange. Fischer is correct to identify the asynchronicity of the exchange-- which makes it impossible to have a real connection. One feels compelled to add that in traditional Freudian psychoanalysis a conversational exchange is precluded. The set up is designed to prevent conversation:

Asynchronous texting is also a fundamental shift in the way therapists do their work. “As a therapist, all of your training is about how to have this conversation in the moment,” said Albert Thrower, a therapist on BetterHelp. “All of your skills and techniques are based around the idea that you are having a conversation.”

Preliminary results suggest that therapy via texting is less effective than therapy via conversation:

Thrower joined BetterHelp after moving out of state so his partner could go to graduate school. Some of his clients said they had trouble putting their feelings into words — they liked having time to write things out, and Thrower appreciated the novel experience of taking time to sit with what they had written. It felt like writing letters. But it was harder to steer a conversation via text; clients would pick and choose what they responded to. And the long missives that evolved out of point-by-point replies to clients’ messages could become unwieldy as exchanges went on. Over time, he noticed that his text-only clients seemed not to be making as much progress as the ones he talked to on the phone.