Medical Examiner

Stop Lumping Video Therapy In With Text-Based Therapy

We’re rightly skeptical of app-based therapy. But video therapy has a lot of evidence on its side.

A therapist talking through a computer screen.
What a friendly video therapist might look like (though he probably wouldn’t be wearing a stethoscope). Photo illustration by Slate. Photos by Ben Kolde on Unsplash and Yourstockbank/iStock/Getty Images Plus.

One morning a week, before work, I sit in bed and have a session with my therapist. I’ve been seeing her for close to a year. We’ve never met in person.

As a professional product reviewer and anxious person, you can bet that I didn’t hand my psychological well-being over to a person in a screen without first carefully reviewing the evidence behind the practice. I’ve reported extensively on internet and app-based therapy, including authoring Wirecutter’s guide on the best services out there. Between that reporting and my personal experience, I’ve learned that video-based therapy can be just as good as, or even better than, in-person therapy.

Which was why I was frustrated by a piece questioning the validity of therapy apps by Jess McHugh, published last week in Elemental. McHugh explores the evidence behind therapy apps and argues that it comes up lacking. But what McHugh—and, I worry, many consumers—doesn’t do is distinguish between the different types of internet-based therapies available, namely video and text. (McHugh also briefly addresses mental health apps that involve self-guided exercises, which in my opinion show promise but are ripe for false advertising and should be evaluated on a case-by-case basis.)

When it comes to therapy delivered primarily by text, I agree with McHugh’s assessment. The research that these companies cite is promising but nascent. Work conducted with robust sample sizes has been done by companies themselves, making it less reliable. Text-based apps like Talkspace and BetterHelp are getting a lot of attention thanks to celebrity endorsements and advertisements on Instagram. But the newness of the exchange—patients engage with their therapists in an intermittent but ongoing conversation via a secure text platform—means they are still very much worth questioning. I’m glad to see McHugh do that.

But video-based teletherapy has been fairly well-tested. One trial that ran from 2006 to 2010 involving nearly 100,000 patients receiving care from the U.S. Department of Veterans Affairs found that those who used video versus traditional services actually saw a decreased need for hospitalization. The researchers theorized this might be because care to keep them from reaching a breaking point was so accessible. For the VA, “telemental health services have revolutionized mental health care delivery,” the authors note. So, consumer-facing services that work via video aren’t charting untested territory in the same way text-based apps are—instead, they’re following in the footsteps of hospitals.

There are potential downsides to video therapy, of course. Therapy is in part about gestures and reading emotion, notes Ellen Vora, an NYC-based psychiatrist and one of McHugh’s sources. But video platforms, where patients meet with therapists over Skype-like calls, allow therapists to see a patient’s body language. Via video, unlike text, a therapist can see if a patient stalls or has trouble getting words out, can sit with a patient while they cry, or can furrow their brow in sympathy. I’ve sobbed to my current therapist many times and have found the experience quite similar to doing so in person.

The major consumer-facing players in video therapy are AmWell and Doctor on Demand, which have the option for a visit over a computer or a phone app. They’re not as app-y and quick fix–y in their posture as some of the text-based companies, and they do not advertise aggressively on social media. But video therapy is also expanding—even therapists with traditional in-person practices are offering video sessions over free telemedicine platforms. And Talkspace allows for users to connect over video if they prefer (though it costs more) while BetterHelp also has an option if you want to be matched with a therapist willing to do video (in fact, despite the text-first nature of these app, some providers will only see patients via video).

One of the main advantages of apps is the convenience, which becomes more than convenience for people who have trouble physically or mentally getting themselves to traditional therapy. (I personally switched to video after I kept finding myself having to take an emergency $35 Lyft to my in-person therapist, but that was mainly because the New York subways were so frequently haywire.) Science writer and Slate parenting columnist Melinda Wenner Moyer, who started seeing her therapist over after the therapist moved away, told me that she was skeptical about the switch but now actually prefers video therapy. “I can sit in the comfort of my own home, with a cup of coffee next to me—it just feels more comfortable opening up in my own space.”

Video therapy isn’t without downsides. One of the major annoyances: Just like regular Skype, the secure video platforms can be buggy. It’s not ideal for couples therapy, where it helps therapists to see the dynamic between two people. Depending on your specific diagnosis and disposition, your doctor or therapist might have her own reasoning why it’s best for you to see someone in a traditional office.

But the place most consumers should draw the line isn’t between in-person therapy and app therapy. It’s between face-to-face therapy, whether in person or via video, and text-based therapy. The real efficacy questions center around text-based therapy, which deploys an under-researched format that is distinctly different than normal therapy. If we lump video in with the rest as iffy and unproven, we risk keeping a lot of people from getting help.