Is Text Therapy Effective?

Over a decade ago, Thomas Derrick Hull, a clinical psychologist who researches digital health, had a bold idea. What if therapists, who are the primary providers of mental-health care in the U.S., began texting their patients instead of requiring them to come into the office?

At the time, it seemed unlikely, even to Hull, that patients and providers could use a screen to develop the strong connections and meaningful conversations that typically flourish in face-to-face interactions. However, the potential benefits were enticing: texting is inexpensive, quick, easily accessible, and convenient, potentially allowing therapists to engage with their patients regularly, rather than waiting for scheduled weekly sessions. Hull began experimenting with this approach, eventually leading this initiative as an executive at the online therapy provider Talkspace. (He left the company in 2020 and now works for a different organization.)

Even if texting proved to be only 60% or 70% as effective as traditional therapy, the convenience and accessibility could make it a valuable alternative, Hull initially thought. “That felt like a fair trade,” Hull says. “But as we started looking at the data, it turned out that it seemed to be just as effective.”

Recent research—some of it funded by text therapy providers like Talkspace—continues to indicate that texting is a legitimate and effective means of delivering mental-health care. In a study published in July, for instance, Hull and other researchers discovered that therapy delivered through text or voice notes is equally as effective as teletherapy—which itself has been shown to be effective—at alleviating symptoms of anxiety and depression over a three-month period.

This implies that individuals who prefer texting with a therapist can feel confident that they are receiving the same quality of care as those who choose video appointments, states the study’s senior author, Michael Pullmann, who conducted the research while working as a research professor at the University of Washington School of Medicine.

How can this be, considering that the connection between a patient and therapist is widely regarded as one of the strongest predictors of treatment success? Can such a bond genuinely develop through text communication? The American Psychological Association expressed skepticism about text therapy as of 2015, and some professionals remain wary of the concept. However, a growing body of evidence suggests that strong relationships can form via text or email, just as they do in person. Some research even reveals that individuals can develop a sense of “bonding” through digital interactions.

Some experts contend that face-to-face relationships produce better outcomes than online connections—but Adrian Aguilera, an associate professor at the University of California, Berkeley, who studies digital health, isn’t overly concerned about this. Aguilera asserts that he’s less interested in whether text therapy is as effective as face-to-face therapy and more focused on whether it offers a better alternative than nothing—because a significant segment of the population currently lacks access to mental health services. “Is it the best? Probably not,” he says. “A better question is, ‘Can it meet an unmet need?’”

The answer appears to be positive. During the pandemic, Aguilera led a study in which participants received daily automated text messages designed to enhance mental well-being. (An example: “Self-soothe is an important skill for coping with distress. What are two ways that you can use your senses [e.g., smell, taste, touch] that will be calming?”) Across the board, individuals who received these texts reported improvements in their anxiety and depression symptoms after 60 days. Notably, the program seemed to be particularly beneficial for Latinx users, who indicated that they gained valuable knowledge from the messages, possibly because they were less likely to access mental health services.

Aguilera’s other research has indicated that patients tend to remain in therapy longer when it incorporates a text-based component. This finding may not be surprising, given that nearly all of us are constantly connected to our phones these days. “Have you ever texted a friend when you’ve been upset or anxious about something?” Pullmann asks. Almost certainly, the answer is yes.

Similar to casual conversations, texting with a therapist offers both the advantage of immediacy (you can send a message as soon as a challenging feeling arises) and asynchronicity (the recipient can take their time to craft a thoughtful response), Pullmann explains.

Some individuals may also find it easier to express a difficult, embarrassing, or vulnerable thought in writing—and research consistently shows that people benefit from expressing themselves through written communication, Hull notes. Furthermore, he suggests that text therapy may provide the advantages of “state-based learning,” that well-established psychological principle suggesting that it’s most effective to study for a test in the same room where you’ll take it. In other words, it’s possible that therapeutic concepts are more readily absorbed when they are delivered in the environments where individuals will actually need those insights, such as at home or work.

Text therapy isn’t without its flaws. Two of the largest online providers, Talkspace and BetterHelp, have faced criticism, with Talkspace specifically being accused of charging users fees even when therapists weren’t available to meet with them. (All claims in the lawsuit have now been either dismissed or settled, according to a statement from Talkspace.) In a 2022 Wall Street Journal report, providers who worked with Talkspace also expressed concerns about the quality of care offered on the platform.

In a statement provided to TIME, Dr. Nikole Benders-Hadi, Talkspace’s chief medical officer, asserted that the platform’s therapists are thoroughly vetted and licensed, and that research suggests text therapy is effective. “Imagine having an always-on, open-door option for people to communicate with their therapists, rather than bottling things up and waiting for their next session,” Benders-Hadi stated. “Ultimately what is most important is meeting members where they are, and letting them choose the modality that works best for how they would like to engage with therapy.”

Meanwhile, BetterHelp reached a settlement with the Federal Trade Commission concerning allegations of improper data-sharing practices. In a statement issued after the settlement, the company emphasized that its “technology, policies, and procedures are designed to protect and secure our members’ information so it is not used or shared without their approval and consent.”

BetterHelp has also recently been the target of criticism on social media from customers who allege that its clinicians provided poor advice or behaved inappropriately. In a statement provided to TIME, a spokesperson for BetterHelp did not directly address those allegations but stressed that the company provides “many ways” for clients to connect with therapists, including phone and video calls, and stated that it is “very rare” for members to exclusively use text messages.

As with any form of therapy, Hull cautions, it’s essential to be discerning. There will always be good therapists and bad therapists, good patient matches and bad ones, regardless of whether appointments take place in a private practice or through an iPhone.

“I don’t think there’s anything about message-based care that reduces quality, in principle,” he says. Increasingly, the data support his perspective.