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Does Text-Based Therapy Really Work?

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An important distinction needs to be made between online and text therapy. I’d like to define online therapy as a psychotherapeutic encounter that takes place with a qualified professional and follows all usual professional protocols (including the assessment phase, evidence-based interventions, therapeutic frame, and clinical support, bar one – the meeting is held over a distance using audiovisual technology.

Text therapy refers to a text-based interaction with a therapist, usually via a commercial service provider. Individuals send text messages (rather than speak or visit) to their therapists who then respond according to a predefined contact such as user texts as much as they like, and the therapist responds twice a day. The promise is for cost-effective, always-available help.  

Both modes of intervention are on a meteoric rise. Ordinarily, I’d say that increasing access to therapeutic help is always a good thing but, in this instance, I’m not so sure. Why? Because there is a real danger that our wish for something to be true clouds our judgement and causes us to act as if it were true long before the facts are clear. This is especially important during times when an industry is applying pressure to promote an outlook that has the potential to drive huge profits, and text therapy has the potential to do that.

Psychotherapy and mental health are both serious matters that deserve the same degree of scientific rigour as any other medical science. Although we don’t often consider it, mental illness carries morbidity and mortality risks just like other medical conditions. We don’t test medications by adding them to the water supply and waiting to see what happens and we should not behave in this way with psychotherapy either.

It is all too easy to dismiss or mistake psychotherapeutic interventions as little more than supportive and encouraging conversations. Don’t get me wrong, supportive and encouraging discussions are valuable, and they offer definite therapeutic benefits, but they should not be confused with intentional psychotherapy.

What’s the difference? Let’s start by answering the question: What is therapy? The rub lies in the word “therapy”. The poetic licence of “beauty therapy and massage therapy” aside, the term “therapy” implies “treatment”.

“Treatment” implies decisions taken that are based on a rigorous evidence base, careful assessment, clinical professionalism, availability of proper support, understanding of potential pitfalls, and the existence of effective, supportive systems and peer review processes that contain and play a serious oversight role.

A convincing argument can be made to support the delivery of online therapy (See: online analytic work by Andreas de Koning) but I can’t say the same for text therapy. The evidence just isn’t there, and so we can’t legitimately claim “text-based treatments (therapy) work”.

Work for what, for whom, under which circumstances, following which protocol? At best, we can say that some people feel satisfied with their experience of it, but we know that reported satisfaction and objective efficacy don’t necessarily match up.

I’m aware that there are venture capital-driven platforms that are pushing hard to steer us towards believing that text therapy is comparable to and as effective as talk therapy, and I see why they would want that to be true. But we just don’t know, and we should refrain from applying the term ‘therapy’ until we do. Continuing to promote text therapy as an effective treatment is akin to promoting a large-scale public experiment.

At this stage, the most prudent and proven efficacious approach remains face-to-face therapy. Clearly, there are severe limitations to this method, most notably cost, inconvenience, feeling too embarrassed to reach out, and geographical location. Fortunately, platforms like TherapyRoute can help you overcome some of these limitations by sidestepping the need to tell your doctor about things you may feel too shy to discuss with them, and by helping you find therapists that consult online if no nearby providers are available.

To date, the single most referenced factor shown to correlate with positive outcomes from therapy remains how highly the therapeutic couple (therapist and client) rate the quality of their relationship. Being in a room with someone you trust has powerful effects, even when you are silent. So how could text messaging ever replicate that?

Ellen Diamond did her degree in psychology at the University of Edinburgh. She is interested in mental health, wellness, and lifestyle.

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