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Can Mental Health Apps Bring Therapy to a Wider Population?

Mental health apps offer therapeutic solutions at far more flexible price points, schedules, and platforms than traditional therapy. But with them comes the chance of inconsistent use and unlicensed clinicians. Do they help more than they harm?

Even the simple things became too difficult for Melissa Woodall—going to parties with friends, doing charity work in her community, going to see her husband’s performances. At one point, she was only able to handle going to work, home, and the grocery store. One day, she decided she’d had enough.

After seeing several Facebook advertisements for Joyable, a mobile mental health application aiming to help users with social anxiety, Woodall, a liquor store manager and Portsmouth, Arkansas, resident, decided to try the app this June. It was reasonably priced, and it was more convenient than scheduling appointments for in-person therapy visits. In August, she completed the program.

“I liked it a lot, [and I liked] that it was not in person. I felt a little bit more comfortable on the phone,” Woodall says. “It was like getting armed with better skills to deal with things, adding skills to my social toolbox.”

According to a 2015 Substance Abuse and Mental Health Services Administration report, 31.5 percent adults age 18 and older with serious mental illnesses, meaning diagnosable, mental, behavioral, or emotional disorders did not receive mental-health treatment or counseling in 2014. With a variety of digital therapeutic services designed to bridge that gap,Woodall is one of many who have turned to mobile therapy apps in search of a convenient solution to help resolve their mental-health challenges. As technology continues to improve medical care overall, many start-ups like Joyable have created mobile health apps as a more affordable, flexible option than in-person, scheduled visits. Though these apps could bring mental health care to a wider range of individuals, there is ambiguity within the mental health care community about which apps are the best and how to apply such technology to meet their patients’ needs.

One of the latest companies entering this market is Level Therapy. Its founder, Dan Miller, knows about anxiety all too well; prior to co-founding Level Therapy with licensed marriage and family therapist Coley Williams, Miller launched a different start-up called Freshsessions, an online marketplace for musicians to book studio sessions. After just a few months though the stress from running and bootstrapping funding for the company, as well as personal stress in his relationship, sparked anxiety symptoms for Miller.

“There’s a lot to learn, and so you [feel like you] are building a plane to fly while you’re falling in thin air,” Miller says. “I really was not functioning. The sense of worrying came over me, and I wasn’t acting like myself.”

His schedule didn’t allow time for in-office appointments. That problem sparked the idea for Level Therapy, an app that matches users to licensed clinicians and allows them to receive mental-health treatments through their iPhone (with an Android app on the way). After talking with a patient intake specialist about what symptoms they’re experiencing, patients can provide preferences in factors like gender and ethnicity to get matched up with the therapist of their choice.

Since its founding in 2015, Level Therapy has grown to serve more than 42,000 users in California, Ohio, New Jersey, Massachusetts, and New York. It doesn’t offer group therapy, but the app boasts full HIPAA compliance and works with insurers to reduce costs for patients.

It’s free to sign up for Level Therapy and receive a brief consultation, but out of network patients have to pay $99 per hour per session. Insurance companies, however, will often later opt to cover 50 to 75 percent of that bill, Miller says.

Insurance acceptance varies across apps and providers. Joyable is in talks with insurance companies to get them to accept the app, but the details aren’t final yet, according to co-founder and CEO Peter Shalek. Talkspace, another popular mobile mental-health app, does not accept Medicare, Medicaid, or other medical insurance. BetterHelp, another app featuring licensed clinicians, also doesn’t accept Medicare and Medicaid, but, similar to Level Therapy, some insurance companies will reimburse user costs. Other mobile mental-health apps like Happify are free (with in-app purchases) or low cost, eliminating the need for insurance coverage.

A November 2016 National Alliance on Mental Illness survey found that 15 percent of respondents paid more than $200 for outpatient mental health therapist costs, but the majority paid between $1 and $199.99, and eight in 10 respondents had out-of-pocket costs of over $200 for psychiatric hospital or residential mental health care.

In the past, costs have prohibited those with mental illnesses from seeking care. Results from a 2011 National Survey on Drug Use and Health survey found that, among the 4.9 million adults who reported an unmet need for mental health care and didn’t receive care, 50.1 percent could not afford it and 28.8 percent thought it could be resolved without care. (A spokesperson for the American Psychological Association couldn’t confirm the average costs for therapy visits.)

“We’re seeing an average of $150 an hour across America and, in cities like New York, San Francisco, L.A., it’s up to $500 per hour,” Miller says. “Therapy has been a luxury item. Certain individuals have been priced out.”

Though Level Therapy uses licensed therapists and connects users via video, not all apps are created equal. Joyable pairs users with coaches, rather than licensed therapists; people who typically have backgrounds in peer counseling or education. Though not actual psychotherapists or psychiatrists, these coaches provide users with exercises meant to help them to better understand and work through their anxiety.

There aren’t enough licensed therapists to meet the demand for Joyable users, Shalek says. Though Shalek declined to provide the exact number of Joyable users, he confirmed the company has grown to reach tens of thousands of users in more than 20 countries since it was founded in 2014.

Similarly to Miller, Shalek and his co-founder Steve Marks saw a need for more flexible, affordable mental-health treatment. Joyable users have to foot the bill for the $25 per week service, but the company is in talks with insurance companies in order to get them to cover the cost. Given the stigma behind going to therapy, Shalek believes the company takes a self-driven approach to mental health, mixed with encouraging coaches — much like the support personal trainers give to gym-goers to help reach their fitness goals.

“The program is designed to be self-help. It’s designed to be more engaging than a book you buy off Amazon, effectively,” Shalek says. “We wanted to be much less expensive than therapy. One of the big problems is that it’s really expensive to get help.”

For Woodall, the liquor store manager, it didn’t matter that her coach was not a licensed therapist. In fact, it was beneficial to call her coach whenever she needed encouragement during an uncomfortable social situation, something that couldn’t be done during an in-person appointment, she says.

Seeing the success rate on Joyable’s site was enough to convince Woodall that the app was worth a try. According to Joyable’s publicly available figures, 93 percent of Joyable users see a social anxiety decline, and the company assesses these figures using the Social Phobia Inventory scale. For some, however, the lack of licensed professionals still raises skepticism.

Dr. Marlene Maheu, a licensed psychologist and executive director of Telemental Health Institute, cautioned users of mobile therapy apps against using apps that don’t have peer-reviewed research to support their claims or aren’t clear about how they secure client data.

“There are a lot of ways that consumers can be bamboozled, especially when they’re hurting emotionally,” Maheu says. “You don’t go to unlicensed dentists. Why would you put your mental health in the hands of a company who uses unlicensed professionals? I don’t know.”

It’s possible that users may have positive results after using apps without licensed clinicians, but clinicians must complete graduate school, pass state tests, and continue meeting stringent standards in order to provide proper care to patients, Maheu says.

Such platforms could cause compliance problems for doctors too. Clinicians looking to service clients through these platforms have to make sure that they are compliant with state laws, because therapists often have to be licensed in every state in which they practice, Maheu says. They must also be careful not to reveal confidential patient information carried on electronic devices.

There’s no clear cut way to tell whether these apps will work for all patients, but they can open up access to care for individuals who don’t have the time or resources to go to in-person visits on a regular basis.

When deciding whether to use an app for care, one has to consider the severity of the situation, says Lynn Bufka, a clinical psychologist and associate executive director of practice, research, and policy at the American Psychological Association.Apps can assist with developing coping mechanisms for some users. However, others with more severe illnesses will likely need in-person care in addition to a mobile app.

“We know that apps can be helpful for some people, but we still have a lot of questions,” Bufka says. “The potential for apps is that they could open up access to care for individuals who don’t have a lot of access to care.”

There’s also a debate over whether mobile therapy apps can stand alone. Such apps can help people develop coping mechanisms, but an app alone might not be sufficient for treatment, Bufka says. Miller and Shalek says their apps were meant to be used alone, but Shalek says some therapists recommend Joyable as an extra tool for clients.

Even with the convenience that these apps offer, the lack of face-to-face communication leaves some users with less motivation to use them long-term. This happened with Mindy, whose name has been changed, when she used Talkspace, a $32-per-week app that offers couples therapy and “unlimited messaging therapy.” The company was working to get accepted by insurers, so Mindy paid for the service out of pocket.

Mindy began using Talkspace for about three months after hearing about it in an email. She also had heard about Joyable via a Facebook ad but decided Talkspace was better because it used certified mental-health professionals. She initially turned to the app for help managing her stress but wound up using the app less and less over time.

She used the messaging service to talk with her therapist, but found that the lack of face-to-face interaction didn’t elicit the candor and progress that she hoped for. Eventually, she decided to stop using the service altogether.

“I don’t really know if I’m discovering anything about taking care of my mental health,” Mindy says. “If you have money to burn on someone looking out for you via text, that’s fantastic, but … if I’m going to monetarily invest in this, I should do it the old-fashioned way.”

This new digital therapy economy offers benefits that traditional talk therapy can’t. Apps are often significantly cheaper, offer more flexibility of schedule, and circumvent the very real stigma of seeing a therapist. Yet there’s still no shortage of limitations present when using a smartphone-turned-counselor. To illustrate these shortcomings, Maheu brings up a case of a patient who acts abusively toward his child: “Maybe your anger is due to the fact that the child looks like your ex, who now is now depriving you of alimony right before the holidays, when you need it the most,” Maheu says. “Questions are quick and easy, but answers are not.”

Ultimately, the goal for all of these apps to reach more people who need mental health care. For those who want a low-cost, flexible option, mobile therapy presents an opportunity to get help on their own terms as medical professionals sort out how to best tailor the technology to their patients’ needs.

In the meantime, as researchers, start-ups, and clinicians work out how to apply this technology, users like Woodall, who’d rather not see an in-person therapist, can deal with the issues holding them back. With the help of Joyable, Woodall can now watch her husband’s live music performances, go out with friends, and order her own fast food.

“I wish that I had done it years ago,” Woodall says. “It made a night and day difference. I’m not gonna say that I’m 100 percent fixed … but I am dramatically less broken.”