From the Digital Couch—Online Therapy for Addiction Recovery

By Renée Fabian 04/17/17

Text based recovery options might be a solid supplemental option for addiction recovery.

A man texts on the phone.
A therapist at your fingertips--could it really help?

"Terence ... understands the many variables of addiction and applies them to his feedback," writes A.N. "He's been an invaluable part of my recovery process."

While this type of therapist review may not be unusual, this one is unique because it comes from a user of the text-based online therapy provider, BetterHelp.

Along with Talkspace, BetterHelp and other online therapy providers are growing in popularity, with each service boasting thousands of subscribers. The services offer unlimited text-based messaging through their online/app-based platform. Users have an open "room" with a trained mental health practitioner who responds to messages regularly. Video, audio and live chat sessions are available for additional costs. All providers on both services are vetted licensed mental health practitioners.

Individual therapy can be crucial for many people in recovery, especially following intensive care. So how useful are these modern day therapy tools for addiction support and aftercare?

The most distinctive feature of text messaging therapy is the regular access it affords. A user's personal chat room is open 24/7. This means clients can write as many messages to their therapist as needed. Though therapists typically only reply to messages once or twice daily, there's still significantly less waiting time between interactions as opposed to traditional weekly in-person sessions.

"You can write a message at any time and counselors will typically respond within 24 to 48 hours if not sooner," says Sonya Bruner, BetterHelp's clinical director and a BetterHelp therapist. "When you're at a moment where you're struggling, you can reach out right then instead of having to hold it all until your weekly session."

Sometimes having an outlet to explore triggers or barriers to recovery in the moment, even if the therapist's response comes later, can serve as a pressure release and help prevent relapse. The near-daily check-ins are a luxury not usually afforded by traditional therapy or aftercare programs, and can make a difference when working on sobriety goals.

"One of the strongest indicators of a person's potential of successful change outcomes includes the presence of a strong helping relationship, someone to help them maintain accountability to the goals they set," says Talkspace therapist Katherine Glick. "Having ongoing contact with their therapist throughout the week allows that client to establish a solid relationship with a helping professional who can provide support, encouragement and help the person stay accountable each day."

Unlimited messaging is useful for sharing difficult thoughts and experiences the moment they arise. On the downside, text-based therapy can't provide immediate support for imminent triggers or crisis situations. In-person therapists, sponsors or other crisis services best support these moments.

Even though interactions occur online, there's still the potential to develop an intimate therapeutic relationship. A study conducted by BetterHelp on the therapeutic alliance showed better outcomes with online therapy compared to traditional face-to-face therapy, a result arguably aided by the anonymity of text messaging. Many people find it easier to be open and honest through a more anonymous platform.

"The patients have said they reveal things to [their Talkspace therapist] they never reveal to their face-to-face therapists," said psychiatrist Irvin Yalom at Talkspace's 2016 Future of Therapy Conference. "Here they work with face-to-face therapists for a year or two and never revealed certain of these things that were very shameful."

Like traditional therapy, however, it can take trial and error to find the right clinician. Upon signing up for a text-based service, a representative will gather background information and then assign a counselor based on the issues highlighted during the intake interview.

Bruner recommends being upfront in the initial consultation that you're seeking support for addiction so you're more likely to be paired with a therapist who has addiction recovery credentials. BetterHelp has many addiction specialists on their roster and can also handpick a therapist to make the matching process more successful.

"If you're having difficulty finding someone who has [an addiction] background, reach out to our support and ask them to hand match to somebody with that expertise," says Bruner. "That is something we can do from our end, is assign somebody from the backside of things."

Glick echoes this statement, adding that clients should "ask about therapist gender, years in practice, experience with addictions, either chemical or behavioral or both, and specific training and modalities."

Some users, despite everyone's best efforts, found the first therapist they tried wasn't a good fit, citing reasons such as the therapist didn't respond enough or wasn't helpful in their approach to treatment.

"When I signed up I went through one other counselor but I didn't feel like I was getting anything out of it," wrote BetterHelp user A.T. "I decided to give it another try and switch counselors and I was thankfully matched up with Debra."

Making the switch to a new therapist through text therapy is less awkward than breaking up with a therapist in person. Both BetterHelp and Talkspace have a "switch" option for finding another clinician at the touch of a button.

"If somebody gets matched to somebody and then for whatever reason ... it's not a fit or that person doesn't have enough addiction experience, it is pretty easy to switch to a different therapist," says Bruner.

While text-based therapy has a lot of advantages in terms of access to regular recovery support, it's hard to talk about mental health services without discussing the cost. That's where BetterHelp and Talkspace blow traditional therapy out of the water, although insurance does not cover the cost.

Monthly rates for text-based therapy start between $128 to $150 per month for the unlimited text option. This means one month of text-based therapy is equivalent to the out-of-pocket expense for a typical single in-person therapy session, let alone months worth of treatment that too often insurance plans won't cover anyway.

But despite its benefits, critics argue that vital parts of the therapist-client relationship are missing in text-based therapy and that clues to a client's mental state may be overlooked. According to Joyce Marter, the president of the Illinois Mental-Health Counselors Association, in an article in The Atlantic in 2015, “Therapy is an interpersonal process, based on a trusting therapeutic rapport, that may not be able to be facilitated in the same way through a virtual medium.” Also, a therapist cannot interpret sensory cues like body language or a smell of alcohol via text, for example, which might be particularly important when diagnosing or treating addictive disorders.

And even with the most up-to-date encryption, “Clients and clinicians both need to be aware that good hackers can access anything online, regardless of industry security standards.”

However, with its ease of use, convenience, affordability, anonymity, and ability to develop an intimate therapeutic relationship with almost daily support, text-based therapies may be a solid supplemental option for addiction recovery.

"Our goal is to really be a resource for people who might not be able to benefit from traditional therapy, just don't have the capability or the access to get the kind of help that they need," says Bruner. "So, if in doubt, give it a try."

Renée Fabian is a Los Angeles-based journalist who covers mental health, music and the arts and cats. Her work has been published with VICE, Wear Your Voice, The Establishment, Ravishly, The Daily Dot, and The Week, among others.

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Renée Fabian is a Los Angeles-based journalist who covers mental health, music and the arts and cats. Her work has been published with VICE, Wear Your Voice, The Establishment, Ravishly, The Daily Dot, and The Week, among others. Find her on Linkedin and Twitter.