If you've been considering getting help for mental illness but haven't done it yet, you're not alone. Nearly 60% of American adults with a mental illness didn't receive mental health services in the previous year, according to the Substance Abuse and Mental Health Services Administration. The reasons why -- stigma, cost, accessibility -- vary, but services like Talkspace and BetterHelp that offer is helping to bridge that gap.
"Online counseling can bring people to therapy who would otherwise not go," says Mark Pines, a licensed marriage and family therapist in California and the CEO and founder of OpenCounseling, a website that helps connect people to free and affordable counseling. But he says, "There are times when it should definitely not be used."
So when is online therapy appropriate and how does it differ from in-person sessions? We asked mental health experts with experience administering both to evaluate both along five main points of consideration: services, efficacy, accessibility, cost and confidentiality.
With traditional psychotherapy, or talk therapy, you typically meet with a counselor at a specified time and place -- usually at the therapist's office -- and speak face to face. The benefit of this is that you and the practitioner can have a real-time conversation, where they can pick up on your body language and tone of voice, which can give them insights on what you're feeling.
With online therapy, there are more options. Many therapists offer online therapy directly to clients through their private practice (you can search for one here). But an increasing number of third-party companies, like Talkspace and BetterHelp, will also remotely connect users with licensed therapists.
The services offered depend on the platform or expert you see, but usually include:
Messaging via text, video or voice: With this option, you're able to send messages to your therapist anytime through a third-party platform. The therapist will reply as soon as they're able, though some platforms do guarantee a response within a certain amount of time.
Live text, video, or phone sessions: These are scheduled in advance and are typically conducted through the third-party platform, or with a therapist directly. They give you and your therapist a chance to communicate much as you would during a traditional in-person session.
Ultimately, the form of communication you use will depend on personal preference -- yours and your therapist's. For instance, text messaging-based therapy is appealing to a generation of young adults who grew up communicating that way. But some therapists, like licensed clinical social worker Ruthie Kalai, prefer to avoid only text-based therapy since so much can get lost -- or misinterpreted -- in translation.
"Some of my clients will message me if they're having a bad day and just need to vent and that's fine," says Kalai, who runs a private practice in New York and Florida. "But I won't do strictly messaging-based therapy. I just don't feel like I'm as effective."
If you feel like text-message therapy is a good fit for you, check if any online therapy service or individual therapist offers that option.
The efficacy of traditional talk therapy can vary depending on the type of therapy that's used -- cognitive behavioral therapy, psychodynamic psychotherapy, interpersonal therapy -- as well as the issue it's being used to treat (depression, anxiety, obsessive-compulsive disorder.
That said, there is research that shows that talk therapy can literally change your brain, strengthening the connection between regions of the brain that can help reduce symptoms and support recovery. And a separate study found that talk therapy can work as equally well as antidepressants during the initial treatment of moderate to severe depression.
In one small study, 93% of telepsychiatry patients said that they felt they could present the same information virtually as they could in person, 96% were satisfied with their sessions, and 85% were comfortable in their ability to talk. However, they did feel slightly less supported and encouraged during online therapy compared to in-person therapy. And there are some other caveats as well.
As the American Psychological Association (APA) notes, online therapy is still very new and "hasn't yet shown that stand-alone therapy online or via texting is effective for everyone in every situation." Indeed, the evidence supporting online therapy is strongest when it's used to treat stress, anxiety, and depression.
Many experts advise against using online therapy -- especially as your primary form of therapy -- to treat severe mental illnesses.
"Generally speaking, the more severe the issue, the more people should seek in-person care," says Pines. "If you are in doubt, speak to your therapist about your concerns. Even if they're an online therapist, they should offer you unbiased opinions about the best place to get care for your specific circumstance."
There are tons of reasons why someone might find it difficult to get to an in-person therapy appointment: social anxiety, chronic illness, physical disabilities, inability to take time off work, difficulty finding childcare, living far from the doctor and so on.
With online therapy, individuals can start a session or continue communication with their therapist anytime and anywhere they have an internet connection. "There's something about being in your own home that I like," says Kalai. "I think it helps people feel more at ease, and when a client feels comfortable they're going to open up more."
The downside of this, of course, is that you and your therapist are both at the mercy of your internet services. "I always tell [my clients] ahead of time, if you can stream Netflix without any problems [your internet connection] should be fine," says Kalai.
Another disadvantage of working remotely is that it can make it more difficult for a therapist to help you in a crisis situation.
"A therapist's job is to make sure that the client is always safe, and it's a lot harder when they're not there," says Kalai. "If they're in your office and they're suicidal, you can make sure that the client doesn't leave and is safe."
While using a third-party provider to conduct therapy sessions, Kalai started to worry that one of her clients was suicidal. But when she reached out to the service provider to get her client's emergency contact information, she realized the client had listed herself as her emergency contact. "I was like, what do I do?" says Kalai. "And they said, 'Sorry, all we can give you is the information the client signed up with."
Now, Kalai runs her own online practice and won't work with someone unless they provide their full name, address, phone number and emergency contact information during onboarding. She also requires them to confirm the address from which they'll be attending her online sessions. "I need the address so that if something happens to them while we're in session (like they faint or have a seizure), I know where to send an ambulance," says Kalai.
Out-of-pocket expenses for traditional therapy can run anywhere from a few dollars to $300 for a 45- to 60-minute session, depending on where you live, whether you have health insurance and what your therapist's training and reputation is. That's according to GoodTherapy and Psychology Today, which both maintain searchable databases of mental health professionals.
A "fair" price would be around $174, finds Healthcare Bluebook, a website that uses national payment data to estimates healthcare costs.
The cost of online therapy also varies, depending on the service and level of support you choose. Adriane Kruer, PsyD, licensed clinical psychologist and owner of Echeveria Therapy Collective, says she charges the same amount for online and in-person therapy since the patient gets the same time and attention. And Kalai confirms that most therapist she knows also charge the same for online and in-person visits.
If you use a third-party service, it is possible to get cheaper care, especially if you pay upfront for a long-term membership. For example, Talkspace charges $65 to $99 a week if you choose to be billed monthly. But if you pay for three or six months of service in advance, the cost per week can go down as low as $52 to $79. And some services, like Amwell, accept insurance.
The first time you go see a new doctor, you're probably used to filling out a bunch of paperwork. In part, that's because healthcare providers must follow strict guidelines dictated by federal laws -- Health Insurance Portability and Accountability Act (HIPAA) -- plus additional state-level rules and regulations designed to keep you safe and protect your privacy. And mental health professionals are no different.
According to Kalai, before she takes on new clients, they must fill out a variety of paperwork, including a release of information form, a notice of privacy practices and an informed consent form. Additionally, all of Kalai's client communication and record-keeping is done using HIPAA-compliant software.
If you're not getting the same level of care from an online therapy platform, you should demand it. Before you sign up, make sure the platform is HIPAA-compliant and employs therapists who are licensed in the state where you live.
During the onboarding process, if you're only asked to fill out a short, generic consent form that leaves you with more questions than answers, ask the therapist if they're able to provide you with additional contracts. Some services put the onus on the counselor to customize and/or augment their documentation.
Further, ask about record-keeping practices. Ideally, all data and communication conducted on the platform you're using will be encrypted to protect against cyber attacks. Both the platform and the therapist you're seeing should also have policies and procedures in place that adhere to your state's record-keeping laws and the APA's record-keeping guidelines.
So which is better: Online or in-person therapy?
"For someone who is nervous about therapy or doesn't have a lot of time on their hands, [online therapy] can be a great way to get their feet wet," says Sal Raichbach, PsyD a licensed psychologist and clinical social worker at Ambrosia Treatment Center.
For someone who is dealing with severe mental illness or who responds better to intimate environments, in-person therapy may be a better bet. It all comes down to your personal preferences and specific circumstances.
"I think it's really is up to a person trusting their intuition -- knowing what they need in the moment -- and then making sure that they pick a [therapist] who feels comfortable to them, whether it's online or in person" says Kruer.
As Raichbach says, "Any therapy is better than no therapy."