Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Saturday, March 7, 2015


I learn a lot on the subway. I spend quite a bit of time commuting. Some days I'm too tired to do anything but play Temple Run2. But I also read recreationally and professionally. And when my eyes aren't otherwise occupied, I look at ads. There's the famous, and recently less present, Dr. Zizmor, the world-renowned dermatologist:

There are all the ads for law firms with track records of successful malpractice suits.

There's the MTA's Poetry in Motion campaign:

Notice that Dr. Zizmor's ad is rectangular, and the Elephant poem is more square. The rectangular ads run across the tops of subway cars, and the square ads run below, to the sides of doors. Often, one company will take up multiple ad spaces in a single car, with different versions along the top and on the side.

There's a company, Manhattan Mini-Storage, that has pretty amusing ads all over the city, including in the subways, that encourage you to clear out your crowded NYC apartment by using their storage, like this one:


A couple weeks ago, I saw a rectangle ad above a square ad, that I assumed were part of the same campaign, since they had the same tag line, "Dream Big", and roughly the same font:  Sorry for the crummy iPhone photo:

Turns out, the bottom ad is for NYU's school of continuing education, and the top ad is for breast augmentation.

But today, I saw an ad for Talkspace:

Talkspace is unlimited messaging therapy for $25/week, billed monthly. (There are other rate plans, as well.)

"...you can now message your therapist every day..., writing as many times as you want..."

There's also live video therapy, $29 for 30 minutes, but this needs to be scheduled ahead of time. And there's couples therapy.

Here's their video:

All kinds of questions, right?

Like, who are these therapists?

There doesn't seem to be anyone I could find with an MD, PhD, or Psy-D. All Masters level. Talkspace says they check the credentials of all their therapists, but the therapists don't work for them, and Talkspace isn't responsible for what they do. They just facilitate the connection.

From their FAQs:

What is Talkspace about?

Talkspace is making therapy available and affordable for all...

We created Talkspace because we strongly believe that in this day and age, everyone should have real-time, simple, and affordable access to professional advice whenever and wherever we need it. get access to leading therapists who can help you overcome your day-to-day challenges. 

Talkspace  is your safe and secure place where with a licensed therapist you can start your journey to fulfillment, empowerment, and happiness. You can share what's on your mind, chat privately with a therapist on your computer or mobile device.

Is online therapy really effective?

Absolutely. If done correctly, by qualified individuals and in the right environment.

Over the last decade numerous prominent research studies have proven the effective potential of online therapeutic conversation. We listed a few on our Talkspace blog research page.

I checked out the list. A lot of the references are newspaper articles, which I'm just ignoring. There are a couple of references to papers having to do with online therapy. These tend to be specific to a condition being treated, or to a specific modality of therapy with predetermined time constraints. They didn't seem to list anything that directly supported the type of "online therapy" they do-unlimited access, text-based.

Is Talkspace a substitute for actual therapy?

No. Talkspace does not aim to create an alternative or competitor to offline therapy.

Rather, we create a doorway for dealing with real life issues that may be an element in our lives, but may not necessarily require full clinical psychiatric process.

Furthermore, therapists are instructed to identify situations where clinical therapy is needed and divert participants towards the most appropriate solution.

So, Talkspace makes "therapy available and affordable for all", but it's not a substitute for actual therapy.

What about my privacy?

At Talkspace your privacy and safety are always the first consideration. We went to great lengths to assure you and your data are always kept safe and confidential

Your safety is our #1 priority. You have the option to remain anonymous. 
Our technology is fully HIPAA compliant. 

I was a bit confused by this part. The site has 141 free therapist-led forums. This is from one called, "How to deal with depression or anxiety":

I guess there's some privacy, since the therapist offers a private chat, but it seems like a lot of information is right out there for anyone to see.

Another comment from the same forum has a lot more information than I'm comfortable with. I suppose if the person posting doesn't mind, it's okay:

I'm also a bit put off by the response:

The therapist seems not to have noticed that the father is dying, not dead.

Call me skeptical, but I have a hard time believing that text therapy can be helpful. Tele-therapy or Skype-therapy is limited enough. Texting makes it completely impersonal.

In terms of therapeutic alliance, it's not even clear to me if you always get the same therapist. I don't see how you could, since they're supposed to be available 24/7.

Also, the responses on the forums are so simplistic, it's hard to imagine anyone finding them more helpful than speaking to a friendly neighbor:

"...it sounds like you are the type of person who likes to please and make others happy but you are not taking care of your own needs."

"...it's about building up your self-esteem and confidence so that you don't have that fear of people liking you or you feeling the need to make others like you."

But mostly, I'm concerned because the whole 24/7 access setup is so anti-therapeutic. The frame is always important to therapy. It creates safety and containment. Scheduling, boundaries, recognizing the limitations in the therapeutic relationship.

What happened to using therapy to learn how not to need therapy? We want patients to carry their therapists around in their hearts and minds, not in their pockets.

And Talkspace completely misses an important aspect of limited access, namely, that the patient learns that other than in a true emergency, he or she can tolerate some anxiety and frustration, and wait until the next session to discuss what seemed like very pressing feelings.

Talkspace will just push people further away from the ability to tolerate delayed gratification.

Addendum: I published this post just a few hours ago, but I just saw the Circa Now column in the NYTimes, and I had to add a link:

Memo to Therapists: It's Not Me, It's You

The author, Henry Alford, writes about wanting to break up with his therapist "on day 2 of our relationship", which takes place on Talkspace. The article is really about awkward and difficult interactions with ones therapist, and how these can be handled well, or poorly. In the cases in the article, mostly poorly.  And it's interesting that the patients quoted in the article have trouble bringing up uncomfortable feelings and thoughts with their therapists, like, "Is it okay to ask my therapist about herself 2 years into the therapy?", or, "Can I mention the fact that my therapist just farted?" without the realization that these are the kinds of things that need to be discussed in therapy, precisely because they're uncomfortable, and politeness has nothing to do with it. And I'm inclined to blame their therapists for not making that clear, or creating an environment that makes it possible to say difficult things.

The article is not about Talkspace, per se, but the timing was so uncanny, I had to include it. And the author does seem to think the activity he's participating in on Talkspace is therapy.


  1. "Talkspace will just push people further away from the ability to tolerate delayed gratification."

    Good point - 80% of people check their Smartphone whether they have a message or not. It is basically a variable reinforcement device. Knowing that there is now a therapist linked to it will increase dependence on it.

    1. Right? People can't stop texting even when it isn't someone they're paying to "listen" to them.

  2. Apropos my comment on your "Counseling" post, Talkspace misuses the term "therapy." It may help some folks to have someone instantly available for texting, but this is counseling at best — and of doubtful quality given the apparent lack of continuity from one encounter to the next. It certainly isn't psychotherapy, as their own promotional language reluctantly admits.

    A text-based suicide/crisis "hotline" was favorably written up in The New Yorker recently. This is free, directed toward teens, and seems a much more sensible, and honest, use of this ever-present technology.

  3. The Verge had an article about TalkSpace a few months back, and the writer shared her own experience with it:

    My own Talkspace therapist set boundaries right away. She explained during the free trial that I could write her whenever I felt the need, and that she would try to answer within 15 minutes, if only to acknowledge my message. She also cautioned that she would mostly be available in the evenings, because she works a full-time job during the day. "But I do try to check my messages throughout the day for people who might be in crisis," she wrote.

    Really stretches the meaning of the word "therapy," doesn't it?

  4. I received a comment from one of the therapists at Talkspace, Nicole, and I want to include it here, but I've removed a paragraph where she writes about a client she helped, a woman who would not have otherwise had access to any therapy. It's a nice anecdote, but I felt there was too much clinical material. The following is the rest of the comment. Thanks for reading, Nicole, and offering your thoughts.

    Many journalists come on the site and try us (some with real dilemmas and they let us know, some with made-up dilemmas and are undercover). It gives people a little media snapshot into the experience in some way....
    Our clients are the most amazing people. They share a part of their lives with us and are wonderful storytellers of their own experience. It is a privilege to be able to serve them. Each person who comes on and speaks with us, we try to help in some way. Whether it is just having the free consultation, using our text messaging therapy, or helping them learn more about video or face to face therapy, we pretty much find that we can give a little something to everyone. We do whatever we can....

    Anyway, I wanted you to know I appreciate the dialogue and feel free to visit the site. You can even pop in my office if you would like at


  5. I agree with your comments -- this texting thing isn't therapy though for some people I suppose it could be helpful. Re: crisis texting: I just realized this is offered via our crisis clinic here in Seattle. I was developing a crisis plan with a patient of mine and saw that texting was offered (I was looking up the crisis clinic phone number). He was thrilled to know this. Some of our patients have so much social anxiety that even a phone call is hard. My pts know this is no substitute for therapy but it helps for them to know they can call/text someone in the middle of the night if they need to reach out. My teenage daughter volunteers for the teen crisis clinic and as you can imagine most teens text way more than they talk. It works for them. I do fear Talkspace is just another example of how disengaged we are becoming from each other. It reinforces distance and doesn't help the patient learn to tolerate much anxiety.

    1. I think a text hotline is a great idea, especially for teens. That's a perfect use of texting.

  6. In the world of internal medicine, there is talk of the increasing use of "tele-medicine." For some, it is access to sub-specialists that might not otherwise be available (our rural hospital uses a "tele-neurology" group for managing acute stroke), for others it is about the "access on demand." As a practitioner, I am saddened to see this move for the most part. One of our local pain management groups does telemedicine routinely after the first visit. They tend to have over-medicated clients. In my world, although we have signs posted to turn of phones in the exam rooms, it is very common that a phone rings and the person "has" to get this. I then listen to a conversation about what to get a Walmart or the tire replacement down the road. Why do we continually give these devices more attention than the person sitting in front of us?

    I know that in some situations, tele-medicine may be desirable (our rural community can not attract a neurologist that will work in the hospital), but for me, I learn much about watching a patient walk into the room, my gestalt of their "color" when I walk in the room, etc. I think those "tells" that I use woudl be lost in the telemedicne world.

    1. Thanks for sharing a non-psych perspective. I was saddened just reading your description.

  7. As a provider, I am trying TalkSpace. After several email exchanges and document signing and online trainings, I still can't figure out how much I'd be making. I assume it's not much but why are they making it so hard??

    1. Feel free to message me directly anonymous and I will talk with you. Nicole

  8. I am so thankful I found your blog. I can 100% confirm what you said is true. I purchased a one month subscription. I was assigned to an LCSW (SOCIAL WORKER) which is the same as a snap shot in your post.

    My therapist mis-understood me totally. Did not take the time to understand. I even heard a BABY crying in the background on one of the pre-recorded audios that she sent me. Seriously, if you walked into a "therapist" office and saw a baby, do you really think you are getting a quality job? No, just no.

    I reported my discontent to Talkspace, to date I have received nothing. Well actually I did, a debit to my credit card!

    To recap:
    It is NOT anonymous. Blog need to quit saying this.

    You may get a licensed SOCIAL WORKER (not a therapist). You may have very limited choices for other therapist. In my case it was another SOCIAL WORKER. No thank you.

    Talkspace does not care if you are not satisfied. They will ignore that and keep pimping the idea that it is "therapy for all". They will also pretend to follow-up if you rate them low in on Google Play Apps.

    1. It's unfortunate that you had such a miserable experience. I hope it hasn't turned you off to therapy entirely.

    2. Could you possibly email me at psychpracticetheblog at gmail dot com? I'd like to ask you something that pertains to your comment, but I don't want to post it publicly, and I don't have your email address. Just reference your comment on this post so I know who it's from. Thanks.

  9. This comment has been removed by a blog administrator.

  10. I have found talkspace very helpful for my ptsd. I have a great therapist that works with trauma and ptsd. But then again, I am pro-active and do as much on my own as possible, including reading books and applying the techniques taught. I discuss the books I read with my therapist, who gives me valuable feedback. As far as social Workers go, I work with several in the rl who provide counselling for hospitals and other gov't facilities. They work with clients with substance abuse issues, trauma cognitive impairment and mental illness. The ones who have mental illness also see psychiatrists. I have tried rl therapist via a psychiatrist (MD)and and a psychologist( PHD). The psychiatrist took too long with monthly visits. The psychologist was way off the mark and I didn't' go back. Both were fully licensed. I find talkspace a better fit, because I am god at writing and am an effective communicator.