Apps are changing the industry, but experts warn against dispensing with human therapists entirely

The road to therapy is often inscrutable, windy and unsatisfying, with availability, cost and fit frequently preventing people from getting the care they need.

A new wave of Bay Area startups is turning to tech to change that, using algorithms and automation to take the guesswork out of finding the right therapist. At a time when mental health care is rapidly moving from clinics and hospitals on to our phones, they’re building software to enhance the human relationship at the heart of successful therapy. But the speed at which this shift has occurred is sparking as much concern as excitement about technology’s potential.

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The mental health industry has come to an inflection point with tech. Thousands of smartphone apps promise real-time relief from anxiety and stress through mindfulness techniques, meditation and mood tracking – all accessible in the palm of your hand rather than embarking on the maze-like, expensive process of finding a therapist. While many of the most popular mental health apps are geared toward improving day-to-day wellbeing without seeing a therapist – Calm (guided meditation), Fabulous (habit tracking and goal setting) and Pillow (a sleep tracker) top the Apple Store’s health and fitness category – others offer a digital alternative to the in-person experience of counseling. Having a bad day? Head online for text-based therapy or open your phone to talk with a chatbot powered by artificial intelligence.

The behavioral and mental health software market was worth $1.32bn in 2017 and is expected to be more than double by 2026, according to MarketWatch. In February, San Francisco-based Calm, which uses meditation and music to help people sleep better, became the first mental health “unicorn”, valued at $1bn.

But startups like Reflect, Two Chairs and Kip in San Francisco – all founded by young people frustrated with their own or their loved ones’ difficulties accessing therapy – are taking a different approach.

“Mental health has two sides to it: the legacy system in private practices and other health systems, and then there’s the Silicon Valley-backed version, which is a lot of apps and a lot of tele-therapy and a lot of tech-forward approach,” said Alex Katz, founder of Two Chairs. “What’s been clear to us from the beginning is there’s immense value in both.”

Facebook Twitter Pinterest Alex Katz, founder of Two Chairs. Photograph: Courtesy Two Chairs

At Reflect, clients fill out a survey that teases out the data needed to predict a strong therapeutic alliance or good chemistry between client and therapist. Research shows this alliance is the single strongest predictor of success in therapy.

The survey results are fed into an algorithm that maps clients’ responses against a data-rich roster of therapists and produces automated recommendations for three potential therapists, which are reviewed by a human before being sent to the client.

Benefits for therapists

Two Chairs, which launched in 2016 and now has five Bay Area clinics, takes a similar approach. Katz started Two Chairs after watching his girlfriend, in the throes of depression and searching for help, struggle for months to find an available therapist, let alone one she connected with.

Users fill out an online questionnaire, followed by a 45-minute in-person meeting with a consult therapist.

The consult clinician enters this data into the company’s software, developed in-house by both engineers and clinicians, which generates a set of therapists who both the tech and humans think will be a good fit.

A client who is a good match makes doing therapy easier for the therapist

Two Chairs charges $149 for the initial in-person consultation and $180 per therapy session.

The benefits of a good fit also extend to therapists. More engaged clients stay longer and are more likely to make significant progress, therapists said.

“Rapport has so much to do with the success on both sides,” said Michael Milazzo, a San Francisco private-practice therapist who works with Reflect. “A client who is a good match makes doing therapy easier for the therapist.”

This also helps a demanding job feel more sustainable, therapists said. In large healthcare settings like hospitals, a first come, first served model often means a revolving door of patients who don’t match with their expertise or approach.

“We’re in a field in which burnout is quite high,” said Katrina Roundfield, a licensed clinical psychologist and Two Chairs’ regional clinical director. “The extent to which as a clinician I can feel confident at Two Chairs that I’m getting clients that meet my expertise level and are within my wheelhouse … is really important to me.”

The startups ease logistical and administrative burdens for therapists, including automating scheduling and billing and walking clients through the byzantine insurance reimbursement process.

The data collection continues throughout the therapy process. At Two Chairs, therapists use a dashboard populated by self-reported client data to make sure they’re on the right track. Reflect clients receive automated texts after sessions with questions like, “How well do you feel heard on a scale of one to five?” Their feedback goes directly to their therapists.

The companies can cull some trends from the data they collect, like what is bringing people to therapy most often. At Reflect, it’s career stress and relationship issues, said founder Jonathan TranPham. Two Chairs said many clients sought therapy for depression, anxiety, and adjustment disorders as well as substance use disorders and trauma.

Facebook Twitter Pinterest The Reflect app. Photograph: Courtesy Reflect

In an age of increasing concern over how companies are managing our data, these startups stand in stark contrast: they cannot sell their users’ data. It is all voluntarily reported by clients and stored on secure platforms. Therapy sessions are confidential, as they would be elsewhere under the federal Health Insurance Portability and Accountability Act (Hipaa).

While the startup Kip believes that in-person connection remains key, its private app works to fill in the gaps that can emerge between sessions. The app prompts clients to record what’s on their minds, their moods and any issues they want to talk about.

Ashwin Kumar, who saw a Kip therapist for about a year to deal with the stress of founding a company, used the app to track his sleep and fill out “thought journals” whenever he became anxious or started going down a rabbit hole of negative thinking. His therapist could also send him resources and administer clinical assessments to keep tabs on his progress. All of this data would become the starting point for their next session.

Kumar described the app as “the glue between the therapist and the patient”. “It was like getting therapy in the session itself but also having the benefit of therapy in between,” he said.

A software engineer, Kumar did at first have concerns about his data privacy – “I’m writing some really personal stuff in here,” he thought. “What if something happens?” – but ultimately felt assured by the fact that the app is compliant with the Health Insurance Portability and Accountability Act, as his therapy sessions are.

Kip charges $180 a session in San Francisco and $200 in Palo Alto.

Technology’s ‘false promises’

Anja Schmitz, a licensed clinical psychologist and Kip’s chief clinical officer, said she was “immediately taken” by the idea of using technology to have a more complete picture of what her clients experience between sessions. She likened the app having “a microphone stuck in their head – what would I be hearing?”

But her enthusiasm for tech’s potential in mental health care has its limits. Without the close involvement of therapists who know the relevant research and best practices, the benefits quickly diminish, she said.

There is no replacement for the in-person connection

“There are a lot of false promises out there,” Schmitz said. “Having people who know what the current state-of-the-art treatments are and responsibly using technology to deliver those treatments is important.”

Other therapists expressed reservations about Silicon Valley’s explosion in their field, particularly the shift into digital-only tools whose efficacy has not yet been studied rigorously. The American Psychiatric Association now runs an app evaluation taskforce to more rigorously assess an area whose growth, the organization said, is “unprecedented in the history of medicine”.

Research shows that “face-to-face interactions encourage vulnerability, intimacy, and empathy between clients and therapists – which we know are fundamentally human experiences that technology cannot offer”, Roundfield said. “In my clinical opinion, there is no replacement for the in-person connection felt between two people in the therapy room, and the potency of that connection facilitates therapeutic change.”

The therapists said they believed in the startups’ commitments to keeping in-person therapy at the core of what they do, despite their dual identity as tech companies.

All of these startups are quick to champion their results. More than 90% of Two Chairs clients are satisfied with their matches. Reflect has a 95% retention rate after the first session. Kip clients report improvements in depression, anxiety and stress symptoms.

But what happens when the matching process fails?

They collect more data.

Reflect asks people not only why they selected their therapist but why they didn’t choose the other two offered to them. Yet another data point, it’s fed back into the algorithm, TranPham said, in a continuing effort to improve technology’s influence on human-driven therapy.