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The Evolution of Therapy    

The Evolution of Therapy

Art by Andrew Wetmore

By Iman Balagam

Admitting that you go to therapy is no longer the taboo topic it once was, instead it’s part of the general lexicon. While there are still strides to be made – like lowering the cost, increasing the number of providers, and enduring cultural sensitivity, the destigmatization of therapy has been a win-win for mental healthcare. Social media has played a huge role in this perception shift, helping normalize therapy and bring greater awareness to mental health issues with infographics, honest conversations, and therapists sharing advice. 

One result of this is that therapy has evolved. No longer limited to the traditional, Sopranos-style approach, we can now rely on telehealth formats like Zoom and text-based apps to get our therapy fix. And this is only the beginning! As we continue to advance as a society, we’ll see more and more integration between new technologies like virtual reality and mental healthcare. We spoke to experts in the mental health space to get the rundown on how therapy has changed, what it’s still lacking, and what therapy will look like in the future. 

The Past

For decades the most commonplace therapy option required you to drive to an office to talk to a trained psychiatrist in a beige room on an old couch, surrounded by Matisse posters. In the late 20th century it was primarily psychiatrists who practiced therapy. Psychiatrists often used a mix of psychotherapy, medication, psychosocial interventions and treatments such as the controversial electroconvulsive therapy (ECT), depending on the needs of each patient. This type of therapy was very expensive, not covered by insurance, and, as a result, reserved almost exclusively for the upper class (primarily white) population. While this traditional format (minus some of the older, questionable tactics) can be effective, it is also time-consuming and costly. 

The Present

As norms shifted and more people started to get in tune with their mental health, the demand for therapy started to grow, leading to an increase in psychiatrists and therapists. While this was beneficial to decreasing stigma it also allowed for a less regulated therapy marketplace. “We have had a rapid increase in the number of people providing therapy in such a short period of time, which has led to an increase in variability – so there are really, really good therapists and really, really bad ones as well,” explains Deepak Gopalakrishna, Ph.D. and CEO of Rey, a mental health startup that combines immersive technology such as virtual reality with traditional therapy options.

“The psychology marketplace figuratively offers both fast food and 5-course meals; either option offers good and bad providers, so [you have to] do your research and choose from the menu that suits your budget and goals,” explains Shari Foos, MA, MFT, and founder of The Narrative Method. Finding the right therapist comes from a mixture of personality and gut instinct, says Foos. “Ask [the therapist] about their method and approach, expectations or benchmarks for success, and be open about timelines,” she says. “Also, never be afraid to ask for references.”

The rise of telehealth has also moved the needle in making mental healthcare more accessible. Companies like Talkspace and Better Help have given us the option to text our therapists 24/7 or schedule a Zoom meeting that allows us to get help from the comfort of our homes. This has been monumental, especially for those who are intimidated by the idea of meeting someone in person or for those who simply don’t have the time to drive to an appointment. 

However, not all telehealth services are created equal. One of the issues, according to experts in the space, is that these mental health startups try to aggregate as many professionals as possible, meaning that you could be matched with a therapist who is coming straight out of a master’s level program and doesn't have a lot of working experience yet. “While there are many highly trained therapists out there, the public’s demand for speed and convenience has given rise to a ‘therapy-lite’ marketplace that includes online therapy delivered at your convenience in 15-minute, on-the-go sessions,” says Foos. Some of these services, while easy and affordable to access, offer nothing more than a safe space to get something off your chest, which can help reduce stress, but not necessarily get to the root of the problem. 

Additionally, Gopalakrishna says it’s key to remember that text and Zoom therapy isn’t necessarily better than in-person therapy, it’s simply more convenient. “These are modalities of communication that make logistics easier – I don't need to drive anymore, and I can connect to someone who is further away on a regular basis from my phone which [can be helpful],” he shares. 

One of the primary issues with therapy today is that we don’t have enough therapists to see the people who need care. According to the American Psychological Association, there are only 34 licensed professionals for every 100,000 Americans. “Even if we increase the number of therapists 4 times overnight, we still won’t have enough to even make a dent. So when it comes to the future of therapy, it’s really all about how do you scale? How do you find the good therapists and create scale for them?” says Gopalakrishna.

The Future

One way to account for this gap in providers that we’ve already begun to see is the advancement of digital therapeutics companies beyond text-based therapy. Recently, the health startup Big Health released the Sleepio app, a cognitive behavioral therapy (CBT) program for sleep disorder sufferers that provides an alternative to pharmaceutical interventions by scaling CBT programs to the masses via technology. Another company, Limbix, launched a self-guided cognitive behavioral therapy-based program for teens called SparkRx run entirely on their phones. The goal of the app is to help manage depression by encouraging teens to take note of their feelings and to schedule activities that help them feel better. 

We’re also going to see newer technologies like virtual reality (VR) become part of the therapy process. VR therapy involves a fully immersive, three dimensional environment that allows patients to have simulated, interactive experiences that can be used to diagnose and treat psychological conditions that cause them distress. While there is still limited research on its efficacy, Gopalakrishna (whose company Rey offers this form of therapy) says that it’s especially useful for those struggling with phobias, social anxiety, post traumatic stress disorder, worry/rumination, and attention management, as they often benefit the most from exposure therapy which VR can replicate. By creating a safe environment, VR allows patients to do things that perhaps they wouldn’t feel comfortable doing in real life, like facing something that gives them anxiety. Since VR today is so realistic, those experiences can evoke the same emotions, physical sensations, and thoughts that the real experience would. While VR therapy should be considered supplemental to talk therapy, proponents say it can help you break down barriers, practice new skill sets, and rewire the brain. 

These new digital interventions can help to reduce the amount of time needed to actually treat patients while also optimizing a clinician's time, which in turn helps to lower the overall cost. “We're trying to create a standardization of high-quality therapy that comes from a grounding in techniques like CBT and DBT (dialectical behavior therapy), and create the best process delivered through accessible technology,” explains Gopalakrishna.

As with most new ideas, there’s always the risk that people will be hesitant to try something so novel. However, Gopalakrishna assures us that he isn’t concerned about the broad adoption of these new modalities. “I believe that when people really want a solution to something that is super painful in their lives, they will do what is necessary to solve it,” he says.“The research around willingness to adopt digital technology in healthcare has been super interesting – the numbers used to be a lot lower but now 85% of people are willing to use tools that have proven outcomes.” 

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