Rethinking the accessibility of digital mental health

By Chris Gamble

July 2022

If your social media algorithm is anything like mine, you’ve probably seen an increasing number of ads for companies offering teletherapy through an app-based platform. Maybe you’ve seen Olympians Michael Phelps and Simone Biles sharing their own mental health stories in TV commercials for a couple of these companies. Regardless of how you come across your information, one thing is clear: the digital mental health (DMH) era is here. 

A 2020 report by the World Innovation Summit for Health defined DMH as “the use of internet-connected devices and software for the promotion, prevention, assessment, treatment and management of mental health, either as stand-alone tools or integrated with traditional services.” This can include platforms that offer varying combinations of therapy, medication management and coaching and those that don’t provide therapy but instead rely more on self-guided, therapist-created content. There are even artificial intelligence chatbots and virtual reality-based mental health interventions, which are likely to expand with the buzz surrounding the metaverse (a digital world where people can interact with others in a computer-generated environment). Throw in meditation apps, guided journals and mood trackers and the crowded bucket of DMH is surely overflowing. 

Although many of these platforms existed before 2020, the onset of the COVID-19 pandemic contributed to their expansion, as many poised themselves as solutions for filling the access gap made wider by the global health crisis.

I have worked as a licensed professional counselor in Washington, D.C., for six years, mostly with low-income, Black youth and families in schools, community-based agencies and currently a children’s advocacy center. So, the constraints of a fragmented public mental health system, long waitlists and a lack of culturally relevant services have been at the forefront of my mind for quite some time now. I regularly see how inadequate availability of quality mental health services can compound trauma and further complicate the healing process. As a Black counselor, I am protective of the populations I serve and vigilant toward any sweeping claims of answers to long-standing problems. Thus, I keep my clients and other marginalized groups in mind when approaching the larger question of how access can be improved through the medium of digital technology. In this article, my aim is not to endorse or dissuade from any specific DMH company but to examine the field of DMH and its shortcomings in improving access for marginalized populations.

Accessible for whom?

In the public discourse around mental health, access is often limited to definitions of ease and convenience. People often assume that removing the burden of internet searches and transportation needs and increasing privacy protection by being in one’s home are key to making mental health care more accessible. In this sense, app-based therapy seems to be a good fit. At least for some. 

The COVID-19 pandemic and the need for schools to switch to remote learning exposed the digital divide in the United States. I personally witnessed similar issues in my community mental health work at the time. For many low-income, Black households, a parent’s smartphone may be the only internet-accessible device they have, or their internet service may not be adequate to sustain full therapy sessions. Add to that the higher likelihood of multigenerational households within certain racial groups, and suddenly one’s home is not so private. Even more barriers exist for disabled people and those with no or limited English proficiency. Considering the amount of work it takes to develop an app, it is concerning that these issues are so often overlooked. If the innovations spurred by DMH continue to ignore cultural differences and structural disparities, the contradictions with goals of increased access will only become more noticeable.

For apps offering self-guided content and therapist-created videos or live discussions, we have to wonder about the cultural relevance of this material. A quick look at popular media and creative content-based platforms supports the suspicion that certain groups could be catered to over others. This is an inherent vulnerability in the “attention economy.” In the battle for our eyes and ears between social media, podcasts, TV and movie streaming, music streaming, and video games, DMH platforms are poised to join the arena. Adding self-guided and therapist-produced content to attract users may seem antithetical to attending to their mental health needs, but when subscriptions and engagement drive a company’s value, what safeguards keep this from happening? 

Given these market-driven incentives, it is imperative that marginalized communities are able to find content that reflects their lived experiences. And DMH companies will need to demonstrate a responsibility to these communities and not stray from public accountability. Suppose a company signs a contract with a popular therapist with a large social media following to produce informational and educational videos for their app. Over time, perhaps users begin to notice cultural bias in this therapist’s mental health tips, or the therapist becomes the subject of a scandal involving discriminatory behavior or public commentary. Would users again be left to trust a tech company to make moral decisions over monetary ones? And how a company responds to such an issue could illustrate whether the well-being of marginalized groups is a priority. Counselors would be wise to take notice of this intersection between the mental health field and broader societal trends in order to understand the varying effects on different groups.

Impacts on the mental health workforce

DMH is also positioned as a solution to fill the gaps in the mental health workforce shortage by using technology to bring clinicians to underserved areas. Let’s first look at what might draw counselors to working for DMH companies. One potential benefit is that therapy apps could handle the business aspects of independent practice, such as insurance paneling, client referrals, scheduling and billing. Taking these responsibilities off the counselor’s plate can make the increased use of these platforms attractive to the field, especially for those who prefer working from home or other remote locations. 

Before looking at how this affects access, we can’t disregard possible downsides for DMH workers. Because many DMH companies are startups, they tend to rely on contract work to facilitate business growth. There have even been instances of changing salaried, benefit-receiving employees into contractors, leaving therapists in precarious financial positions. Other practices such as being paid per the number of words texted to clients call into question whether a counselor would be incentivized to provide care for clinical reasons or personal financial ones. Everyone’s finances and living conditions are different, but these parallels to the gig economy should draw caution. On a broader scale, accepting pay that doesn’t match the labor, along with following business practices that are possibly out of line with the ACA Code of Ethics, can influence how the counseling profession is perceived.

In the presence of a DMH industry looking for more workers, the previously mentioned problem of the digital divide becomes heightened. As more mental health professionals transition to DMH platforms, fewer are left to work with those who can’t access them. This trend could accelerate even further if we consider the recent progress with establishing the Counseling Compact. I and many others have been eagerly awaiting this development, but I also wonder: Could expanding our reach through the Counseling Compact amid increased DMH options end up siphoning the counseling workforce away from those most in need within our proximity? For instance, if I took advantage of licensure portability in the future and was able to practice in several different states, my caseload would likely be easier to fill and maintain, but marginalized D.C. residents would suddenly find my services to be less available. If licensure portability were implemented on a larger scale, counselors may cast a net so wide that those closest to them end up falling through the holes. 

What to do?

Now that the possible effects of DMH on marginalized groups and the counseling profession have been laid out, the question remains: What can we do about it? Here are some ideas to consider.

1) Get to know the research. With billions of dollars being invested into DMH, the industry does not seem to be going anywhere anytime soon. Counselors need to pay attention to the research and marketing around these products in order to understand what is being prioritized. Determining whether apps are equally or more effective than in-person therapy will be an ongoing project, with outcome-based studies being conducted both internally by DMH companies and by independent parties. It is important for counselors to know what constitutes a quality study design and how companies represent their evidence-based claims. Sample size, outcome measures and the time range of studies are all things to keep in mind. A glaring omission I’ve noticed within much of the DMH research is the lack of racially diverse participants and the fact that sometimes racial demographics are not collected at all. To position DMH as improving access without even looking into possible differential outcomes for people of various identities could actually result in deepening preexisting health inequities. I encourage counselors to take the time to browse the websites of different DMH companies to see if the research studies they reference collect comprehensive demographic data, and then ask themselves what this means in the context of who the app is marketed to.

2) Find the problem-solvers. There are growing pockets of research focused on these problems and their potential solutions. In a 2021 article published in JMIR Mental Health, Elsa Friis-Healy and colleagues developed five recommendations for how the DMH industry can design products that increase utility for racially and ethnically minoritized groups. There are also implementation studies such as Samantha Connolly and colleagues’ 2020 narrative review, published in the Journal of Technology in Behavioral Science, which examined factors for successful implementation of mental health apps, from their design to their uptake and sustained usage. Counselors can use research such as this to understand what elements make for a quality app, thereby empowering us to make informed decisions around their use. Additionally, we can get involved in developing ways to advocate for these solutions or propose our own, whether through national organizations already doing this work or by creating local networks attuned to local needs.

3) Know your clients. Most importantly, counselors who work with marginalized populations need to recognize all the ways their clients can be left behind by an increasingly tech-focused field. By leveraging what we know about the social contexts we work in, we can become better equipped to dismantle barriers to DMH or identify more appropriate solutions to access needs.

Conclusion

The necessary uptake of teletherapy onset by the pandemic lockdowns seemed to open a door to solving the long-recognized problems associated with accessing mental health services. If the heads of DMH companies are the main force behind this change, however, there may end up being more hurdles than expected. This article explores some of the mismatches between DMH’s promises and the needs of communities most affected by the inaccessibility of mental health services. By incorporating the conversation of technology and access into the counseling profession’s efforts to practice with cultural intentionality, we can ensure the best interests of all clients are maintained amid the rapid changes occurring in our society.

Chris Gamble is a licensed professional counselor, national certified counselor and certified clinical mental health counselor based in Washington, D.C. He is committed to showcasing the power within marginalized communities. Contact him at cmgamble92@gmail.com and follow him on Instagram @chris_thecounselor.

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