Late last year, Reno, Nev., Mayor Hillary Schieve proposed a novel idea to try to meet the mental health needs of her community: The city would spend $1.3 million of expiring coronavirus relief funding on virtual therapy through the app Talkspace.
With the exception of young children, every resident would have free access.
Nothing of the kind had been tried before. Reno doesn’t usually tackle mental health issues — it doesn’t have a behavioral health department — and Talkspace had never offered its service to an entire city. “It was extremely risky, and politicians hate to be the first one to go out there,” Schieve told STAT. “But I’m not afraid.”
Schieve has long taken an interest in mental health, and when the state experienced a deadly surge of Covid-19 cases in the fall, she felt she had to do something to help her residents, including those who had been living in isolation for months.
The plan was well-intentioned, but it was not universally well-received. Local therapists, distrustful of Talkspace and frustrated they hadn’t been consulted on how best to serve the community, were aghast. They wrote furious emails, submitted public comments before the city council, and put together an alternative proposal that would keep the money local.
To many, the deal represented not only a threat to their own interests, but a clinically dubious attempt to help people in need. Talkspace relies largely on text-based therapy, unlike traditional therapy, as well as live video sessions.
“There’s a lot of really amazing, important work and ideas within our local community,” Erin Snell, founder of the local suicide-prevention center Rise Wellness, told STAT. “And then we have the politicians who decide, you know, ‘we think this is the best way to manage that,’ and really they haven’t asked anybody that’s in a real position that could inform what that might look like.”
The conflict in Reno underlines the broader tensions between conventional therapy and the cash-flush companies racing to disrupt it. Many therapists are skeptical of the quality of care delivered by Talkspace and startups offering similar services. In Reno, they also say a short-term deal won’t have a lasting impact on mental health care.
But supporters say that apps like Talkspace are effective and that they fill a gap in the nation’s tattered mental health system. In many communities, therapists couldn’t meet demand even before the Covid-19 crisis stretched their services beyond their limit. Conventional therapy is also increasingly expensive, with many providers declining to accept health insurance.
“Talkspace is not going after therapists,” Mark Hirschhorn, Talkspace’s president and chief operating officer, told STAT. “What Talkspace is doing is providing a very, very essential need that has been unmet in the marketplace as a result of the either shortage of available therapists or the inability of individuals to access those therapists.”
Founded in 2012, Talkspace made its name as a consumer wellness app with eye-catching advertisements featuring Olympic swimmer Michael Phelps. It’s one of many billion-dollar digital startups that have cropped up to make mental health treatment more accessible.
While some people forgo mental health treatment because of the difficulty of getting appointments, others resist because of perceived stigmas surrounding therapy. Talkspace, however, makes finding a therapist as simple as signing up for an app. From there, therapy proceeds over text, audio, and video messaging; more expensive plans include weekly or monthly live video chat sessions.
The company expanded its business recently with contracts to offer services to employees of large companies and, in a few cases, local governments, including Irvine, Calif., Riverside County, Calif., and Memphis, Tenn. In January, Talkspace announced it would go public through a merger with a special purpose acquisition company, valuing the startup at $1.4 billion.
Until recently, Schieve had never heard of Talkspace. But last year, devastated after her brother and sister both died within weeks of each other, she started calling around to several local therapists seeking help. Frustrated she was unable to get an appointment for weeks, she ultimately found help through the app.
“I realized that even the mayor of your own city could not get comprehensive therapy services,” Schieve told the city council late last year. “I was just thinking to myself, how can this be in a time when so many people are feeling isolated and they’re struggling?”
It didn’t help that Nevada’s mental health crisis is dire. The state ranks last in the country on a composite score used by the nonprofit group Mental Health America to rank states based on issues like prevalence of mental health issues and access to care.
The city initially was working on a plan to start a 24-hour center for mental health emergencies, using coronavirus relief money. But once it became clear the proposal wouldn’t pan out, Schieve directed staff to find out how the money could be spent to support the mental health of her community. “I felt like we were on some crazy game show where we had to spend all this money by the 29th of December,” she said.
She also consulted Kathryn Goetzke, a business owner and nonprofit director who moved to Reno a few years ago and has been working on global mental health strategy for over 15 years. Goetzke’s company, the Mood Factory, has sold numerous wellness products. Through her nonprofit work with the International Foundation for Research and Education on Depression, or iFred, Goetzke had become aware of Talkspace and reached out to the company.
The Reno deal was cooked up in meetings between Goetzke, city staff, and Talkspace representatives. Talkspace did not have an existing payment structure to provide therapy to all residents of a city, but Hirschhorn said the proposition bore many similarities to Talkspace’s deals to provide services to health plans with large populations. The final contract arrived at the monthly rate of 55 cents per person for chat and monthly video sessions. Ordinarily that service would cost $316 per month.
In all, roughly 200,000 residents would be eligible. Talkspace committed to spending $200,000 marketing the effort to residents. In an adjacent deal, iFred was granted a $281,000 contract to create materials for an education, marketing, and awareness campaign about the “science of hope.”
“I introduced Talkspace because we know that we don’t have the number of providers for the people that need help,” Goetzke told the Reno City Council late last year. “So you’ve got to integrate technology, and Talkspace is well-known in the space, has the best platform. So really, I brought them in as part of a solution.”
Under the terms, the company gets to keep all $1.3 million no matter how many people use the platform, but Goetzke predicted that usage would be high enough to justify the cost. “I think it’s going to be a bad business deal for them,” she said.
Resistance to Talkspace in Reno is rooted in a commonly held suspicion that the app’s therapy services are therapy-lite. Providers who live out of state communicating over text may not be able to offer the rigorous, evidence-based treatment a patient could receive from a local provider who can set boundaries, work toward goals, and encourage adherence. Local practitioners are also better able to escalate the intensity of care or contact emergency services as necessary.
“There are always going to be needs way outside of what a Talkspace type of service can offer, especially when we look at the depth of people’s trauma and stress and anxiety,” said Snell, who is active in the local therapist group that grew out of opposition to Talkspace.
Therapy opens a wound and requires “skill and commitment (more than just a few texts and emails) to close that wound,” a number of therapists wrote to Schieve. “Engaging in extremely brief or surface level therapy can actually be harmful, as there is no one left to close that wound, and doing this puts our citizens at risk of emotionally ‘bleeding out.’”
Talkspace’s Hirschhorn said such claims are spurious but “resonate in a marketplace where individual therapists are fearful of being left out by advances in technology.”
“Unfortunately, they cannot use empirical data to support their position,” he said, adding that the company has 10 independent studies that back its approach.
Beyond general hesitation over Talkspace, therapists argued that the precious coronavirus relief resources should be invested locally, both to support local businesses and to build long-lasting infrastructure that might serve the community after the money is exhausted.
“When Talkspace goes away, then what?” said Snell. “We’re still left with the same issue. … So we haven’t really fixed anything. We’ve just band-aided something that we have been wanting to fix for a long time.”
Schieve maintains that the goal was never to replace the important work done by local therapists. Instead, the idea was to provide an opportunity for people like her who couldn’t get into therapy, or people who might otherwise never have entered therapy. She also notes Talkspace isn’t meant to be a substitute for people who need intensive therapy or treatment for complex conditions.
Those arguments aren’t convincing for local therapists. Led by Kat Geiger, owner of Thrive Wellness, a clinic offering a range of mental health services, some 30 local therapists lobbied Schieve to fund vouchers to pay for therapist work instead of sending the money to Talkspace. They said their proposal would help support therapists who had reduced rates or made other financial accommodations to keep patients on during the pandemic. It would also open the door to people who go without therapy because of cost.
To address the mayor’s desire to expand access through technology, participating therapists would be required to deliver telehealth services. All told, the group estimated 12,000 Reno residents might be served by the program.
Despite the last-ditch effort, the Talkspace contract turned out to be a done deal. Company representatives and city employees who’d spent weeks working on the proposal made a slick presentation. A few city council members asked pointed questions of the Talkspace reps, but ultimately the deal was unanimously approved in December.
“I think that the horse had already left the barn, so to speak, by the time the therapeutic community heard about it,” said Geiger.
As of late March, Reno’s grand experiment with Talkspace has roughly 1,350 active users — people who have signed up for the service and communicated with a therapist. Whether that’s good or bad depends on who you ask.
“It is beyond the initial figures that we have projected,” said Hirschhorn. “… We’re very pleased with that.”
Therapists, on the other hand, frame the number in financial terms. “We’re still at $1,000 per person,” said Snell. Geiger pointed out that at common reimbursement rates in Reno, that would work out to roughly seven full talk therapy sessions per active user.
The city undertook a deliberately slow rollout, starting with city employees and involving a soft launch to the public before a more aggressive digital marketing campaign that began in January. There was concern that Talkspace wouldn’t be able to adapt to a huge influx of new signups. To prevent any delays caused by a surge, Talkspace maintains a therapist capacity for 500 more users than the number of those in the area who actively use the service. (Talkspace tried to recruit local therapists, offering a $500 sign-up bonus, but many practitioners interviewed for this story scoffed at the company’s rates.)
Recently, the company revamped its sign-up system for residents, so that rather than having to enter an address showing they live in Reno, they can simply use their phone’s location. The company is also in the process of ramping up its digital marketing efforts with some outdoor advertising in the city.
There’s some evidence the program is having a positive impact. In a Facebook post cited by the mayor and shared by members of the city council, one resident explained that he had never sought therapy, despite struggling with anxiety and depression since he was a teenager. Under pressure from the pandemic, he said he felt his symptoms getting worse, and recently tried Talkspace. It “has helped turn things around in a very short amount of time,” he wrote.
Therapists cite the experience shared by another Facebook user who could only find a 4 a.m. Talkspace appointment with an out-of-state therapist.
“These are things that occur when we’ve got 55,000 individuals receiving therapy at any given point in time,” said Hirschhorn. He added: “Every now and then you will find somebody who is offering a time or offering a day that is somewhat in conflict with an individual’s expectation.”
Dylan Shaver, the city’s chief of staff, is forthright about the challenges involved in introducing the program and said his short-term goal is reaching the “critical milestone” of enrolling 2,000 people, or roughly 1% of the eligible population.
Shaver said that he’s concerned about Talkspace’s ability to provide Spanish-language service. Hirschhorn said that the company has successfully matched people in the program to “therapists of multiple language capabilities.”
Shaver also noted that, as with all technologies, the necessity of a smartphone itself would be a barrier for some. He said that the city and Talkspace need to be very intentional about trying to reach populations that will be receptive to the platform.
“We went into this sort of wanting to get this out to as many people as possible, as quickly as possible because the need was so acute,” said Shaver. “But now there’s eight months or so left on this contract. And so it becomes, you know, what numbers are we targeting in terms of people? What kind of demographics are we pulling in? Can we be more accessible to those demographics? And can we hit some of these other targets?”
The contract expires on Dec. 21, and Shaver said there’s no pool of money to renew the program right now. Hirschhorn said he’s hopeful the city will find a way, but if it can’t, the company will pursue aggressive discounts or some other method for ensuring that people aren’t left in the lurch.
“We would never leave people hanging,” said Hirschhorn. “We would never cut off therapy to those that are currently receiving therapy without giving them a number of options.”
As for the local therapists opposed to Talkspace, they’ve been galvanized into a group now known as the Reno Mental Health Consortium. Their goal is to act as a single voice to advocate for mental health needs in the community.
There’s still hope that some city money might make its way to consortium projects, but the group has taken a longer-term view. Snell wrote a white paper describing the consortium’s goal of forming a nonprofit run by “individuals who understand the mental health field” who can write grants and disperse funds, to help develop more trained practitioners, and to bring together experts with many different specialties to build “a solid network of mental health services in Reno with fast and easy access to care.”
Schieve, meanwhile, recognized that she needed to engage with local therapists and directed the Reno Police Department’s “embedded resource officer” to work with the therapist community.
Geiger, the local therapist who runs Thrive Wellness, said she believes the city is engaging with the consortium in good faith and that the mayor, who has attended a number of consortium meetings, means well. “I know that our mayor is an incredibly good, well-intended human being who really values mental health,” she said.
Still, it remains to be seen if the consortium’s lofty goals can work within complexities of city politics. Geiger said the group is dedicated to get the work done even if the city doesn’t provide funds. She also allowed that, despite her opposition to the Talkspace contract, some good did come of it.
“Our city really needs this,” she said, referring to the proposals the consortium is putting together. “I’m so grateful that this whole Talkspace thing happened because it’s really made it evident to me the different areas of need in our community.”