Author’s note: In the time since I originally conducted the following interview, a number of legal, ethical and privacy concerns have been raised about TalkSpace. These issues are not easily summed up and are best read from their original sources:

• Talkspace Reveals Clients’ Email, Violating Clinical Confidentiality
• BREAKDOWN- Inside the messy world of anonymous therapy app Talkspace

Also, In a recent article, I address some of the important ethical considerations of using online technology in our counseling work: https://ctarchive.counseling.org/2017/03/technology-tutor-ethical-legal-considerations-counseling-tech/

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There’s no denying that telehealth is quickly growing in use as a medium for delivering counseling services. (Read my previous article on the ins and outs, ethics and legalities of telehealth at tameyourpractice.com/telehealth.) Although most of the focus is on the use of synchronous video, other modalities are growing in popularity too.

Recently, I had the opportunity to interview Tasha Holland-Kornegay, a licensed professional counselor supervisor who has been providing “messaging therapy” to clients through a platform called Talkspace. The service primarily consists of asynchronous messaging via text or web, although some video and audio options are also available. I was especially curious to hear how she was addressing some of the ethical and legal issues raised by this format.

Rob Reinhardt: I’m very curious to hear about your experience with messaging therapy but, first, can you tell me a little bit about yourself?

Tasha Holland-Kornegay: I am a licensed professional counselor, and I’m also an HIV advocate and have an HIV nonprofit (Partners Against Sexually Transmitted Diseases at pastd.org/). I go out into the community and speak to family members and educate individuals. Believe it or not, there’s still a lot of misinformation out there about it. So that’s another piece of what I do on top of counseling. In private practice (at ourtreatmentcenter.com/), I work with individuals anywhere from the age of 3 up to seniors.

RR: Very interesting. What is it that led you to messaging therapy? What made you say, “This looks like a great way to provide counseling services. Let’s give it a try.”

THK: I think it was a couple of things. With my passion for HIV [advocacy] and counseling, I have a Facebook page that I use as an educational forum. But a lot of times, once people find out that I’m a counselor, I’ll get private messages, and they’ll start with, “I just got tested.”

I knew that Facebook wasn’t a secure way to respond to them, and the messages were coming from all over the country. A lot of times I would make my response very basic and general and refer them to their local health department and HIV counseling and remind them that the Facebook page was more for informational purposes. But I didn’t want to turn my back on them; I wanted to help them more.

The second reason was that I recently had a baby, and I was thinking, “Oh my gosh, I don’t know how I’m going to continue what I have been doing and still have time home with the baby.”

RR: What convinced you that messaging therapy would meet the needs of more people and provide you more time at home with family while still practicing ethically and legally?

THK: I was a little nervous and skeptical because you don’t want to cross state lines and you want to make sure your clients will get everything your face-to-face clients would be getting. I spent a good month researching and processing. I think Talkspace, the company I work with, probably thought, “Is it her again?” because I was asking so many questions. But I wanted to be sure people were getting quality service and help.

So, I did a lot of research on the company and platform before I took the plunge. The company really does things well. They only allow you to have two clients when you first get started, and there are a lot of other things in place that addressed my concerns.

RR: It sounds like you got the answers you needed to make you feel confident in moving forward.

THK: Yes, and they were very fast to respond, and that was another quality that made me very comfortable with the platform. It was pretty much within the hour that they would respond, and they were very welcoming and informative.

RR: What was the process like once you decided to move forward?

THK: They signed me up and put me through a vigorous training process. I felt like I was back in school. They send you thorough lessons on how to navigate the platform and then on how to handle the relationship with the client, and there were tests. They want to be sure they are getting quality therapists, so there were case scenarios and “how would you deal with this?” Then you do one-on-one training with someone who tests your knowledge of the system and does mock counseling with you to be sure you’re ready.

After that, they set you up with your first two clients, and you have to let those clients know that you’re new. After about a month in training, they let you take four more clients, and then you are transferred out of training and into a mentoring group. My group has about five people in it. It really felt like a full-blown training program to make sure the clients are taken care of.

RR: So the people at Talkspace take an active role in setting the clients up with counselors?

THK: Yes. In a space in the app, all the clients are listed with age, gender and a general reason why they are seeking services. Then I can go in and say that I’m a good fit for this client because of my background, training and techniques, and I provide details. The employee who’s called the “consultation therapist” may even ask you for more details about why you’d be a good fit. Kind of like, what are you going to bring to the table for this client, because we want to make sure you’re a good fit. From there, they decide which therapist to assign the client to. Once you’re assigned, you connect with the client.

RR: Apart from the platform and environment, what has been different about providing messaging counseling from providing counseling services in your office?

THK: Because it’s unlimited texting and the clients take advantage, some clients will write a lot of journal entries. When I log in, there’s a lot to read and catch up on. I’d say 80 percent of my clients are active every day. So it feels like a lot of contact, unlike sessions in my office, where we meet and then go a week between.

I go into the platform five days a week, twice a day, and spend an hour and a half to three hours at a time replying to clients. You really end up forming a relationship with clients because you’re interacting with them a lot.

RR: If I understand, this process is asynchronous. You aren’t actually texting directly back and forth with clients, but rather reading and responding at different times of the day, unless they happen to be on at the same time as you.

THK: Exactly, unless they request it. And I’ve only had that happen once when a client was really antsy about a job interview and wanted to direct-message a couple hours before the interview. They do have a video option now, though I haven’t used it yet. People are working all day, and time zones are off, so it’s convenient for people to get it out and then wait for a response.

RR: Do you find yourself working with clients similar to those in your office?

THK: I’m currently dealing with a lot of clients with anxiety and relationship issues and some depression. It’s probably 75 percent clients dealing with anxiety. I’m not sure if that’s because I’m actively picking those [cases] or because of other reasons.

RR: I can see that making sense because people dealing with anxiety may be more likely to use online services.

THK: Yes, and I do see that a lot of these clients are experiencing counseling for the first time. They also find it to be really convenient, especially if they work a lot and don’t have time to go to a therapy office.

RR: In talking about what is different between counseling in your office and online, I thought you might say that working with clients online was briefer because these clients are looking to address a singular issue quickly. Has that been your experience?

THK: Actually, much like in the office, people will come in with surface issues and then later open up and reveal other layers — talk about their childhood and the fact that they’re actually experiencing anxiety in a lot of situations, for example. I’m finding myself working with clients over a period of time similar to [what I would] in the office.

RR: Do you find it challenging to deal with the lack of social and communication cues such as facial expression and tone of voice?

THK: The platform really does a great job of addressing this. They include the option to use audio, so if I feel that I’m not hearing a message clearly, I can propose to [the client], “For your next message to me, would you mind using audio?”

I also use a lot of emojis, and some of my clients don’t do written journals, they do voice journals. They can also send pictures to show me how they’re looking and feeling.

RR: So we can’t really refer to this as “text therapy” because it’s a lot more
than that.

THK: Yes, it really is. This platform was really thought out. It really answers a lot of the questions and needs in providing services in this environment.

RR: Speaking of questions, I know I have a lot of questions about how privacy and confidentiality, HIPAA (Health Insurance Portability and Accountability Act) compliance and other legal and ethical issues are handled. What things have you run into that you think are unique with this platform regarding those topics?

THK: The platform covers consent and not moving forward until you have the client’s consent. This includes clients consenting to working with you if you’re in a different state and that they agree to the license rules and laws of the state where the counselor is licensed. (Editor’s note: The American Counseling Association recommends that counselors check with the licensing board in the client’s state.)

I was also concerned about privacy. When clients and counselors log in, they are using their own username and password, and there’s a significant security and verification process that therapists have to go through.

RR: This concept of a client agreeing to abide by the laws of another state is an interesting one. I’m not an attorney, but I have to think the platform had its attorneys vet that policy. I’m not aware of it ever being tested in court though. This makes me wonder what might happen if a complaint is filed — how the courts or a licensure board might rule on it.

THK: I’ve thought about that, and I think we need to start somewhere. I think that it has been well planned and thought out. This is a national site with over 700 therapists. The client sees our full information about our license, and I think the wording in the consent is very tight.

I may well be in a “test group” because there are unanswered questions. We’re in a whole new world with technology, and we have to test it out. There are so many people out there who need help and may prefer to meet this way.

RR: Back to privacy. Is there any attempt on Talkspace’s part to verify the identity of clients? Are they allowed to stay anonymous?

THK: Talkspace verifies identity through things like credit card information. The client has the option of being anonymous with their therapist, but all of my clients tell me who they are and where they live. (Editor’s note: Standard H.3., Client Verification, of the ACA Code of Ethics states: “Counselors who engage in the use of distance counseling, technology and/or social media to interact with clients take steps to verify the client’s identity at the beginning and throughout the therapeutic process. Verification can include, but is not limited to, using code words, numbers, graphics or other nondescript identifiers.”) You’re building a rapport that’s remarkable like you’d never think you could do over texting.

RR: Because Talkspace does verify the client’s identity, does it have safety plans in place for crisis?

THK: They do. They warn clients up front that this isn’t an appropriate platform for crisis intervention. It states on the website that in crisis, clients should call the 24-hour National Suicide Prevention Lifeline at 1.800.273.8255 or 911.

And we do have a plan to address things as they arise. In addition to providing clients with local resources, we also always have a community and mentors to touch base with about situations to make sure that we and the clients get help if needed.

RR: You’re in a very interesting position of helping to innovate this new platform.

THK: Yes, and in some ways, it’s scary. But they have really done their homework with this platform and addressed the things I am most concerned about, so it helps me feel confident about working this way.

I think it’s fascinating that therapy and technology are finally merging in this way, and I feel good about it because there are so many people we haven’t been able to reach. This [lets] me know that I can help and reach more people and that I have a support system there that a lot of other people don’t have.

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Please note that I have not personally evaluated the Talkspace service. As Tasha Holland-Kornegay suggests, it is important that counselors fully investigate and evaluate any technology they might consider using to provide services to clients. This includes looking into the ethical implications of such use. Additionally, because state laws regulating telehealth vary widely, it is strongly recommended that you also consult with your state licensure board and a qualified attorney.

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Rob Reinhardt, a licensed professional counselor supervisor, is a private practice and business consultant who helps counselors create and maintain efficient, successful private practices. Before becoming a professional counselor, he worked as a software developer and director of information technology. Contact him at rob@tameyourpractice.com.

Letters to the editor: ct@counseling.org