Friday, February 23

New York City Is Offering Free Online Therapy to Teens: Will It Work?

For the past month, New York City has been inviting teenagers to participate in one of the biggest experiments in the country aimed at helping struggling adolescents: a program offering free online therapy to all residents ages 13 to 17.

The city has entered a three-year, $26 million contract with Talkspace, one of the largest digital mental health care providers. After a parent or legal guardian signs a consent form, teenagers can exchange unlimited messages with an assigned therapist and receive one 30-minute virtual therapy session each month.

The rollout of the program, NYC Teenspace, on Nov. 15 took many in the city’s large mental health care community by surprise. In interviews, providers hailed the effort for having made mental health care available to teenagers who otherwise might not have had access.

But many also worried about whether the limited treatment Teenspace offers will meet the needs of teenagers who have more complex issues. And some questioned why the city was partnering with a for-profit provider like Talkspace, which is the target of a class-action lawsuit filed by a former client.

“Conceptually, this could be a game changer,” said C. Vaile Wright, senior director of the Office of Health Care Innovation at the American Psychological Association. “This could absolutely revolutionize access to care.”

But, she added, the “devil is in the details.” It remains unclear whether digital providers can “realistically meet capacity,” and set appropriate expectations around response times and informed consent procedures, she said, “so there aren’t unintended consequences if someone is disappointed or even harmed by this model of care.”

Dr. Ashwin Vasan, New York City’s health commissioner, acknowledged in an interview that the city was “taking a risk here” by embracing teletherapy at this scale. But, he added, given the alarming levels of distress among teens, the “cost of inaction is much higher.”

In New York City public schools, there is one guidance counselor for every 272 students. In addition, a report released this month by the state attorney general’s office surveyed 13 health plans and found that 86 percent of the mental health providers listed as in-network were actually “ghosts,” meaning that they were unreachable, not in-network or not accepting new patients.

“What we wanted to do was create the easiest low barrier, democratized access to help that we could,” Dr. Vasan said. “This is free of charge. It’s in the palm of your hand. We’re very much empowering the young person to be comfortable asking for help, and to do that independently of any adult, other than the initial parental consent.”

So far, about 1,400 teenagers, or less than 1 percent of the more than 400,000 eligible adolescents, have signed up.

At a webinar on the program this month, city parents were shown head shots of the available therapists — an array of young, dynamic faces, some with dreadlocks or hijabs. Teenspace’s smartphone sign-up page also flashed on the screen: “You get free therapy through NYC Health department!”

Parents typed questions to a chat window.

“Is text therapy effective?”

“Can students remain anonymous?”

“Is this free or not?”

The arrival of Teenspace comes amid a wave of similar partnerships across the country. An analysis published this month by The Associated Press found that 16 of the largest U.S. public school districts are offering online therapy sessions.

In February, Los Angeles County signed a two-year, $24 million contract with Hazel Health, which offers virtual health care to more than 160 school districts nationwide. The Los Angeles partnership will deliver teletherapy services for up to 1.3 million public school students in grades K-12.

Few areas of the country have a larger mental health work force than New York City does, and some advocates questioned the city’s decision to partner with a for-profit company at a time when city agencies are being asked to slash their budgets.

“Choosing to privatize this while simultaneously forcing deep cuts across the social sector (and beyond) does not make any sense to me,” said Matt Kudish, chief executive of the National Alliance on Mental Illness of New York City.

Steven DiMarzo, president of the New York Mental Health Counselors Association, said digital platforms typically offer relatively low pay and push their employees to meet “unrealistic expectations.” He said he had heard nothing about Teenspace until a reporter contacted him, but was “concerned” about the quality of care it would provide.

Other experts questioned the level of treatment Teenspace offers adolescents.

Dr. Zachary Blumkin, senior clinical director of the Psychiatry Faculty Practice Organization at Columbia University Irving Medical Center, hailed the spirit behind the initiative as “pretty amazing.” But he said he had seen no evidence that a monthly therapy session and text exchanges would offer a substantial benefit for teens with mental illness.

“One concern is, this could be kind of a Band-Aid over a gushing wound, and that could make things worse,” he said. As a provider who treats adolescents, he said, “this is not a level of intervention that I would feel comfortable providing.”

As teletherapy has become more prevalent in recent years, digital providers like Talkspace and BetterHelp have sometimes been criticized for care that falls short of traditional psychotherapy.

“The whole point of these platforms is scale,” said Livia Garofalo, a researcher at the nonprofit research institute Data & Society, who studies telehealth. “That is their jam; we need to scale it up. And in the process there are compromises that both the therapist and the client have to accept.”

In March, a school administrator, Naomi Weizman, filed a class-action lawsuit against Talkspace in a federal court in California, charging that the company “creates the false impression that Talkspace has a large enough network of therapists to meet demand,” and then unilaterally enrolls clients in automatically renewing payment plans.

A motion by Talkspace to dismiss the class claims in the lawsuit was denied last week. The judge in the case, P. Casey Pitts, dismissed two elements of Ms. Weizman’s claims, including a request for an injunction that would halt the platform’s subscription plan.

John Reilly, the chief legal officer of Talkspace, said on Monday that the allegations in the claim were not accurate. “We work to connect members with providers as quickly as possible, and they are typically connected to a therapist within one to two days,” he added.

Dr. Vasan said the city “went through a long and quite detailed due diligence” as it considered digital providers, and opted for Talkspace in part because of its size and focus on New York.

Dr. Jon R. Cohen, the chief executive of Talkspace, said the company stood out because it is based in New York City and could match teenagers with a therapist “within hours.” Talkspace is also “an incredibly inexpensive, affordable platform,” he added.

Dr. Vasan said the health department expected to analyze and update the service as it grows, adding therapists if necessary and streamlining referrals for teens who need more intensive services.

“We can make those adjustments over time,” Dr. Vasan said. “And this is going to be some rigorous learning that we’re going to be undergoing. And I just want to reiterate that last point — I wish I knew all the answers in advance, but I think the cost of inaction is greater.”

After teenagers verify that they are between the ages of 13 and 17, they must provide a parent’s email address, and, except in rare exceptions, their parents or guardians must sign and return a consent form. After signing up, they can use the platform’s self-guided exercises, or opt for therapy.

The teens share their presenting problem and preference for a provider’s gender, and will then be matched with one of Talkspace’s New York State-licensed therapists, which number about 500.

Right now, only 40 percent identify as specialists in adolescent care, but a company spokesperson said the training in the specialty, led by a Talkspace clinician, is being offered to any therapist who is part of the Teenspace program.

In addition to the monthly video session, clients can send an unlimited number of text, audio or video messages to their therapist, but the response will not be immediate. Typically, providers communicate at least once or twice daily during their working hours, “depending on the cadence and preference of the teen,” a Talkspace spokesperson said.

The providers cannot prescribe medicine. “The guts of this program is therapy,” Dr. Cohen said. He declined to disclose the metrics outlined in the NYC Teenspace contract, but said “one of the benchmarks is to get teens to use it.”

Teenagers who are in crisis are directed to call 988 or another help line instead of using the app. As an added precaution, the company uses artificial intelligence to scan text conversations for indications that a client is at risk for self-harm and then alerts the therapist, who decides what to do next.

Talkspace struggled financially after going public in 2021, but its business-to-business revenue, which is derived from partnerships with cities as well as companies, has been a bright spot in its financial reports.

In 2020, Hillary Schieve, the mayor of Reno, Nev., announced a $1.3 million, one-year contract with Talkspace to provide care free of charge for citizens. Usage was relatively low — around 3,100 of the city’s roughly 250,000 residents used the service — and the city did not renew the contract.

In an interview, Ms. Schieve said she was satisfied with the mental health services provided to individuals, but disappointed by the company’s efforts at promoting the service.

“They failed there pretty miserably,” she said, adding that she would advise cities partnering with digital providers to pay platforms based on the number of clients served.

“I don’t think they will get their money’s worth, though I hope they do,” said Ms. Schieve, who, as president of the U.S. Conference of Mayors, has made mental health an area of focus. “I want cities to be cautious when working in this space.”

When asked about the promotion in Reno, Dr. Cohen, the Talkspace chief executive, responded that “we all would have liked to see better utilization.” He added that in New York City, “we are concentrating a significant amount of our efforts right now to get the word out.”

Dr. Garofalo, the telehealth researcher, said the quality of the experience on Teenspace is particularly crucial because it will, in many cases, be a young person’s first encounter with mental health care.

“This is your chance to maybe convince someone they need help, or would benefit from talking to someone,” she said. “What if there is case management that needs to be involved? It’s a monumental task they have set for themselves.”