Over the past month, New York City has invited teens to participate in one of the country’s largest experiments aimed at helping troubled teens: a program that offers free online therapy to all residents ages 13 to 17 years.
The city has entered into a three-year, $26 million contract with Talkspace, a major provider of digital mental health services. After a parent or legal guardian signs a consent form, teens can exchange unlimited messages with an assigned therapist and receive a 30-minute virtual therapy session each month.
The launch of the program, NYC Teenspace, on November 15 took many in the city’s greater mental health community by surprise. In interviews, providers praised the effort made in making mental health care available to adolescents who otherwise would not have been able to access it.
But many also worry about whether the limited treatment offered by Teenspace will meet the needs of teens who have more complex problems. 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, he added, “the devil is in the details.” It’s unclear whether digital providers can “realistically meet capacity” and set appropriate expectations about response times and informed consent procedures, he said, “so there are no unintended consequences if anyone is disappointed or even harmed by this model of treatment”.
Dr. Ashwin Vasan, New York City’s health commissioner, acknowledged in an interview that the city was “taking a risk” by adopting teletherapy on this scale. But, he added, given the alarming levels of distress among adolescents, “the cost of inaction is much higher.”
In New York City public schools, there is one guidance counselor for every 272 students. Additionally, a report released this month by the state attorney general’s office examined 13 health plans and found that 86 percent of mental health providers listed as in-network were actually “ghosts,” meaning they were unreachable, not online or networked. do not accept new patients.
“What we wanted to do was create the lowest barrier and easiest democratized access possible,” Dr. Vasan said. “This is free. It’s in the palm of your hand. We’re empowering young people feel comfortable asking for help and do so independently of any adult, other than initial parental consent.
So far, about 1,400 teens have signed up, or less than 1% of the more than 400,000 eligible teens.
During a webinar scheduled for this month, parents in the city were shown photos of available therapists: an array of young, dynamic faces, some with dreadlocks or hijabs. Teenspace’s smartphone sign-up page also appeared on the screen: “Receive free therapy through the New York Health Department!”
Parents typed questions into a chat window.
“Is text therapy effective?”
“Can students remain anonymous?”
“Is it free or not?”
Teenspace’s arrival 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 public school districts in the United States offer 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 provide teletherapy services to up to 1.3 million K-12 public school students.
Few areas of the country have a larger mental health workforce than New York City, and some advocates have questioned the city’s decision to partner with a for-profit company at a time when city agencies are being asked to cut their budgets.
“Choosing to privatize this sector while imposing deep cuts on the social sector (and beyond) makes no sense to me,” said Matt Kudish, CEO of the National Alliance on Mental Illness in 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 hadn’t heard anything about Teenspace until a reporter contacted him, but he was “concerned” about the quality of care he would provide.
Other experts have questioned the level of treatment Teenspace offers teenagers.
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 hasn’t seen any evidence that a monthly therapy session and text exchanges offer a substantial benefit for teens with mental illnesses.
“One concern is that this could be kind of a Band-Aid on a wound that leaks out, and that could make things worse,” he said. As a provider who treats adolescents, she said, “this is not a level of intervention I would feel comfortable providing.”
As teletherapy has become more widespread 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 scalability,” said Livia Garofalo, a researcher at the nonprofit research institute Data & Society, who studies telemedicine. “This is their jam; we need to make it bigger. And in this process there are compromises that both the therapist and the client must accept.”
In March, a school administrator, Naomi Weizman, filed a class action lawsuit against Talkspace in federal court in California, accusing the company of “creating the false impression that Talkspace has a large enough network of therapists to meet demand,” and then unilaterally enrolls customers in automatically renewing payment plans.
A motion by Talkspace to dismiss the class-action claims in the lawsuit was denied last week. The judge in the case, P. Casey Pitts, rejected two elements of Ms. Weizman’s claims, including a request for an injunction that would block the platform’s subscription plan.
John Reilly, Talkspace’s chief legal officer, said Monday that the allegations in the complaint were inaccurate. “We work to connect members with providers as quickly as possible and they are typically connected to a therapist within a day or two,” he added.
Dr. Vasan said the city “went through lengthy and quite detailed due diligence” in considering digital providers and settled on Talkspace in part because of its size and focus on New York.
Dr. Jon R. Cohen, Talkspace’s chief executive, said the company stood out because it was based in New York City and could connect teens with a therapist “within hours.” Talkspace is also “an incredibly cheap and convenient platform,” he added.
Dr Vasan said the health department plans to analyze and update the service as it grows, adding therapists as needed and optimizing referrals for teenagers who need more intensive services.
“We can make those changes over time,” Dr. said. Vasan. “And this will be rigorous learning that we will have to undergo. And I just want to reiterate the last point: I wish I knew all the answers up front, but I think the cost of inaction is greater.”
After verifying that they are between the ages of 13 and 17, teens must provide a parent’s email address and, with 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.
Teens share their current problem and provider’s sex preference and will then be matched with one of Talkspace’s New York State-licensed therapists, of which there are approximately 500.
Currently, only 40% identify as teen care specialists, but a company spokesperson said training in the specialty, led by a Talkspace clinician, is 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 a day during business hours, “depending on the teen’s cadence and preferences,” a Talkspace spokesperson said.
Providers cannot prescribe medications. “The heart of this program is therapy,” Dr. Cohen said. He declined to reveal the parameters outlined in NYC Teenspace’s contract, but said that “one of the benchmarks is getting teenagers to use it.”
Teens in crisis are asked to call 988 or another helpline instead of using the app. As an added precaution, the company uses artificial intelligence to scan text conversations for indications that a customer is at risk of 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 comes from partnerships with cities and companies, has been a bright spot in its financial reporting.
In 2020, Hillary Schieve, mayor of Reno, Nevada, announced a one-year, $1.3 million contract with Talkspace to provide free assistance to citizens. Usage has been relatively low – about 3,100 of the city’s approximately 250,000 residents have used the service – and the city has not renewed the contract.
In an interview, Ms. Schieve said she was satisfied with the mental health services provided to people, but disappointed with the company’s efforts to promote the service.
“They failed miserably,” he said, adding that he would advise cities that partner with digital providers to pay the platforms based on the number of customers served.
“I don’t think they’re going to get their money’s worth, although I hope they do,” said 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, CEO of Talkspace, responded that “we would all like to see better use.” He added that in New York City “we are focusing a significant amount of our efforts right now on getting the word out.”
Dr. Garofalo, a telehealth researcher, said the quality of the experience on Teenspace is especially crucial because, in many cases, it will be a young person’s first encounter with mental health care.
“This is your chance to maybe convince someone that they need help or would benefit from talking to someone,” he said. “What if case management needs to be involved? It is a monumental task that they have set themselves.”