How mental health apps are changing the telemedicine landscape
COVID-19 has caused many patients to shift from their usual office visits to now-covered telehealth appointments. Virtual visits allow for the ability to remotely manage medical issues during a time when in-person care may not be an option for many. But even in pre-pandemic times, the U.S. has limited access to mental healthcare, while demand for support increases. We explore the mental health app landscape and investigate how effective telepsychiatry really is. We hear from Karan Singh, CEO of Ginger, an on-demand mental healthcare app, on how his platform delivers care. Dr. Lynn Bufka, of the American Psychological Association, discusses if therapy is as engaging over a screen versus face-to-face. Lastly, digital mental health researcher Dr. Jennifer Nicholas helps us understand how to vet mental health apps, addresses privacy concerns, and talks about issues in the space.
Show Notes + Transcript
Emily Kumler: I’m Emily Kumler. And this is Empowered Health. This week on Empowered Health, we’re talking about mental health apps. So many people know about apps that help you relax or sort of purport to be meditation apps, but there are actually sort of medical apps out there that are supposed to help you with anxiety, depression, all kinds of things. And some of these are available to us as consumers and more and more employers are signing up for these kinds of services and then offering them to their employees. So this brings about a whole host of questions, as I’m sure you can imagine, not least of which is how do you distinguish one app from another, besides just the reviews that are online, which we know more and more are now paid for, whether it’s the Apple star review or whether it’s like, you know, something that you find by Googling in the app. So you have to kind of vet these things a little bit, both for your own privacy and also to make sure that they’re doing what they say they’re going to do, and that they’re treating the condition that you think you have, or that you’re wondering that you have, or helping you to set goals. A lot of them seem to have very specific functions, whereas others are sort of catch-alls. So I immediately, obviously, as someone who’s very protective, felt like my ears went up when I heard about these apps, because I just think, huh, that’s sort of strange, right? That like you’re gonna use an app to try to help with your mental illness or something that’s really hard for you. Like I just, I always am sort of skeptical of our reliance on technology when really what we’re missing a lot of the time is human interaction, but I wanted to be open to the idea that these apps could be useful. So we taped these interviews, then we had the COVID-19 pandemic hit. And what we saw was sort of fascinating, which was that a lot of people probably like me that were a little resistant to some of these sort of telehealth platforms, were kind of forced to use them because we couldn’t actually have in-person interaction. And so sort of anecdotally, I think, you know, anybody who had to have a doctor’s appointment over the last few months has probably had it via Zoom or Skype or a phone call or something. And I think that’s probably opened all of us to the possibility that these could be useful. And certainly, things like insurance companies didn’t use to pay for any kind of telehealth benefits. And they have changed that because they needed to make sure that people were having some access to care. And the only way to do that was to do it virtually. So we’re going to start this episode by talking to somebody who kind of research this and then has now built his own platform, which is called Ginger, which is a provider-based platform or an employer-based platform. And as you’ll hear from him, there are sort of different levels of care. So you kind of can have a coach that you can text with all the time 24/7, or you can be bumped up and actually get some more traditional therapy, but it is run only through the employer so we could not test it out. And we’re reliant on the founders sharing of information in this interview.
Karan Singh: It’s a pleasure to be here. My name is Karan Singh, I’m co founder and chief operating officer at Ginger. And we are an on-demand mental health care system. Think of it like a virtual clinic for mental health care, with a team of coaches, therapists, and psychiatrists, all available 24 hours a day, seven days a week. And typically under a minute, all about backed by technology and available through your smartphone. I sort of stumbled into this space, frankly about a decade ago, was, was working in the biotechnology world launching a billion-dollar cancer drugs, frankly, kind of slammed into the space, had a loved one who tried to take their own life and sort of shook me to my core. I got a phone call out of the blue really and started to dig into this space of mental health care. And the deeper I dug, the more I realized just how broken it was. And that mental health is something that actually impacts most everyone. And so I decided to go back to graduate school at MIT and Harvard at the business school, medical school, really interested in this intersection of healthcare and technology and particularly data, and the deeper I dug, the more I realized there is no blood test for your depression. There’s no easy way to measure your stress. And I wanted to see if we could bring a level of rigor and objectivity to a space that’s really sorely lacked it. And so we’ve been on this journey for the better part now of about eight years, and originally started as a technology platform and ultimately decided to become a fully integrated mental health care system. We typically work with large self-insured employers and health plans who offer Ginger as a benefit to their teams. And now we’re working with over 300,000 covered lives (editor’s note: as of publication of this episode, Ginger reaches over 650,000 members in 23 countries) everybody from Pinterest and Buzzfeed and the technology world to Sephora,the large cosmetics retailer, to even SEIU 775, a large labor union made up of home healthcare workers. So pretty wide spectrum of membership. The company itself has actually set up as a medical entity. So we are legally a hospital or a clinic, if you will. It’s just that our front door is a mobile application rather than, you know, a physical setting.
Emily Kumler: And so what does that mean from the patient perspective like that you guys are a medical company like you’re HIPAA compliant? I would imagine like all that kind of stuff, or is it, does that have more to do with the fact that you guys go through the insurers or the company rather than the patient portal or the patient facing sort of like, I couldn’t go sign up for this, right.
Karan Singh: It’s a little bit of both.
Emily Kumler: Okay.
Karan Singh: Legally we’re set up as a, as a medical entity, which means that we abide exactly by all the regular rules and regulations that a typical hospital or, you know, your doctor’s office might. So that includes, you know, your data through HIPAA, and ensuring that, that your data is really only used for the direct delivery of your care. But it also means that, we are actually, when we deliver care that care can be covered as part of your health insurance. And so, you know, both were incredibly important for us, to make sure that a people feel comfortable and confident in being able to access care in a virtual care model without having to sacrifice any sort of privacy, but also that they can access that care in a way that doesn’t actually cost a whole lot where typically most of most mental health providers are out of network. And so as a result, they don’t have access to health insurance. And so, wow, when you, when you seek out a provider you’re typically paying out of pocket,
Emily Kumler: And that is a huge problem that we’re facing as a country right now is sort of like this shortage of mental health care providers or access to good mental health care. So I think, you know, let’s just back up a little bit and will you just explain what the app does and like sort of what it’s capable of or like what the parts of it are that are most often used?
Karan Singh: Yeah, absolutely. I think you covered off on a two things, but we’ll talk through that sort of member experience and how you engage with the app. And then we can talk a little bit about the sort of broader challenges in the ecosystem. So the way it might work is if you let’s say work at a company that we’re currently partnering with or have access through your health plan, you would download the Ginger mobile app from the app store or the Google play store. And you’d enter a unique access code that we provide you through a variety of different mechanisms through some direct communications. And within typically under a minute, you are talking to a mental health coach, engaging via text. And so you’re able to access, and talk to that coach 24 hours a day, seven days a week.
Emily Kumler: And that’s a real person. It’s not an automated algorithmic
Karan Singh: That’s exactly right. That’s exactly right. It’s a real person. These are typically masters-level providers who have a background in mental health care, or they’ve worked in, typically worked in psychology or related field. They go through about 200 hours of training on our system to ensure that they can deliver high-quality care, but exactly right. You’re talking to a real human and we’ve really found that there’s no replacement for that personal connection that personal accountability. And so the coach really gets to know you through text. And you can have a conversation about, you know, what might’ve brought you there in the first place. And the coaches are trained to really use evidence-based techniques like motivational interviewing to start to pull out the core issues that you might be tackling and pull together a game plan or care plan if you will, to support your needs. And so that’s, I’d say 90% of the use cases for most members who engage with Ginger, they can talk to their coach via text, and they can also engage in a variety of content that we’ve developed in the application. Things like breathing techniques or goal setting techniques that sort of compliment the care that the coach is providing. But for about 10% of members who might need an escalated level of care, they might actually need to see a therapist or even a psychiatrist. The coach will then get you connected to someone on our support team who sets you up with an appointment within typically a few days. And that’s a far cry, just kind of speaking to some of the challenges in the space for you know, the typical wait times for most people who are seeking out a mental health provider. It can be 25 days on average in certain rural parts of the country, upwards of six weeks. And so we typically are able to then set you up with an appointment within a few days, and you’ll have a video session with those clinicians. So with your therapist or psychiatrist, and that’s a typical call, 45 to 60 minutes video session. And the idea is that you can continue to work with that with your coach in between sessions. And so rather than engaging with your therapist once a week, let’s say for eight weeks, you actually have the ability to continue to engage with your coach on whatever it is that your therapist might be working with you on. And it’s that team-based care model. That kind of combination of not only the coaches, but the clinicians and the technology and the backbone that really makes up the fundamental experience for the member.
Emily Kumler: And so is there a communication between the coach and the therapist?
Karan Singh: There is, we work in a, in a team-based care model and so on the back end, and that’s really where a lot of the technology plays a critical role, is being able to share notes from those conversations and make sure that there’s coordination and collaboration. It’s something that it’s typically and historically incredibly challenging in healthcare and an actually an area where, you know, virtual care model and technology can play a great role in supporting that communication and collaboration. So the care is coordinated and folks get the right level of support at the right time.
Emily Kumler: And is the coach sort of like a gatekeeper or like a prerequisite to getting the therapist, or can people go on and just sort of say like, nope, I need a psychiatrist.
Karan Singh: Yeah. The latter is very much true. The challenge is that most people, you know, don’t necessarily have the right level of education around kind of what’s required. And so the coach can help them with that. They can give them a sense for the kind of different types of care that we might offer and when it might be most useful, but they’re by no means a gatekeeper. So if an individual comes through and they ask to see an additional level of care, we’ll set them up for that and at least have an initial evaluation or appointment, so they can understand if there’s additional diagnoses or additional support that they need.
Emily Kumler: And are there any limitations on like the, I mean, I feel like a lot of insurance companies will say like, Oh, you can go for eight sessions or whatever it is that they’re willing to pay for. And then the rest is out of pocket, or you have to pay a higher percentage of the cost. Do you guys have, like sort of stopgaps or whatever you wanna call it like that?
Karan Singh: Yeah. A lot of that actually I think has to fundamentally to do again with another sort of challenge in the space is, is the payment model, because most of those insurance companies and others providers are working, in a fee for service environment where you pay per transaction or per interaction. For our coaching, that is complete, that’s unlimited care. So you can access that as much as you want 24 hours a day, seven days a week, you can continue to engage with those coaches as and when you need to. Depending on what kind of plan your employer may have purchased for you, a good, a number of those sessions may actually be fully covered, or you might just need to pay a copay to seek a therapist or psychiatrist, but then there are in some cases, you know, certain limitations to that in terms of the number of sessions that are fully covered after which you’d pay out of pocket or pay and get reimbursed as an out of network expense.
Emily Kumler: And then I feel like I’m just like firing questions at you as it should be more of a conversation, but I’m just curious as somebody who has always sort of believed that therapy is something that we all need, right? Like we all need somebody, who’s not a part of our family or our friend group who we can go talk to about things that we’re thinking about. And I don’t even think actually it needs to be a big struggle. I think it’s just sort of like helpful to organize your life experiences. But I also know that in my personal quest to find like the world’s greatest therapist, it’s a compatibility game a lot. Right? So like, you might go talk to somebody and realize after the first session or after the first three sessions, like, you know what, like this person isn’t getting me, or I don’t really feel comfortable telling them all my deepest darkest secrets or whatever. Is there flexibility or like, how are you matchmaking therapists to people?
Karan Singh: It is very much a personal decision. We talk about it often, internally as establishing a therapeutic alliance, a number of studies actually demonstrated that that therapeutic alliance is really most critical to the kind of care that someone might receive and that’s personal. And so what that means is when you engage with your coach, for instance, when you first install the app, mobile app. Through the course of that conversation, you may decide that you know this isn’t a good fit for whatever reason. And you have the ability to actually rate your coach after every interaction. And what we do is for any interaction that’s below a four out of five stars. Our support staff actually reaches out and asks what might be going on. And if you know, coach fit might actually be a reason for, let’s say, a lower score and the same is actually true for our therapy and psychiatry interactions as well. And so really for us, we’ve built a system that’s based on measurement. That’s based on data, that’s tracking this information and creating kind of trigger points to reach out because for many people, you know, they feel embarrassed or they might actually feel scared to make a change for fear that they might lose, you know, lose the care altogether. And so we’re trying to figure out ways where we can reduce that friction and reduce that burden, but also ultimately empower the patient or the member to raise their hand if they feel like they want to make a change.
Emily Kumler: I’m sort of curious, like how often that happens, that people switch. Cause I feel like, like you guys actually have numbers on that. Whereas like, I don’t know that anybody’s like really tracked that privately.
Karan Singh: We do. We do. You know, we have, we have numbers on a whole host of information from, you know, the average time to see your coach, which is typically about 56 seconds, the average star rating across every interaction on the system, which right now is hovering about 4.6 to 4.7 out of five stars. And that’s for coaching, therapy, and psychiatry. And then ultimately, you know, something we haven’t talked a whole lot about, but actually measuring the efficacy of the treatment. And so we use two primary surveys, the PHQ-9 and the GAD-7, they’re the two standard assessments for depression and anxiety. And we find that 70% of our members see a full symptom response within roughly eight to 12 weeks, which is about two times the leading collaborative care protocol in this space.
Emily Kumler: What do you attribute that to? Like, why is Ginger so much more effective than the status quo?
Karan Singh: You know, I think it has to go with sort of reducing the friction at every step in the process for a member. So it starts with the stigma, which is to say, you have to admit to yourself that you have a challenge. And for many people that’s incredibly, incredibly hard and you then ultimately have to find a provider. And like we talked about, finding a provider is incredibly hard and, you know, 50% of us counties today don’t even have a single psychiatrist (editor’s note: studies are finding more like 60% of counties lack a psychiatrist). And then finally, when you get into to see a clinician, 70% of that care is inadequate. And so, you know, every step of that process, we thought, how could technology and how could a new care delivery model sort of transform that? And so the fact that the app is available 24 hours a day, seven days a week, and you can talk to your coach, reduces the friction of access right out of the gate increases the likelihood that someone’s actually going to take that next step once they decide that they’re actually looking for some level of support. The fact that they can access that conveniently, we’ve heard stories of members who are talking to their coach with their, you know, their spouse or their partner on the couch next to them. You know, they’re effectively having a session if you will, with, about that individual. And they don’t even know. And so that sort of flexibility and convenience factors is really, really valuable. But then finally, you know, it is about leveraging data to understand what works for whom, when and how. And I think that’s really the new frontier. What gets me incredibly excited is thinking about how we can start to bring technology and data to figure out this incredibly personal decision. Like you said earlier, you know, the relationship you have with your clinician is incredibly personal and there are patterns that are merged. There’s a whole quality assurance process that we run on those conversations using natural language processing and other sort of augmented artificial intelligence techniques that gives us better data about the kinds of traits that might make for a better alliance or better care. And we use that to inform who we might recruit. We use that to inform the clinicians themselves so they can actually improve the care they’re delivering. And ultimately to actually share that back with the member in different forms to demonstrate that they’re seeing progress over time. Easy question, but I think lots of dimensions that might go into that and something, frankly, that we’re continuing to research and really track to improve the system over time.
Emily Kumler: Yeah. I mean, it’s also interesting to me because I feel like the, you know, a million years ago when I was in college studying psychology, it’s like, there’s a huge amount of emphasis in a therapeutic session that’s put on the last 10 minutes.
Karan Singh: Right, sure.
Emily Kumler: And I think, you know, you kind of see this with friends when you go out to coffee or drinks or whatever, it’s the same kind of thing. Like people will talk and talk and talk, and then it’s like, when you realize the conversation’s over, that’s when you often share the thing that your… maybe is the most significant. And I wonder when you’re having, when you have access like that, how that changes, that kind of traditional model of therapy right. Where it’s like, okay, we’ve got 50 minutes go, right? Like all I can text you that my husband’s annoying me because he’s on the, you know, he’s sitting there, he’s burned dinner again. Like, you know what I mean? Like that’s just, it sort of changes it. Maybe it makes it more personal. I mean, not personal in that obviously therapy is very like intimately personal, but like friendshiplike. Do you know what I mean?
Karan Singh: I do. You know, it’s a, it’s a really interesting observation. And I agree, I don’t actually know if we have data on whether that they like the conversation. Let’s say the video session you might have with your therapist is any different, but what is different is the 167 hours between appointments. So let’s say you’re typically seeing your therapist once a week. There’s a whole lot of time in between sessions and you forget what happens. You know, you have recency bias. You remember maybe the issue that happened yesterday, but certainly not six days ago. And the value of actually having this team-based care model is that the coach actually sort of takes what you learn in your, therapy appointment, or maybe what you uncover and really starts to build some, some solutions and some training for you to work on that in between sessions.
Karan Singh: You know, I think where that’s played out, actually, interestingly enough, is we typically see that most members who are in therapy are in therapy for about seven sessions. And so that maps to the standard of care, which is typically around eight sessions for a full course of treatment. The challenge is that, you know, for most other people in a traditional medical care setting, we just don’t even know how long they’re in there for. And so, I do think that the, you know, there’s changes like this to the model that A. Might encourage more trust or more transparency, but B. Might also encourage better efficacy so that people can graduate faster and aren’t necessarily don’t necessarily need to be in care for, you know, in perpetuity if you will.
Emily Kumler: Well, yeah, but, you know, that’s also interesting because I feel like that’s such a goal-oriented way of thinking of therapy. Like, I mean, I think it’s like if you’re going in and you’re like, okay, I need to lose 20 pounds. Like, let’s get this program started kind of thing. Like, why do I eat when I’m sad? Or like something that sort of sounds cliched, then it’s really easy to come up with like action items. But I think the point of analysis is that you decide what’s important by reflection, right? Like if I go into a therapy appointment and it’s been a week or a month or whatever, since my last appointment, that judgment of like, okay, I have an hour to talk about the things that are the most important to me is a huge part of the process, right. Rather than saying like, oh, I see from your coach that this week, like you, you know, had a hard time with this, or you had a hard time with that, I’m making that call by sharing what I feel like is most important. You know, I sort of think that the idea that the time in between sessions is a period of reflection and analysis done by the patient. Right. So that, like I go in and I know, gosh, I’d love to spend four hours talking to you about all the things that are on my mind, but I only have an hour and I need to talk about the things that are really bothering me the most or that I’m most excited about, or, you know, sort of, I think the idea that everything has to be based around a goal of some sort of behavior to change is just a different kind of therapy. Right. I mean, like, so that’s sort of interesting because I think in some ways, technology is just perfect in terms of reminding you, oh, you know, like everything from like your Fitbit or your Oura Ring telling you like how you’re sleeping or how you’re walking or whatever. But it’s so interesting because I feel like when you’re thinking really deeply about your mental health, a lot of that is stuff that you actually have to kind of just sit with and it can be kind of mundane. Right. And it’s less action-oriented. Does that make sense?
Karan Singh: Yeah, no, it’s a great observation. And I think it both is true in that there may be certain things that you raised where you have a specific goal and you’re, and you’re looking to make some progress against things, but then there are others and certainly within therapy where the point of it is actually the reflection and to review and then, you know, dissect, but then to put away if you will, or to be able to figure out a way to feel comfortable with it. And I think that’s, that’s the power I’d say of this team-based approach where the coach can help you in having that conversation in between sessions. It may not necessarily be again, an eight weeks to happiness. It’s not a specific program that we’re running you through. And that’s very rigid. It’s very personalized. Every individual kind of has a different path through this, but there are also certain ultimately they lead up to, for instance, using a measure like the PHQ-9 that’s used for the treatment of depression or the assessment of depression to figure out if, if these things, if this issue might actually be impacting other parts of your life, like your sleep or your relationships and whatnot. And so it is still solution-oriented. It’s not necessarily goal-oriented.
Emily Kumler: And so what percentage of people are using Ginger because they have some sort of depression, like when you do the initial baseline, what percentage does that represent of the population that you’re treating?
Karan Singh: It’s hard to talk through the, to the averages because sometimes they skew sort of the specifics, but largely speaking about 90% of the population can actually be supported within just the coaches themselves. And for about 10%, they might actually have a diagnosed clinical issue that requires a licensed clinician, like a therapist or psychiatrist
Emily Kumler: Again, just to make sure that I have this right. If somebody felt like they were depressed, they could right away get linked up with a clinician rather than a coach
Karan Singh: In addition that’s right. So it would, it would not be instead of, but exactly, they would have to also be able to get escalated, to see a therapist or psychiatrist if they’d like to.
Emily Kumler: And so what are some of the most common things that people are using Ginger for? Like, what are some common problems that people are working on or things they’re looking for solutions to?
Karan Singh: It’s fascinating. This list has probably been pretty consistent for the better part of three or four years now. And now that we’re live in about 19 countries (editor’s note: At time of publication, Ginger is live in 23 countries), beyond the United States, it’s also consistent. People use different language and different words to describe them, but largely speaking it’s about workplace stress. It’s about relationship issues. And often it’s about sleep. Say those are the top three most common challenges that people bring, and those relationships could be in many forms. It could be your spouse, it could be a brother, it could be, you know, a father-son. But there’s a lot of family dynamic questions that come up, and that along with the workplace or stress and stress related to your job, that’s probably most common and most consistent, no matter what time of year and no matter what employer health plan we’re working with.
Emily Kumler: I mean, that’s fascinating too, the workplace stress. Cause I think Americans think that they’re like the most stressed out. Right. And if you’re seeing that in other countries too, that’s sort of probably more a product of the time that we’re living in.
Karan Singh: You know, it absolutely is. And we’ve seen certain spikes in kind of other higher-risk issues, even things like suicidal ideation or homicidal ideation. We saw an incredible spike last year after Anthony Bourdain and Kate spade, you know, committed suicide. And we’ve seen other situations like the elections, for instance, in the United States on a pretty regular basis that where we see a material spike in utilization, sometimes three, even four X on a, on a typical week or typical month. And, you know, the data allows us to be able to actually predict that and make sure that we have enough capacity or supplier or clinicians, if you will, to support that. But it’s absolutely true.
Emily Kumler: And then, in terms of thinking about acute mental health, do you think that Ginger is an application that would help somebody who was feeling suicidal?
Karan Singh: So Ginger is not a crisis resource. So whenever we do see individuals who are in crisis, we refer them out to a variety of different great programs. The National Suicide Hotline crisis text line. There are a couple of really great resources that are available. That being said, we often find people who are sort of in a precursor state to that. And so we might leverage the natural language processing that’s happening. That’s scanning the conversations of our coaching interactions to flag individuals who might be trending in a certain way and flag that for not only the coach, but perhaps some of the clinical supervisors to review those cases and consider either escalating that individual up to, let’s say to see a therapist or psychiatrist for a more robust evaluation and or to escalate them out because they actually might need in person and in person hospitalization or in person treatment. And so, you know, I think it’s important to know what we are just as much as what we’re not. And so I’d say for a vast majority of mental health needs call it about 80%. We can treat that in a virtual care model, but there are absolutely certain individuals that are more acute that do require some of the in-person resources. And I think that’s really where we see ourselves helping to support the massive sort of supply and demand imbalance in this space, which is to say there’s some great clinicians and great existing clinics and infrastructure, but it’s not enough to meet the tidal wave of need. And so if we can actually support those that are more mild, moderate, and even some that are acute, we can actually free up some of that, the in-person capacity for those that are most acute and those that are most in need of an in-person treatment.
Emily Kumler: And about how long are the typical interactions between the patient or client.
Karan Singh: Yeah, we refer to them as members.
Emily Kumler: Okay.
Karan Singh: It really depends. So typical again, a hard one in this case because the point of the system is really build a lot of flexibility and to adapt to whatever someone might be coming with. So for instance, you know, we have some members who reach out to their coach at 2:00 AM. They’re nervous, they’ve got an interview the next day, they’re going to be on air, want to want to work through a, might be having a panic attack and talk to their coach and get resolution. And that’s good enough. There are others who let’s say are working with their coach, or even a therapist for the course of call it eight to 12 weeks. They see they started a score of X and they’re down to a score of half X by, you know, that eight to 12-week mark. And they feel like they’re in a good spot and they might actually kind of graduate quote unquote at that point. And then there are others in, and this is kind of roughly one third, one third, one third here, that will engage with their coach, or their clinical network for an extended period of time months, if not even in some cases, years on end. And you know, all through three of those are valid sort of ways to use the system. They’re different. I think that the critical part is that, you know, we can, we can measure that you’re seeing some improvement on whatever it is that you’re trying to work through, and that you can, we can provide transparency and visibility to you around that, because ultimately this is about, you know, we built an experience that’s first and foremost for the member, and if we can get them better or get them feeling like they have fewer, let’s say depression, or more rather depression-free days, then that’s that’s success. And that’s ultimately kind of how we’re measuring the impact that we have.
Emily Kumler: And so then on the flip side of that would be like, how do you measure the people who are providing the services, whether it’s the coaches or the practitioners.
Karan Singh: We do a lot of work around clinical quality assurance. And so there’s a number of different techniques that we’re using or approaches that we’re using. So it’s some of the data that we’ve just discussed, the satisfaction metrics, the access metrics and the quality metrics are really critical to that. But then it’s actually the next level of detail, which is to say, you know, what makes for, we were talking about therapeutic alliance and how d you establish rapport and doing that over text for instance, is kind of a unique skillset, but there are certain ways that, and certain coaches who have developed certain techniques that work incredibly well. And so we’ll look for sort of what level of engagement or ongoing engagement do we see does a certain coach have, you know, higher rate of that or a lower rate of that. Do certain coaches actually engage with their members more over a certain period of time? There’s a number of dimensions that are feeding into it, we’ve studied the clinical literature and they’ve actually honed in on it on quite a few sort of core attributes that we think make for a great coach and, or a great clinician. And then we’re leveraging that some of the data to effectively, for instance, shortlist a set of transcripts that go through human review. So that can actually go through and another level of review from some of the clinical supervisors. So we can actually work with the coaches and coach the coaches. So we’re actually leveraging that data because it’s recorded, if you will, as part of the chat conversation to improve the kind of care that they’re delivering. And frankly, I think that’s been a really critical part of how we’ve been able to retain our staff and ensure that they’re not burning out and they’re continuing to grow is that they feel like they’re continuing to learn and get better at their craft. And that we’re really closely monitoring when they feel like they might be at their edge where they might actually be at their limit and we need some additional capacity to support the volume that’s coming through. So kind of, I think all of that data comes together in this quality assurance program to give us better feedback for our coaches and identify what makes for a great coach.
Emily Kumler: And then are they all in like a, I’m imagining them in like some big call center or something, or are they like at their homes? I mean, I feel like if you have to be available at like two in the morning, right? Like that’s sort of an interesting, and I, you know, you have to like, sort of have enough people available that like, if there was some sort of national emergency and everybody was freaking out that you’d have enough people available
Karan Singh: That’s right. So we have a pretty sophisticated model on the backend. That’s anticipating demand by, you know, frankly minute, if not certainly half-hour blocks throughout the day and throughout the week. And certainly by seasonality. So we have different shifts for our coaches. They’re not all clearly working 24/7. And those shifts match too when we see that those peaks. And so typically, you know, in fact, our, our peaks are actually in off-hours. And so, you know, a typical therapist let’s say is available nine to five Monday through Friday. And what we find is are a lot of our peak utilization is outside of that time. And whether it’s even seeing a therapist on a, you know, Thursday at 9:00 PM or a Saturday at 10:00 AM, because your kids are at soccer practice. It’s being able to sort of actually create supply for when we know there’s demand. And I think right now, you know, the reverse is true. And the reality is for most working people, being able to carve out time during the middle of the day and going to see a clinician is incredibly challenging. And so that’s, you know, again where a virtual care model like this can be really, really valuable.
Emily Kumler: Yeah. And I think one of the other things that’s striking to me just, I mean, cause I feel like what that does in a sort of larger, on a larger level, is it solves for the access problem just in terms of like the logistics of someone’s day, right? So like if you have a lot of work-life balance stress that you’re trying to figure out and you’re out of your, you know, you leave for your job at seven in the morning and then you get back at six at night, like you’ve got to find a therapist who’s taking patients who takes insurance, which by the way that will leave you with like five people in the whole country. And then you have to find somebody who’s willing to take you at eight o’clock at night. Right? Like, so I think that is phenomenally important that you guys are sort of open those other hours. Cause I think that flexibility will obviously increase the sort of incidents of use or the adherence to the program or, you know, any of these other things that are just is so logical.
Karan Singh: You know, I do think that part of our vision and our mission, a vision of a world where mental health has never an obstacle is that we can find you early. We can get you treatment and support far before you’re at a point of being, or at least ideating around suicidal thoughts or even homicidal thoughts. And so that’s, we believe the power of these sorts of approaches and technologies. And certainly Ginger is one example of that. But there’s now, you know, really growing movement. That’s building around this, that you’re dealing with life, you’re dealing with stress and life can be incredibly hard. And if you can actually start to get care when things are bubbling, rather than when things are full blown, we might start to head off, you know, at a societal level, this, this trend that you, that you’re citing which is absolutely been true that the, you know, suicidal rates are going up across the board
Emily Kumler: After talking to Karan, it seemed important to talk to somebody who’s a practitioner. So what do therapists think of these apps and how does it change the way that you do therapy, both from the patient’s perspective. And also from the therapist’s perspective, we reached out to somebody who is a therapist and also in charge of sort of regulating these and evaluating them. And she’s going to talk a little bit about how the experience is both different using an app than it is sitting in front of somebody, but how this access to care issue is such a big deal that almost like what we have suffered through in this pandemic, that in some ways, this is probably much better than nothing, but she’s going to explain to us from the therapist perspective, why these are really interesting and hold a lot of potential.
Dr. Lynn Bufka: This is Dr. Lynn Bufka, I’m a licensed psychologist. I work for the American Psychological Association. I do a lot of work as it relates to healthcare policy and intervention. And I have a clinical specialty in the treatment of anxiety and other related disorders.
Emily Kumler: We are excited to have you on, and we’re going to try and focus this conversation a little bit on the sort of new phenomenon of telemedicine as it relates to mental health. And so I know that you’re sort of working on some of the guidelines and stuff like that, for people to have a better understanding of how to sort of source the good advice online from the bad advice online. And I mean that in terms of providers who are providing services, I’m sort of curious in terms of the evolution of this. Like, I mean, I’m sure the technology is a component of it, but it also strikes me that more and more Americans find themselves in positions where they don’t have access to good care. I mean, we see this with ob-gyns, right? In rural areas, there’s like, no OB-GYNs anymore.
Dr. Lynn Bufka: Right.
Emily Kumler: And so I sort of wonder whether it’s like a supply and demand kind of being met by technology or whether this is something else that there’s a new audience that might not seek out, you know, psychiatric care or mental health care in general, but feels more comfortable doing it on the internet.
Dr. Lynn Bufka: So I think there’s a combination of things that are happening. Certainly we have technology that enables us to deliver health care via apps, via telehealth, via all kinds of tools. So that has certainly been a piece of it. We certainly have seen greater concentrations of professionals in urban areas, leaving those farther afield, less access to specialized kinds of care, which would facilitate more technology-based interventions. And I think there’s also a growing understanding that mental health and psychological concerns are not something that you have to just suffer with, right. That there is the opportunity for help. And I think we’ve really turned a corner in the U.S. About that, that people recognizing, no, I don’t have to just sit with this anxiety all the time. There might be something I can do. I don’t have to be depressed or be, I have struggle with the intrusive memories. There may be something I can do. So people are more open to that as a possibility. So it’s kind of a confluence, all of that. And then I think the last piece of it is we’re learning a lot about the kinds of information and tools that are really helpful to individuals. And increasingly that can be conveyed in ways via technology that makes it accessible to individuals. It doesn’t necessarily always require a one on one interaction with a professional. There might be ways technology can augment and facilitate that.
Emily Kumler: What are some examples of that?
Dr. Lynn Bufka: So there are some wonderful apps that have been developed often through the VA or the Department of Defense, because they’re trying to reach a very scattered audience who needs their help. So there’s various apps that could be used that could be helpful. There are ways that as a therapist, I might direct somebody to use things online in between sessions to sort of facilitate the work that we’re doing. And sometimes it makes sense even clinically to meet via technology as the intermediary. If you’re a far distance away and we’re able to meet via Skype, well, not Skype because of the quality of the data security, but if we’re able to use a secure platform to meet that facilitates us having sessions that maybe we wouldn’t be able to have, if it always required us to be face to face in the same room.
Emily Kumler: Okay. So what are some examples of the kind of intermediary like between sessions kind of stuff? Is that like behavioral tracking kind of stuff?
Dr. Lynn Bufka: Sure. So there’s a lot of things that can be done. There can be educational materials where you might talk about a particular issue in session and then give someone direct someone to an app or test some materials online or some guided reading to amplify what they’ve learned in the session and to think about how it applies to their life. It could be that you have an app that supports say smoking cessation and gives you some accountability in between your sessions with your therapist or your health coach, whoever you’re working with to try to quit smoking, or maybe you are using something like to track behaviors.
Emily Kumler: And so as a provider, how do you vet those kinds of things?
Dr. Lynn Bufka: That is a really tricky question because there’s, so much is out there, but what we always recommend to individuals is look at the source of the development of it. Is it a source that you understand to have a basis in mental health, that they’re individuals who have some expertise in the content area. So you want to make sure that the content of the source, the app, the whatever is based on the best that we know in the psychological and professional research, but then you also want to look at how easy is it to use and does it make sense for the needs of the individual that you have as a technology that fits with what their skills are?
Emily Kumler: And so are most of those apps that you’re recommending or that you feel should be on an approved list coming out of hospitals or universities, like sort of the traditional research fields, or are they coming more out of like the Silicon Valley tech startup world?
Dr. Lynn Bufka: They come from many sources. They come from health systems, they come from universities, they do come from startups. And so when they’re coming from a place that maybe doesn’t have the credit in terms of healthcare, like automatically you might have with a university maybe, or with the hospital, you know, as a provider, I try to look at who are the developers behind it? Do they seem to have mental health professionals who have worked to develop the content or have served as consultants in the development of it? So I try to look at those kinds of things before I make a determination about the app. And is it appropriate for use with the individuals I would want to use it with.
Emily Kumler: I mean, I immediately am struck by the fact that like everybody is tracking everything right. And so I would think the privacy component, which I think is really hard to judge, I mean, we had, you know, this incredible sort of ovulation tracking app was just like less than a year ago, was exposed for being funded by all these pro-life people. So you kind of wonder like women are recording every little detail of their sex life and like if they get pregnant and what they decide to do with the pregnancy, and now all that data is in the hands of, you know, these individuals who clearly have a political agenda. I sort of wonder about stuff like that when it comes to mental health where the information might be really private.
Dr. Lynn Bufka: Right. And so I think that’s another thing that people really want to take a look at is the information contained within the app? Is there some way that information is being transmitted to others? And if so, under what circumstances, how is that information going to be used? Is it de-identified all of, that’s really important to know. So I’m a person who’s going to be much more likely to ask you to do something that’s contained within your device. You know, that’s not likely to be sharing that information other ways because of that, because I want you to be able to use it as best suits you.
Emily Kumler: And honestly, right.
Dr. Lynn Bufka: Exactly. But that’s tricky because how many of us really read the fine print on things? Right.
Emily Kumler: Right. I mean, these disclaimers are like 30 pages long. I don’t think they’re actually designed for anybody to fully understand what’s in them.
Dr. Lynn Bufka: Exactly. So I think it’s really important, you know, for anybody to really think through the use of an app and to talk with a professional about what have they used in their practice, what are the limitations, those kinds of things to really think it through.
Emily Kumler: And then just to sort of touch on the idea of doing therapy, you know, whether it’d be via some sort of online video chat or just this sort of remote idea, my bias towards this, just to put this out there is that if you already have a relationship with a therapist who you’ve been meeting with regularly in person, and then you move or you’re traveling or something, and you can’t get to them, that rapport that was established earlier allows you to carry through remotely. I mean, I’m a big believer in like we all let off energies, right. And that not necessarily only in the metaphysical sense, but that like body language often speaks volumes, right. Facial expressions tell us a lot. And some of that you capture on a screen, but I think there’s something about really being in a room with somebody and like sort of smelling them and, you know, sharing the space together. That’s much more intimate. Right. And that makes you maybe feel more, both, I would say, like vulnerable and also supported. Right. Rather than like just sort of a chat online. Is there any research behind that or like any data that you’ve seen that either backs up or refutes that idea?
Dr. Lynn Bufka: It’s a really good question. I would say most therapists get into wanting to be therapists for exactly those reasons. They feel that being present with somebody there’s some really important value to that in the person, in person in the room really has meaning to it. When we look at data comparing outcomes of interactions, there’s some pretty good data supporting videoconferencing as a means for good outcomes for psychotherapy. So seeing the person on the screen, being able to talk with them that seems to be, can be as effective as in the room face to face.
Emily Kumler: Yeah. That’s interesting. I mean, cause even just feel like you’re just like when I’m on my computer, if I’m chatting with somebody, you know, and an email pops up or the phone rings or something like that’s so different than being in a therapist office, I’m not gonna look at my phone. Right. Or check email.
Dr. Lynn Bufka: Well, and I think you have to do it in that way. Right. You got a therapist needs to have just you on the screen that they’re looking at, not looking at email and other kinds of information and that you really need to invest that same level of engagement, whether it’s in the room or whether it’s via computer and that’s a challenge. Right. So we usually talk about that when we’re going to provide treatment via therapy technology, sort of how are we going to do this? Can you make sure you’re in a secure room where you’re not going to be interrupted because this is just like your therapy time. Even you wouldn’t get interrupted sitting in my office. I don’t want you to go into a coffee shop to do this where you’re going to have lots of distractions. You’re not going to be able to be private and communicate some of the things you might want to do.
Emily Kumler: I was actually thinking recently, like in preparation for this interview that like maybe modern-day going into an office sitting down or lying on the couch or whatever with one person without any distractions is a more potent experience today than it would have been 20 years ago, just based on the fact that we don’t really do that anymore. Right. Like very rarely do I sit down even with like my husband and have like a face to face conversation about something for 45 minutes unbroken. And that like that is very powerful. And like being able to sort of collect your thoughts and think about something, I mean, I guess whether it’s remote or in person in a quiet room feels, you know, sort of strangely out of the regular routine for most people.
Dr. Lynn Bufka: Right. And I think that’s when you’re, if you’re going to engage in therapy, no matter what medium you’re using to do that, trying to have that very precious time, that’s for you. And that’s about you is really critical. There are some kinds of therapy where it’s really an exploration, some of the, you know, very painful or difficult challenges you love. There’s other kinds of therapy where the focus may be a little bit different in terms of looking at sort of thoughts and how you’re approaching the world in that respect that may, and they may be more or less suited to in-person or via technology. And that needs to be sort of a negotiation between the individual seeking therapy and the person able to provide it, trying to figure out what’s the best fit, but there is a huge value in human connection. And you’re right, that I think the way technology is right now, our connections with people have changed.
Emily Kumler: We always like to talk to people who are experts in the field that we’re covering. And so this week we reached out to somebody who is an expert in terms of studying mental health apps and how effective they are and how they work and what to be careful of. And so this next interview is going to give you all, some sort of takeaway advice on how to evaluate these and what to look for. And our producer, Jill Webb conducted this interview.
Dr. Jennifer Ni…: My name’s Jennifer Nicholas. I did my PhD in digital mental health. And I now work at Orygen and the Center for Youth Mental Health at the University of Melbourne. My background’s been in how we can be using apps to facilitate treatment and management of mental health conditions. I think the power of apps is that they’re with you all the time. I mean, for better or worse, our phones are integrating to our lives. So that’s really powerful in that you can place tools and resources into the hands of people who need them sort of when and where to be accessed when they need them, without them having to, you know, reach out to services that, you know, oftentimes are closed or hard to get to, or have long appointment lines.
Jill Webb: Yeah. And especially with barriers to getting mental health help and kind of that access, just being able to log onto your phone and kind of talk to a therapist or go through a mindfulness practice is like really a new way to look at things.
Dr. Jennifer Ni…: Yeah. I think that’s the attraction that, you know, there are a lot of barriers to care as you say, cost just access in terms of long wait times or geographical barriers. And also, unfortunately, stigma still exists, which stops people from seeking treatment for mental health conditions. So having something that can be discreet can be on your phone, you can access it whenever you like can really help, you know, overcome some of those barriers. And we hope that once people have good experiences with an app that that might spur them to seek further care if that’s needed.
Jill Webb: Yeah. And kind of just going off the idea of experience with an app. I know you’ve talked a little bit about how sometimes there’s an assumption that if an app is in the app store, it’s going to work correctly. When you do these studies looking at these apps, what do you look for when evaluating what makes a mental health app good?
Dr. Jennifer Ni…: Yeah, it’s a really complex question. We know, unfortunately, there are no quality controls on apps available through the app stores and that really does present a challenge. I think both for individuals who are looking for apps to support them, but also clinicians who might want to use apps to sort of facilitate and extend their treatment. You know, we come at it from a very research, and have a lot of time on our hands perspective. So we’ve you know, developed some things that I’ve done is developed sort of a set of checkmarks off either guidelines for absent present information or sort of the tools that are normally used in practice, which back when I was doing some of these first studies were still quite paper and pencil paste and looking at whether the apps that are available are sort of checking off those boxes that we sort of made in a list from those tools.
Dr. Jennifer Ni…: I very much understand that sort of the average person and clinicians aren’t, you know, going to be inclined to do that. I’d say that a good mental health app has to sort of have three broad boxes that it ticks. Obviously being evidence-informed is really important. And that’s something that apps developed from researchers or health services are quite good at, but unfortunately, the majority that are developed from either individuals or companies can miss the mark on. Apps have to be easy to use it engaging. I mean, this is something that apps out there from companies and individuals might be quite good at. And us researchers have lagged in that area I think, in truly making apps sort of appealing to people, but you know, as good as an app might be for your mental health, if it’s not engaging and it’s not easy to use, then no one’s going to use it and it’s not going to do the job. And I think finally people should be looking at how apps protect their privacy and data and where they’re sharing that data with.
Jill Webb: What would you say are some of the examples of kind of boxes you check off when you’re looking through, I guess like factors of the apps, like I know you’ve written some things about like addressing symptoms, keeping track of medications, what would be the top like five important things to look for when let’s say somebody out there is looking to find a new mental health app?
Dr. Jennifer Ni…: Sure. Well, I did my research in apps of bipolar disorder. So, what I was really looking for is, for example, a lot of people with bipolar disorder, like to track their symptoms, to sort of keep track of either to identify some of the things that may precipitate an episode or to keep track of how they’re going and be able to recognize those things and act early. And the tools that we use within clinical practice to help people do that really do ask people to track their mood daily, their medication and their sleep. Those are sort of big things, particularly for bipolar disorder that will influence people’s wellness. So what I did when I looked at apps that were tracking is I tried to determine, okay, so these three things are generally on clinical tools. Are they reflected in the apps for the disorder? And what we sort of found is the answer was unfortunately, no. I think it was only a third really gave people the option to track all three of those important factors. But even when it came to something as simple as tracking your mood for bipolar disorder, people experience quite a spectrum of mood. So they can be feeling well or they can be feeling depressed or they could be feeling manic and that’s, you know, a spectrum of mood that they can experience, which is important for them to sort of know where they’re at. But a lot of the apps only allowed them to track mood, like quite superficially by, you know, clicking some smiley faces or only had them track the sort of depressed to wellness section of that mood and sort of ignored the mania. So it was looking at resources and understanding, okay, well what do people need? And then how do these fit people’s needs or in a lot of cases don’t.
Jill Webb: Yeah. And I don’t know if this was the same study that you were just referencing. One of your studies mentioned that only three of around 900 apps you looked at included a full citation to a published study. I thought that was really interesting that there’s kind of a lack of, I guess, furthering that education or even just citing it. So people know they’re actually getting good information from the app versus kind of just blindly following whatever. What do you think about that?
Dr. Jennifer Ni…: Yeah, for sure. I think that’s a big problem, one of the reasons it occurs is that, you know, if you’re going to have a citation to a paper in your app, usually that means that you’ve run a study and you’ve done the research to show that yes, you’re app compared to either another app or compared to sort of a treatment as usual sort of condition is effective in really reducing symptoms or helping you manage the condition. And unfortunately, that research takes time. And as we know, the app store and technology, that sphere just operates so quickly. So there is that mismatch between how long it takes for research to evaluate an app versus how quickly technology can develop apps can and how quickly technology changes. So there are very few apps out there that actually have studies behind them saying that particular app works, but there are a lot of apps which potentially use techniques and sort of strategies that we know work in other spheres. So for example, like mindfulness, we know that mindfulness can be helpful for people with depression. So if an app is using mindfulness, then it’s based on that we know to be effective. So we call that evidence-informed. So there is a problem in terms of, if we’re looking for reference apps that have references, we’re going to find very small amount. But I think at a next level, we can at least look to see whether the app is using skills and strategies, which we know to be effective in sort of studies and therapies, or just sort of real life. And they’re using the app to facilitate you in some way to help practice it.
Jill Webb: And also that these apps that are kind of following the best practices and are clinically relevant. I know that your study found that there is an issue with them just remaining stagnant in the app store. And that a lot of them will become unavailable to download. So the app market is kind of volatile. Let’s say you start to really like an app, but then it’s gone in a week or so why is this happening?
Dr. Jennifer Ni…: I think it’s just a space that’s moving very quickly and that anyone can contribute to from a researcher point of view, if we’re to develop an app and research it, usually that’s where the money stops. So, you know, in terms of research developed apps, being able to then be on the app store and have money to keep it up and update it when the new phone or the new iOS comes out, like all that stuff requires resources. So I think that’s why no, for research, we find it difficult because usually funding bodies want you to do the study that finds out that it works. So within that scheme, there’s very little money for being able to have something that’s available and sustained and updated. And I think probably a lot of other people who are developing apps are running into that same issue.
Jill Webb: Yeah. And just during this developmental phase, what would you say the people who were kind of designing the best apps are looking for in the design, like looking at socioeconomic status or developing the app for health literacy and being able to read across different levels of knowledge, what are some baseline things like that that are helpful when starting these apps from the ground up?
Dr. Jennifer Ni…: Sure. I think when it comes to design, really the biggest message is that it’s critical to involve the intended user from day one. So I’m very lucky to work at Orygen and the University of Melbourne, which really put an emphasis on youth involvement. So Orygen is a youth mental health Institute and really ingrained within the center. There are pathways to connect with young people and to get young people’s input on research and thinking about things. And I think that’s in design. When you think about the group, that’s going to be using them. You really want to get their input to understand their needs and to therefore make a product that’s eventually gonna successfully meet those. So I think that’s the same, whether you’re designing for people of lower economic groups or indigenous individuals, people living with varied mental health literacy, or even sexual minorities, really, including your users from the get-go to understand their needs is really paramount. We are struggling with getting people to use these tools and integrate them into their lives. Like we would like, and like, you know, Maps or Uber has seemed to do like you don’t generally have to think about what you’re going to do if you want to try and go some way, you know, that you’ve just plug in your app and off you go. So I think one of the big things in terms of engagement is really understanding different user groups and how to meet their needs and how they patterns of use and patterns of needs may be different.
Jill Webb: Do you think that the low engagement rate, when there is such a need for mental health resources, do you think that’s just because people are kind of concerned about privacy and trusting the app or it’s more of like a use factor?
Dr. Jennifer Ni…: I think the engagement puzzles, yeah. Something that I think we’re all trying to suss out at the moment actually in research. I think definitely some of it has to do with making sure that people are comfortable with the privacy and data sharing that’s happening on apps. And we know from large things like the Cambridge Analytica blow up that, you know, these are things at the forefront of people’s minds, but also I think, you know, making an engaging tool that meets needs for mental health when a lot of mental health conditions are very varied. So someone with depression, two people with depression can have very different experiences, very different symptoms, and also the same person can experienced depression and then sort of remit or come to a state of wellness and then experienced depression again. And even within that person, those two episodes of depression might look quite different. So it is a challenge to build engaging resources for people that experience very different things. And then for obviously very different people. So it’s definitely sort of, I think the sort of new frontier in looking at digital mental health apps is really figuring out how we can make these attractive to users and meet people’s needs for varied populations and over periods of time.
Jill Webb: Yeah. And even just kind of going over the differences in like two peoples, the way they handle like depression or the way it affects them. I’m wondering if apps they work better or worse with certain conditions. Like do people generally have better results using a mental health app with anxiety or depression or anything across the board?
Dr. Jennifer Ni…: Yeah. In terms of efficacy, I think this is like a relatively new and growing field. Most of our evidence at the moment shows that the best evidence for apps is for apps for anxiety and depression. So, there are apps out there for a whole range of mental health conditions and how we in research synthesize an evidence base for something is by doing sort of systematic reviews and meta-analysis, which really take the results of a lot of individual studies and combine them together to create sort of a bigger pool of data to then say like overall what’s happening. And I think the best evidence at the moment in terms of being able to do that for mental health conditions and for mental health apps that are sort of aiding those conditions is definitely for depression and anxiety at the moment.
Jill Webb: For anyone listening, is there any apps that you think are really good and that you recommend to people for mental health?
Emily Kumler: I think my takeaway from this episode is that we are in the beginning stages of becoming more comfortable with technology and mental health is something that is so intimate. That for some people, this might be just fine. And for other people it might not be fine. And so again, it’s sort of like, you need to know yourself, but you also need to research the specific platform that you’re thinking about using and try to consider what your other options are. So if you’re at the point where you’re sort of saying to yourself, you know, this Covid-19 crap has made me feel really anxious and I’ve been in my house for three months and I know it’s starting to be safer to leave my house, but I’m nervous about how to do that. And I’d really like to reach out to somebody, but I don’t really want to go to a therapist and sit in their office and try to figure that out. What I really want is like some coping skills then like maybe you can find an app that does that. We’re not going to recommend any specific apps because I, you know, I sort of agree with the experts here who are saying like, that’s probably not the right way to go, but I think if you’re talking about something else that has to do with what Karan mentioned, where it’s sort of the family issues that come up or spousal issues or true feelings of hopelessness, then you really probably need to get more expert advice in person and also develop a relationship. I mean, I think this idea that we have eight weeks to solve a problem is kind of ridiculous. Like I don’t think any habits even are really changed in eight weeks. Like you might be beginning to change a habit, but I find it unlikely that you are going to overhaul some, whether it be early trauma or something more serious in eight weeks, and that feels like a bandaid. Maybe that’s the, you know, the way to get you comfortable with therapy. Maybe that’s it. Maybe you do use these apps and then you realize that you want to go see somebody in person. But I think maybe everybody will have a different, different experience with these. I’m Emily Kumler and that was Empowered Health. Thanks for joining us. Don’t forget to check out our website at empoweredhealthshow.com for all the show notes, links to everything that was mentioned in the episode, as well as a chance to sign up for new for our newsletter. And get some extra fun tidbits. See you next week.