Ep. 125: Technology & Talk Therapy: A Conversation with Talkspace CMO Dr. Nikole Benders-Hadi

In the five years since COVID-19 shook the world, the use of telemedicine and virtual platforms to deliver health care has become commonplace, helping to break down barriers of distance, transportation, and time. Those challenges still exist today, and the evolution of virtual health care delivery continues, led by innovators like Nikole Benders-Hadi, MD, Chief Medical Officer, of Talkspace. 

Dr. Benders-Hadi joined us to talk about the current state and future of virtual mental health services, including the growth of asynchronous text-based therapy, the use of large language AI models to determine the risk for self-harm among clients, and the ways Talkspace is supporting its therapists in maintaining client empathy in the virtual health care space. 

Watch episode 125 on our Nemours YouTube Channel.

Guest:
Nikole Benders-Hadi, MD, Chief Medical Officer, Talkspace

Carol Vassar, host/producer

Views expressed by guests do not necessarily reflect the views of the host or management.

Subscribe, review or let your voice be heard at NemoursWellBeyond.org.

Transcript

Announcer:

Welcome to Well Beyond Medicine, the world's top-ranked children's health podcast produced by Nemours Children's Health. Subscribe on any platform at nemourswellbeyond.org or find us on YouTube.

Carol Vassar, podcast host/producer:

Each week, we'll be joined by innovators and experts from around the world, exploring anything and everything related to the 85% of child health impact that occur outside the doctor's office. I'm your host, Carol Vassar, and now that you are here, let's go.

MUSIC:

Let's go, Well Beyond Medicine.

Carol Vassar, podcast host/producer:

Can you believe that it's been five years since COVID-19 shut down the world? It was a time that, by necessity, changed the shape of healthcare delivery for millions of patients across the nation, bringing telehealth and other virtual platforms into our homes and helping to overcome immediate barriers of distance, transportation, and time. Those barriers still exist, but innovation in the virtual healthcare delivery space continues to make inroads and breaking them down. Innovation by people like Dr. Nikole Benders-Hadi, who joined us at HLTH in Las Vegas to talk about the state and future of virtual mental health services, the growth of asynchronous text-based therapy, the use of large language AI models to determine the risk for self-harm among clients and intervene, and how her providers work to maintain empathy in the virtual space.

It's all part of our rich conversation, which began with the question, how has the Talkspace platform evolved in recent years, especially since COVID-19, given the growing mental health needs of our nation, especially our youth? Here's Dr. Nikole Benders-Hadi.

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Talkspace was founded over 10 years ago, really with the idea of using technology to expand access to care. The goal has really been to make mental health care more convenient, allow more people to get into care, allow our providers to deliver care across an entire state's graphic footprint. Really over the last few years, it's been expansion of our suite of services, so we also offer self-guided tools, we offer virtual therapy, and that's both video-based as well as asynchronous message-based therapy, and then we also offer psychiatry and medication management. We've also, in the last couple of years, something that's been really exciting has been our evolving AI tools and the use of AI and technology to expand access but also the quality of care that we're delivering, so happy to talk more about that too.

Carol Vassar, podcast host/producer:

Well, let's hold AI for the moment. I want to ask about the asynchronous care that you mentioned. How does that work? I'm used to sitting down with my therapist now in an online setting and talking with her about whatever's going on. Talk about how this happens asynchronously.

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Asynchronous therapy, and that's a question that I get a lot so thanks so much for the opportunity to clarify this, Talkspace was really a pioneer. It's really the idea that a client is able to send messages into their therapist at any time. That may be text messages, that may be audio messages or video messages, what we find is that it really allows clients to connect and send their thoughts and feelings in the moment rather than having to wait until that next scheduled visit. When looking at things like our teen population in particular, we know they're already on their phones, and so being able to meet them where they are, have them send in messages at any time, and then have their therapist respond back to them during their working hours, we find is really effective for getting in-the-moment feedback about how someone's doing with their mental health.

Carol Vassar, podcast host/producer:

Let's talk about traditional versus online therapy. What are the advantages of online, or even asynchronous, or AI-assisted versus traditional talk therapy in a provider's office?

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Yeah. A really important aspect of in-person versus virtual care is rapport building. It's that therapeutic relationship that a care provider is able to establish with the client that they're seeing. What we find is that in virtual settings, we are able to establish that relationship in the same way as in-person, and that is what allows our clinicians to really get to improved clinical outcomes the same way that you would in-person. I think one of the big barriers to mental healthcare out there are things like transportation barriers, needing to take time off of work to travel to an in-person doctor's office or therapist's office, so being able to engage in a virtual care setting really helps by eliminating those barriers.

Carol Vassar, podcast host/producer:

Let's get to the AI. How does AI work for Talkspace and in the online space for both patients and clients?

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

One thing that we really wanted to do at the beginning of this road into AI was think carefully about how we were going to engage with AI in a responsible way. In the beginning, that really involved setting up an AI governance committee, which consists of clinicians, members of our product team, members of our legal and compliance teams, to think through how are we going to use AI, what types of features are we going to develop, how do we ensure that we're ethically responsible and not introducing bias in any of the AI tools that we're featuring. Number one, that was very important to us, but we also think about AI in several different ways that we can use it.

One is just operations. How can we use AI to enhance how quickly customer support agents are able to get responses back to clients when they call in? Another aspect though is also the use of AI for clinical decision-making and for really assisting our providers. For example, we want our therapists to be able to send AI-informed welcome messages so that they could introduce themselves to new clients in a faster and more effective way. We want to use AI to prep for sessions by summarizing that last visit for a therapist so they can arrive to that next follow-up visit more prepared.

We are also using a machine learning algorithm. That's a really exciting one that's actually been in place for the last several years. It's a machine learning algorithm that is running on the backside of our platform. It's scanning the content of messages between a therapist and a client and then servicing to that therapist when there's a rising risk for suicide in that therapy room. That then allows the clinician to perform either assessments, or intervene sooner, or direct that client to a higher level of care, and we've seen that it's actually working. Unfortunately, a lot of people are really struggling out there now. To be able to surface to a clinician that those rising risk is something that we find is really helpful.

Carol Vassar, podcast host/producer:

A lot of that has to do with the research into language patterns and "I" statements, doesn't it?

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Exactly, and it's really the context as well. The example I like to use is that if someone uses the word knife, they type the word knife in a message to their therapist, it could be in the context of them wanting to self-harm or cut themselves in some way or they could be describing how they ate their dinner last night. That context becomes really important.

Carol Vassar, podcast host/producer:

Talk about how you are able to serve underserved communities. I think one of the advantages, as you mentioned, of having online therapy is it is there, it is available, it is online. It's as far away as your phone or your computer. Some people don't have high-speed internet, some people have barriers that prevent them from actually getting online. How are you reaching out to underserved communities and getting over those barriers?

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Yeah. The ability to connect asynchronously and really reduce stigma associated with seeking care in the first place is something we find is really important for underserved communities as well. What's really interesting when looking at the New York City population in particular, because we have launched a program in collaboration with the New York City Department of Health to serve all 465,000 teenagers in New York City, ages 13 to 17, and they all have access to free therapy through Talkspace, what's really interesting when looking at this demographic is that we can also pull in zip code data. We see that the majority of those teen users in New York City are coming from socially disadvantaged neighborhoods in New York City. We find that it's actually [inaudible 00:08:40]. People who wouldn't ordinarily have access to care are getting into care in a way that's more convenient for them and that it's helping to reduce stigma.

Carol Vassar, podcast host/producer:

I'm curious, how long has that been in place, and do you think that can be scalable?

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Absolutely. The New York City program has been in place for about a year. We just passed our one-year anniversary, so it's been really interesting to look at just some of the data, some of what I just mentioned to you, the fact that in New York City, 70% of users are female. When looking at the reasons why those New York City teens are coming in, we do see clinical conditions like depression and anxiety, but also in the top five, teenagers are reporting that they're coming in because they want to view their best selves or they want to improve their communication. What that says to me is it's really helping teenagers in particular get access to care sooner prior to their symptoms escalating to the point of being a clinical condition. This program is absolutely scalable. We've launched a similar program in Baltimore County schools. We've launched in Syracuse City schools. We're talking to a number of cities and school districts across the country because we absolutely see there's the youth mental health crisis out there, and so being able to offer access to services to this population is something that we're committed to.

Carol Vassar, podcast host/producer:

Do you see a difference between young women accessing Talkspace in places like New York and Baltimore as opposed to young men?

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Yes. I talked a little bit before about the presenting problems or reasons why those teenagers were coming in. We do see that boys, young men, are more likely to report focus and concentration problems and anxiety and trauma-related disorders. Our young women, the top three is more related to those being my best self and improving relationship types of presenting problems. It is an important distinction because I think that that's going to inform how we approach young men versus young women and really tailor treatment that's going to help them with those specific needs.

Carol Vassar, podcast host/producer:

Are you seeing more young women than more young men accessing, or is it pretty equal?

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

About 70% of those New York City Teenspace users are women, are female.

Carol Vassar, podcast host/producer:

Why do you think the young men are not necessarily coming forward as the women are?

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Yeah. I think it's probably, again, related to stigma, the ability and desire to talk openly about mental health concerns. I think that as we thought about that and really tried to solution around it, for me, it comes back to role modeling and having people that look like you talk openly about concerns so that you feel comfortable discussing your own concerns so you feel like you're not alone. When we think about that and have these kinds of thought leadership opportunities, getting more of our male therapists out there is something that we're focused on so we can try to reduce that stigma in that way.

Carol Vassar, podcast host/producer:

It sounds like that partnership with the school systems is really crucial. Talk about the importance of that partnership, as well as other partnerships that can get all sorts of therapy to the teens who need it where they are.

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

The partnership is so important when talking about integrated care models and care collaboration. When teenagers and students, for example, are spending so much of their time in schools, being able to collaborate with their school systems, their school administrators, their parents, other community resources, to be able to have that connection and know where to guide the teenagers who may be in need of different types of services becomes critically important. Yeah, it's absolutely something that we're partnering with.

Carol Vassar, podcast host/producer:

Let's talk a little bit more about integration. There's a lot of talk about mental health integration into the primary care setting. What, in your estimation, does true integration look like in that world, and how is Talkspace fitting in there?

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Yeah. Oftentimes, primary care physicians are the first ones to hear about mental health concerns. Same goes for pediatricians. Actually, we're talking about youth populations. For care integration to really work well, I think it's about removing barriers, removing that friction that oftentimes is related to communication. How are you sharing information about a particular individual, how are you sharing what medications they're taking, what kind of care that they've sought in the past and how well that care has worked for them. Integration, I think, has to be focused on improving communication and data sharing. I mean, that's another way that technology really comes into play. When dealing with so much data, being able to share that in an efficient way, I think, is really key to integration.

Carol Vassar, podcast host/producer:

Let's talk about privacy there. Since you've brought up integration and data, what privacy barriers does Talkspace have in place? I'm assuming HIPAA is applicable here. What other barriers, securities, do you have in place when it comes to privacy and data?

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

HIPAA regulations absolutely is something that we're adherent to. When you have access to so much data, that I've talked about as well, and think about all the millions and millions of messages that have been exchanged between therapists and their clients over the years, encryption of that data becomes something that is critically important. Our compliance and privacy officer at Talkspace is really wonderful. I think she's a gem at really ensuring that a consideration and a mandate for us in all of the work that we're doing, and it's looking at things like who has access to data. We're not selling data. We're not providing access to this in any way that's not de-identified and encrypted, so that becomes just so critically important. We're talking about healthcare data in particular.

Carol Vassar, podcast host/producer:

Does this also help to feed any research that's being done either by Talkspace or somebody else?

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Yeah, absolutely. Our clinical research team does report to me as Chief Medical Officer at Talkspace. I think it's a really exciting time in research to think about innovation and how can we be using that data in new ways. Back in the spring, one study in particular I'll tell you about is I'm really excited about it, we published in [inaudible 00:14:38] with a company called Listen, which is another technology company, and that research data was really looking at what is the content of therapy in these messages that helps clients remain engaged and get better faster.

This study looked specifically at how much empathy was displayed in therapy, how many open-ended questions did the therapist ask, how much time did the therapist spend speaking versus the client speaking. We have really clear insights that the more empathetic the therapist is in that room, the better engaged that client is going to be, the longer they'll stay in treatment, and the better symptom improvement that they'll receive as well. Being able to actually look into those therapy rooms, again, in a de-identified way, of course, and to examine it through that study, I think, is a game changer as far as how we ensure quality care is being delivered.

Carol Vassar, podcast host/producer:

You bring up an excellent point. Empathy is a huge part of being really wonderful and effective therapist. Given the distance between... The physical distance, you're not in the same room together, how do your clinicians and clinicians who work in this kind of a space, this either asynchronous or in real-time space, but our distance make certain that empathy is still there in the room for effectiveness?

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Yeah. We do have a very large network of clinicians, over 5,000 clinicians in all 50 states, so being able to work with that network, a network of that size, it's really something that we have to train on. I like to think of it as website manner, your traditional bedside manner in a typical hospital setting.

Carol Vassar, podcast host/producer:

I like that.

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

But instead, we focus on training on website manner. What does it look like when you're maintaining good eye contact through a computer camera? What is it like to develop a healthy welcome message to help that client feel connected and that you're the right fit, the right match for them? What does your camera placement, what does your lighting look like? There's a ton of things that go into that development of website manner in order to reduce any barriers that the distance through virtual care is creating.

Carol Vassar, podcast host/producer:

I'm curious. I worked in a public health entity and licensure of clinicians was part of what we did, did it in the state of Connecticut but there had to be reciprocity, how does that work in the online space? If I'm looking at a therapist in California but I'm in Connecticut, how do you get over some of those legal issues that each state presents when you're trying to make certain that your therapists are serving the right people and legally able to do so?

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Yeah. It's an important question, for sure, and adhering to all the laws and regulations and keeping up with the laws and regulations as they change was a big part of our team's work day to day. Essentially in teletherapy, telehealth, the clinician needs to be licensed in the state where the client is. We do expand the capacity of our clinician network by licensing them in multiple states, for example. But it really is about making sure that we have confirmation of client's location, we are keeping all of our clinicians licenses up to date. We have a credentialing process through Talkspace that is based on NCQA standards. It's really something that we have an entire team working behind, because we know that's so important.

Carol Vassar, podcast host/producer:

As Talkspace works to serve clients, families are a big part of the process, and also being able to refer to perhaps local resources. How does that work at Talkspace?

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Yeah. It is all about, I think, equipping our clinicians with knowledge about what those local resources are. In many cases, I'm in New York, for example, I just happen to know what some of those local resources are. But if I'm seeing someone that's licensed in another state where I'm licensed, I may not have that information. It's all about, I think, creating the databases, the resources, the libraries, so that our clinicians are equipped with that information when they're in need of it, but we also create... One of the things that's part of our clinical quality framework is the clinical supervision piece so that all of our clinicians know where they can turn in case they have questions like that that come up. I think that when needing to refer a client to a community resource or another level of care, being able to do that quickly and efficiently can make all the difference, so that's why we have a team of political leaders that are in place to help support our clinicians with that as well.

Carol Vassar, podcast host/producer:

What about the family role? How did they interact with Talkspace when perhaps the teen or youth is getting their therapy asynchronously or online in maybe in their bedroom? What's the family role? How do you draw in the family to support this person, this teenager, or youth, as they work to improve their mental health?

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Yeah. The role of family is just so important in all of our evidence-based practices. Cognitive behavioral therapy, when we're trying to teach a teenager or a client how to develop those, your coping skills, or change their negative patterns of thinking, oftentimes, it involves pulling in family members who can help them practice those skills. With New York City in particular, there's a parental consent process that's in place that will vary state to state. Some states don't require parental consent. But because we are training all of our clinicians on holistic care, that's always going to involve pulling in family members, helping understand family dynamics that may be contributing to symptoms, and then actively involving family and parents, in particular, in ongoing care.

Carol Vassar, podcast host/producer:

As we sit here at an innovation, a health innovation conference, what's exciting? What are you seeing here that maybe you can bring back to Talkspace and say, "Hey, this is something we want to use or may want to use"?

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Well, I think just coming back to the research front, I've been really thrilled to see the lens of preventative mental health care. Again, thinking about mental health as health, not waiting until symptoms are high acuity or really significantly interfering with day-to-day functioning before seeking help. It's asking those questions earlier. It's been able to use technology to identify those types of symptoms earlier. Yesterday, I was chatting about the use of emotional sentiment, emotional tone, facial expressions, to really predict mood disorders in advance. I think that's what really excites me about looking in the future, is being able to continue to prevent more and more serious mental health conditions through the use of technology.

Carol Vassar, podcast host/producer:

Do you think that youths will almost always be doing this online in some way? They are digital natives, if you will.

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Yeah, yeah. There's less barriers than we see with other generations, for sure. Just to come back to that New York City teen population I was talking about, another really interesting tidbit we found in the last year that the program has been running is that 60% of those teenagers are engaging in asynchronous messaging therapy only. They have access to live sessions as well, but 60% are only asynchronous messaging. 35% are using a combination of messaging as well as the live sessions, but only 5% of those teenagers are using live sessions only.

Carol Vassar, podcast host/producer:

Interesting.

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Yeah, yeah.

Carol Vassar, podcast host/producer:

What does your research show? Any outcomes with asynchronous therapy only?

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Yes. We've done a number of studies that have been published over the years looking at the effectiveness of asynchronous therapy, and we see it as on par with in-person and live therapy sessions. We've looked at that in a number of ways, from engagement to symptom reduction, symptoms of depression and anxiety, for example, and we see that those rates are comparable with asynchronous care.

Carol Vassar, podcast host/producer:

That's good news.

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Yeah, very good.

Carol Vassar, podcast host/producer:

What's the future for Talkspace specifically? Where do you want to be in three years, five years, 10 years?

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Well, I think that, over the last couple of years, we've been really focused on getting more people access to high quality mental health care that's affordable. The last couple years has been really focused on getting in network with all the major payers so that most people now have access to therapy for just the cost of their copay. That's been really remarkable and it has expanded access to, towards the end of this year, been nearly 200 million lives that have access to therapy through their insurance. Next for us is really increasing utilization. I think that once you're aware of resources that you have access to, it's getting in, it's engaging with it. It's ensuring that the quality of care that is being delivered is high so that we can continue to see in clinical improvements in folks. That's going to be our focus, is quality and utilization over the next few years.

Carol Vassar, podcast host/producer:

Anything I haven't asked you that you'd like to share with our audience?

Dr. Nikole Benders-Hadi, Chief Medical Officer, Talkspace:

Well, I really appreciate this focus on youth mental health in particular. Again, we're in a youth crisis right now. One surprising statistic that always sticks in my mind is that one in five youth have reported having a major depressive episode in the preceding year, but over half of them don't access any treatment. We're seeing rising rates of things like suicidal thinking and self-harm, and I think that, as a mom myself, I'm really focused on this youth population, how we can make sure that they're feeling okay, and get them access to the care that they need, so very much appreciate this focus for our youth in particular.

Carol Vassar, podcast host/producer:

Dr. Nikole Benders-Hadi is the Chief Medical Officer for Talkspace.

MUSIC:

Well Beyond Medicine.

Carol Vassar, podcast host/producer:

Thanks to Dr. Benders-Hadi for joining us on the Well Beyond Medicine Podcast, and as always, thanks to you for listening. Lots of great conversations all focusing on the factors, 85% of them, that affect children's health and happen outside of the doctor's office. Have an idea along those lines? We want to hear about it. Email producer@nemourswellbeyond.org or visit our website, nemourswellbeyond.org, and leave a voicemail. That's the same place where you'll find all of our previous podcast episodes, and you can subscribe to the podcast too, which is also available on your favorite podcast app and on the Nemours YouTube channel. 

Our production team for this episode includes Cheryl Munn, Susan Masucci, Lauren Teta, and Steve Savino. Join us next time as we look back at highlights from the hot topics in Neonatology Conference with our friends from The Incubator podcast. I'm Carol Vassar. Until then, remember, we can change children's health for good, well beyond medicine.