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Streamers aren’t therapists. But some therapists are streamers

The doctor is in

Illustration of a couch on a dark background with a Twitch logo hovering above Illustration: Alyssa Nassner/Polygon

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Nicole Carpenter is a senior reporter specializing in investigative features about labor issues in the game industry, as well as the business and culture of games.

It’s no longer unusual to see your therapist over a computer screen. Over the past year, more therapists have switched to remote counseling with their patients, a product of the ongoing COVID-19 pandemic. But what if your therapist was streaming on Twitch?

Though it’s known most as a video game streaming space, Twitch has evolved over the years. Video games are still central to the business, but the platform also attracts people creating art, making music, and just chatting with friends. Site usage has increased during the pandemic, with people turning to the computer screen for connection. Twitch streamers curate and cultivate their own communities, and mental health often comes up in these spaces. From that, a new genre has emerged: mental health streams.

Mental health advocates and therapists alike are using Twitch as a way to reach people and to talk about therapy. Sometimes, those streams look a lot like therapy itself — especially now that more and more people are meeting their therapists through a device or screen.

Some mental health streamers play video games while talking about their experiences with mental illness — such as anxiety, PTSD, or depression — and they answer questions from the chat. These people aren’t necessarily mental health professionals; streamers like Mxiety and DyllonKG describe themselves as mental health advocates, people who talk about their own mental health as a way to destigmatize it on the platform.

“There’s much more awareness [regarding mental health], but it is still a stigmatized topic,” Dr. Yvette Wohn, professor and director of the New Jersey Institute of Technology’s Social Interaction Lab, told Polygon. “Streaming is great, especially [for] people who feel very isolated. They’re able to find people who are similar to them, and have these discussions.”

Discussions about mental health happen all around Twitch, including in spaces where streamers may not be ready or equipped to handle it. But some streamers choose to operate in the “Mental Health” tag, denoting their streams as spaces where it’s OK to talk about these things. Twitch isn’t a clinical space; there are no rules for what is and isn’t a mental health stream. Anyone can use the tag, and people’s definition of what counts as a mental health stream varies: There are also a lot of ASMR channels using the mental health tag, which isn’t really relevant.

“The vast majority of people who are using the mental health tag are either doing ASMR, or they themselves are a mental health advocate, or are indicating that their channels are places where you can talk about mental health,” Dr. Kelli Dunlap, a clinical psychologist and game designer, told Polygon. “It’s a broad landscape.”

Mental health streaming on Twitch is like a long-form version of the mental health content that’s taken off on TikTok and Twitter, where the format prefers short-form, viral snippets that list out symptoms of mental illness in an effort to destigmatize care. But, often, creators on TikTok are mistakenly confused for professionals, which can be dangerous: Misinformation and generalized treatment can cause problems for people seeking care. If viewers think this sort of content is a replacement for therapy, too, that’s also a problem; it can instead be a supplement, a way to push people toward personalized care.

Meanwhile, Twitch has some actual mental health professionals — like licensed therapists and psychologists — who stream on the platform. There’s been an uptick in recent years with professionals carving out space on the platform to build dedicated communities centered around mental health. There is no one way for a mental health professional to operate on Twitch, with different streamers taking different approaches, but largely it’s therapists or mental health professionals giving lecture-style talks — say, about therapy — while playing a video game. Maybe it’s a professional playing a video game that covers aspects related to mental health, then discussing the themes. More rarely, it’s therapists doing therapy-style interviews with streamers or viewers, asking and answering questions over the course of some time.

Twitch Photo: Thomas Trutschel/Photothek via Getty Images

Take, for example, this video of controversial streamer Félix “xQc” Lengyel sharing vulnerable, personal stories about his life in a stream led by a psychiatrist — including Lengyel’s thoughts on his relationship with his father, unraveling the parts of his past that influence his life even today. It’s easy to see why this sort of content is appealing: The vulnerability of the participants is compelling, showing a part of people that we don’t often see.

People have sought out this sort of content for decades. Take, for instance, Dr. Phil, which has been in production with Phil McGraw since 2002. Phil McGraw started his TV show, Dr. Phil, in 2002. Produced by Oprah Winfrey’s Harpo Studios, Dr. Phil was marketed as an advice show helmed by a real doctor — McGraw, who has a PhD in clinical psychology. Each episode has a new topic; for example, some episodes are about “problem” children who don’t listen to their parents. McGraw often discusses addiction, mental health, and relationships.

McGraw has been the subject of controversies over the years, including multiple lawsuits, but his influence is largely propped up by an older audience — one that still has cable TV. But his television show has faced significant scrutiny in the past, with critics claiming he exploits vulnerable people desperate for some kind of help. His show still influences mental health conversations and colors the way people view mental health in entertainment settings.

For better or worse, mental health streaming on Twitch is an extension of mental health in entertainment. With the Dr. Phil comparison in mind, most mental health coverage on Twitch is ultimately viewed by the steamers and experts as a positive for the platform’s community — a stark difference to the potentially exploitative nature of shows like Dr. Phil, and before him, Dr. Drew Pinksky.

Dr. Nance Roy, clinical director of the Jed Foundation, a mental health nonprofit centered around teens and young adults, told Polygon that Twitch broadcast experiences need to be clear about what they are and aren’t. “While they may be talking about real issues, I think that fact that it’s broadcast in front of many people can have unintended consequences that streamers need to be aware of.”

The more haunting danger regarding Dr. Phil and other reality-style mental health shows is that some people feel they don’t have any other options, and that it’s the only way they’ll actually be able to afford or access help. That feeling is not unfounded. The United States is woefully underserved with regard to mental health care, and that’s only been exacerbated by the pandemic. There are large numbers of people who don’t have access to therapy and other resources, whether that’s due to location, financial reasons, a lack of knowledge about how to receive care, or from feeling unseen or misunderstood by conventional treatment. This demand for mental health care has increased even more during the pandemic.

Mental health streamers and professionals on Twitch are attempting to lessen that gap by meeting people where they are, such as Take This, an organization that closely ties together mental health and gaming as a way to encourage “support for mental health in games.” As an organization, Take This has a number of different avenues for servicing the industry, like AFK Rooms at conventions, which are described as “quiet, supportive” spaces where people can relax and access mental health wellness information. Take This also runs an ambassador program that encourages and supports mental health streamers, and provides training and research on mental health topics.

[Ed. note: Take This was originally founded by Polygon co-founder Russ Pitts. Pitts left Polygon in 2014, and stepped down from all roles at Take This following a controversial article published on The Escapist, followed by a disparaging Twitter post regarding GamerGate’s impact on Zoe Quinn.]

“People don’t know about warm lines,” Dunlap said, referring to the 24/7 phone lines open to people who just need someone to talk to. “They don’t know about the free groups the National Alliance on Mental Health posts every single week on their webinars. They don’t know how to navigate insurance [...] or the difference between an LPC, LMFT, a psychologist, and psychiatrist — all that mumbled professional jargon that’s inherent in our profession.”

take this logo in orange Image: Take This

She continued: “The people who I see doing the best work as the ones who are consistently demystifying and destigmatizing mental illness. And then creating a community where you can talk about mental health and have it be something that other people are going to support, as opposed to something that’s scary.”

Dunlap is a community manager for Take This, with Dr. Raffael Boccamazzo, a doctor of clinical psychology, operating as the clinical director. Take This was the “first mental health nonprofit to serve the game industry,” Dr. Boccamazzo told Polygon. “We offer a variety of mental health workshops, and have consulted with game studios on both wellness policies and mental health representation in their games. Finally, we’re about to launch some fun and educational streams.”

Other therapists, psychologists, and psychiatrists, like Dr. Ryan Earl (better known on Twitch as “Dr. Mick”) and Dr. Alok Kanojia (who goes by “Dr. K”) take different approaches to mental health streaming. Earl told Polygon that he noticed that many streamers have discussed feeling uncomfortable with the ways that viewers opened up to them during streams. Viewers can form parasocial attachments to streamers where a one-way familiarity gets built up, and sometimes, viewers start to cross boundaries. That’s part of why Earl started his stream; he saw a need that wasn’t being met on Twitch, and had the professional training to responsibly bring information to people in the space.

“[Viewers] see somebody who looks like me, where I don’t look like a normal therapist, and can ask questions and I can answer them,” Earl said, referring to his laid-back appearance, long hair tucked under a backwards baseball cap, an image not unlike plenty of streamers on Twitch.

Wohn, professor and director of the New Jersey Institute of Technology’s Social Interaction Lab, has studied the emerging trend of viewers bringing up mental health during otherwise unrelated streams. “Obviously, most streamers aren’t mental health professionals,” Wohn said. But some streamers feel like they need to be prepared for these conversations, given the frequency of it happening.

Streamers with professional mental health qualifications — like licensing — are theoretically more qualified to talk about mental health topics during broadcasts, but because of their training and licensure, they must be mindful of the ethics at play. There are codes of ethics with organizations like the American Psychology Association and American Psychiatric Association (both, confusingly, are shortened to APA). For instance, the American Psychiatric Association has rules about licensed psychiatrists giving professional opinions on situations or people without “an examination.” That means officially licensed streamers like Earl and Kanojia are unable to answer certain questions on Twitch, if their answers may be read too closely as a personal recommendation, suggestion, or diagnosis. Most of Twitch’s mental health streamers have some sort of documentation on their channel or profile page laying this out to viewers: They’re not their mental health professional, and they can’t offer advice. Their streams are not a stand-in for therapy, but rather, a supplement or an encouragement to seek out further help.

But the general guidelines — created for mental health professionals operating in traditional spaces — leave a major gray area for how to operate ethically on streaming platforms. Things are changing, partially due to the pandemic. Three quarters of American Psychology Association members transitioned to telehealth in 2020, according to Dr. Lynn Bufka, senior director of practice transformation and quality at APA. And that growth means understanding how patient safety and technology interact.

“A lot of professionals and professional organizations are really grappling in some new ways with some ethical questions that, because of changes of technology, are somewhat newer,” Bufka told Polygon. “But fundamentally, as a licensed professional, my duty is always to protect my patients.”

Some professionals suggest that progress toward new technologies isn’t moving fast enough. “The vast majority of clinicians have no idea what Twitch is, much less something like Discord,” Dunlap said. “The majority of psychologists still think that video games are just shooters and still believe stuff around video games — like violence and addiction.”

dr k speaking on video with xqc Image: HealthyGamerGG/YouTube

“The mental health services available today are too old, too slow and too expensive,” Kanojia told Polygon via email. “Young people in particular are enormously underserved and are under more pressure than ever. We work for them: the people who grew up on the internet, who are unserved by traditional resources, and who don’t see a way forward. Not their parents. Not their insurance. Not a profit-driven medical system.”

Kanojia, for his part, streams therapy-style sessions — that he says are not therapy — on Twitch to thousands of viewers. His streams are easily some of the most popular of Twitch’s mental health programming, as he frequently has popular Twitch streamers and influencers (like Felix “xQc” Lengyel and Imane “Pokimane” Anys) on his show to talk about their mental health and their personal lives.

Some of Kanojia’s streams have been criticized for seeming too much like therapy. In 2021, NPR reported on an instance wherein Kanojia streamed a therapy-style interview session with popular World of Warcraft streamer and esports player Byron Bernstein, wherein Kanojia seemingly psychoanalyzes Bernstein: “You may have clinical depression, but I think what you’re describing is not clinical depression,” Kanojia said. “I think your problem is that your life is empty. That’s different.”

Bernstein had publicly struggled with his mental health over the years, and he frequently discussed it with his viewers on his own channel. He died by suicide in July 2020 at age 31. NPR reported that the exchange between the two “got a lot of attention” after his death.

Kanojia addressed the suicide on a Twitch stream following Bernstein’s death. In it, he started with multiple disclaimers reminding viewers that his streams are not a replacement for therapy.

“The line for us is when the topic is getting too close to giving medical advice: a diagnosis or medications,” Kanojia told Polygon via email, describing his Twitch channel and interviews. “If someone wants to talk about their diagnosis or experiences on medication, that can be incredibly impactful. At the end of this, while we do have several layers of policies to protect everyone involved, we’re humans trying to help other humans through impactful, relatable conversations about mental health. Simply knowing that you’re not alone, everyone struggles, and that there is a way forward no matter how hopeless it seems can make all the difference.”

He continued: “Innovation in healthcare is risky for a variety of reasons.”

Again, these mental health streams and channels aren’t a stand-in for therapy. They don’t offer personalized, in-depth care. But the reality in the U.S. is that personalized mental health care isn’t accessible to everyone. Some viewers may feel that Twitch streams are their only option to access mental health care — and depending on their situation, they might not be wrong.

“I fully believe that if mental health care was accessible — in terms of financial, geographical — and if there was less stigma around seeking mental health care, I think we wouldn’t see so much of this on Twitch,” Dunlap said. “You wouldn’t need to go to our entertainment spaces to manage our emotional and psychological well-being.”

The line between a telehealth FaceTime call with your therapist and calling into a therapists’ advice show is clear to most — one is therapy, and one is not. The therapist title, though, does lend the streamer influence and power, which means their advice rides a fine line — an ethical gray area for some. Also, the line between, say, a telehealth group therapy session moderated by a professional and a Discord server advertised by a therapist is less clear. Medical professionals don’t yet know the effect that these spaces will have on people — the rise of mental health content on TikTok and Twitch, with widespread medical information and sometimes misinformation. That misinformation puts viewers at risk; there’s also the possibility of viewers acting on advice that could be ineffective or, at worst, harmful.

There’s still a lag between the conventional mental health community and more modern practitioners’ desire to circulate mental health education via online platforms, although the pandemic has decreased that gap. There is a space for mental health on Twitch; the state of mental health care is so dire that the platform continues to be used to reach new people. But professionals continue to grapple with uncertainties in this new corner of the industry, highlighting a larger problem necessary in fixing the broader systemic issue: The need for widespread mental health reform, and ensuring mental health care is truly accessible.