Should therapists email patients?

[David Baxter PhD]

Take Two Prozac and E-Mail Me in the Morning
By RICHARD A. FRIEDMAN, M.D
Mind
July 15, 2008

Ah, the promise of e-mail! The minute I started giving out my address to my patients, I fantasized about how much time I would save on routine phone calls and how clear and unambiguous the communication would be.

Indeed, there was a honeymoon period. Could I change a Monday appointment for Wednesday? Of course. Would I phone in a renewal of Prozac? With pleasure. This was really neat: no more phone tag with patients, just simple requests with simple solutions.

Not for long.

?Dear Dr. Friedman,? one patient e-mailed at 3 a.m. ?I am having dark thoughts and wonder if I should increase my antidepressant. Can you let me know what you think??

It was 8:30 that morning when I opened my e-mail and read her message with alarm. What exactly were ?dark thoughts?? I wasn?t sure, but I had to assume the worst ? suicidal feelings or thoughts ? and called her immediately.

She came in later that afternoon and explained that she felt bleak and hopeless and thought she and her family might be better off with her dead.

?Why didn?t you call me right away?? I asked, as I recall the conversation.

?It was the middle of the night and I didn?t want to disturb you,? she replied.

Getting disturbed is what I do for a living, and in this case e-mail seemed like a potential obstacle to her care. Considering the sheer volume of messages, and how many of them are spam, it was lucky I did not miss it.

I was beginning to worry about what I had gotten myself into. When patients had only my phone number, I just had to keep track of voice mail; now I had to be on the lookout in my e-mail, too. This was going to make my life easier?

?I know we ran out of time, but there was just one more important thing I wanted to tell you,? a patient e-mailed me and signed with a smiley face. ?I mean it would only have taken five minutes of your time ? tops.?

Couching the sentiment in humor, my narcissistic patient was enraged that I had not given him what he felt entitled to: more time.

At least this was grist for the therapeutic mill. I brought up his message in the next session: ?You are angry and resentful that I didn?t give you five extra minutes, in the same way you feel the world owes you special treatment.?

Not all my attempts to make therapeutic use of e-mail were as successful. A young woman who was jilted by her boyfriend e-mailed me between sessions: ?Here?s installment No. 2. I had a terrible date last night. The guy was a disaster. Can?t keep at this social scene. Or should I??

?Let?s discuss it when we meet this week,? I e-mailed back.

That was not what she wanted to hear; she was expecting immediate reassurance or advice. This was a patient who had trouble tolerating any frustration or separation from people she felt close to, including me.

For her, e-mail was probably antitherapeutic: it meant, in effect, never leaving my office ? and never disconnecting from me, something she was supposed to accomplish in therapy.

?Why did you give your e-mail in the first place?? she asked angrily, when I tried to explore the topic with her. She was right. I had made a mistake.

On one occasion, e-mail was critically valuable. A patient traveling in India lost his medication when his backpack was stolen. Given the time difference, it would have been hard to connect by phone, so he e-mailed from an Internet cafe. Though his medication was not available in India, I was able to give him quick advice about a substitute.

For all the convenience and clarity of e-mail, it can be perilous for a clinician; as part of the written record of patients? treatment, it can be subpoenaed just like chart notes in the unfortunately common event of legal action. Not just that, but e-mail must comply with the Health Insurance Portability and Accountability Act, which has complex rules to safeguard patient privacy and confidentiality. Your psychiatrist could not, for example, send you a reassuring message about your recent lithium blood level ? unless you e-mailed first and specifically asked for it.

Still, being an impatient person, I love the speed of e-mail. But being a psychiatrist, I am leery about the quality of information it conveys. How can I tell whether my patient is being humorous, sarcastic or ironic? Smiley faces are no substitute for the real thing.

Which brings me to e-therapy. Cyberspace is full of therapists happy to treat you ? for a nice fee. But unless you live where there is nary a therapist, I would have second thoughts about this. Internet-based therapy, whether by e-mail or live chat, seems like a poor substitute for a real human bond with all its nonverbal cues and face-to-face exchanges.

After all, if there is no excitement or emotional charge, you?ve probably got a sterile therapeutic relationship that is more likely to liberate you from your money than from your conflicts.

So here is what e-mail with my patients has taught me: if you need to reschedule an appointment or need a routine medication refill, please push ?send?; if you have something on your mind you want to talk about, please call me ? the old-fashioned way. I?m almost wistful for the sound of a ringing phone.

 

[Banned]

I wonder if this comes down to personal preference. I suppose every therapist has the option of whether or not to give their email, or state what it is and is not to be used for. Perhaps some even charge extra for the time to read and/or respond to it?

Thankfully, my therapist has given me free reign with her email - she has encouraged me to use it as a journal, so to speak, and email her freely with whatever I need. I often send her my thoughts, or reflections after a session, or information on what I want to talk about during an upcoming session. I don't, however, use her email if I want a prompt response, as she checks it infrequently...on a good week, maybe once, but it is not unusual for her to only check it once every 10-14 days. So if I need to reschedule an app't, or have an urgent matter, I either phone her, or send her an email, followed by a text message to check her email.

 

[Lana]

I can see the value in emailing a therapist. However, I find facial expressions, eye and body movements, tone, tears, distress, playfulness, speech patterns, etc. are very telling when talking to a person. Often, they can drastically change the meaning of a message. Consider a happy, "I'm fine"...and angry, "I'm fine"....and sad, "I'm fine"....and annoyed, "I'm fine"...and so on.

Statistically, words account for only 7-12% of communication (the rest is visual and auditory) and because of that, I think that email may not be appropriate for therapy. Feedback, reminders -- sure. Therapy....I don't see how that can work...no matter how well you think you know a person. It's just seems too risky.

 

[David Baxter PhD]

I don't disagree, Lana - given a choice, face to face therapy is probably always preferable.

However, the unavailability of competent therapists in some areas of the world means that online therapy may be their only option (e.g., smaller rural areas, the far north, parts of Australia, to name just a few).

Additionally, it may be the only feasible option for people with certain disorders such as agoraphobia, at least initially.

 

[Adam777]

Yeah, I think it's a great idea. I would love to be able to email my therapist... not that I would take advantage of it, but once in a while, I think it would be great.

 

[Banned]

I know there are many therapists now offering e-therapy, but for the same reasons David mentioned, I'm not a fan of it either. When I email my therapist I don't expect e-therapy at all, but it's an opportunity to bring my thoughts to her attention between sessions which I find extremely valuable.

 

[NicNak]

With my Psychiatrist, he does not have a receptionist. It is an "unwritten rule" in his office that if the phone rings during your session, he answers it. He will give quick advice and continue back with the patient in his office.

It has been a life saver, when having an impulsive "episode" and the usual dosage of medication was not helping and needed to know if it was ok to take more or what to do.

I can see how the email could become tricky.

I think it is important I have a separation from my Psychiatrist, this is just my personal opinion. Apparently it is typical of people with Anxiety, but I see my Psychiatrist as almost Godly. When I call, I know I am interpupting, so I only do it when I have to. Cause I almost feel rude for interupting him. (not cause of how he reacts, he is always kind to me) It almost forces me in a way to problem solve on my own, if I can. Then if not resort to call him.

I could see, for me personally, that if after an appointment he said "Email me in a few weeks" I would feel obligated, then could possably start thinking I needed to get his permission for things I did. This is how I am wired to think. It would almost turn into a co-dependant thing.

I am sure in some cases, it can be quite benificial. For me, I don't see how it would. I think it would be deteremental as I need to develope my own
coping skills and independance. <--- I really lack in this area. Especially in my times of anxiety.

I can fully understand how for many it is helpful. I would never debate that. It is all individual.

 

[Banned]

I often remind my therapist at the beginning of our session to turn her cell phone off. I used to go looney when it would ring, and loonier if she'd answer it. She only rarely did, but it made me crazy. I would remind her that this is *my* hour. She was really good about it. Now she knows to turn it off before we start.

Her computer is at her home, and I used to be able to email her at work (at her "real" job), but then, because of privacy/security issues, they were all told no more emails from private practice clients. I still email her at home several times a week, but I also know it likely won't get seen for a long time. But thank goodness I can.

I know therapist/client relationships didn't use to be like this...I wonder if, before email was the way of the world, if therapists received far more phone calls, or clients stuck more to their hour a week with no contact between sessions.

 

[Meg]

This is something that I have wondered about from time to time. I have thought it would be very convenient if clients could e-mail me rather than constantly having to play phone-tag with them. I also know of many people who have found e-mailing their therapists between sessions to be very helpful.

I've never given my e-mail address out, though, for the simple reason that I know I have great difficulty restricting the amount of time I spend when answering people in written form. I've been posting on various psychology-related forums for about five years, I've responded to thousands of threads, and, still, I agonise about what I write and how I phrase it. I'd never get anything else done

 

[Sparrow]

I think the email scenario is poppycock , but that's just my opinion. Too much of a disconnect with ambiguity.

 

[Banned]

If I were in the other chair, I think I'd be very selective in who I gave my email address to, or who I allowed to contact me via email for anything other than appointment changes or basic stuff. There is just too much value in the face-to-face interaction, and it would be so easy to get consumed by my email even after seeing clients all day. It would be a strong boundary I would have in place for my own sanity.

Having said that, I'm soooo grateful for the free reign I have with my therapist's Inbox. It's been a life-saver.

 

[Sparrow]

Emailing a therapist?...Hmm. For appt's o.k., but 3 a.m. analysis? How about a bit more personal responsibility.
Not to be narrowminded, and it's great if emailing a therapist has helped anyone but I'm not a fan. There are crisis and hot-lines, 911's, and emergency wards.
Makes me think of... in search of efficiency we'll invent the 25 hour clock.
I think it cheapens the whole equation and takes away the humanity.
(touchy feely turns more distant, impersonal, and cold).
But I expect it to be pretty good red herring from a lobbyist some time soon

 

[David Baxter PhD]

Actually, I encourage clients to email me. It doesn't matter whether they do it at 3 am or 3 pm - they understand that I'll read it when I get time. Just because it's received at 3 am doesn't mean I'm awake and reading it at that time.

And emails aren't a substitute for therapy sessions but rather a medium for asking a quick question or two, or asking for clarification of homework or instructions from the session, or advice about what to do in a crisis - that sort of thing.

 

[Banned]

Actually, I encourage clients to email me.

Do you wait until you've had a few sessions and know them a bit better, or is it something you encourage right off the bat? Have you had instances where it's been "abused"? Would you get to the point with someone where you might ask them to not email you any more because the emails are excessive or take up too much of your time?

 

[David Baxter PhD]

I haven't had any problems with "email abuse" to date.

As to the first question, I'm not entirely certain. Of course, many new patients find me via my website and make the initial appointment via email. Additionally, my business card, which I use for recording the next appointment, contains my email address as well as my telephone and fax numbers.

 

[white page]

And emails aren't a substitute for therapy sessions but rather a medium for asking a quick question or two, or asking for clarification of homework or instructions from the session, or advice about what to do in a crisis - that sort of thing.

__

I agree that email is another valuable communication tool, for instance I am not good at leaving voice messages , I used to send letters to my therapist when I had a question which did not need a session . Finding it easier to write rather than speak , emails are just much quicker . Also good point about agraphobics ( I can't remember who made it )

In the future, if not already possible, therapy would be perfectly feasable with the use of webcam
for those who are in an area far from a therapist and for persons with limited mobility , I find this idea more than acceptable , and this would bring help to
so many persons who need it ,who are penalised by their pathology , geographical situation and lack of easy transport possibilties , for instance I am sure in Canada there are areas which are very isolated coupled with harsh climatic conditions which make travelling difficult if not impossible at times .
(sorry I wavered of the initial subject )

 

[David Baxter PhD]

Good point, white page. I do have clients with anxieties about using telephones. It just provides another option.

 

[amastie]

I used to be able to email my previous counselllor and found that helpful to ask simple questions related to sessions times etc. My psychiatrist either doesn't allow it or isn't given to using the computer very much. I know that she will take notes regarding my therapy which are posted to her. I respect her boundaries but I do think that emails which would be much more convenient.

amastie