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New Therapist 57, September/October 2008
I love these emails...
or do I?
The use of emails in
psychotherapy and counseling
I love these emails...
or do I?
The use of emails in
psychotherapy and counseling
24
New Therapist 57, September/October 2008
I
checked my emails the other day and saw that a client
wanted to change his appointment for the following week.
I swiftly responded affirmatively. Next I shot off an email
to a client asking her whether or not she could change her
appointment the next Monday from 10 am to noon. Within
seconds she responded with a one-word response, “Yes.” A
couple of months ago I discovered that I needed to be out
of town the following week due to a family emergency. In
one swoop I sent a single email to a couple of dozen people
(using Bcc not CC so their identities and email addresses
remain private), telling them that I would be out of town the
next week, I would neither be available by phone nor by email
during that time, giving them names and phone numbers of
my emergency back-ups, and asking them to let me know if
they could make the same day and same time appointment for
the week after.
Don’t you like these emails? I do! They are simple, quick
and effective. Long gone are the days where we play phone tag
with clients; when we need to start the phone conversation
with “How are you?” only to listen to a long winded response;
hear long back-and-forth scheduling messages; get busy phone
lines, get put on hold, deal with overworked, low-paid, irritated
receptionists or operators. These emails have saved therapists
time and energy so we can focus on what is important. Many
therapists love the flexibility allowed in receiving and sending
emails from our computers, Blackberrys, or iPhones, during
working and non-working hours, from the office, living room,
beach, boat, another country, or from whenever or wherever.
Realizing how helpful emails can be, many therapists
have started giving their email addresses to their clients,
including them on their business cards and posting them on our
professional websites. After all, they can save time and spare
us from long, wasteful phone conversations.
Then, I woke up the other day to a short email from
a depressed client: “Doc, I cannot take it any longer!!!!!” I
noticed it was sent at 2 AM. Now what am I to do? Send an
email, call the patient back, call her listed emergency contact
(not a good idea, it’s her toxic mother), call the local crisis
team or 911, or …?
Another morning, I got an email from a client who was so
excited about her "break through" dream the night before, how
it relates to our therapy, and apparently I was in it. Scrolling
down the email I noticed it was several pages long. Even
though I was aware of the clinical significance of the dream, I
did not have the leisure or desire to spend half an hour reading
her dream that morning. She felt deeply offended when, during
the next session, she realized that I had not taken the time to
read her "break through" dream analysis.
Later on that very night, I checked my email and saw an
email from a client which started with: “I know we ran out of
time, but there was just one more important thing I wanted to
tell you.” He proceeds to write an insightful email, in essence
extending the session by about 20 minutes. We neither have
an agreement that he would pay for reading time nor would it
fit within his rather tight budget.
A young woman had gotten into a fight with her best
girlfriend, who is the topic of discussion during many of our
sessions. She wrote: “I am so upset, can you believe that she
told me ……” She went on to express her distress and rage in
a long-winded email. She got furious with what she called the
“dismissive” response of “I am so sorry about the fight with
your friend. Let’s discuss it further when we meet this week.”
Many therapists report that clients often ask them “quick”
questions via “brief” emails, such as “My mother is coming over
tonight, should I bring up with her what we discussed in our
last session about my brother molesting me?” or “I met this
girl, she seems perfect and I am panicked. Do you have any
quick advice? We have a date later on tonight.”
Email, like any technology, has at least two sides, if not
more. Like a hammer, it can be constructive and helpful or can
be misused and be destructive. In our MySpace era, where social
networking takes much of many people’s leisure (and often not-
leisure) time, there is an expectation that anyone with an email
address is instantly available and responsive, 24/7, therapists
included.
We used to check our phone messages regularly or have
phone message services page us. Now we need to be on the
lookout for emails from depressed, suicidal or homicidal, or
existentially depleted or spiritually lost clients. Emails were
supposed to make our lives easier, not harder. Then come the
obvious questions, what if the client committed suicide a day
after she sent her “end of the rope” email to me; how to deal
with the disappointed client whose elaborate description of her
dream went unread; or with the furious young woman who felt
dismissed because I did not reply with a lengthy, supportive
email, like her best girlfriend would have done.
The main issue has become what is the proper use of email
in psychotherapy? To add to the complexity, there are several
legal, ethical and clinical questions that are related to emailing
our clients.
The main question is how do we deal with clients who
expect us to respond quickly and/or read lengthy and numerous
emails between sessions? The answer lies in the communication
between our clients and us. We must be clear about our
parameters in regard to general use of emails, time, frequency,
etc. While our office policies should attend to these issues,
personal communication is likely to be much more effective in
bringing clarity to the email dilemma. This issue is not likely
to be resolved in one conversation. With some clients who
rely heavily on online social networking, it is likely to be a
continuous dialogue about expectations, disappointments and
boundaries.
If you are ready to engage in dialogue and treatment via
email in conjunction with face-to-face therapy, state this to
your clients. In this case you many need to inform them how
you charge, if you do, for such e-services. Do you charge per
email, per minute, or other ways? I suspect that most therapists
prefer to use emails primarily for administrative purposes and
only at special times for distinct clinical purposes. In this case
I would explain it verbally either in the first session or when the
right time comes. Our office policies that we give to each and
every client at the beginning of therapy should have a section
on policies regarding emails. This section should discuss issues
of privacy, confidentiality, security, availability, response time,
content, emergencies, etc. [An example of which can be found
on page 11 under the heading Emails, cell phones, computers
and faxes.]
There are a number of other questions
that come up in relation to emails
between therapists and clients. They
include:
Are emails considered psychotherapy or counseling?
Yes. These emails, whether profound or mundane, are part of
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New Therapist 57, September/October 2008
the therapeutic process and are considered part of the clinical
records.
If I give my email address to my clients, must I check
my emails often?
The fact that you give your email address to your clients
does not obligate you to check often or even weekly. What
is important is that you provide your clients with written
information and verbal communication about how frequently
you check your email, if you respond to emails, and what are
your general policies regarding emails (see details in the body
of the article).
What about confidentiality and privacy?
Confidentiality and privacy are applied to emails in the same
ways that they are applied to any other verbal or written
exchanges between psychotherapists and clients.
Must emails be encrypted?
At the present time, emails between therapists and clients do
not need to be encrypted, as long as clients are informed about
the vulnerability of emails being read by unauthorized people,
and they elect to use email. (For more details, see above note
about office policies and the next question.)
What is an email signature and what may it look
like?
An email signature goes at the end of the email. It can be
set automatically. Make sure that every email to a client or
patient includes an electronic signature that covers issues such
as confidentiality and security. Following is a sample of such
an email signature.
Notice of Confidentiality: This email, and any attachments, is
intended only for use by the addressee(s) and may contain
privileged or confidential information. Any distribution, reading,
copying or use of this communication and any attachments by
anyone other than the addressee, is strictly prohibited and may
be unlawful. If you have received this email in error, please
immediately notify me by email (by replying to this message)
or telephone (707-xxx-xxxx), and permanently destroy or delete
the original and any copies or printouts of this email and any
attachments.
It is important to be aware that email communication can
be relatively easily accessed by unauthorized people and
hence can compromise the privacy and confidentiality of such
communication. Emails, in particular, are vulnerable to such
unauthorized access due to the fact that servers have unlimited
and direct access to all emails that go through them. A non-
encrypted email, such as this, is even more vulnerable to
unauthorized access. Please notify Dr. X if you decide to avoid
or limit, in any way, the use of email. Unless I hear from
you otherwise, I will continue to communicate with you via
email when necessary or appropriate. Please do not use email
for emergencies. While I check my phone messages frequently
during the day when I am in town, I do not always check my
emails daily.
Name/Degree/License: xxxx
Address: xxx
Phone: xxx
Email: xx
Web Site: xx
If we email to clients, does it mean we are
conducting tele-health or e-therapy?
If the emails involved are primarily dealing with administrative
issues, such as scheduling, they are not likely to fall under
the definition of tele-health or e-therapy. However, if
they are clinically oriented (i.e., including assessment or
interventions), extensive, and used routinely, they may be
viewed as tele-health or e-therapy. There is not a clear line in
the sand yet, differentiating between tele-health and face to
face therapy, and mixing the two modes can be effective and
ethical when done ethically, competently and properly.
Are these emails part of the clinical records, and
can they be subpoenaed just like chart notes in the
unfortunately not uncommon event of legal
action?
Generally, emails between therapists and clients are considered
as part of the clinical records and can be subpoenaed, just like
chart notes.
Guidelines to using email with clients
The subject and discussion about the role of email in therapy
is common, relatively new, unsettled, and very complex.
There are a few things that therapists can do to keep clients
informed, increase therapeutic effectiveness, and help protect
themselves from board complaints and other liabilities.
Clarify to yourself your thoughts and feelings regarding z
email communication with clients. What are your prefer-
ences, your limits, etc.?
Discuss the issue of email communications with clients, z
when relevant, in the first session. Learn from them
about their expectations and clarify your expectations
and boundaries. Continue the dialogue as clinically and
ethically necessary throughout the course of therapy.
Make sure that your office policies include a section on z
the use of emails.
If you are conducting tele-health, follow state laws, z
relevant codes of ethics, and have a separate informed
consent, which is required in some states, such as Cali-
fornia.
Make sure your computer has a password, virus protec- z
tion, firewall, and back up system.
Make sure that each email includes an electronic sig- z
nature that covers issues such as confidentiality and
security.
This article can be found on the Zur Institute website http://
www.zurinstitute.com. Permission to reprint this article was
kindly granted by Ofer Zur.
