Over the weekend I was cleaning my basement and found one of my appointment books from 10 years ago.  I have a history of saving these as a way to chronicle the year and to keep track of phone calls and messages I need to return.  Back then, when I received a voice mail, I would write down the message and phone number on the date the person called to be sure I would call back as soon as possible.  There were up to 8-10 phone messages in a day sometimes.  Then I looked at my appointment book for 2014 (and yes, I still keep a paper appointment book).  I noticed that at most, I have 2-3 phone messages per week!  I’m not seeing fewer clients now than I was 10 years ago, but the way my clients communicate with me has changed dramatically. 

Instead of phone messages, my clients are now using email as a primary form of communication.  I even have new clients reaching out to me for the first time through email.  Despite leaving me a phone number, often I’m not able to catch them by phone to speak live.  Consequently, all communication occurs through e-mail and, at times, a first appointment is scheduled with me never having spoken live to my client once. 

There is utility in being able to communicate through email, and being able to leave and receive messages at all hours of the day and night.  Still, I am ambivalent about the use of email in therapy, whether to seek services, schedule or cancel an appointment, or to communicate information between sessions. 

I miss being able to hear someone’s voice, notice the inflection, and experience the pitch as an issue or concern is being communicated to me.  My prospective client also misses the tone of my voice and the way I speak as a way to determine goodness of fit.  There is an asynchony with e-mail that disrupts the natural flow of communication present when speaking with someone live.  Now, however, email and other forms of electronic communication have become the norm and despite my reservations, I am experiencing the benefits and challenges of email in my clinical practice.

Email For Recording History

I’d been seeing Glen for several years before he was diagnosed with dementia.  He was 58 years old, and the diagnosis was a shock for him, his wife, and his adult children.  The original reason he came to see me was to help manage a long history of depression, though after his diagnosis, we began to focus not only on managing depression, but planning for his future, which sadly included a decline in his cognitive abilities, leaving his job in technology, applying for disability insurance, and helping him and his family make plans for when he might need more extensive care.

At first, the dementia was barely noticeable.  It seemed sporadic and spotty, manifesting in what initially seemed like forgetting very inconsequential parts of a conversation, or not remembering what he had for dinner the previous evening.  It was even hard to believe that he was facing something debilitating.  As time progressed, however, he began to lose track of his thoughts during sessions, and while he knew there were important things he wanted to discuss as he began a session, he began forgetting some of them. 

Using email as a tool in therapy happened organically.  It wasn’t something he and I talked about before it started happening.  He began to send me e-mails between sessions that included topics he wanted to be sure to address, or things that happened during the week that he thought were important for me to know.  I’d print the emails and we’d talk through them when he came to his appointments.

It was a logical shift when he began copying me on emails he sent to other people---especially his sons who lived in other cities.  He also began to forward me their responses.  “I want you to know what’s happening with me and the people I care about,” he explained a few weeks after he began this strategy with email.  “I won’t remember what I’ve told them, and I won’t remember what they said to me.  This way I am sure to keep a record."

We continued this strategy for a number of months, until there was too much happening between sessions for Glen to share through email.  There also came a time when Glen’s short term memory was so impaired, that he didn’t remember conversations that occurred only minutes before.  While he could still type on a keyboard, he’d forget what he was wanting to type.  E-mail between session stopped, and my work with Glen broadened to work with his wife and sons as they prepared for him to move to a skilled nursing facility.

After Glen died, I received an email from his wife thanking me for allowing him to send me so much information between sessions.  For her and for their sons, the email streams became a part of their family history and one that helped in their grieving process.

Email to Manage Anxiety

Sharon’s use of email served a very different purpose.  Our relationship began from a traditional phone conversation where we talked for a few minutes about her desire for therapy.  In the first session, I learned that she came from a home where both parents were highly anxious.  Their anxiety permeated her childhood and adolescence.  As a result, she explained, she and her sister were both anxious adults.

Impulsive decision-making was a consequence of Sharon’s anxiety.  This was especially prevalent in employment situations, in friendships, and in romantic relationships.  Each time she experienced a circumstance at work, or a conflict in a friendship or romantic relationships, her anxiety spiked and her immediate response was to remove herself from the situation by quitting her job, ending friendships or ending romantic relationships.  Hours after reacting, she regretted her impulsivity, but sometimes it was too late for her to repair the damage that had been done.

During one session, we looked more deeply at how she ended relationships impulsively when she felt anxious due to conflict, or sometimes due to feeling particularly vulnerable.  She reported noticing an immediate decrease in anxiety when she thought about removing herself from anxiety provoking circumstances and then further relief when she took action.  I invited her to experiment with using our relationship to help modulate these impulsive responses to anxiety.  Specifically, I invited her to send me an email each time she wanted to end a relationship.  Rather than calling a friend or employer, she was to send me an email telling me the same thing she wanted to tell her friend, romantic partner, or employer. 

In subsequent weeks, I received a number of emails between sessions that might otherwise have been impulsively sent to others.  Each week, we reviewed the e-mails and the circumstances that triggered them.  Through reading the emails in session, we were able to look at the specific anxiety triggers and her impulsive responses to these triggers.  We also explored other strategies she might exercise when she experienced this anxiety outside of sessions.  Her emails to me between sessions alleviated her anxiety without garnering the negative consequences that typically came from impulsive decision making.  Over time, she was able to delay her response time, using other skills and strategies to manage anxiety in relationships.

Email to Discharge Emotion

Despite going over our policies with Jaime, he had different ideas about how he would use e-mail communication.  Typically, in a first session with a new client, I talk about phone calls and emails between sessions.  I’ll explain that I’m available to talk between sessions if an emergency arises, and that I’d like to reserve email for scheduling purposes only; to cancel a session and reschedule, or to schedule sessions into the future if someone has irregular work hours.  Jaime signed our initial office procedures statement, but I began receiving substantive emails between sessions.

Initially, the emails between sessions came in the form of a thank you for a great session.  Occasionally there was a thank you, and then the addition of a sentence or two about something he forgot to say in the session.  The progression of content in the emails happened so gradually that I didn’t realize the pattern that was being created until one day I received an email that was pages long. 

In sessions prior to the email, we had been discussing Jaime’s history of depression with some suicidal ideation.  He shared that his current depression was worsening and he didn’t think his medication was working.  He was having some thoughts about suicide but shared they were nothing he would ever act on, that he didn’t have a plan, and knew he needed to have his medication re-evaluated.  We agreed that he’d make an appointment with his psychiatrist  and that we’d see each other twice per week until he felt better.

After that session, I received an email from Jaime and the subject line read:  “I’m Done!”  My heart began to race and I felt my face flush.  I quickly opened the email.  The time was stamped 1:15 am and I was reading the email at 9:00 am that same morning---almost eight hours after he sent it!   In the email he explained that his depression was getting the better of him, he didn’t know how long he could go on like this.  “I really need help,” he wrote.  His email contained several paragraphs about how sad and hopeless he was feeling and how he wasn’t sure he’d ever feel better.   I called his cell phone immediately, fearing the worst. He answered after only two rings, saying how much better he felt after getting some sleep.

While I was relieved, I was also frustrated with myself for not having set better boundaries around the use of email.  I wasn’t paying close enough attention to Jaime’s escalating emails between sessions.  I came to the conclusion that our sessions had been diluted as the content of his between-session emails was becoming more dense and more filled with emotion.

At his next session, we had a very explicit discussion about emails between sessions and I acknowledged that I’d not been paying close enough attention to the growing number of emails between sessions; how the content of his emails was looking more and more like issues we could better address in face to face sessions together.  We agreed that if he was feeling more depressed, he would call me.  If he did send an email he would simply say in the subject line:  “Please call me.”  We also agreed that he would schedule additional sessions as needed, and would use “911” in an extreme emergency.  Not surprisingly, after having this conversation and setting these limits, our sessions became more regular, his depression began to lift, and I stopped receiving any emails between sessions---not even a “thanks for the great session!”

Despite the challenges of email with Glen, Sharon, and Jaime, there were some powerful positive outcomes.  Email served a different purpose with each person, opening channels for communication within and outside of sessions that 10 years ago might not have been possible.  For me, however, it requires a higher level of awareness as I email clients or receive e-mail from clients.  The idea that the therapeutic relationship extends far beyond the session itself has never been more true.

Speaking and Breathing the Culture of the Web

As I try to make peace with email as an inevitable mode of communication, I am still not completely comfortable with it.  Clinical psychologist Ofer Zur quotes the work of Tucker Harding (educational technologist) and Marc Prensky (writer, consultant and game designer) when he talks about the idea of digital natives and digital immigrants. 

A digital native is someone born after 1964 who “speaks and breathes the language of computers” while digital immigrant applies to those of us born prior to 1964 in a pre-computer world.  According to Zur, “digital natives speak and breathe the language of computers and the culture of the web into which they were born, while digital immigrants will never deal with technology as naturally as those who grew up with it.”

I am definitely a digital immigrant.  I remain ambivalent about email in psychotherapy despite acknowledging how we were able to use e-mail creatively and thoughtfully with Glen, Sharon, and Jaime.  I would even say that without email, we might not have been able to make some of the progress we did.  Still, I find myself sometimes wishing for more voice to voice, live contact with my clients, like it was “back in the day.”

I have a renewed empathy for my father, who at 93 years old, returned to the store each new remote control we purchased for him.

I don’t believe in e-mail.  I’m an old-fashioned girl.  I prefer calling and hanging up.

—Sarah Jessica Parker