Tuesday, September 23, 2008

I Love These E-Mails, or Do I?

I Love These E-Mails, or Do I?
The Use of E-Mails in Psychotherapy and Counseling
By Ofer Zur, Ph.D.

To cite this page: Zur, O. (2008). I Love These E-Mails, or Do I?
The Use of E-Mails in Psychotherapy and Counseling. Retrieved 9/23/2008 from http://www.zurinstitute.com/e-mail_in_therapy.html.

I checked my e-mails 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 e-mail 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 e-mail to a couple of dozen people (using Bcc not CC so their identities and e-mail addresses remain private), telling them that I would be out of town the next week, I would neither be available by phone nor by e-mail 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 e-mails? 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 e-mails have saved us-therapists time and energy so we can focus on what is important. Many of us-therapists love the flexibility allowed in receiving and sending e-mails 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 e-mails can be, many therapists have started giving their e-mail 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 e-mail from a depressed client: "Doc, I cannot take it any longer!!!!!" I noticed it was send at 2 AM. Now what am I to do? Send an e-mail, 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 e-mail 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 e-mail 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 and disvalued 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 e-mail 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 e-mail, 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 e-mail. 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" e-mails, 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."

E-mail, 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 non-leisure time), there is an expectation that anyone with an e-mail 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 e-mails from depressed, suicidal or homicidal, or existentially depleted or spiritually lost clients. E-mails 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" e-mail to me; how to deal with the disappointed client whose elaborate description of her dream went unread; or with the furious young women who felt dismissed because I did not reply with a lengthy supportive e-mail, like her best girlfriend would have done.

The main issue has become what is the proper use of e-mail in psychotherapy? To add to the complexity, there are several legal, ethical, and clinical questions that are related to e-mailing our clients.

The main question is how do we deal with clients who expect us to respond quickly and/or read lengthy and numerous e-mails 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 e-mails, 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 e-mail 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 e-mail 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 e-mail, per minute, or other ways? I suspect that most therapists prefer to use e-mails 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 and Informed Consent to Treatment (see form 1 at Clinical Forms) that we give to each and every client at the beginning of therapy should have a section on policies regarding e-mails. This section should discuss issues of privacy, confidentiality, security, availability, response time, content, emergencies, etc. An example of such a paragraph is:
E-MAILS, CELL PHONES, COMPUTERS AND FAXES: It is very important to be aware that computers and e-mail and cell phone communication can be relatively easy to access by unauthorized people and hence can compromise the privacy and confidentiality of such communication. E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. Additionally, Dr. X's e-mails are not encrypted, and faxes can be sent erroneously to the wrong address. Dr. X's computers are equipped with a firewall, a virus protection and a password, and he also backs up all confidential information from his computers on to CDs on a regular basis. The CDs are stored securely off-site. Please notify Dr. X if you decide to avoid or limit, in any way, the use of any or all communication devices, such as e-mail, cell-phone or faxes. If you communicate confidential or highly private information via e-mail, Dr. X will assume that you have made an informed decision, will view it as your agreement to take the risk that such communication may be intercepted, and he will honor your desire to communicate on such matters via e-mail. Please, be aware that e-mails are part of the medical records, and do not use e-mail for emergencies. Due to computer or network problems e-mails may not be deliverable, and Dr. X may not check his e-mails daily.

There are a number of other questions that come up in relation to e-mails between therapists and clients. They include:
Are e-mails considered psychotherapy or counseling?

Yes. These e-mails, whether profound or mundane, are part of the therapeutic process and are considered part of the clinical records.

If I give my e-mail address to my clients, must I check my e-mails often?

The fact that you give your e-mail 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 e-mail, if you respond to e-mails, and what are your general policies regarding e-mails (see details in the body of the article).

Does using e-mail make you automatically a Covered Entity by HIPAA, which means you must be HIPAA Compliant?

Different experts may give different answers to this question. In my opinion, exchanging e-mail with clients is likely to mean that you have to be HIPAA compliant, if you are not already. (Becoming HIPAA Compliant is not that hard, check our HIPAA Compliance Kit or Online HIPAA Course for CE Credits.)

What about confidentiality and privacy?

Confidentiality and privacy are applied to e-mails in the same ways that they are applied to any other verbal or written exchanges between psychotherapists and clients.

Must e-mails be encrypted?

At the present time, e-mails between therapists and clients do not need to be encrypted, as long as clients are informed about the vulnerability of e-mails being read by unauthorized people, and they elect to use e-mail. (For more details, see above note about Office Policies and the next question.)

What is an e-mail signature and what may it look like?

An e-mail signature goes at the end of the e-mail. It can be set automatically. Make sure that every e-mail to a client or patient includes an electronic signature that covers issues, such as confidentiality and security. Following is a sample of such an e-mail signature:

Notice of Confidentiality: This e-mail, 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 e-mail in error, please immediately notify me by e-mail (by replying to this message) or telephone (707-xxx-xxxx), and permanently destroy or delete the original and any copies or printouts of this e-mail and any attachments.
It is important to be aware that e-mail communication can be relatively easily accessed by unauthorized people and hence can compromise the privacy and confidentiality of such communication. E-mails, in particular, are vulnerable to such unauthorized access due to the fact that servers have unlimited and direct access to all e-mails that go through them. A non-encrypted e-mail, 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 e-mail. Unless I hear from you otherwise, I will continue to communicate with you via e-mail when necessary or appropriate. Please do not use e-mail for emergencies. While I check my phone messages frequently during the day when I am in town, I do not always check my e-mails daily.
Name/Degree/License: xxxx
Address: xxx
Phone: xxx
E-Mail: xx
Web Site: xx

If we e-mail to clients, does it mean we are conducting tele-health or e-therapy?
If the e-mails 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 appropriately and competently. (For more information, see out Telehealth Online Course.)

Are these e-mails part of the clinical records, and can they be subpoenaed just like chart notes in the unfortunately not uncommon event of legal action?
Generally, e-mails between therapists and clients are considered as part of the clinical records and can be subpoenaed, just like chart notes. You may want to consider printing important e-mails and placing them in the chart, in case your computer crashes.

Guidelines To Using E-Mail With Clients

The subject and discussion about the role of e-mail 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 e-mail communication with clients. What are your preferences, your limits, etc.?
If you are considering using e-mails as an adjunct to therapy, make sure you become HIPAA compliant.

Discuss the issue of e-mail communications with clients, 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 the use of e-mails.
If you are conducting tele-health, follow state laws, relevant codes of ethics, and have a separate informed consent, which is required in some states, such as California.

Make sure your computer has a password, virus protection, firewall, and back up system.

Make sure that each e-mail includes an electronic signature that covers issues such as confidentiality and security.

To cite this page: Zur, O. (2008). I Love These E-Mails, or Do I?
The Use of E-Mails in Psychotherapy and Counseling. Retrieved 9/23/2008 from http://www.zurinstitute.com/e-mail_in_therapy.html

Copyright © Zur Institute, LLC, 2008. All Rights Reserved. Reprinted with Permission.

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