Sunday, September 13, 2009

Internet Communication between Therapist and Patient

The ethics of email communication between a therapist and a patient has been readily discussed in recent years.


• Supportive therapy from a familiar source when a patient travels (for some people, travelling may raise specific issues that would otherwise not be addressed in regular treatment).

• Having a boundaried (the therapist replies on their own time and in their own manner) means of communicating during distress. The act of writing the letter itself, regardless of being sent, may aid in attenuating emotions.

• Being able to communicate thoughts before they are forgotten (note taking without emailing is also an option in this case).

• Provides an un-intruding way of reminding the therapist of small details that may have been forgotten during session (prescription refills, rescheduling appointments, etc.).

• Patients having difficulty discussing certain issues may find email a way of beginning discussions (though encouraging patient confidence would eventually need to be addressed).


• May promote ruminating through overuse.

• Patient distress may increase if there is no response or the response is felt to be inadequate.

• Patient may become overly attached to the therapist.

• Information may be misinterpreted.

Email can provide some support to patients in special circumstance and I certainly not opposed to its use. However, as in structured DBT strategies, boundaries as to content and frequency of such communication (as well as whether or not a reply can be expected) need to be well defined.

There are many private companies that offer email-counselling. I am wary of these. Certainly, as a one time effort to gain assistance with a situation, this may prove affective. But as a long-term therapy, I would not recommend it. Another, free, option which may prove beneficial to the same situations would be to join an online discussion group.

A newer area of internet interpersonal accessibility is through blogs. Patients have blogs and therapists have blogs. Patients Google their therapists (therapists probably do not do the same). A therapist may develop a blog in order to make extra information available, should anyone be looking for it. Yet, they have to know that patients will probably use the anonymous comments function to interact with them.

So, I suppose the ethical questions here are:

1. Should therapists publish a blog under their own name?
2. Should therapists advertise their blog to patients?
3. Should therapists publish anonymous comments?
4. If a therapist suspects a patient of abusing the forum, should they confront that patient?

I may discuss this in more detail in a later, “Is It OK…” entry, but for now here are my short answers:

1. Everyone is aware of the accessibility of information on the interwebs. So, if a therapist publishes a blog under their own name, they should do so with the full expectation that patients will be reading it and therefore ensure that the content is appropriate for that audience. If the therapist wishes to discuss more sensitive subjects or if they want to remain anonymous, then they should publish under a pseudonym.

2. This depends on the content of the blog. If it is primarily worksheets and therapy strategies, it could provide a useful, impersonal, resource to patients. If the blog is opinion based and not directly relevant to treatment, such advertisements may weigh in on the narcissistic side.

3. As long as the comments are not-offensive and are related to the article, sure.

4. Of course. Tactfully. Therapy is a place to practice interpersonal skills and is (or should be) a safe place to confront awkward issues.

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