Canadian Medical Association Journal 1996; 155: 1606-1607
[en bref]
© 1996 Cameron Johnston
Dr. Kenneth Silk, head of the Personality Disorders Clinic at the University of Michigan, told the recent annual meeting of the American Psychiatric Association (APA) in New York that he has used email counselling to treat seriously ill patients. He said the results were positive and suggested that "email therapy" is an option that more psychiatrists should consider for certain types of patients.
Silk said he first used email therapy with a patient who had a borderline personality disorder with narcissistic features and a 10-year history of depression, which included one suicide attempt. A more recent patient was a chronically suicidal and self-mutilating mother who had been married many times by age 40.
The first "must" in using email therapy, he said, is to let patients know that you will respond to email only when your schedule allows, and that might not necessarily be at their convenience. "You're not always able to reply as soon as the patient's message has been sent," he said. "For example, I don't [read] my messages every day, and I do [not have access to] my email on holidays."
email should not be seen as a substitute for phone messages or for use in emergency and crisis situations, he warned, adding that a psychiatrist should not try to analyse, comment on or otherwise interpret anything that is best handled in a face-to-face counselling session. email does not diminish the need for personal contact, but is simply another way for physicians to communicate with patients. [Harper's magazine reports that a group of New York doctors offers "Psychoanalytically guided self-inquiry" via email for $125 an hour. -- Ed.]
He said correspondence with patients should be sent as a "New Message," and not as a "Reply," because it is easier for unauthorized people to gain access to emailed replies. He did warn that some patients might resent the use of email if it means less face-to-face contact with the psychiatrist.
He also cautioned that email therapy carries exactly the same legal and medical risks as face-to-face therapy and paper copies must be kept of all communication with patients.
Such caveats might lead physicians to wonder whether email psychiatry offers any benefits, but Silk believes it provides "a special connection" without disrupting either the patient's or doctor's life. For example, his narcissist patient used to call him at his office or home up to five times a day, but after he suggested that she contact him by email, the number of phone calls dropped and soon ceased entirely; by learning to use email, the patient developed a strong interest in computers and obtained a job involving the use of computers. Silk said this helped considerably in her recovery.
Similarly, a patient who had trouble expressing her feelings in face-to-face sessions was able to discuss them freely via email: "She felt safer expressing her feelings at a distance, and email has permitted her to bring more of her thoughts and feelings into the therapy."
Patients who might be less articulate in person may be able to express themselves more effectively on line, so the psychiatrist may be able to help the patient refocus and feel safe until the next person-to-person session.
Some of Silk's APA colleagues were sceptical about the practice, suggesting that email therapy might allow patients to "do an end-run around the 50-minute hour." Others felt that by providing patients with his email address, he was being unprofessional and unwisely letting the patient into an aspect of his personal life.
Silk acknowledged that email therapy might give the patient some free advice, but countered that telephone calls do the same thing. Furthermore, he said, email forces the "conversation" to remain on track, whereas telephone conversations frequently degenerate into unfocused and inconclusive ramblings. email also gives the psychiatrist and patient something concrete to focus on during the next face-to-face session.
He conceded that a disgruntled or angry patient could create a problem by spreading the psychiatrist's email address around chat rooms across the Internet. However, he said psychiatrists can also use the Internet to publicize their practices by setting up home pages and promoting their areas of expertise.
While Silk's original email sessions ended because both patients resolved their problems, he said he would not hesitate to use this form of electronic therapy with new patients as long as they were amenable and their problem lent itself to Internet-style counselling.