Communications of the ACM
Email as Therapy
Not everyone is ready to visit a therapist or counselor in person. Online therapies, including email exchanges, videoconference sessions, and app-based counseling services can help meet the needs of individuals seeking mental health assistance.
Credit: Let's Talk Online Psychology Service
A person's mental health impacts their emotional, psychological, and social well-being, and directly affects how they think, feel, and act. The state of one's mental health also shapes how they handle stress in everyday situations, during times of personal crisis, or when external factors come into play, such as the emotional stresses of pandemics, wars, or economic turbulence. Many people have realized the value of turning to professional therapists or counselors to help them navigate through these difficult feelings and situations.
However, not everyone is ready to visit a therapist or counselor in person, due to an unfamiliarity with or fear of visiting a therapist in an office setting, the cost of in-person sessions, or difficulties finding convenient transportation to and from a counselor. That's where online therapies, including email exchanges, videoconference sessions, and app-based counseling services can meet the needs of individuals seeking assistance, and a variety of published research has found it can be effective for some people.
"For so many people, [in-person counseling] is really threatening, and just too much of an alien process to engage with," according to Ben Ford, a psychotherapist offering anxiety and depression counselling in North Wales, UK, who offers email-based counseling services. "And it made me think that there must be some way of still helping out those people who don't want to do face-to-face therapy. And I thought that writing as a process is a really great way of someone being able to be at home, be wherever it is that they feel comfortable, and engage at a pace and a time that's suitable for what it is they're going through."
According to an American Psychological association survey of 1,141 U.S. psychologists conducted between August 30 and September 17, 2021, the majority were providing at least some services remotely (96%), with just 4% returning to seeing patients entirely in person. A hybrid approach of seeing some patients in person and some remotely was adopted by 50% of psychologists polled. For those psychologists providing some sort of remote service, 93% of respondents used videoconferencing, 67% of them used voice telephone services, 23% used secure messaging, 9% used a digital mental health tool or app, and 3% of respondents used "something else."
Email- or messaging-based modalities offer a great deal of flexibility for the client, allowing them to interact with counselors whenever is convenient for them, as opposed to committing to a time and day each week, as is often the case with face-to-face sessions. These asynchronous approaches allow clients to spend more time engaging in the therapeutic process by reflecting and writing responses over several days.
Examples of applications that support a variety of online modalities include TalkSpace (live video therapy, text messaging, audio or some combination); BetterHelp (live video sessions, phone sessions, texting, or live chats); and ReGain (written therapy, using both synchronous and asynchronous communications). Note that these apps are platforms that connect patients to licensed mental health providers, rather than offering mental health services themselves.
Simply sending emails back-and-forth to a therapist using traditional commercial email services such as Gmail or Hotmail is not advised, according to Ford. He says that to ensure confidentiality and security, patients should use a secure email platform such as Protonmail.com, which "has neat features, like setting an email to auto-delete after a certain amount of time in the recipient's inbox."
That said, the asynchronous nature of email or some apps does not necessarily work for therapists who rely on live client feedback that can only be viewed and analyzed, either in a videoconference or live setting, which can include observing and analyzing not only the words that are being spoken by the client, but the body language, tenor, and signs of distress or anxiety that may not be apparent in an email exchange.
"My primary issue with [email-based counseling] is that it doesn't give you live feedback," says Robert Blondeau, an Atlanta, GA-based therapist providing in-person and online counseling services. Blondeau, who has been working with clients for 10 years, says asynchronous sessions with a client suffer from a lack of engagement, as well as a lack of the non-verbal data that he uses to help the patient.
"When I ask a client a question, I want the data, but often I'm asking a question to see how they respond, and that's then going to dictate the next intervention that I use," Blondeau explains, noting that sometimes the data is non-verbal. "So if I ask a client a question and they look away, there's data right there, there's information – 'what's happening; what are you not wanting to look at inside of yourself?'"
Blondeau said he started using Zoom during the COVID-19 pandemic, as the real-time, synchronous nature of videoconferences allows him to read body language and facial expressions, and to identify anxiety or other emotions or whether the patient is engaged or disconnected, all factors that simply cannot be replicated through email or an asynchronous app. Further, he says Zoom provides an extra level of scheduling flexibility that both he and his patients require.
"I would say about 60% of my clients are in-person," Blondeau says. "Sometimes people who like to work in person, they just can't make it and it's just easier to do an online session. Now that I have that flexibility, I actually really appreciate it."
Ford, meanwhile, says his client base is roughly evenly split between in-person and online clients, adding that email can be a stepping stone for those who are unsure whether counseling is right for them. "Some start [with email] knowing that talking will not be an option for them, and desire to work through writing," Ford says. "Others like the idea of email being a sort of bridge, then eventually migrating to online work, like Zoom. [However], I've never had a local person start via email, and then migrate to face to face, probably because I live very rurally."
Keith Kirkpatrick is principal of 4K Research & Consulting, LLC, based in New York, NY, USA.
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