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Complete strangers often email me intimate details about their eating issues, desperately hoping that I can help. An American visiting Paris once inquired if I could convince her subconscious that crème brûlée tasted like plastic.
As an eating disorder therapist, I hear from virtual pen pals who are so distressed by the measure of things — pounds lost and regained, dress sizes before and after kids, calories consumed and burned -– that they email me to save them from themselves. I offer therapy for local clients and Skype eating-awareness training for those who live farther away.
But even when I can’t help, I exchange unsecured emails as willingly as I once answered phone calls. Despite the inherent risks of corresponding electronically, I’ve always considered it my duty to reply. At least I did, until early last January, when Cara (details changed to protect privacy) emailed me about helping her 19-year-old daughter stop bingeing on whole packages of Oreos, chips and other junk food.
If I’d known a simple information exchange would become as long and complex as some therapy cases, I never would have typed, “Happy to help.” Only in hindsight can I see this e-relationship for what it became: an exemplary case about the pitfalls of treatment-related email.
Cara’s initial email described her daughter, who had gained 65 pounds bingeing in London, where she was studying abroad sophomore year. Dashing off a hopeful message about binge eating being the most treatable of the eating disorders, I looked beyond the computer screen to the frozen remains of my summer garden. If her daughter joined one of my online groups, the New Year could be off to a better start than this sad, barren winter.
'The Epic Correspondence'
When I started my private practice, I’d sit on the edge of my new suede couch, waiting for the phone to ring. A quarter-century later, I much prefer a beeping inbox to a ringing telephone. Potential clients seem to share my preference for connecting via email, which is significantly quicker, easier and more convenient than trying to connect by phone. Less threatening, too. There’s something about the separation between sender and recipient that enables even the most hopeless to reach out for help across the internet.
While the use of email for treatment-related communications is not prohibited under medical privacy laws, therapists and other health care providers are encouraged to protect client privacy by limiting the content of unencrypted exchanges to simple matters that can be efficiently handled.
For potential clients, the main concern should be privacy -- the possibility of an email being read by unintended parties. (Think: DNC email leak.) My standard reply spells out the privacy risk and their liability if they continue to use email. But truthfully, when you email a therapist, you are tacitly agreeing that email communication is acceptable.
The other concern, far subtler and more insidious, is what WaitButWhy.com blogger Tim Urban calls “the epic correspondence” — an email exchange that goes on and on until one of the people dies or someone finally has the guts to end it.
Days pass without a snowflake or another word from Cara, then a small blizzard buries my garden and inbox. First comes a general inquiry into my mindful eating training, then an urgent request for a three-way phone consult with her husband, followed by an effusive thank you for my responsiveness with a promise to be in touch.
A week later, she inquires into my next weekend workshop: “I’ve been looking into eating disorder treatment centers, but I’m worried that sending my baby on her own might be too overwhelming.” Against a cacophony of computerized beeps, I dash off a reply without giving “my baby” more than a millisecond of thought.
Between further inquiries, Cara emails a series of lengthy updates about who said what to whom about her daughter’s 65-pound weight gain. What do I think about regular weigh-ins? (The school therapist recommends weekly; the obesity doctor says no need.) Now that her daughter weighs more than 200 pounds, what do I think about a medical leave from school? (Her husband insists yes; the school psychiatrist suggests waiting for the weight-neutral antidepressant to take effect.)
What do I think? I think about screaming: TMI! Too many questions! Then I remember that this poor woman needs help navigating the terrible maze of conflicting opinions, treatment options and family dynamics. If a little more hand-holding helps her make an appointment, this e-correspondence is not for nothing.
That’s what I think, but I don’t really know.
All I know is I’m engaging in an email correspondence without having begun formal therapy — with no agreement about when, where and how long to meet; no fee; no assessment, none of the standard things I cover upfront. I think I’m using email to set up therapy, but I wonder if this email exchange is therapy.
The Limits Of Email
Soon after Valentine’s Day, when Cara emails yet another question, my furious fingers hammer out the clear, directive reply I should have written weeks ago: “No small task finding clarity amidst all the confusion. At this point, my best and only suggestion is to come in for a consultation.”
Just like that, Cara makes an appointment. When the appointed hour arrives, I head to the waiting room, where I find two people — a scruffy guy and a bony bird of a woman, lost in her iPhone. I’d pictured a larger woman.
“Cara?” Sure enough.
She perches mid-couch, within easy reach of the tissue box. Her anxiety about her daughter’s weight gain gives way to guilt over her own eating disorder, and the twin grief of an emptying nest and a loveless marriage. In turn, any remaining irritation I feel toward Cara, the relentless emailer, dissolves into care and concern for Cara, the young anorexic, the mournful mother, the disillusioned wife. I’m heartened by the depth of our initial connection.
When Cara emails the next morning to say our first session will be our last, because of insurance problems, I’m stunned, then irritated all over again. Would I be so kind as to recommend someone in-network? My mind is not kind as my fingers pound out a terse reply with a few referrals.
Only months later, when I compare notes with the colleague who took the case do I learn that Cara was emailing us both at the same time. Hearing the same outrageous story from another therapist's mouth — countless emails, a single appointment, more emails — I hear echoes of my own outrage, and acknowledge my own truth: I'm angry with the wrong person.
I was the one who put the convenience of a remote connection over the central importance of a living, breathing human relationship. As maddening as I find Cara’s mass mailing habits, I’m mad at myself for allowing our e-correspondence to exceed the relational limits. Email is a fine way to initiate communication, answer a question or two, but it’s no way to establish a compassionate relationship. Compassion springs from thoughtful attention, open communication, real human connection, not the distraction, miscommunication and disconnection that email invites.
Five months later, Cara writes: "Things are not improving despite constant medical, psychiatric appointments. I'm wondering if intensive individual therapy would be effective in the six weeks left of summer? I did reach out to your colleague, but I'd welcome any opinions you have on this matter."
Before I reply, I take in the glorious abundance of my vegetable garden and gather my thoughts: "Sorry to hear of your ongoing struggles. Your daughter's case is complex enough that you really need someone to help you navigate the maze of choices. I'm glad you're in touch with my colleague, and I encourage you to make an appointment with her. Gathering advice by email, I'm certain, only adds to the confusion."
I'm so certain, in fact, that the next time I encounter a potential client who sends one too many emails, I pick up the phone and make her an offer she can’t refuse: a 50-minute phone consultation with 10 minutes of email support.
Just like that, she books a consultation and cashes in on one minute of support. I owe her nine, but she’s stopped emailing.
Jean Fain is a Harvard Medical School-affiliated therapist and the author of “The Self-Compassion Diet.”
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