Psychotherapy by emoji: Mental health community wrestles with texting

Dr. Carlene MacMillan was at a garden party in Brooklyn when the text message appeared on her phone. The sender was alone, in a hotel room, unable to stop thinking about killing herself with an overdose, and she was sending an electronic plea for help.

MacMillan is used to this kind of urgent message. As a child and adolescent psychiatrist at New York University, she relies on texting alongside pills and talk therapy to coax her patients from the brink of mental breakdown. “For them, picking up the phone and making a phone call is quite foreign,” MacMillan said. “They definitely prefer texting, and I see my job as forming an alliance with them.”

Not all mental health practitioners are ready to embrace texting, though. Little research and no consensus exist about whether this new technology is effective as part of the psychotherapy toolkit, and there are few official guidelines. Some doctors worry that it undermines the doctor-patient relationship; others say it can erode professional boundaries. And if a therapist charges for the extra contact, insurance companies typically don’t cover that cost.

It’s not the first time the field has wrestled with technological change, experts say. For therapists to communicate with patients by phone or Skype is now far from unusual, especially in urgent situations. And texting has become a kind of native dialect for teenagers and young adults.

So it’s only natural, according to proponents, to use the technology to help combat depression or personality disorders. Millennials text with their friends. They text with their parents. Why shouldn’t they text with their shrinks?

“To many of us, it feels like a horse that’s well out of the barn,” said Dr. Sandra DeJong, a psychiatrist at Cambridge Health Alliance.

Karen Jacob, a psychologist at McLean Hospital in Belmont, Mass., peppers her messages to some patients with emojis and GIFs. Later, in therapy sessions, she’ll use the SMS discussions to map out her patients’ crises — what triggered a suicidal episode, what can help them calm down. That way, she said, patients better understand their own emotional patterns.

Jacob sees texting as a way of helping patients become more independent. The simple act of typing out a message can be therapeutic in itself. It forces patients to step back and think more clearly — no mean feat during an emotional crisis. Then Jacob can remind them of techniques they’ve learned to calm themselves down even further. The point is for them to be able to eventually apply these methods on their own.

But in rare cases, the opposite happens, and patients become too reliant on her responses. One woman’s dependency grew so strong that Jacob worried the treatment was no longer helping. “When we talked about not actually having contact, she escalated into a crisis and landed up in the hospital,” said Jacob. Ultimately, she felt that the best solution was for the patient to start over with a new psychologist.

For patients, losing text contact can be devastating. One 25-year-old from New York City, who requested anonymity, used to text her therapist almost every day to help deal with post-traumatic stress disorder, anxiety, and depression — and found some therapists couldn’t take the rhythm. “They get overwhelmed, and instead of decreasing the amount of texting, they’ll say, ‘No more texting at all, ever,’ ” she said. “And then you fall apart. Because you rely so much on therapists.”

The woman knew that her therapist was not always available. She knew about other text-based resources, like Crisis Text Line, a national nonprofit service with trained counselors available 24/7 to respond to people in distress. But, unlike a text from an anonymous hotline, even just a few words from her therapist carried the weight of all the hours they had spent together face-to-face. “They know you,” she said, “so they know how to help you.”

Many practitioners, however, feel that connection can be eroded when therapy is administered via text messaging. “The core of empathy is in a person-to-person relationship,” said Dr. Eugene Beresin, director of the Clay Center for Young Healthy Minds at Massachusetts General Hospital.

There’s also the potential for misunderstandings. “There are sometimes miscommunications face-to-face; there are always miscommunications with emails and texting,” said Dr. Michael Brody, a child psychiatrist in private practice in Maryland.

Last year, Dejong and Dr. Tristan Gorrindo, director of education at the American Psychiatric Association, coauthored a perspective article on the clinical and ethical considerations of texting with patients. They argued that texting can be helpful in some situations but that adopting it as a tool requires careful forethought.

The risks are serious enough that Gorrindo urges clinicians to discuss the issue before they begin to text with their patients, the way a surgeon would talk through the pros and cons of an operation. “Almost like an informed consent,” he said.

Part of that discussion could be about privacy. The Health Insurance Portability and Accountability Act, better known as HIPAA, is flexible on the subject, said Mark Rothstein, a health policy expert at the University of Louisville, but “any health care provider would have to take reasonable steps to ensure the security of the communication.” For some doctors or therapists, that means using an encrypted cell phone network. Others choose to use initials instead of full names in their list of contacts.

Cost is also sometimes a concern, because therapists often charge more for coaching outside of sessions. One Boston-area psychologist sets her price at $180 for an hour of in-person therapy, for example, and at $210 if the therapy requires texting or phone calls between appointments. But even if that coaching is necessary to help the patient get through the week, insurance plans won’t cover anything that happens outside of the sessions.

For mental health professionals, beyond the concerns about misinterpretation and overdependence, there is the worry that they could miss an all-important text for help if they’re out of reach or if their phone is dead. Even those therapists who text with their patients every day often won’t wake up to the ping of an incoming message. In emergencies, they say, patients should still call 911.

MacMillan acknowledges she won’t always be able to respond immediately — but for her, the priority is that her patients can reach out when they need to. “If they are in distress,” she said, “I would much rather that they text me than do nothing.”