Using E-mail in Clinical Practice

Like most registrants, I attended the 2001 Academy for Eating Disorders conference in Vancouver, British Columbia, for a variety of reasons. I wanted to reconnect with colleagues and learn about the latest research efforts, but ultimately I hoped to gather ideas that could potentially enhance my clinical practice as a dietitian. I was not disappointed!

One of several conference highlights for me was a presentation by Dr. Joel Yager, “E-mail as a Therapeutic Adjunct in the Treatment of Ambulatory Anorexia Nervosa,” which was part of the plenary session Emerging Technologies in the Treatment of Eating Disorders. Dr. Yager, who is editor of EDR and professor of psychiatry at the University of New Mexico School of Medicine, Albuquerque, caught my attention by posing two thought-provoking questions. The first question was, is e-mail a clinically effective and user-friendly service that can engage treatment-resistant patients? The second question was, how can clinicians use e-mail as an adjunct to traditional eating disorders treatment?

In a case-series report, Dr. Yager described his initial experiences using e-mail with 15 adolescent patients seen for treatment of anorexia nervosa. Although the computer supplemented his clinical contact with patients, he emphasized that it did not replace face-to-face interactions and other treatment components such as psychotherapy or nutritional counseling. Using e-mail, Dr. Yager encouraged patients to correspond with him between sessions. He wanted to know what was happening in terms of their struggles with eating-disordered thoughts and behaviors.

The Clinical Effectiveness of E-mail

He soon discovered that patients were more engaged in treatment when they realized he wanted to maintain contact with them. Several of his patients reported that e-mail was an incentive to do well because they were checking in on a regular basis. To provide him with updates, they had to pay attention and become more aware of their behaviors every day.

By communicating progress reports several times a week or even daily, patients were essentially record-keeping–an integral cognitive-behavioral activity. In turn, Dr. Yager noticed a more effective use of his clinical time. Because patients had reported their behaviors via e-mail, their eating and exercise patterns did not require as much preliminary discussion during office visits.

A User-Friendly Treatment Service

Dr. Yager presented interesting reasons why patients may be attracted to e-mail. Social psychologists have reported findings that suggest e-mail can change the identity and relative social status of the individuals engaged in this form of communication. The person sending the e-mail may no longer see herself/himself as subservient to the recipient. Instead, social and psychological studies have shown that e-mail may give greater voice to those who are less dominant in a relationship. “It is a democratizing type of interaction,” stated Dr.Yager.

In addition, patients can use their electronic “voice” when they feel most inspired. For example, they can communicate their thoughts to their health-care provider at any time of day. The computer will take whatever they want to say, whenever they want to say it, increasing the likelihood of patients reporting thoughts, feelings and behaviors that they may otherwise forget during sessions. “They may be able to look you in the computer better than they can look you in the eye,” reported Dr. Yager. For this reason, e-mail may be especially useful for patients who are shy or have social phobias. It may be easier for them to be emotionally honest and make a connection when they are not sitting in front of their care provider.

Based on his observations, Dr. Yager found that perfectionistic or obsessional patients did well with e-mail. In general, those who were impulsive in nature lacked the diligence to adhere to the routine of sending messages. E-mail also seemed to suit patients who valued honesty and integrity. “They will either tell you what is going on, or they won’t say anything at all. You will get a blank screen,” he said. Dr. Yager interpreted a patient’s silence on e-mail as a sign of resistance, and explored possible barriers during office visits.

Clinician’s E-mail Habits

To make e-mail an effective treatment component, Dr. Yager believes clinicians should be explicit about their e-mailing habits. Patients need to know how often their clinician reads their e-mails and how they will respond. He informs patients that he responds with one or two lines of encouragement and not paragraphs of advice. While he acknowledges the patient’s struggle, he intentionally avoids detailed messages because of confidentiality.

The Limits of E-mail

Dr. Yager cautioned health-care professionals to obtain informed written consent from patients prior to engaging in e-mail. For those younger than 18 years, parental consent is needed. During the process of getting informed consent, patients should be made aware that e-mail is not a secure and confidential medium. Dr. Yager advises patients not to put anything in a message that they would not want others to read or that might appear in court at some later point in time. According to guidelines recently established by the American Medical Informatics Association, e-mails are official documents that must become part of the permanent medical record. Dr. Yager recommended that care providers create separate files containing all e-mails received from each patient.

Clarifying Appropriate Types of Communication

Finally, Dr. Yager advised clinicians to clarify their boundaries with patients and to discuss the types of communications that are appropriate. The social conversation inherent in e-mail makes caregivers more vulnerable to boundary violations. They need to be careful about the interactions they invite. However, he stressed that any message that contains thoughts of self-harm or threats to others should be treated like a clinical communication. Dr. Yager responds immediately to any distress communicated via e-mail by getting on the telephone and talking directly with the patient.

— Linda Watts, MA, RD