EUROPEAN JOURNAL OF INTEGRATIVE PSYCHOTHERAPY

Relatively little has been written about the use of electronic mail (e-mail) in psychiatric practice (especially in dynamic psychotherapy), with attention given to medico-legal recommendations (Silk & Yage, 2003; Person & Beck 2003), informed consent (Recupero & Rainey, 2005), economic aspects (Tang & Helmeste, 2000), research on psychotherapy outcomes, and the implementation of highly structured therapies based on manuals.

Beyond the field of psychiatry, there is a substantial literature on the social impact of email. From the introduction of email to the social impact of email. Since the introduction of email in 1961 as part of the demonstration project at the Massachusetts Institute of Technology, it has represented, as can be demonstrated, a force for democratization, making major contributions to public health service activities. A search in the Pub Med database for the words "Email and psychiatry" leads to 332 articles, with a range that extends from the use of email in planning malaria eradication campaigns in East Africa, to organizing needle exchanges in San Francisco, to bringing together members who politically support presidential candidates. Social science researchers have studied email as a form of "social capital" since 1995 and have adopted it for clinical studies by public health researchers such as Kawachi in 1999, as a cheap, widely available tool that can be used by anyone, including those with limited economic resources. For example, email can be accessed from a public library or an Internet café in a war-torn area with scarce resources. The popular use of Internet sites, such as MySpace and Facebook, has been studied, and although this work indicates groupings by various affiliations, including race, age, religion, education, and economic status, it can be demonstrated that interactions through email allow for faster formation of alliances along other axes, such as common hobbies—or more relevant to medicine and psychiatry, common sufferings.

Given the importance of email in the formal and informal establishment of support groups on the Internet, which range from a chat room about myotonic dystrophy to message boards and websites with references for common and rare diagnoses, email can be considered a means of increasing access to psychiatric treatment and individual psychotherapy. It can be a tool for "practical psychoanalysis" and for bringing psychoanalysis "out of the office, into the world".

Before his death in June 2006, Dr. Edward Messner from Massachusetts General Hospital regularly led psychiatry modules for psychiatry residents in the hospital's department. He had a very different perspective on email than those described above, firmly arguing that email should never be used to communicate with a patient. He prohibited responding to emails received from patients – regardless of the circumstances in which they appeared. Receiving them should not be confirmed using the same medium, but in person, or, if that opportunity did not exist, by phone (and by these means only if absolutely necessary). In Dr. Messner's view, when personal therapy was taking place and the patient's safety could be assessed in real time, not confirming or responding to an email received from a patient was a perfectly reasonable option.

Case 1

A few days ago, Mr. F, a 43-year-old gay man living in a small town in Nevada (population 800), learned the news that he is HIV positive. He had no psychiatric history and had succeeded in his professional career as a graphic designer. Mr. F had moved back to town to save money, care for his elderly mother, and recover from a romantic disappointment. He is able to continue his very productive career through telecommunications. He is not "far away" from those in town and as he told a friend in Chicago during a late-night phone call, "email is my lifeline." He had just obtained the email address of a renowned therapist in Chicago, who had medical and psychoanalytic training and specialized in issues related to homosexuality and gender. As a university student, Mr. F had read several psychotherapy books, including "The Velvet Rage," some excerpts from the essays of Freud and Jung, and had obtained a minor in psychology. He was interested in starting e-therapy immediately, corresponding at least once a week with the therapist. In an effort to distance himself from the news of his diagnosis, he had even searched online furniture sites for a used psychoanalyst couch that he intended to set up in his mother's basement and lie on while writing to the therapist on his Blackberry during sessions.

Case 2

Ms. A is a 48-year-old American woman, born in Iraq, who had planned to return to Iraq with her husband - an exporter-importer, who cooperated with the U.S. military - and her nine-year-old daughter. She did not know how long she and her husband would stay in Iraq, but anticipated no more than 3 months. In Iraq, Ms. A had been a college professor, and in the U.S. she had been an Arabic language tutor. Her English was excellent and she had been in psychodynamic psychotherapy with the same psychoanalyst (who was of Indian ethnicity and had a Muslim education) for 8 years. During therapy, she discovered that writing a journal helped her. Ms. A had sought treatment when she turned 40, and the doctors had told her that a heart condition made trying to get pregnant for a second time inadvisable. Partly due to her upbringing and religious beliefs, it was extremely difficult for her to accept that she might only have one child. Returning to Iraq inevitably brought up amplified feelings of depression and helplessness. She recalled her status regarding pregnancy and faced symptoms of post-traumatic stress disorder triggered by having witnessed the bombing of a house 10 years ago. Her uncle had died in that bombing, and she had suffered a minor brain injury, being struck by a piece of wood that had fallen, which had caused her immediate memory loss after the event. (The results of the scans had been normal).

A few weeks after arriving in Iraq, Ms. A sent her psychiatrist an email from an Internet café in Baghdad. Since the counselor she had intended to consult at Ibn Sina Hospital had fled to Jordan, Ms. A hoped to continue her therapy via email whenever she could access the Internet.

Case 3

T. a 17-year-old girl, had undergone psychodynamic psychotherapy for the past 2 years. Initially, T. was depressed, kept the secret about self-harming by cutting and burning herself, and had poor school performance. She had made progress in the last year and expressed a desire to use Instant Messenger (I-M) and regular email to communicate with her therapist between sessions, "when I still feel anxious or scared about a test or something momentary that will pass, therefore, there’s no need to call." She had been sending messages for several months without any incident, messages that were always updates about certain events, such as a meeting, a success at school, a meeting with parents. Beyond the occasional "Great" or "Let’s talk more about this in the session," the therapist felt that no response to these IMs seemed warranted. In recent weeks, the messages had become somewhat more frequent, although still neutral in content, with the therapist still not responding to them. Recently, the therapist received the following I-M: "You really hurt me and I am scared," a statement that the therapist interpreted as urgent and responded to by phone – but the patient refused to talk during that phone call or during therapy.

Time, place, space, figure, and grace

These cases reveal few of the risks of using email for therapy – from the high cost of breaching confidentiality (if, as happened in case 1, emails were accidentally sent to the wrong addresses, compromising a patient trying to keep their sexual orientation and HIV status private) to cracks in the treatment alliance that can be introduced or widened by email (as happened with the vulnerable adolescent in case 3).

The more carefully we examine the potential for problems of any use of email in psychiatry, we also use a formula that seems mnemonic: "Time, place, space, figure, and grace." This is built directly on the categories of limits and boundary violations that appear in

"time," "place and space" as described by Gutheil and Gabard (1993). Additional themes of the discussion include "person" and "tangibility" as developed in literary theory and psychoanalysis. This framework aims to address the gap in the literature identified by Peterson and Beck (2003) regarding the discussion of "the variables and dynamic processes of electronic communication."

Time and Email

Essential to the psychoanalytic limit of "time" are the following:

• a limited duration of time for a given session,

• a prior agreement regarding the frequency of sessions (any change being discussed carefully and deliberately)

• scheduling sessions according to a certain standard, a widely accepted definition of working hours for practicing psychotherapy (i.e., not usually assuming the hours of the day reserved for sleep or other personal or intimate activities.)

Other time limits include the completion of psychiatric training and "forced termination" carried out by graduate residents with their psychotherapy patients, terminations of treatment determined by other causes, such as the patient's relocation and "discharging" a patient for refusal or inability to consistently utilize the allocated treatment time. Delays in a session or multiple sessions also provide material for analysis, given that treatment is time-bound.

The email undermines this boundary in many ways, some of which are not obvious. Since its increasingly widespread use since the 1980s, email has distinctive elements that indicate the moment in time when the email was sent. The email address is also distinctive, often marking access to email from a professional or home setting. By receiving an email, the patient is given the opportunity to glimpse how the psychiatrist spends their time outside of the session—providing a "proof" from real life that, at times, could unpredictably support various fantasies regarding the time frame in which the therapist is not connected to the internet or the absence of it. For a psychotic patient, the email can blur the boundaries between thoughts and reality, between desires and the actual responses of the other individual, between the self and the external world. In daily activities, as well as in psychotherapy, for schizoaffective patients, for example, issues related to the use of email have been reported in the specialized literature.

Email has begun to be legitimized as a source of clinical material and as a way to assess the mental state of the patient (as seen in recent studies of email texts written by self-harming patients, for example in Whitlock, 2007). The path to a violation of the time boundary may begin with the therapist's feeling that the email will provide "more material" and by adopting a laissez-faire attitude towards unsolicited emails from current patients.

However, important interpersonal ambiguities are not absent from the email material, despite the vividness and superficial "clarity" of the words visible on the screen. The ambiguities of the email revolve around the intentions of the writer, tone, and rhythm. All of these can be important for therapy and have serious implications for patient safety. The intentions of the psychotherapist writing an email can be truly obscure to the patient due to the conciseness of the email, its extraction from a context of giving and receiving in real time, and the difficulty in determining what type of response would be expected in the case of emails or IMs from the patient that do not seem urgent. As in case 3, the lack of a response from the therapist to a given IM or email can be experienced by the patient as painful, despite a pattern of lack of response that had been considered acceptable or even preferable in the past. Similarly, the intentions of the patient may be unclear in email communication, for example about chronic suicidal thoughts that the patient does not intend to act upon and would not feel the need to express if there were not the availability and "aspect of permission granted" of the email. Other intentions, such as thoughts of harming others, may not be expressed directly via email, but indirectly, as happens in an extremist or paranoid characterization of others that, retrospectively, may show signs of homicidal ideation. The email may provide sufficient evidence for legal action to protect the patient or the target of the patient's destructive thoughts, but it may be used after the incident has occurred to hold the clinician who received that email accountable.

In addition to activating transference and providing a means for projection, email can also serve as a medium for countertransference in relation to time limits. The psychiatrist or therapist has the task of maintaining a mental separation between professional time and personal time in a way that is different from that during clearly demarcated session hours. The intensity of being involved, even if not physically, during therapeutic activity can be seductive – especially for a therapist who enjoys expressive writing or who, by using email outside of office hours, feels conscientious, validated as a devoted clinician, or is gratified by the fact that the patient acknowledges the importance of therapy by putting something in writing.

Ultimately, the pace of symptoms communicated by a patient via email can be difficult to perceive, especially if an escalation (i.e. sending several messages in a short period of time) represents the distress of encountering silence (and the perceived absence and unavailability) and not an escalation of a plan of destructive actions. Some patients will be able to structure their use of email based on the understanding that emails will not receive responses with the same frequency as phone calls. Other patients may not adapt well to this difference or may not be able to predict the intensity of their transfer regarding the fact that their emails have not been responded to immediately. Given the difficulty of ordering different dynamic aspects in intersubjectivity, email can also create an unnecessary “pause,” giving the patient an unrealistic feeling of “suspended animation” (to use a formulation from the treatment of a schizoid patient presented by Lingiardi) and a false sense of “psychic withdrawal” from the difficult labor of analysis and from enduring the painful and conflicting emotions involved in intersubjectivity. Therefore, an important difference between email and telephone is that a phone conversation takes place in a common “real time” (and, therefore, in a time-limited analytic space) while email does not do this.

Patented in 1876, the telephone precedes psychoanalysis and has always been a potential means of patient-physician communication in psychiatry. A search in PubMed for the criterion "telepsychiatry" yielded 183 articles. The extensive activity conducted in this field includes randomized studies of the efficacy of manual-based therapy (such as cognitive-behavioral therapy CBT, prolonged exposure therapy, and comparative studies with manual-based face-to-face therapies), guidelines for telepsychiatry for inmates in prisons compared to face-to-face interactions, and emergency phone interventions for substance users without access to detox services but victims of domestic violence. More recently, researchers have studied the impact of videoconferencing in cognitive-behavioral therapy with a step between email and phone that maintains the advantage of increased access.

So it happened with email, the more incidental or logistical use of phone calls must be distinguished from "teletherapy" as the primary means of therapist-patient communication. Few would complain about the use of phone calls for changing or setting the appointment time, obtaining concise clarifications regarding healthcare plans, and for psychiatric or medical emergencies. However, the use of phone calls for "check-ins" or as supplements to in-person psychotherapy can illustrate some of the potential issues of using email. As Linnehan (1993) described, the use of the phone as part of psychotherapy in the treatment of borderline personality disorder is important for preventing suicide and minimizing repeated hospitalizations, and it is a method that therapists practicing dialectical behavior therapy (DBT) commit to from the outset. Several conditions are established:

The phone is primarily used for emergencies, such as suicidal or homicidal ideation.

Clients (as patients are called in CBT) must use the phone in non-emergency situations only if they are prepared to receive time-limited, task-oriented coaching designed to help them get past a specific, time-limited obstacle (i.e. "a tough night where I am so angry at my sister that I am thinking of hurting myself") and,

The therapist must communicate in a "real" way their own limits and the ways in which extending therapeutic activity outside of scheduled sessions can put the therapist at risk of burnout syndrome and, ultimately, may interfere with therapy.

In this very structured, thoughtful, and transparent way of using the phone within a manual-based therapy, there is a clear agreement between the client and the therapist that the phone will not be the medium for long-term activity. There is also an element of object relations theory in Linnehan's modified CBT model, which allows the therapist practicing dialectical-behavioral therapy to create a supportive environment and a constancy of the object, being available for phone coaching. The patient is instructed that they will be called back within an agreed-upon time frame that ranges from one hour to 24 hours and that the phone call will not last more than a previously agreed-upon time frame, usually no longer than fifteen minutes.

In this model, the phone has an advantage over email because the time spent on the phone is clearly delineated. Neither party is able to do anything else while engaging in a conversation with the other, and the time spent on the phone does not “mix” with personal activities in a hidden manner. The technique encourages CD therapists to disclose personal limitations in a way that supports the alliance: ” Well, I haven’t finished my dinner and I need to hang up the phone in about five minutes to do something. I want to be helpful to you, but you need to take some responsibility for both of us, following our plan: being “available” also supports a medical model that reinforces boundaries, and not a gradual or insidious, long-term transition of personal time into time spent with a patient or an extension of working time, although “being called” constitutes an unusual event that requires a disruption of personal routine and a return to being “on duty.”

Place , space and email.

I have already mentioned how email potentially violates boundaries by revealing the physical location of the psychiatrist or psychotherapist outside of treatment hours. The place and space of email also pose another problem for both the psychiatrist and the patient. Email as a space can be where love letters (and hate letters) are exchanged, where a wide variety of messages from different sites reach, kept at a distance from professional life. Email is also the space of numerous other professional obligations and identities, of communication with friends and family, and potentially, it is a place of commerce and personal accounting. It can be the place where some realities can take place, often in haste. As a result, in another sense, email is not only too private, but it is also not private enough. Like a psychotherapy session in a train station, by using email, both the patient and the therapist can lose the unique, unmistakable space of partial solitude, of silence and calm that characterizes effective psychotherapy.

The email raises other questions related to intimacy and disinhibition. A famous anecdote is told about Melanie Klein, who would ask patients coming to therapy during her vacations in the Black Forest to relax on the bed in her hotel room. Is it different if you are lying in bed next to a partner and typing on a laptop an email to a patient? Even if the time of day when this happens wouldn’t necessarily make the patient imagine this scenario (of being metaphorically and, in some ways, even literally 'in bed' with the therapist), the portability of email creates for the therapist the task of maintaining a mental boundary of space. There may be an unexpected emotional impact (including mutual arousal) of emails that reach places previously outside the boundaries, especially with BlackBerry and other portable wireless systems (the American Medical Association warns against using them for communication with patients due to the low security of the network). The patient's uncertainty about where the computer is kept, in intimate spaces, can add to this feeling of arousal, similar to how, in the case of phone calls after hours, it can be assumed that the phone is next to the bed and therefore a call can intercept or supplement the therapist's intimate relationships and personal needs.

In the Exploitation Index, Epstein and Simon (1990) urge those who risk a violation of boundaries to inventory their thoughts at home and determine if their feelings, thoughts, or concerns regarding a given patient are creeping in there as well. They argue that such an inventory helps protect against a violation of boundaries in real life, such as meetings held in social places. Gutheil and Gabbard provide examples of such places that are off-limits – social activities, lunch, the therapist's or patient's car. In light of these warnings, the desire to send an email to a patient after hours can be a similar red flag – especially since email and IM technology provide a way to instantly satisfy such a desire. Sending an email during a lunch break from the car, train, elevator, gym, or another social situation (all made possible by the wide availability of public internet access and handheld devices) is a way of intensely engaging the patient outside of the session in areas where, if the therapist and patient were to accidentally meet, a polite nonverbal acknowledgment (such as a shrug or a fake smile) would typically be considered sufficient to maintain the alliance while keeping the frame. The accessibility and "speed" of email as a medium of communication can blur the therapist's advantage of simply noticing impulses to communicate outside of therapy hours without acting on them. Similarly, for many patients, establishing a quickly written "intimacy" via email does not align with the contract in personal presence, which can create feelings of awkwardness, inadequacy, or alienation towards the present therapist.

Although the use of email in modern life has been criticized for promoting a lack of intimacy, for example, through the disconnection between neighbors who send an email instead of socializing, the special closeness created by email also raises questions about the spatial boundaries of treatment. In Tips for the Doctor, regarding psychoanalytic treatment (1912), Freud emphasizes the necessity for the patient to accept the arrangement of the psychoanalytic session, in which he lies on the couch, and the therapist is positioned outside of his visual field, somewhere behind the patient. For Freud, who treated the wives and daughters of his friends, this distance seemed to be the minimum space necessary for him to conduct his work. Space matters as part of therapy: calibrating the distance, including the physical space between the patient and the therapist, is crucial for differentiating roles, literally and metaphorically allowing a breathing space in which the patient can remember and respond through other scenarios in which he felt powerless or invaded. Email eludes the social apparatus and gives the impression that thoughts are "sent" from one person to another, perhaps at the cost of a certain reduction in distance and authority.

In describing a phase of the "online disinhibition effect," Suler elaborates on the nature of this intimacy. He portrays a "toxic disinhibition" that can be activated through email or "acting out disgusting needs" exemplified by sending impulsive, angry, or threatening written messages by non-violent users for whom it would be very unlikely to make threats in person (or even over the phone). Suler provides an explanation in which he presents several facets of such disinhibition.

Dissociative autonomy - the username can hide someone's true identity and can therefore eliminate the possibility of a negative concession of an uninhibited email.

Invisibility - even when the identity of the writer is known, they are not physically visible to the recipient and, therefore, are protected from what could be a difficult or embarrassing confrontation.

Asynchronicity - since online messages can be indefinitely ignored, the pressure for an immediate reaction to something said is removed and,

Minimization of status and authority (as discussed above).

These factors in "online disinhibition" are based on that "nowhere" of email, although the user is somewhere, typing a message, there is no established location for the delivery of that message. The other two factors described by Suler that may be particularly relevant to the psychoanalytic implications of email, solipsistic introjections and dissociative imagination, are linked, as we will demonstrate below, to projective identification,

Projective identification is a type of influence exerted by a patient on the analyst in which the patient sees the unbearable aspects of their personality and behavior as belonging to the analyst. As initially described by Melanie Klein and object relations theorists, projective identification differs from transference and simple projection in that projective identification can directly provoke the very behaviors and feelings that the patient has defensively attributed to the analyst. In Love and Hate in the Analytic Setting (1996), Gabbard refers to this intersubjective aspect of the therapist's experience as a "foreign ego force that is felt as particularly unfamiliar."

It would seem then that projective identification can be a force that hinders psychoanalysis, a kind of transfer out of control in which projected feelings return to the patient in the form of self-fulfilling negative prophecies about how therapy will go. But writers like Ogden feel that projective identification and the corresponding introjective identification are important activities for creating what he calls the "third analytic." For Ogden, projective identification and introjective identification involve a process of giving and receiving in which each participant has access to the experience of the other and of themselves, being active and present in therapy. This dialectical process creates a "third something," without which psychoanalysis cannot continue. Introjection in this perspective is the incorporation of a new self-understanding into the beliefs and self-images that have been brought into therapy and engaged both consciously and unconsciously.

In Ogden's view of projective and introjective identification as being important and structured for psychoanalysis and psychodynamic therapy (and not obstructive or undesirable), email can be seen as interfering with this process. Suler's (2004) observations regarding solipsistic introjection and dissociative imagination are particularly relevant. The processes of introjective-projective identification depend on a subtle interaction between what has been said and truly "followed" by the analyst.

In contrast, a solipsistic introjection occurs in the "void" of cyberspace, without real-time interaction and without the objective reality of another person opposing the subjective experience of projections and introjections. Therefore, email can blur the boundaries between one's own thoughts and the thoughts emanating from the Other (the analyst, through the computer screen). As Suler writes:

,,,many people spend this time having conversations in imagination throughout the day. People fantasize about a flirt, argue with the boss, or confront a friend honestly about how they feel…Online text communication can lead to a psychological tapestry introjected in which a person's mind weaves these role-playing games from fantasy, usually unconsciously and with considerable disinhibition.

In the case of more seriously ill patients, this can lead to extremes of derealization and depersonalization, but even in the case of patients with high functioning, email can artificially blur reality and fantasy. It can also give rise to 'dissociative imagination' with a split of a certain aspect of the self that communicates primarily via email. The risk of email stimulating a non-therapeutic regression in both patients with more primitive functioning and those with higher functioning seems to be related to the absence in email of facial indicators and the physical presence of another person, as will be described further.

Facial expressions and email

There is also an extensive area of literature regarding the nature of empathy in psychiatry, and more recently, regarding the neurobiological basis of the emotional bond between therapist and patient. The issue of how empathy with physiological bases can be mediated by the facial expressions of the patient and therapist in relationship to each other is still being explored. Among the many exciting recent discoveries in this field is the description of "mirror neurons." These neurons are part of neural networks activated when a person is asked to evaluate their own emotional state when looking at a facial image or to discern the emotional state of the person represented in the image. Functional investigations through magnetic resonance imaging (fMRI) have measured what appears to be significant overlap in the neuroanatomical regions activated by these seemingly separate tasks. Seeing another person's emotions as facial expressions has certain inextricable and important connections with understanding that person's emotions and one's own. This would certainly be an argument for the central role of face-to-face interactions in psychotherapy, a facet absent from email, which makes email a form of surrogate treatment.

Thanks and email

Silence, like other responses that cannot be put into words, such as laughter, has meanings that go beyond an absence of judgment or reaction - to include expressions of an intangible yet vital solidarity between patient and therapist. A moment of silence from the therapist following a painful revelation is not necessarily an indifferent gesture. Silence can signify and be perceived as an empathetic response - a speaking act that conveys the therapist's deep understanding that nothing can be said that is as important as the patient's own words.

Perhaps especially for patients with religious or spiritual inclinations, silence as a therapeutic intervention can allow for a state of grace - the feeling of being healed, accepted, and above all, being seen. Laughter can have a similar effect, with recent studies suggesting that laughter can confer a sense of being included in a therapeutic alliance, a sense of the analytic space intersecting with the real in a positive way. As Freud highlighted in The Joke and Its Relation to the Unconscious, laughter and the tension of silence, which often precedes it, are both of crucial importance for accessing the unconscious material of psychoanalysis, as important as dreams and in other similar ways. From its description, it does not seem that this process can be separated from creating a moment in time for the treatment hour during which laughter or silence can occur as real-time events versus the symbols “LOL” in the mute, disembodied environment of email.

In psychotherapy, the state of grace can be understood in a different way - in terms of the respect and care demonstrated by acts from the therapist that protect boundaries and show great attention to how to manage closeness and distance. In the discussion of boundaries and physical touch conducted by Gutheil and Gabbard, it is described how a patient's physical advances can be rejected while remaining on safe medico-legal ground.

Persona and email

The concept of persona has been extensively explored in literary theory, from the analysis of the Homeric voice to its use in the modern poetry of Yeats, Eliot, Stevens, and in numerous writings about the 1996 film with psychoanalytic influence by Ingmar Bergman, Persona. Similarly, Jungian thought attributes rich meanings to this word, locating the concept of self in persona as the center of change in psychoanalysis.

In psychiatry, the persona can encompass the following: the patient's perception of the identity and role of the therapist: the tone and words chosen by the therapist, reflecting both the therapist's self-concept and what is awakened in a particular patient, and finally, the therapeutic voice. Role confusion can result from transgressions of physical boundaries, as described above and in the article written by Gutheil and Gabbard, but also from the potentially dangerous fluidity of the 'writer self' manifested through email.

The cohesion and durability of the therapeutic voice that we use here to refer to the distinctive way a clinician expresses their thoughts, gathers information, and, in general, is with the patient can be the most important aspect that makes therapy meaningful for the patient. This element of therapy has often been characterized as style. Hearing the therapeutic voice is part of the mentalization process, part of how a patient in psychotherapy develops an observing self by initially imagining in different scenarios what the therapist would think or say. This is the voice that is mourned when therapy ends. Some therapists are particularly good writers, capable of exercising an unusual ability to control and personalize their voices through the written word, and these therapists may feel that writing an email still allows them to have a distinct voice. However, in these cases, the patient may experience the author's presence as an intrusion into their experience of simply trying to utilize therapy.

Tangibility and email

What do patients do "when they come out of therapy?" Why does grief and a sense of loss accompany almost any ending, regardless of the success or failure of therapy as treatment? The patient cannot be blamed for saying, like Woody Allen, "after thirteen years of analysis, certain characteristics of mine are undoubtedly different now. I was twenty-two when I started, now thirty-five."

The use of email in psychotherapy could arguably short-circuit this question to the detriment of the patient. When they are existentially stuck in a position from which they must individually respond to this question, often through a private relationship about personal growth and change, the tangibility of therapy is controlled by the patient and helps the patient to independently claim whatever has been achieved in the therapeutic activity.

The patient can give any form to the tangible result of therapy. The intangibility of the transaction between the psychotherapist and the patient is further maintained by the exclusion of gifts and services from the therapeutic relationship.

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