Why Your Therapist Will Say the Wrong Thing

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What follows might not be what you want to hear. Therapists don’t talk about it publicly. I hope, however, this gets you thinking about your counselor’s aims, what you might want him to do, and what is reasonable to expect of her or him in the effort to be the best possible healer.

Girl in Therapy recently wrote a post called How Your Therapist Signs Their Emails, reblogged by Life in a Bind with an insightful preface. The gist is captured here:

This thing, let’s call it a pet hate, is email sign-offs. You know the thing people write just before their name? And more specifically, the way my therapist signs off on an email or text.

She “hates” such closings as “kind regards” and “best wishes.” The blogger wants something different from her therapist than the equivalent of “a warmed-up, just vomited fur ball that I’ve stood on in bare feet in the middle of the night.” She is both funny and serious. Sirena (her name) desires the parting portion of a missive to acknowledge the intimacy and importance of the relationship. At least, that’s how her plea sounds to me.

Quite understandable and, based on comments to the two bloggers I mentioned, she has lots of company. The easy “solution” for a shrink called out on this point is to be more creative. Fashioning personal words is simple enough. We can all do with some small tenderness. A thoughtful parting sentiment touches the heart.

The target I want to address, however, is a problem reaching beyond text farewells. Sirena’s concerns lead to the general issue of a therapist’s delicacy in communicating with his client vs. the use of words that cut or fall flat, whether in session or in an email.

The counselor has lots going on in his head, as I wrote in What is Your Therapist Thinking?  He needs to weigh his words and avoid frank episodes of insensitivity. And yet, there are reasons he sometimes misses the mark.

Here’s why: at the same time he is trying to help you he must not be preoccupied with a paralyzing, word-by-word self-analysis of his language. Were he to do everything in his power not to injure you (by an oh-so-careful self-scrutiny) he would risk hurting you by missing a different portion of the overall picture with which you present him. Once bereft of needed spontaneity — a slow, studied, halting treatment would be a bitter masquerade for a proper talking cure.

Self-consciousness psychotherapy by the person guiding it is useless. Your doc couldn’t do his job — the job you want him to do, the job he is trying to do — with this restriction.

Think of a surgeon terrified by a possible slip of the scalpel while he is guiding the knife. Were I his patient I wouldn’t expect ignorance of the worst medical errors, but I’d much prefer him to be “in the zone,” not fraught with the potential for a literally paralyzing surgical mistake. A doctor characterized by calm, focused attention, and control is the person I’d want. This is the reason surgeons don’t operate on their own children. This is why your counselor’s concern for you might, on occasion, seem callous or inattentive. If he were your parent and therapist — both — he’d be an emotional wreck and you’d be the worse for it.

Miedo-ajeno

A  counselor cannot be equally burdened by the anticipated impact of his every word and simultaneously dialed-in to all the other important events happening in session. Put differently, if the surgeon or the therapist is too self-conscious he will not leave you unscathed (pun intended) by an injury much worse than an occasional, temporary hurt feeling caused by an ill-chosen expression.

I am not saying he wants to harm you. Indeed, words matter, as does your safety, but I hope you do not put his office on surveillance by the word police. His care of you and for you cannot be like holding a priceless antique Chinese porcelain doll. If the shrink must maintain perpetual alert over possible injury, he risks infantilizing you.

We all deal with a similar challenge. How much protection should we render in conversation with our friend or neighbor? Can we expect a dinner companion to acknowledge his own tendency to misinterpret or over-think what we’ve  said? Are we alone to blame for misunderstandings?

Most patients make lots of allowance for an occasional undiplomatic comment, to their credit. Were the doctor’s office a place where nothing painful between the shrink and his client occurred, no patient could return to the world ready to thrive. The first step out the door would be like the shock of a newborn’s exit from the womb.

In summary, I’ve tried to explain the following:

  1. The therapist mustn’t steal the patient’s initiative and responsibility for owning his own part in the relationship with a counselor. Yes, sometimes a problem is all the healer’s fault, but not always.
  2. Part of growing, in and out of the treatment room, is learning what’s important, what are the little things, who is your friend (however imperfect), who the enemy, which issues will be resolved if you work at them, and those requiring only patience and time. We all need to do this. I am not immune from the obligation of trying to sift through the events of life and attempting to put everything in the proper cubby-hole, working on a few things that are my issues, setting others aside, ignoring some slights and addressing others.
  3. Whatever your work is, you can paralyze yourself (like the the surgeon I mentioned) by a too constant internal look, especially while you are in the act of performing that work. Remember, even if the therapist utters an ill-considered phrase from time-to-time, in the long run the most important things eventually get addressed by a good practitioner.
  4. If his words bother you, raise the alarm, especially when this is a continuing pattern. What seems obvious to you might not be clear to him. He should want to know of errors and improve himself. Be prepared, however, that whatever you say is potential grist for the treatment mill. Sometimes the issue is his, sometimes yours, and often you are co-owners. The percentages depend on you, him, and your interaction together.

These opinions are mine alone, though I’d guess I’m not the only therapist holding such beliefs.

Hope this helped.

The top image is called Miedo-jeno by RayNata. The photo is Adolescent Sad Girl by stars alive. Each of these is sourced from Wikimedia Commons.

27 thoughts on “Why Your Therapist Will Say the Wrong Thing

  1. Interesting consideration, Dr. Stein. The best form of closing our e-mails can be a source of discomfort in some relationships, such as the case between therapist and patient. Perhaps, we should dispense with closures entirely and just write our name. That, in itself, suggests informality between the two parties.

    I love the Brazilian way: beijos (kisses) and abracos (hugs).

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    • The closings issue reflects the importance of the relationship and the vulnerability of some of those who come for treatment. A question I did not raise is whether an acceptable closing might also become routine over time and thus, once again, not be satisfying. Perhaps another reader who is in therapy and who identifies with Sirena’s concern might address the question. As always, your thoughts are much appreciated, Rosaliene, especially enlightening me about the affectionate Brazilian parting.

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      • The question you didn’t raise is an interesting one, and a post wrote itself in my head while I was in the shower – an excellent place to think, I find! Sadly one can’t just download it and I have no idea if I will remember it (!) but I am hoping to reblog your post this week with a preamble which is a reply giving my thoughts on that question…..I love it when posts spark continuing ‘conversations’ both by comments and by linked posts 🙂

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      • Beethoven always kept a notebook with him to write down musical thoughts as they came to him, in the hope of a future use. The secret to his never losing such inspirations, obviously, is that he didn’t have a shower! 😉 I do appreciate your anticipated reblog and will look forward to your preamble and continued “sparks.”

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  2. Fascinating post Dr. Stein. I also wondered about the importance of boundaries in relation to this issue: what was painful for Sirena was being reminded that she was ‘just a patient’, and actually that is true. I write as both a therapist myself and as someone with a complex trauma history who is in therapy. My previous therapist went out of her way to write warm and affectionate things that soothed me temporarily, but ultimately they could never be ‘enough’, and actually rescuing me from the pain of coming up against the real boundaries of the relationship, having to grieve the real losses they represented and tolerate my anger and pain, was in the longer term unhelpful, and led to the breakdown of the relationship. My current therapist never lets me forget the boundaries, whilst still providing a warm and secure space: I don’t quite know how he does it but it is more painful and simultaneously more helpful. He doesn’t ever let me get lost in the fantasy of being ‘special’, or ‘loved’ or that this relationship is as meaningful to him as it is to me. I am obsessed with him, but he’s at work, and when I am at work myself and in the therapist role I can hold and understand that. My clients matter to me, and i care for them, but I see them looking at me the way I look at him and i just think, ‘i am not the answer, I am not the one who can rescue you, and you are going to hate me when you realise I cannot take away or soothe this pain, all I can do is give you tools and model a secure attachment for you.’ I know how much it hurts, being handed back that responsibility for yourself, but I do believe that it is the pathway to healing, and therapists being too kind and warm can detract from the patient’s journey-the focus becomes too much on the relationship and not on the patient themselves.
    I hope that makes sense!

    Kind regards,

    Pink

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    • It makes wonderful sense, Pink. I couldn’t have said it as well. I think you’ve captured a desperately important aspect of the client/therapist relationship that so many patients struggle with. Thank you for posting this.

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    • I wish it were possible to reblog a comment! This is incredibly helpful Pink and for me personally, comes at exactly the right time. Although these sorts of questions are often in my mind, every so often in my therapy we will reach a point where I really come up hard against the boundaries of therapy because of an almost impossibly strong desire for something (reassurance, some particular words, etc) which feels like it should be obvious or easy for my therapist to provide, and cruel for her not to. It seems self-evident (to me, at those times) that what I feel I need would be immensely helpful and therapeutically beneficial. But her response is such that she _does_ let me come up against those boundaries and it _is_ very painful, and she specifically commented that whatever she provided it would never be enough, and that really resonates with what you have said. But also I have recently realised that I _do_ have a very strong resistance against the ideal of grieving what has not taken place – part of me is still adamant that she can somehow make up for that. She has told me that it is not possible for therapy to do that – that is ‘stands for’ what was lost – which again, chimes with your description of therapy modelling secure attachment. I am slowly starting to think through these issues – in quite an intellectual way at the moment – I want to give myself a framework how how to think about these things, because emotionally, I am still far from accepting that I need to grieve something rather seek to replace it….
      I think the only thing I would say is that I think this approach is compatible with quite a large amount of kindness and warmth (which I’m sure you display to your clients!) and that in a way, a tendency to try and rescue is not the same as simply moving too far along the line of kindness and warmth. One could argue it is not kind to rescue – even if it _seems_ kind to the client. And I may not feel my therapist’s warmth when we are having these hard conversations, but that is more about my perception of her at the time and how difficult I find those things to hear, than about how she genuinely feels about me (which I believe _is_ with a great deal of warmth, and I hear that in her voice sometimes). Of course I take your point about the relationship not being reciprocal – but I am trying to make some room, in a ‘wishful-thinking’ kind of a way, for an element of ‘special-ness’ and a different sort of ‘love’ that doesn’t mark out one particular client in any way above another, but represents a unique kind of relationship that both parties are engaged in, albeit it looks and feels different from either side…..
      Thank you again for your comment, and of course, for Dr Stein’s fantastic post….. 🙂

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      • You and Pink would perhaps make a good public speaking team — no joke. Both of your comments add something that might only arise from a therapist who is also a present client and a client dealing with the issues described by the therapist/client. Thanks again to you both.

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  3. Hi Gerald, I read your post and also the one from girl in therapy. I find it amazing how such little things in the therapy can become so huge in our minds, well at least in mine.
    Im fortunate because my therapist signs off his emails with “take care”, its also the last thing he says before I leave which is a nice thing to say without putting to much strain of the emotional attachment. Another thing I find hard is when he comes to get me from the waiting room to go into his office, is he says a really quick hi and hardly looks at me until he sits in his seat and the session starts, he’s never really changed in three years, even after long breaks, he doesn’t give any bigger smile or say its good to see you. I sometimes think that he could show a bit more warmth in his welcome and be abit more natural after three years. Once our session starts though he gives 100% of his focus. I try not to dwell to much on these little things, I think they can end up being a distraction from the real reason Ive gone to therapy in the first place. I think to it must take a great deal of effort to give that kind a focus to a patient and keep the professional boundaries so as not to harm the client unnecessarily and be warm and empathetic as well. It’s alot for someone to think of but I do believe the caring is real, and the goal of therapy to help get me better and work through my issues is why I am in therapy and I know he gives alot of commitment to that. Every now and then it good to have a bit af a rant and get it off your chest so you can get back to the real work at hand

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    • You seem to have a sensible and forgiving approach to your therapist, Claire. The boundary and reciprocity issues are surely big ones. As Pink points out, “My clients matter to me, and I care for them, but I see them looking at me the way I look at him and i just think, ‘I am not the answer, I am not the one who can rescue you, and you are going to hate me when you realise I cannot take away or soothe this pain, all I can do is give you tools and model a secure attachment for you.’ I know how much it hurts, being handed back that responsibility for yourself, but I do believe that it is the pathway to healing, and therapists being too kind and warm can detract from the patient’s journey-the focus becomes too much on the relationship and not on the patient themselves.”

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  4. My therapist admitted to being curt via email for legal reasons – God forbid he send some intimate reply that breeches confidentiality to the wrong patient. I honestly think the biggest semantic misstep is when you guys call yourselves “shrinks” (hate that term!) because the idea of a head-shrinker likens therapy to voodoo and contributes to an ugly stigma that scares some people away from getting the care they need.

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  5. Guilty as charged. As I reflect on my use of the term, it’s something I almost never used when I was in practice. My use of it comes out of a desire to find another word for therapist in order not to bore the reader and to lighten the mood of some of what I write. Does this scare people away from treatment? I’d be interested to know whether others are also troubled by this.

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    • Troubled? I don’t think it’s that serious. It’s just a word that gets a little nose-crinkle from me, and I think it’s rooted in (rather than contributing to) something that makes people shy away from seeking counseling.

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  6. Dr Stein, just wanted to say I love the new look of your site 🙂 Apologies for not having had the chance to comment etc as fully as I would have liked either in response to this post or indeed to your comments on my own. Therapy recently _has_ been very productive if tumultuous, and it continues to be full-on, coupled with a very full-on time personally and at work. My head is spinning and I’m exhausted! There are lots of conversations I would love to have (and lots of posts waiting to be written!) but whatever is going on, reading your posts is always a joy and is always thought-provoking and enlightening…. 🙂

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  7. Dr. Stein, Like Claire stated above, it is amazing how much weight the small things carry in the therapeutic relationship. As someone with MDD and PTSD, I find my biggest hurdles in therapy, as in life, are establishing trust and safety. I am miserable at leaps of faith, because I expect the worst outcome. Nonetheless, after five+ years, we have come to a shorthand in signing off emails which represents my push to consider both my therapist and his office as my safety bubble, the one place I hope to consider a place to house my demons without me being demonized. So it’s a virtual bubble — (). It is a way to connect and to be reassured on a consistent basis without being overly demonstrative. And this little two piece () bubble is a gift that gives me hope. If that makes any sense. As always, thoroughly enjoy reading your words of wisdom – I learn something from every blog entry, so thanks heaps..

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    • You are very welcome. And, thank you for this ingenious solution to the dilemma you’ve described. Brava to you and your therapist. If he is male, he gets a bravo instead! I’m sensing you are female, but if I’m wrong, both apologies and a second bravo. Best wishes on your continued progress.

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  8. Dr. Stein, Yes I am female and he is male. So you are spot on. With this way of signing off (since we do exchange emails frequently), nothing is ever misconstrued and yet our bond is reinforced with each bubble (). And he has very slowly, through an enormous amount of painstaking work and patience on his part, finally established that his place might be an OK place to heal. We are both so comfortable with this sign off that after all these years, there is no second guessing, at least on this one thing! I am blessed to have found someone who has explicit boundaries but is willing to work with me within those very walls, and is willing to be flexible if need be, without doing damage. I imagine you were much the same in your practice. Thank you again. ()

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  9. Reblogged this on Life in a Bind – BPD and me and commented:
    Last week, I reblogged a post by ‘Girl in Therapy’, on the subject of how therapists sign off their emails. I prefaced the reblog with a few comments about my own experience, and those comments and ‘Girl in Therapy’s’ original post prompted Dr Stein to write the following excellent post, addressing the question from the therapist’s point of view. I think his perspective is incredibly important in helping patients deal with the inevitable – when one’s therapist ends up saying the upsetting, inadvertently careless, or ‘wrong’ thing – because it shows what the price of trying to avoid that inevitability would be; a therapist who is far more preoccupied with what they should be saying, than with what the patient is saying.
    As with many of Dr Stein’s posts, this one generated a number of interesting comments and much helpful discussion. In reply to one of the comments, Dr Stein wrote the following: “A question I did not raise is whether an acceptable closing might also become routine over time and thus, once again, not be satisfying. Perhaps another reader who is in therapy and who identifies with Sirena’s concern might address the question.”
    I wanted to take up this challenge and try and address it, at least from my point of view, because I think it’s an important question to raise, and one which throws further light on why this issue of email sign-offs is a difficult one. I don’t know if ‘Girl in Therapy’ would agree with this point of view, but it seems to me that the difficulty with email sign-offs (whether that is ‘Best wishes’, ‘All the best’, ‘Yours’ etc), is not about whether or not they are satisfying – but whether or not they are jarring.
    If it were about satisfaction – as with many areas in therapy and in my life in general – I suspect it would be a case of ‘never enough’ and that, as Dr Stein has hinted, what was once ‘satisfying’, would become less so after frequent repetition. And it is fairly obvious even if difficult to accept as a client, I think, that what might ‘feel’, on one level, really satisfying – a very personal, ‘chummy’ or loving sign-off – is not possible when it comes to therapy. And so when I discussed this topic with my therapist, I wasn’t thinking about what I wanted her to write, or what would be satisfying for me read; I was concerned only with what I found it uncomfortable to read, and with trying to avoid that discomfort.
    Therefore I think what is more important is what the email sign-off is not – rather than what it is. I don’t think its purpose is necessarily to provoke a positive reaction, but I think it is important that it doesn’t provoke a negative one. A jarring email sign-off is like a session where the therapist has failed to mirror the client, but because of lack of understanding rather than for the therapeutic benefit of providing the client with a different experience to the one they may have been used to.
    Email sign-offs can be jarring for different reasons, in different contexts, and the same sign-off can be jarring in one case, and acceptable in another. Speaking personally, I find ‘Best wishes’ jarring if used by my therapist, because it feels much more formal than is warranted by the therapy relationship (which is intimate), but also because it is very much the language of my working world. Equally however, in most contexts I experience the lack of a formal beginning (e.g. Dear X) and the use of only a name or initial to sign-off, as being quite curt and ‘unfriendly’, even though I know that this is a perfectly standard approach used by a large number of people who certainly do not intend their emails to come across in that way. And so I can accept it at work, but I would still find it difficult to feel ‘cared for’ if a close friend sent me emails in that format.
    And yet I am perfectly happy for my therapist to sign-off emails by using only her name or initial. I recognise that in the absence of a wide choice of other ‘legitimate’ sign-offs, this is a format which does not feel too formal, and does not feel incompatible with a caring therapeutic relationship.
    Coming back to the question of whether repeated use of a particular sign-off would become dissatisfying over time – I think it’s worth bearing in mind that there is much more to an email than the sign-off, and I believe this is another case where the it’s more important to avoid jarring, than to use exactly the ‘right’ words at the end. You can convey particular sympathy and close attention to a distressed client by choosing to sign-off with ‘take care’ at the end of an otherwise brief exchange, rather than the usual ‘see you tomorrow’, for example –but you can equally convey the same sentiment in the body of the email, while leaving the sign-off the same. In such cases I think that it is not that repeated use of the same sign-off becomes dissatisfying, but that it runs the risk of becoming jarring in itself if neither it nor the tone of the substantive email exchange, varies to take account of the where the client is at, emotionally.
    I say all of this, of course, from the position of someone whose therapist varies their sign-offs, and so I am trying to imagine myself into a situation where this was not the case! It’s also worth bearing in mind that in the comment threads on ‘Girl in Therapy’s’ post, my own post, and Dr Stein’s, there are clearly those who very much value consistency in their therapists’ email sign-offs, as it is reassuring and eliminates the temptation to try and read anything into variations. I would imagine that for these individuals, the reassurance persists over time, and does not turn to dissatisfaction –but of course, I could be wrong, and would welcome being corrected if so!

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    • Many thanks for the thoughtful reblog. One thought prompted by your introduction. The chances of being jarred by an email sign off or anything else in the email are (I think) greater because of the format. If someone says something to you as they sit before you, you can take in all the body language and facial expression cues, along with their tone of voice. An email or a text is stripped of all this and the nuance associated with such factors. My guess is, the more emails and texts you have with a therapist the more unhappy a client will be because there will simply be more chances for misinterpretation.

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  10. Boundaries, boundaries, boundaries. That actually is for me the only useful answer to the statement of some patients that their therapist would be signing off emails with the ‘wrong’ ending. I understand the patient should at least be able to establish a bond and a level of trust and understanding with their therapist for him/her to feel secure enough to express him-/herself properly, however, when I see the way patients are hanging onto (every word of) their therapist, I’m shocked. They indeed want to feel special, loved, like a friend, (and I’d almost say reading some comments: like ‘a lover'(?) ) Of course there is the matter of transference that comes into play here too, but still people: your therapist has a life of his/her own too. It’s still a job he/she is fullfilling to make an income, your therapist has many patients and can not be your friend (not to mention that he/she could not take proper distance anymore and treat you with a certain objectivity if he/she would). Your therapist is not listening to you for hours and hours since he/she would love to do so every day without getting paid (still some patients seem to think that email should give instant access to their therapist all day, every day). Imagine if a good amount of work-related clients would send you massive emails every day not paying for your time expecting you to read them completely and respond all the time – outside of work hours?
    I saw an article in which a therapist discussed the many many lengthy emails she would get from her patients. I saw a forum where patients were angrily and desperately discussing how their therapist was not responding to the many massively lengthy emails they were sending. When a therapist had responded in the past and had stopped doing so, patients felt even worse as they felt abandoned. In other words: the therapist would have done better not responding at all in the first place, it appeared to me. Since this email correspondence only seemed to have intensified the dependence of the patient on their therapist. If the therapist would just respond to a lengthy email and personal story with ‘we’ll discuss this next week’ patients felt rejected and not listened to, and so on, which would even motivate episodes of severe depression, anger, etcetera.
    I see a danger in all this email correspondence between therapists (or doctors in general) and patients. (And that is next to the issue of patient confidentiality, or liability if the therapist/doctor would for example make a wrong diagnosis based on information obtained per email). But the biggest issue to me seems boundary crossing that can not only create a strong(er) dependency of the patient on the therapist (the patient starts to believe he/she is really special to the therapist and considers this email correspondence as a confirmation of that), which will result in constant feelings of rejection/abandonment if the therapist can not respond or stops responding or is not responding in a way the patient would want, but such email correspondence could even result in a physical/romantic relationship if the therapist/doctor isn’t cautious enough. That may seem far-fetched, but scientific research indicates too that romantic relationships between patients/doctors regularly started with situations of boundary crossing over email. And the emails a patient sends to his/her therapist must be more personal than any email most patients would send to a doctor in any other speciality. I also say this having been in a (to me traumatizing since it was threatening) physical relationship with my then doctor (not therapist), realizing how easily boundary crossing can/does take place and what it can cause (although this did not start over email). Either way, if I was a therapist, I would ask my secretary to respond to any email and I would absolutely not correspond with any patient per email as it appears to me it creates an obvious dependency and contributes to (what often appears to be unhealthy) attachment. I do not believe this contributes to the treatment of a patient (although there will always be exceptions to that rule, but then read the email, let your secretary respond, use the email content in the sessions you have with the patient, and never respond to email yourself to not cause irrational feelings of bonding, confusion, attachment, feelings of rejection/abandonment, etcetera. Do not take that risk.

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  11. My post, on another note, stems from the fact that after ‘what occured’ I have reflected quite a bit on the theme of boundary crossing. It seemed to me this is such an important theme that is so prevalent in the doctor-patient relationship – without both parties often being aware of it. And it carries so many risks and consequences: for the treatment and health of the patient, the professional life and thus wellbeing of the doctor, etc. Reading the blog of that patient it appears to me she is pressing for intimacy that can result in boundary crossing. Intimacy and expectations that I feel should have no place in a professional therapist(/doctor)-patient relationship. There is on one side the pressing of the patient; on the other side the therapist potentially giving in, bit by bit, to that pressure, and boundaries become more and more blurred. The patient becomes more dependent, more attached, etc. The patient seems to be losing touch with the reality of a normal therapist-patient relationship with a healthy distance when she starts to push for her therapist take note of her email endings and how they should be personalized.
    As I had to continue treatment I resumed treatment with another doctor after what happened. This doctor has the tendency to give long body-to-body hugs, send emails that could certainly give off wrong impressions (and when I saw part of my medical dossier I could see my emailed treatment questions were included, but the sometimes irrelevant and highly personal email responses I would get were cut out of the printed emails – responses that described me as a person, personal questions that were asked to me, statements to “want to do anything” for me and so on). Now I certainly don’t want to suggest this doctor too would do the drastic things my previous doctor did. But I do think, more professionality and better boundaries need to be the base again of the patient-doctor relationship. That doctors (and patients pushing their doctors/therapists for more intimate contact as the girl in her blog is doing) should be more aware of this. I feel email is an important facet in blurring those boundaries. I also think ‘maintaining boundaries’ and to what degree, should be an important aspect of medical schools and training – and yes, also the facet of potential email contact with patients. I saw a therapist discussing how important it is to bring physical touch and hugs back into the patient-doctor relationship. I saw another therapist arguing how he found it unprofessional. I can see how a patient that is in a very painful situation for example, could use a hand on his/her shoulder, but I see no use in blurring boundaries further, but to confuse the patient, create more attachment, with all sorts of consequences, or even making the patient feel uncomfortable, etcetera. This can’t be good for the reputation of the medical profession, the trust the patient needs to be able to put in the doctor, and the overall treatment of the patient. I really hope doctors in general will keep a good understanding and will want to ensure (and even bring back) professionality, proper distance into the doctor-patient relationship. That they will understand that no matter if the patient is pressing for a certain intimacy in email contact as the girl in her blog is doing, and as many patients appear to do when they are angry, upset and frustrated that their therapist doesn’t reply to email or not in the way they want, that the core of the doctor-patient relationship should be based on professionality and a proper distance. Since the patient clearly doesn’t recognize that fact (she is upset already about an email ending after all: what is the next thing she is upset about in this email contact? Likely it would be about the frequency, or the tone of the email, or the warmth of the email, etcetera). Professionality and clear boundaries, and absolutely in the email contact with the patient too.

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  12. drgeraldstein

    Many thanks for these two comments, Odette. Yours is a very rich and thought provoking perspective that adds much to the impact of all the other comments and the essay itself. I’ll add only a couple of things, an that with respect to the email question. If the physician you mentioned included your emails in the medical record and he was based in the USA, I believe he is required to do that. However, I think the same individual needed to include his responses to you, instead of excising them. That he didn’t suggests he knew they were off-base. As to my own use of email, back when I was in practice, I tried to avoid encouraging it, even to the point of listing only my phone number as a way to contact me. Ultimately, some patients did find my email address (or get it from me), but our contacts were limited to making and breaking appointments. I realized some of the dangers you describe, certainly including the amount of time it would take to respond, but also to maximize the chances that my interactions with my patients would be therapeutic and reduce the chances they would be misunderstood. Thanks again.

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  13. Your approach sounds like the most professional and therapeutic approach, that I wish most professionals in the (mental) health field would follow. I’ve been reading quite a bit of anecdotal patiënt perspectives (I guess in an attempt to make some sense of my own past situation). And, albeit based purely on anecdotal material: what seems to be the red thread is that an (ongoing) email contact raises so many expectations with the patient that often ultimately can’t be met, thus raising frustration with the patiënt, and I’m sure also with the therapist since it seems to foster attachment from the patiënt to the therapist and sometimes to great lengths. Admittedly I understand the perspective of the patients better now too. Quite regularly, it appears, patients that tend to search for ways to stay in contact with their therapist per email and/or asking for hugs, touch etcetera, seem to face some form of social isolation and/or to see the therapist as one of the few or even the only supportive persons they have in their social surroundings. Which only illustrates it is often a recipe for disaster. Since any disappointment or when there is a change in email correspondence, if the correspondence is seen as too distant, or if the patiënt now feels deprived from hugs, ofend ends in a painful clash, leaving the patiënt in an even more vulnerable position (feeling rejected/abandoned, sometimes even severely depressed), and often leaving the therapist in a more vulnerable position too. Plus when transference was already present (and in the described situations that is not too unlikely) that can only add to the problem. (Either way, as I had mentioned my current doctor in my previous post, just to clarify: I certainly would never want to accuse my current treating physician of anything similar to what I ran into prior to his treatment.) As mentioned, I just in general feel that keeping proper distance and maintaining boundaries is of importance for the treatment, and the health and wellbeing of both the patiënt and the doctor. And I can’t help but wonder sometimes if the emphasis to keep proper distance and boundaries, also concerning email contact, is an integral part of current studies at schools for medicine. Overall I think your approach with regard to email contact was very sensible and in the best interest of your patients (and yourself). Either way: thank you for this brief moment of reflection.

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    • drgeraldstein

      You are welcome, Odette, and thank you for your carefully considered and we’ll expressed comment. Historically, most therapists had no formal training re: boundaries and communication outside of office hours. Given the lack of agreement among the various counseling professions even concerning the essential elements of preparation for a practicing therapist, it is no wonder there are so many differences in the way calls and emails are handled. I’m afraid the field has a long way to go.

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