When Lindsay, a 26-year-old health-care worker in Queens, started texting with her therapist in 2013, they were both ahead of the curve in terms of using messaging as a therapeutic tool. At first, she would mostly text things she wanted to remember to bring up in the following session, a sort of note to self, with more accountability built in — until 2014 when she became obsessed with a guy who she had her first kiss with at the age of 20. “She let me text her whenever I wanted to text him,” Lindsay tells me. “It really helped with my impulse control.”
Still, Lindsay concedes their casual texting relationship eventually eroded some professional boundaries and she began to see her therapist more as a friend — albeit a very helpful, dependable one. “I once gave her advice about the guy she ended up marrying and moving to California with,” Lindsay laughs, adding that the out-of-state move was what ended their therapeutic relationship, rather than the lack of professionalism. They did, however, have her last session at a restaurant, a meal the therapist paid for. “We definitely toed the line there,” she admits.
All of this may not be that weird by quarantine teletherapy standards in 2020, but texting wasn’t always considered an appropriate form of communication between therapist and client. And in fairness, many clinicians are still divided on the issue. Therapist Erin Cantor says the split is mostly between old-school psychologists who practice more Freudian forms of psychoanalysis and psychodynamic approaches, and new school psychotherapists (namely social workers such as herself) who tend to use cognitive and dialectical behavioral therapy — approaches that are more concerned with harm-reduction strategies and meeting clients where they’re at.
“Most, though not all, clinical social workers are amenable to it since the core of our value system is to be where the client is at,” says Cantor, who mostly treats college students and young adults. A large part of this requires them to adapt to their clients’ favorite forms of communication — namely, texting. Her willingness to do so helps her build “a strong therapeutic alliance.” “The healing in therapy is always in the therapeutic alliance,” she continues. “So the challenge is in weaving the texts into the session and exploring them with the patient together.”
The other challenge is with individuals who demand feedback immediately by barraging Cantor with texts, and who occasionally fire her via text when she won’t engage further or respond right away. She always follows up by stressing the importance of talking about that in person, but it doesn’t always work. Other times, clients will get defensive a few days later when their texts are mentioned in person, and they no longer want to talk about it.
Cantor estimates that the tipping point for when it became okay to text your therapist came around 2015, about a year after the online therapy company Talkspace started offering unlimited text-therapy in 2014. Therapists outside of Talkspace likely adopted it for practical reasons like scheduling and billing, but also to stay competitive with things like Talkspace.
Unfortunately, within two years, Talkspace had become plagued with privacy issues. Former clients, therapists and Talkspace employees have accused the company of both data mining and sharing transcripts of confidential text sessions internally — despite advertising that it employed “banking-grade encryption” to maintain privacy. And therapists outside of Talkspace acknowledge that even with burner phones and HIPAA-compliant messaging services like Spruce, text-therapy is never 100 percent secure.
“Texting isn’t confidential or digitally secure, anyone can see a clinician’s iPhone,” Cantor warns. For this reason, she doesn’t discourage her clients to text her, but she makes it clear from their first appointment that she will never provide therapy through text, meaning zero reflective listening, emotional interviewing or any other therapeutic strategies via text.
The one exception is assessing those in crisis, specifically people in danger of overdose, self-harm and suicidal behaviors. When going over the parameters for texting, Cantor tells her clients that if they’re in crisis and need a call back, they need to clearly state that in the initial text so there’s no miscommunication in an emergency. Many suicide hotlines have started introducing a text option for the same life-saving reason, but any therapy outside of that would breach the trust Cantor works hard to build. “Unless a client is a danger to themselves or others, it’s a sacrosanct relationship and no one knows about it or what is said,” Cantor stresses. “Texting isn’t treatment; it’s an accessory to it. When therapists start to engage in anything resembling therapy or treatment via text, they’re violating a client’s boundaries.”
Boundaries have a tendency to get blurred in the intensely emotional process of therapy anyway. In fact, unknowingly projecting onto a therapist complicated feelings for a family member or romantic partner is so common that there’s a psychological term for it — transference (or countertransference when therapists reciprocate). In some cases, texting can make these breaches more subtle and difficult to spot — like Lindsay and her therapist treating each other like gal pals — but not inconsequential. Lindsay doesn’t think their texting was harmful; if anything, she regards this therapist as the best she’s ever had. Still, she admits that holding future therapists to the same standard has left her somewhat disappointed. “There’s a messaging system with my current therapist, but she’s too professional sounding on it, so I avoid using it,” Lindsay tells me.
In some cases, blurred boundaries can become predatory, especially when transference and countertransference turns sexual. (One survey found that as many as 87 percent of therapists admit to being sexually attracted to their clients, and anywhere from 2 to 10 percent of them actually make a move.) And for Michael, a 25-year-old photographer in San Diego, there was an extra fine line between texting and sexting with his therapist. “He was getting in my texts like he was a best friend,” Michael says. “I thought, ‘Oh cool! Free bonus therapy.’ Next thing I knew, he showed up at my home one morning hours before an appointment demanding I get in his car, where he tried to get frisky.”
In the moment, Michael stated he was uncomfortable with anything that resembled therapy in the car, not to mention his therapist’s hand on his thigh, and exited the vehicle. Afterwards, he received a text from his therapist, stating that because he was unwilling to “go with the program” that their work wouldn’t be effective, and therefore, needed to end. Michael reported the therapist to the local service that referred him, but “the person basically said, ‘It’s only natural to not jive with every therapist. We’re glad you’re making the effort to try different therapists.’ I should’ve reported it further to the licensing board, but I decided to just move on,” Michael tells me.
In retrospect, the big red flag was that his therapist initiated the texting, which Cantor says, outside of scheduling, professionals should never do. While the traumatizing incident didn’t turn him against therapy completely, Michael refuses to engage in anything resembling a texting relationship with a therapist again. “Even in the world of teletherapy and Zoom, the goal is to get those bits of guidance at the time slot scheduled,” he says. “Anything outside of that, you should exercise caution.”
His, of course, is an extreme case. But it’s also a good reminder of how quickly a text exchange/relationship can turn — and how sometimes it might be best to text a friend instead. Besides, a true pal will remind you to bring up whatever was bothering you at your next therapy session anyway.