Psych jargon as media hype

To be heard over today’s cacophony of voices, one needs a hook: a meme, a viral photo, a catchy phrase, a juicy zinger, a sound bite.  Speakers soon learn that overstimulated, desensitized attention spans require more and more goosing.  Some call this the attention economy feeding our dopamine addiction.  To others it has a simpler name: hype.

Jessica Bennett presents the problem very cogently in a recent New York Times guest essay.  She focuses on a particular strategy: hyping all setbacks or frustrations as “trauma,” and hyping every offense as “abuse” or “gaslighting.”

It’s an excellent essay and certainly worth reading.  But the phenomenon goes well beyond Bennett’s many examples of clinical terms that pathologize the actions of others.

Poisoning the well

Pathologizing the others themselves has an even longer history.  For one thing, it led to the 1973 Goldwater Rule, which (still) forbids members of the American Psychiatric Association from offering psychiatric opinions about public figures.  The APA created this rule because in 1964 a provocateur magazine publisher persuaded nearly 1200 American psychiatrists to wield psychiatric concepts as weapons to attack presidential candidate Barry Goldwater.

According to these doctors, Senator Goldwater didn’t merely hold offensive political views.  He was “schizophrenic,” a “megalomaniac,” and plenty of other bad names casually borrowed from the professional literature.  Since this flood of pseudoscience reflected more poorly on the psychiatrists than on Goldwater himself — Goldwater won a defamation lawsuit against the publisher — the APA established the rule to save its members from further embarrassing themselves and their profession.

A tool (that seemed) too handy to set aside

Few challenged this prohibition in the 42 years before Donald Trump’s presidential run.  Then it suddenly became important among certain mental health professionals not merely to slam Trump’s politics, values, and attitudes, but to declare them the product of a sick mind.

Alleging psychopathology, especially by credentialed experts, often proves a more powerful weapon than simple disagreement.  In this case, however, it wasn’t powerful at all.  Preaching to the choir about Trump’s mental ills merely invited counter-pathologizing of Trump’s opponents — clearly not what these authors had in mind.

Of course, amplifying disapproval by adding psych jargon doesn’t require a mental health professional.  (Nor is such jargon always, or mainly, critical.  Therapy-speak is rampant for all kinds of reasons.)  Historically, evildoers have been “monsters” — the word originally meant an infant born with birth defects, believe it or not — or “madmen.”  Now reprehensible people are “narcissists” or “sociopaths,” especially on social media.  They “gaslight,” “abuse,” and “love-bomb” the innocent.  As Bennett writes, it’s a lot more powerful to call someone an abuser than to admit they hurt your feelings.

Winning by losing

A few years ago I wrote about “onedownmanship” — oneupmanship in reverse — as a method to win arguments by positioning oneself as the more victimized party.  Just as social media algorithms guide users to more and more extreme content, our victimization “race to the bottom” rewards greater hurt with greater attention and legitimacy.

Saying this risks blaming the victim.  Indeed, many commenters assailed my post where I held that “psychopath” often serves as a vague epithet of disapproval.  They said my view was “gaslighting,” and at least one suggested I might be a psychopath myself.  (Psychology Today has since removed comments from all posts.)  In other words, unhappy commenters employed popular pathologizing terms to discredit me for failing to honor the terms of their victimhood.

I do not mean to blame victims.  Nor do I believe rhetorical misuse of psych jargon is premeditated or intentionally manipulative.  I’m sure it feels self-justifying.  And it simply works as a way to get one’s point across, to be heard above the din.  That’s why people use it.

Why not use psych jargon as hype?

Nonetheless, drawbacks abound.  Pathologizing others in public discourse is essentially an ad hominem argument, a logical fallacy.  Popular terms such as “abuser” (and “racist” and “snowflake”) are personal putdowns, not valid arguments.

Psychiatric labels compound the problem by linking destructive stereotypes to named disorders.  Whether Donald Trump is a malignant narcissist matters less than continual cultural reminders that narcissists are dangerous, “toxic” people we need to beware and avoid.

Using psych jargon as hype also cheapens these otherwise useful terms (see “trauma creep”).  If everyone who feels down or disappointed is “depressed,” how do we describe those who ponder suicide all day and haven’t showered in weeks?  If a bad date is “traumatic,” what term do we use when someone is critically injured in a terrorist attack?

Don’t hate the player, hate the game

In a noisy restaurant (remember those?) everyone speaks louder to be heard.  Yet this adds to the noise that all must speak over — a vicious cycle.  The cacophony is no one’s fault, but everyone’s doing.  Likewise, if it takes psych jargon and similar hype to attract an empathic public, can we blame those who use it?  We can’t.  The hype is no one’s fault, but everyone’s doing.

Fortunately, both situations eventually self-correct.  Diners learn that a noisy restaurant is not a good place for serious conversation.  They go elsewhere for earnest talk, and as a side-effect they stop feeding the vicious cycle.  In like fashion, eventually we’ll realize that overstated language conveys less information, not more.

Hype, of the psych-speak variety and otherwise, will one day strike us as florid, perhaps foppish, and in any case less compelling.  It will self-correct.  We can hasten that day by noting when rhetoric is inflated for effect.  Is frustration or disappointment really “trauma?”  Is an isolated act of disrespect “abuse?” Does all misbehavior reflect a psychiatric condition?  Only if we say so.

Photo by Verena Yunita Yapi on Unsplash

“Being with” patients in the office and online

A natural experiment

Which is better: psychotherapy using video, or in person while wearing masks?

At the very start of the pandemic last year, I met with a couple of patients in the office while we wore masks.  Based on that limited experience, I quickly concluded that seeing each other’s faces, even if over video, was of paramount importance.  That, plus the infection risk, led me to close my office to in-person appointments.  For more than a year I exclusively conducted my practice by video (mostly) and over the phone (occasionally).  Even though phone calls preclude seeing faces, they seemed no worse in that respect than a masked office visit.

A few months ago I reopened my office to vaccinated patients, and saw them without masks.  Most of those who were eligible returned to the office; a minority did not.  I didn’t conduct a survey, but it seemed clear that those who remained online did so for practical reasons, i.e., time or distance, not because they felt it was more clinically beneficial.

For me, meeting again with patients in the office felt like the good old days.  I sometimes joked that it was “3-D,” not on a screen.  Indeed, I was occasionally struck by how much “presence in the room” mattered.  Being with another person in the same space is a different experience. Among other things, it connotes intimacy and privacy.  My hybrid (in person and online) practice persisted out of necessity — not because the options were interchangeable.

Unfortunately, the coronavirus Delta variant recently added another twist.  Just this past week, San Francisco and surrounding counties mandated indoor masking in public places, for the vaccinated and unvaccinated alike.

I support this new public health law, which aims not only to protect the unvaccinated from severe disease and death, but also to decrease asymptomatic spread by everyone.  This, in turn, decreases the risk of new, perhaps more deadly variants.  So this past week my in-person sessions have been masked.  These switches — from a year of video, to a few months of in-person unmasked, and now to in-person masked — create a natural experiment, allowing my patients and me to compare these situations.

Face to face is better, even masked

Somewhat to my surprise, and in contrast to my quick impression back in March 2020, I find masked, in-person encounters more engaging, real, and human than the video alternative.  Even with masks, it is still “3-D.”  There are no technical glitches.  We are still in a room together.  I also asked those who came to the office whether, given the masks, they’d rather return to video.  The results were nearly unanimous: they preferred meeting in person with masks to mask-free video sessions.

The only possible exceptions were two patients who refused to don masks last week despite the new law, and despite my advising them to do so.  (I wore one but they didn’t.  I didn’t insist, as it didn’t feel acutely dangerous to either of us, and I considered their refusal a clinical issue, perhaps to resolve with time.)  One such patient had met with me by phone only this past year; the other shunned remote sessions and had not met with me at all.  It thus seems fair to conclude that not a single vaccinated person who opted to see me in the office would choose video instead, simply to avoid masks. 

This was all something of a revelation.  I had assumed that seeing a person’s face is a central ingredient of psychotherapy:  I read my patient’s subtle emotional expressions, he or she reads my attention and caring.  This may be less crucial than I thought.  Instead, physical presence is more important.

Being with each other in therapy

Being with each other is a subtle but crucial matter in psychotherapy.  In the traditional office setting, being with goes well beyond simple physical proximity.  It also includes attentional focus, emotional attunement, mirroring, empathy, and other relational nuances.  But physical presence is foundational.

Granted, there is also a sense of presence (“telepresence”) over video or telephone when the medium falls away, i.e., when we can ignore it.  At such times our attention, attunement, and similar factors determine whether we are being with the patient.  But telepresence is transient.  As soon as the video lags, the audio is garbled, or we simply become aware of missing information we would have had in person, we become conscious of separation.  Our attention momentarily turns to the technology, or to the intellectual challenge of inferring from limited, noisy data.  We are no longer being with the patient.

As technology improves, telepresence presumably will as well.  Perhaps someday there will be no distinction between being with someone in the same room, or halfway around the world.  However, for now, and for most of the patients in my practice, in-person presence is even more significant than seeing each other’s faces.  That says a lot.

Photo by Thought Catalog on Unsplash

Retronyms, teletherapy, and implicit bias

What is a retronym?

 Retronyms are adjectival qualifiers, like “acoustic” guitar and “snail” mail, that were previously unneeded — because all guitars were acoustic and all mail was slow.  We only added qualifiers when alternatives arose.  As these two examples illustrate, retronyms can be nearly neutral — the status and popularity of acoustic and electric guitars are roughly equal — or plainly judgmental.  Snail mail is explicitly inferior to faster email. “Snail” is not a neutral term.

Psychotherapy conventionally occurred between two people in one physical room.  Although teletherapy — psychotherapy conducted over telephone or video — is not new, it was previously a special case.  As such, it required specification while regular therapy did not.  Consider an analogy with “skateboard”: without a qualifier, the word clearly refers to the kind operated by foot power.  An electric skateboard is an innovation that must be specified.

However, as alternatives become more established, we often employ retronyms.  In contrast to “skateboard,” it is less clear what we mean by “scooter.”  There are kick scooters, electric and gas scooters, even “stand up” scooters in contrast to those with seats.   Now we routinely disambiguate the word “scooter” by specifying which kind.  Likewise, the growing popularity of teletherapy, which was greatly accelerated by the pandemic, now compels many of us to disambiguate “psychotherapy” with a retronym.

 Which words should we use to describe these alternatives?  And what do our word choices imply about how we judge each alternative’s quality, desirability, and legitimacy?

How do we feel about teletherapy?

When it comes to psychotherapy, many argue for value-neutral contrasts such as “onsite” versus “online,” terms carefully chosen not to telegraph a preference.  In particular, “online” therapy avoids the implicit negative bias in alternatives like “remote” or “distance” therapy.

But using “onsite” as a retronym levels the playing field awkwardly and artificially.  “Onsite” obscures real differences between talking face-to-face with another live person in the same room, versus through screens and microphones.  (And technically speaking, therapy could be onsite and online at the same time, say in adjoining rooms connected electronically.)  Even an alternative such as “unmediated,” which more accurately contrasts the two options, tiptoes around the essential differences between them.  We’d be more honest simply sticking with “in person” despite its positive emotional bias.  Or we could use no qualifier at all, and rely on the assumption that psychotherapy is in person unless otherwise specified.

Expressing honest values is not a hard-sell

It’s nearly impossible to scrub value judgments from natural language.  If a term doesn’t already come with an explicit value judgment, it often develops one over time.  “Juvenile delinquent” and “mentally retarded” were both introduced to replace prior stigmatizing terms — and then became stigmatizing themselves.  In similar fashion, the fortune of “online therapy” as a term will rise or fall depending on how the public comes to feel about the practice.  Meanwhile, “in person” or “face to face” therapy sounds superior because intimacy is inherently good, especially in a healing context.  No linguistic contortion can change that.

Of course, there are competing goods.  “New, improved” teletherapy also sounds attractive, as does teletherapy that is “economical,” “accessible,” or “hassle free.”  Descriptions of therapy from any angle can sound like an advertising pitch.  As healing professionals, we walk an ethical tightrope between presenting alternatives realistically, even though this reveals our values and biases, versus crudely touting our own approach and denigrating others’.

Face to face therapy is different

In walking this ethical tightrope, some try too hard to be carefully neutral.  The result is dry and unrealistic.  The essential difference in the two types of therapy is not that one is onsite or even unmediated.  It’s the difference between talking to a person and talking online to a person.  

Subjectively, we all know these are quite different experiences.  Moreover, barring practical considerations, the former is usually preferred. When family members meet on Zoom or FaceTime, they typically look forward with anticipation to their next meeting in person (or reminisce about past such meetings).  The reverse is not true.  When family members meet in person, they do not typically look forward with anticipation to their next virtual encounter.  This asymmetry holds in other relationships as well, e.g., in business and romance.

Note that humans have been talking to one another for decades using telephones, and more recently computers.  Yet we often don’t employ a retronym to disambiguate “talking” when we mean in person, face to face — the original kind of talking.  “I talked to Mary” is usually clarified by context, e.g., where Mary is located, not by an adjective.  By extension, “I had a therapy session with Mary” naturally connotes doing so in person, unless the context suggests otherwise.  The choice to use (or not use) a retronym is essentially a political act: a way to grant or deny status to the new, as compared to what came before.

This isn’t going away

Looking to the future, we may someday feel pressure to specify “human” therapy in order to distinguish it from computer-generated “AI” therapy. This pressure will come from those who aim to grant AI therapy a legitimacy comparable to the human default. Advocates may even complain that “human” is unfairly positive, and suggest something more neutral.

Does “human” carry positive connotations, an implicit bias?  Of course it does.  This is inevitable — and it stands in clear contrast to putting our thumb on the scale with terms like “meatware therapy” (to denigrate the traditional type, see “snail mail”) or “inhuman therapy” (to denigrate the new type, see “junk food”).  Sometimes accurate descriptors such as “human” or “in person” sound more attractive because they really are — if we choose to use them at all.

 Image courtesy of zirconicusso at

COVID Hysteresis

Caught your attention, eh? Am I calling some political group — anti-vaxxers, anti-maskers — hysterical? What a crude charge for a psychiatrist to make, not to mention sexist!

Hang on. “Hysteresis” has nothing to do with hysteria. It’s a term from cybernetics that describes a lag in a system’s response to a change in input. A simple example is a home thermostat. Change the setting and it takes time for the house to heat up or cool down to that temperature. The system has a built-in lag.

Psychological hysteresis

While pandemic lockdown in the spring of 2020 occurred quickly, it took time for most of us to adapt to the new normal. We gradually found ways to live our lives. Even greater hysteresis is occurring now as restrictions are lifted, especially for the fully vaccinated. Here in San Francisco, where well over half of adults are fully vaccinated, most still walk outside wearing masks, weeks after the Centers for Disease Control (CDC) declared it unnecessary. Many hesitate to eat inside restaurants, visit gyms, or attend indoor concerts, even though health authorities now consider these safe.

There are many ways to characterize this widely-reported lag: anxiety, inertia, better safe than sorry, feeling socially “rusty,” and so forth. Psychological hysteresis usually goes by other names, because we have fuller accounts than a simple cybernetic description. For example, we all know that, in general, feeling unsafe happens much faster than feeling safe again. Sudden danger, such as news of a new, lethal virus, instantly erases our sense of safety and trust. Regaining that sense of safety takes a long time. Some now declare it will take forever.

Peer pressure (social learning theory) matters too. A critical mass of early adopters must perform a new behavior before others feel comfortable doing so. It’s harder to go mask-less when in the minority, harder to resume indoor activities when friends and family are still avoiding them.

What it means about us

And then there’s self-image. Many blue-state residents strictly followed pandemic guidelines this past year, and took pride in our self-sacrifice on behalf of larger society. Diligent masking and social distancing meant something about us. At times this took the form of virtue signaling, a kind of “safety theater” that telegraphs certain attitudes to oneself and others without really enhancing safety. Wearing a mask while driving alone or walking down a deserted street serves no practical purpose. But it may serve a symbolic purpose for the wearer by reinforcing self-identity and self-esteem.

With newly relaxed guidelines from the CDC, the symbolism of wearing or not wearing a mask is muddled. When we pass a masked person on the sidewalk, we can no longer tell virtue signaling from (undue?) anxiety. When we pass unmasked persons, we can no longer know if they carefully follow the latest guidelines or have been spitefully flouting them all along. A similar, more subtle confusion occurs in each of us as well. What are our true motives? Fear? Defiance? False bravado? Rational assessment? Obsessive concern? This is uncharted territory. None of us fully know ourselves.

Adopting a new normal

We cannot live as though COVID-19 never happened. The pandemic changed our work habits, our use of teleconferencing, our personal and business relationships, our attitude toward contagious viruses. Living through any routine year subtly changes us, so it’s no surprise that the past momentous year has done so. All the same, the best medical minds now say vaccinated people can do almost everything we could before — without masks, without social distancing, without worry. The hysteresis is in our heads, and we will overcome it as fast as our sense of safety allows.

Returning to the office

I finally returned to my office after a year and a month. Or more accurately, since I was in my office all along making video calls, it’s some of my patients who returned.

Two weeks ago the CDC issued new guidelines: people vaccinated against COVID-19 can meet safely inside without masks. The guidelines appear aimed at social occasions like dinner parties, not psychiatric practices. But after reading them I no longer felt limited to offering virtual treatment.

The mechanics

To be clear, I am fully vaccinated, and this only applies to patients who are too. I continue to see the unvaccinated virtually. And for now at least, it’s voluntary. I don’t insist that anyone return to the office if they prefer video.

I developed standards: This is not for anyone who has a high-risk person in their family/pod. I run an exhaust fan in the office. I open the windows in the waiting room and bathroom. For new patients, I ask to see their vaccine card, and I show them mine.

I have rules: Do not come to the office if you feel sick. Don’t bring anyone along, e.g., to sit in the waiting room. Wear your mask in the building until we are in my office.

And then we meet without masks in the office. I don’t disinfect surfaces. It’s pretty much like 2019.

Issues I considered

Is it discriminatory to see only the vaccinated in person? I decided it’s okay. Vaccination status is not a protected class. I already discriminate against would-be patients who seek psychiatric services I’d rather not provide, and sometimes for other reasons. Presumably it’s stickier for a publicly funded mental health clinic; fortunately not my situation. I see no reason to deny the option to some, just because others can’t (yet) partake of it.

I also decided not to exclude vaccinated folks with riskier lifestyles. For example, those who work directly with COVID patients themselves, or who sometimes ignore social distancing rules. The CDC made no such distinctions in its guidelines. Also, I’d have to make difficult judgments of risk, not a role I want.

I ask patients to choose either video or in-person appointments, not to switch back and forth haphazardly without discussion. I consider this a “frame issue,” that is, part of the consistent structure of therapy that makes it safe to feel vulnerable. (Similar frame issues include keeping sessions the same length, not varying the fee, and not shocking the patient with sudden changes in the tone or setting of treatment.) I still invite a rare phone or video session for extenuating circumstances, as I did before the pandemic. And while it hasn’t happened yet, I’d permit a rare in-person session for a vaccinated person who usually meets with me remotely.

The future

I anticipate most of my existing patients will eventually return to in-person treatment, which I’ve always believed is superior to virtual alternatives. However, some can’t. During the pandemic I began seeing a few people who live very far away. It isn’t practical to meet in person. If for no other reason, my practice will indefinitely remain a mixture of in-person and virtual.

And some can return but won’t. A few vaccinated patients recently told me they prefer meeting by video even though they could, and in some cases formerly did, come to the office. As mentioned above, I haven’t insisted they make office appointments. I’m not sure I ever will. But their refusal confirms a concern I expressed almost exactly a year ago, that some will find the compromises made for the pandemic attractive, and they won’t want to give them up.

My thinking has lately evolved on this point. The problem is not that virtual convenience is inherently bad. Some people, e.g., busy single parents, might not pursue treatment at all without a virtual option. There are situations where virtual treatment is needed, and many more where it’s a sensible choice. What’s bad is ignoring the trade-offs.

At some level, I find it hard to believe that anyone seriously doubts the superiority of in-person psychiatric treatment or psychotherapy. Those who can come to the office without undue hardship enjoy the “full-bandwidth” experience: in 3-D, with nary a video lag or audio malfunction. Subtle nonverbal cues and transient facial expressions carry important meaning. There’s a “presence” lacking in mediated communication. It’s simply a more real human relationship.

Closing the virtual door

And that’s why I made my biggest decision: I’m not taking on any more virtual patients, vaccinated or not. Many individual clinicians, not to mention startups that aggregate therapists into rows of pretty headshots on their websites, already supply the video option. More of them pop up online every day. As in fine dining versus fast food, the discerning will value quality over convenience. Granted, there’s a time for convenience: a difficult individual circumstance here, a worldwide pandemic there. We’ve all had to live on convenience food, and convenience treatment, for the past year. Now it’s time, for those who can, to improve their diet.

Photo by Daniel Schludi on Unsplash

Does psychiatry add to political discourse?

Quick, grab a weapon!

Millions of alarmed Americans, and people the world over, grabbed the nearest bludgeon to fend off the Trump presidency. They reached for anything handy: street marches, sympathetic pundits, counter-tweets, progressive infotainment, social media. Unfortunately, most of these reactions only fed a vicious cycle of attack and counter-attack.

For the relatively few psychiatrists and other mental health professionals who took up arms, the bludgeon readily at hand was psychiatric diagnosis and a self-proclaimed “duty to warn.” Hastily written petitions and books preached to the choir. If you already knew Trump was disturbed, here was confirmation by experts.

The converse was also true. If you believed the left played underhanded tricks to disempower a democratically elected President, these statements were your proof as well. Condemnation of Trump by woolly-headed liberal therapists was hardly news. It simply confirmed that educated elites are not above it all. We merely chant our political slogans in fancier language.

The warrior psychiatrist

A prominent voice in this chant was Bandy X. Lee MD, a psychiatrist affiliated with Yale University who helped organize a small conference to discuss Trump’s mental state — the “Duty to Warn” conference — and who later authored the bestseller, The Dangerous Case of Donald Trump: 27 Psychiatrists and Mental Health Experts Assess a President (Thomas Dunne Books, 2017). Dr. Lee published an expanded edition in 2019, and another book about Trump in 2020.

Positions like Dr. Lee’s led to wide debate over the “Goldwater Rule” of the American Psychiatric Association (APA). This ethical standard prohibits APA members from issuing a professional opinion about a public figure’s condition unless the psychiatrist has conducted an examination “and has been granted proper authorization for such a statement.” During the Trump administration the APA defended this standard, while others, including Dr. Lee, held that a duty to warn the public superseded it.

In reality, most of the debate over the Goldwater Rule was moot. The Rule only applies to members of the APA. Dr. Lee is not a member. Nor, of course, are the vast majority of mental health professionals who are not psychiatrists. The ethical standard of a voluntary membership organization is hardly the “gag rule” Dr. Lee and others claimed.

No constitutional right to teach at Yale

However, other “gag rules” hit closer to home. As reported this week in the New York Times, Yale canceled Dr. Lee’s volunteer faculty position last year after colleagues warned that her public statements called into question her “clinical judgment and professionalism.” Dr. Lee then sued Yale, alleging that her dismissal violated her First Amendment rights and impinged on her academic freedom.

The courts will decide the merits of her case. However, on the face of it, Yale has not prevented Dr. Lee from writing or speaking. The First Amendment protects speech from government restriction, not from deplatforming by a private university. Indeed, Yale has countervailing First Amendment rights of its own.

It is also worth emphasizing that Dr. Lee had a non-tenure, volunteer faculty teaching position. I have held such positions myself throughout my career. A psychiatry department’s decision to use or not use someone to teach trainees often boils down to subjective personality factors. If an instructor has an “agenda,” or brings unwanted controversy to the department, that alone may be enough to end the affiliation.

Do we help or hurt?

The bigger question, which goes well beyond Yale’s choice of teaching faculty or a rule for APA members, is whether academically-toned denunciations of political figures by mental health professionals add anything to political discourse.

The practical implications seem quite limited. Dr. Lee’s books didn’t move the needle. They merely fed the the cycle of attack and counter-attack. Trump’s critics and supporters alike found confirmation of their prejudices. Moreover, Americans were again reminded that our means of removing a sitting president — impeachment and invoking the 25th Amendment — are political acts, not governed by medical or psychiatric wisdom. Diagnosis is a sharp instrument for helping patients, but at best a blunt weapon in politics.

Psychiatric outcry can do very little, whether in the court of public opinion or the actual machinations of government. Ours is one small voice in a sea of voices, all clamoring to be heard.

Risk of self-harm

Meanwhile, there’s a real risk of self-harm to the mental health professions. When we make dubious claims to authority, we appear smaller not larger. When we trade professional integrity for momentary media coverage, the whole field suffers.

Worse, we may unwittingly invite a dystopia where all political factions deploy mental health experts to declare their opponents unfit. A cacophony of warnings to shun the allegedly unbalanced — the very thing misguided psychiatrists did to Senator Goldwater in 1964 — bodes poorly for a democratic process premised on voters making independent assessments of character. Such warnings are also the very definition of an ad hominem attack. Little surprise Yale drew the line.

Image courtesy of bplanet at

HIPAA-compliant email: a review

The problem

In the months since the COVID-19 pandemic forced me to practice by video and phone, I’ve exchanged much more email with patients than I did before. Previously, I discouraged email from patients. For one thing, I knew it was an insecure channel, not “HIPAA-compliant.” It’s also somewhat less personal than a phone call. But starting last March I gave patients my work email, which they needed in order to connect to my video link (usually for sessions. Most also use it to pay me online. Perhaps inevitably, email has become the most convenient way to send short messages back and forth, mostly medication refill requests and appointment confirmations or changes.

Due to the pandemic, I also linked an online version of my intake form to the front page of my website, so new patients could complete it remotely. The completed form was transmitted to me by non-secure email as well.

As the months dragged on, I realized I needed to treat all this electronic communication more carefully. I started researching secure email designed for medical practices. Below I’ll tell you what I found.

What is HIPAA-compliant email?

But first, a brief dive into terminology. HIPAA, short for the Health Insurance Portability and Accountability Act of 1996, is a federal statute that, among other things, regulates the secure sharing of medical information, especially electronically. Those of us who traffic in “protected health information” (PHI) — “covered entities” such as doctors, hospitals, clinical laboratories, insurance companies, and others — must store and transmit PHI in secure ways. We also sign “business associate agreements” (BAAs) with each other. A BAA is basically a contract that says covered entities will only share PHI with other covered entities.

While many people assume HIPAA exists to assure privacy, the law actually arose to facilitate electronic information exchange, often without the patient’s explicit consent. For example, HIPAA allows behind-the-scenes sharing of PHI to “coordinate care.” But for purposes of this review, I’ll focus on the privacy safeguards, not the many other parts of HIPAA.

To be HIPAA-compliant, email must be protected at both ends, e.g., with passwords, and engineered to prevent interception and reading en route. Technically, HIPAA does not demand that email be encrypted (translated into unreadable code), although that is typically the strategy used. The email provider and the covered entity using that provider should sign a BAA.

Regular email, in contrast, isn’t designed to be secure. Messages are copied in readable form from one internet node to the next. Bad actors can intercept them along the way.

What I found

So who offers HIPAA-compliant email? One option are companies that provide complete electronic practice management systems. These typically include secure messaging with patients as part of their larger range of services. I didn’t deeply research this, as I’m not in the market for such a system. Using one solely for secure messaging seemed too expensive, unwieldy, or both. But I did briefly look into ChARM EHR and Luminello, both of which include secure communication with patients, and offer a free version with limited features to try out. ChARM is designed for all types of small medical practices, not just mental health, while Luminello is for mental health only, including non-medical therapists and “wellness clinicians.” Perhaps thanks to its specificity, I found Luminello much more user-friendly; I’d seriously consider it if I were in the market.

But I’m not, so I turned to free-standing email services.

Best I can tell, all HIPAA-compliant email is actually webmail. That is, the recipient receives a regular email with a link to a secure website to pick up the message.  Services differ with respect to email storage, often 1 to 5 gb; ways that non-subscribers, e.g., patients and potential patients, can reach you securely; whether you can use an existing email address versus having to get a new one; and whether you can choose an email address from a website domain you own (e.g.,  All include a BAA.

Several companies provide secure email to larger clinics with multiple clinicians, administrative staff, and maybe a dedicated IT person. They usually charge monthly fees to match. That’s not my situation, and I do not review them here. Instead, here are a few sized for the solo practitioner:

Hushmail for Healthcare ( – $109/yr:
Pros: Secure forms submission, with two nicely customizable forms at the above price. 10 gb storage. Can use your own domain for email.
Cons: Can’t use an existing email address in a domain you don’t own (e.g., gmail, hotmail, yahoo, etc).  The price doubles for more forms.

MailHippo ( – $60/yr:
Pros: Arguably slightly stronger encryption than Hushmail (AES 256 bit versus OpenPGP).  Can recall an email message, for example if addressed incorrectly.  Uses your existing email address.  Includes a personal URL so anyone can send you a secure email; adding this URL to your website, or to your signature at the bottom of regular email, invites secure messages from others.
Cons: No forms.

MD OfficeMail ( – $23/yr with their email address, $32/yr with your own
Pros: Cheapest paid HIPAA-compliant email I could find.  Includes a personal URL so anyone can send you a secure email.
Cons: User interface is old and clunky.  No forms.

The following offer encrypted email — and are based in Europe, not the US — but are not designed for HIPAA specifically, i.e., no BAA: 

ProtonMail ( – Free, or $48/yr for more features and email storage
Tutanota ( – 12 euro/yr for “business,” free for “private.” Includes a secure calendar and address book, which would make Tutanota my choice if I merely wanted these encrypted features for personal use.

There are also a number of free, ad-supported apps that will encrypt email on handheld devices. These aren’t HIPAA-compliant either.

And the winner is… my patients

In the end I decided to go with Hushmail, mainly because it offered the secure forms I needed: a general contact form and an intake form for my website. I also was able to use my own web domain ( for my new email address. If I hadn’t needed the forms, I would have chosen MailHippo instead, to keep my existing email address.

Once signed up, I converted the contact form and intake form on my website to Hushmail. Then, using my old, unsecured email, I sent a final message to my active patients asking them to stop using that address, and to expect secure email from me going forward. Since replying to a secure email also makes the reply secure, this is a good way to start a private, HIPAA-compliant email channel with each patient.

One of the best uses I’ve found so far for secure email is sending monthly billing statements electronically, as pdf attachments, instead of by mail. If patients or potential patients want to reach me securely before I send them anything, they use the contact form on my website to start the exchange. So far, my new system has been working well.

In the comments below, let me know how any of these solutions work for you, or if you have others to recommend.

Image courtesy of Stuart Miles at