Therapists don't always reply to email inquiries: An ethics discussion

[sue_frantz]

I have had occasion to send out emails with some sort of inquiry. When I don’t get any response, it ticks me off. I don’t do well with being ignored. I’ve learned that about me. Even a short “I’m not the person to help you. Good luck!” would be welcome. I mention that to acknowledge that I brought that particular baggage with me when I read an article in the Journal of Counseling Psychology about counselors ignoring email messages from people seeking a counselor (Hwang & Fujimoto, 2022). As if the bias this study revealed was not anger-inducing enough. The results are not particularly surprising, but that does not make me less angry. I’ve noticed that as I’m writing this, I’m pounding on my keyboard.

Wei-Chin Hwang and Ken A. Fujimoto were interested in finding out how counselors would respond to email inquiries from potential clients who varied on probable race, probably gender, psychological disorder, and inquiry about a sliding fee scale.

The researchers used an unidentified “popular online directory to identify therapists who were providing psychotherapeutic services in Chicago, Illinois” (Hwang & Fujimoto, 2022, p. 693). From the full list 2,323 providers, they identified 720 to contact. In the first two paragraphs of their methods section, Hwang and Fujimoto explain their selection criteria. The criterion that eliminated the most therapists was that the therapist needed to have an advertised email address. Many of the therapists listed only permitted contact through the database. Because the researchers did not want to violate the database’s terms of service, they opted not to contact therapists this way. They also excluded everyone who said that they only accepted clients within a specialty area, such as sports psychology. They also had to find a solution for group practices where two or more therapists from the same practice were in the database. Hwang and Fujimoto did not want to risk therapists in the same group practice comparing email requests with each other, so they randomly chose one therapist in a group practice to receive their email.

This experiment was a 3x3x2x2 (whew!).

• Inquirer’s race: White, African American, Latinx American (the three most common racial groups in Chicago, where the study was conducted). Researchers used U.S. Census Bureau data to identify last names that were most common for each racial group: Olson (White), Washington (African American), and Rodriguez (Latinx).
• Inquirer’s diagnosis: Depression, schizophrenia, borderline personality disorder (previous research has shown that providers find people with schizophrenia or borderline personality disorder less desirable to work with than, say, depression)
• Inquirer’s gender: Male, female. (Male first names: Richard, Deshawn, José; female first names: Molly, Precious, and Juana)
• Inquirer’s ability to pay full fee: Yes, no.

In their methods section, Hwang and Fujimoto include the scripts they used. Each script includes this question: “Can you email me back so that I can make an appointment?”

The dependent variable was responsiveness. Did the provider email the potential client back within two weeks? If not, that was coded as “no responsiveness.” (In the article’s Table 1, the “no responsiveness” column is labeled as “low responsiveness,” but the text makes it clear that this column is “no responsiveness.”) If the provider replied but stated they could not treat the inquirer, that was coded as “some responsiveness.” If the provided replied with the offer of an appointment or an invitation to discuss further, that was coded as “high responsiveness.”

There were main effects for inquirer race, diagnosis, and ability to pay the full fee. The cells refer to the percentage of provider’s email messages in each category.

Table 1. Responsiveness by Race of Inquirer

Name	No responsiveness	Some responsiveness	High responsiveness
Molly or Richard Olson	15.4%	33.2%	51.5%
Precious or Deshawn Washington	27.4%	30.3%	42.3%
Juana or José Rodriguez	22.3%	34%	43.7%

There was one statistically significant interaction. Male providers were much more likely to respond to Olson than they were to Washington or Rodriguez. Female providers showed no bias in responding by race.

If a therapist does not want to work with a client based on their race, then it is probably best for the client if they don’t. But at least have the decency to reply to their email with some lie about how you’re not taking on more clients, and then refer them to a therapist who can help.

Table 2. Responsiveness by Diagnosis

Diagnosis	No responsiveness	Some responsiveness	High responsiveness
Depression	17.9%	20%	62.1%
Schizophrenia	25.8%	43.8%	30.4%
Borderline Personality Disorder	21.3%	33.8%	45%

Similar thoughts here. I get that working with a client diagnosed with schizophrenia or borderline personality disorder takes a very specific set of skills that not all therapists have, but, again, at least have the decency to reply to the email saying that you don’t have the skills, and then refer them to a therapist who does.

Table 3. Responsiveness by Inquirer’s Ability to Pay Full Fee

Ability to pay full fee	No responsiveness	Some responsiveness	High responsiveness
No	22.4%	39.7%	38%
Yes	21%	25.4%	53.6%

While Hwang and Fujimoto interpret these results to mean a bias against members of the working class, I have a different interpretation. The no response rate was the same with about 20% of providers not replying at all. If there were an anti-working-class bias, I would expect the no responsiveness percentage to those asking about a sliding fee scale would be much greater. In both levels of this independent variable, about 80% gave some reply. It could be that the greater percentage of “some responsiveness” in reply to those who inquired about a sliding fee scale was due to the providers being maxed out on the number of clients they had who were paying reduced fees.

One place to discuss this study and its findings with Intro Psych students is in the therapy chapter. It would work well as part of your coverage of therapy ethics codes. Within the ethics code for the American Counseling Association, Section C on professional responsibility is especially relevant. It reads in part:

Counselors facilitate access to counseling services, and they practice in a nondiscriminatory manner…Counselors are encouraged to contribute to society by devoting a portion of their professional activity to services for which there is little or no financial return (pro bono publico) (American Counseling Association, 2014, p. 😎

Within the ethics code of the American Psychological Association, Principle 😧 Social Justice is particularly relevant.

Psychologists recognize that fairness and justice entitle all persons to access to and benefit from the contributions of psychology and to equal quality in the processes, procedures, and services being conducted by psychologists. Psychologists exercise reasonable judgment and take precautions to ensure that their potential biases, the boundaries of their competence, and the limitations of their expertise do not lead to or condone unjust practices (American Psychological Association, 2017).

Principle E: Respect for People's Rights and Dignity is also relevant. It reads in part:

Psychologists are aware of and respect cultural, individual, and role differences, including those based on age, gender, gender identity, race, ethnicity, culture, national origin, religion, sexual orientation, disability, language, and socioeconomic status, and consider these factors when working with members of such groups. Psychologists try to eliminate the effect on their work of biases based on those factors, and they do not knowingly participate in or condone activities of others based upon such prejudices (American Psychological Association, 2017).

This study was conducted in February 2018—before the pandemic. Public mental health has not gotten better. Asking for help is not easy. When people muster the courage to ask for help, the absolute least we can do is reply. Even if we are not the best person to provide that help, we can direct them to additional resources, such as one of these crisis help lines. For a trained and licensed therapist who is bound by their profession’s code of ethics to just not reply at all to a request for help, I just don’t have the words. Again, I should acknowledge that I have my own baggage about having my email messages ignored.

For anyone who wants to blame their lack of responding on the volume of email you have sort through (I won’t ask if you are selectively not responding based on perceived inquirer personal characteristics), I have an hour-long workshop that will help you get your email under control and keep it that way.

References

American Counseling Association. (2014). ACA 2014 code of ethics. https://www.counseling.org/docs/default-source/default-document-library/2014-code-of-ethics-finaladd...

American Psychological Association. (2017). Ethical principles of psychologists and code of conduct. https://www.apa.org/ethics/code

Hwang, W.-C., & Fujimoto, K. A. (2022). Email me back: Examining provider biases through email return and responsiveness. Journal of Counseling Psychology, 69(5), 691–700. https://doi.org/10.1037/cou0000624