Abstract

SMS messages sent by mobile phone can represent a therapeutic resource: they make it possible to guarantee that the therapist can be reached, to provide support in serious situations, to prolong the strength of the therapeutic relationship by extending the intervention beyond the end of the session, and to make a reduction in the frequency of meetings possible.

In order to explore these functions, we examined all the messages received over a period of three to four months by two therapists with different characteristics. A quantitative analysis of the messages received, taking into account the characteristics of the messages and of their senders, is followed by a more detailed examination that includes the therapists’ replies and takes the exchange of messages into consideration.

The conclusions, besides confirming the hypothesis of a consciously psychotherapeutic use of SMS messages within the framework of a therapy, also seem to bring out the flexibility of the SMS tool, which gives the impression of lending itself equally well to purposes of practical communication and to purposes of support or of therapeutic intervention, as the case may be, at once concise and incisive.

An inexpensive, fast and effective instrument

SMS messages, written messages of at most one hundred and sixty characters, sent by means of mobile phones, are today one of the most economical, fastest and most effective forms of communication. They have entered into the usage of young people to the point of creating particular linguistic forms, rich in abbreviations and condensed symbolisms, accompanied by smileys (emoticons) that add a nuance of non-verbal meaning, and to many they seem an almost folkloric element of present-day communication: in reality, SMS traffic is very high and represents a considerable source of income for mobile telephone companies. Messages, with rare exceptions linked to traffic or to residual areas not covered by the signal, arrive immediately; they cost less than a call; they cross national borders; they remain archived in the phone’s memory with the time of sending and the sender’s telephone number; and they can be deleted, kept or forwarded to others.

Can this instrument have a use, a place in psychotherapeutic practice? We believe it has already found one with most professionals, and that this as yet uncodified practice calls for an investigation that can verify it and promote a correct and profitable use of this new possibility of communication.

The possibility of keeping an open line of communication with patients through SMS may make it possible to:

The aim of this work is to illustrate the characteristics of the use of SMS, understood as an instrument meeting the objectives described, within therapeutic processes.

What the literature says

The literature on the relationship, more or less substitutive, more or less integrative, between psychotherapy and computer-based instruments founded on the Internet – chats, electronic mail, blogs, role-playing games and videoconferences – is abundant (10, 1, 9, 18, 19, 21, 5); among relational therapists, Luciano L’Abate (14, 15) carried out pioneering work, taken as far as the design and testing of modalities and instruments capable of reducing face-to-face interaction to a minimum.

Material concerning the use of SMS messages, by contrast, is scarce; often the specialist press and the mass media point out, in a more or less alarmist tone, the risks of dependence (christened infomania) (25).

But there are also accounts of experiences in which SMS have been used in medicine to reduce the anxiety of the relatives of patients about to undergo surgery (11), to improve attendance rates at outpatient consultations (7, 17), to administer medication follow-up for diabetic patients (13) and to facilitate communication in the presence of hearing impairments (20).

The youth phenomenon of SMS has been studied for its characteristics of use and of language (6, 2, 12) and taken into consideration by psychoanalysts for its meanings of distancing from the direct relationship with the other, including with the eventual therapist (26); a therapeutic use of the mobile phone in cases of phobic disorders while driving had already been proposed by Flynn in 1992 (8).

As regards the use of SMS, we have a few indications for the purposes of counselling thanks to the description of the activity of a listening service for adolescents in Lecco, where the preferred means of access turned out to be SMS (3). A genuinely therapeutic use of SMS, even in the form of standardised reinforcement, is attested by a significant New Zealand study on the use of messages as support for a smoking cessation programme (22). This study shows that after six weeks a group of smokers included in a programme for receiving SMS of advice and encouragement showed a rate of giving up nicotine twice as high as that of the comparison group; the positive results were maintained six months later. Certain websites deal seriously and in depth with the question of the relationship between psychotherapy and the Internet (24, 28, 29, 4), one of them also dealing with SMS (27).

Method of the investigation

We set out to examine from various angles all the messages, excluding none, sent to two therapists by their patients over a fairly long stretch of time (three to four months), together with the corresponding replies. The choice of aiming at a high number of messages, a prolonged period and a limited number of therapists was made in order to reduce the variability that the involvement of a larger number of professionals would have introduced, through an excess of distinct therapeutic and communicational styles; the two therapists, a psychiatrist and a psychologist, both specialised in psychotherapy, share the same type of relational approach and habitually use SMS in full awareness and with therapeutic intent. Indeed, what interests us is not the occasional use of SMS as a practical form of communication, common to all mobile phone users, but their conscious use by patients and by professionals within a therapeutic relationship and process. The two therapists have for years used the mobile phone as a working instrument, giving their number to all their patients and personally answering every contact; for their personal, private and family life, they have another, reserved number, which can remain accessible even when the work number is switched off.

The messages sent by patients were studied as a whole, but also separated by therapist and translated into percentages, with regard to:

Relating the messages received to the replies sent by the therapists also made it possible to complete the quantitative indications of this first phase of the investigation with a qualitative evaluation, drawing out a few suggestions for a therapeutic use of correspondence by SMS.

The messages received, like the replies, were downloaded each week onto a computer by the therapists; at the time the research began, they were not informed of the parameters that were going to be studied, but only of the need to keep all the messages received and their own replies.

The patients who sent the messages do not constitute a population selected from any angle among the two professionals’ clientele: they are simply those who, in the period examined, resorted to this form of contact. The instructions they received are likewise the same as those given to everyone from the first interview onwards: they provide that the therapists have their mobile phones switched off on public holidays or during holidays, and that they answer telephone calls directly from 9.30 a.m. to 8 p.m. on working days and on the eves of public holidays; that, in any case, even on those days, under conditions that make it unavoidable, the mobile phone may remain switched off for more or less prolonged periods. In that case, if they prefer, patients can send an SMS, assured that as soon as possible the therapist will read it and reply with another SMS; even on public holidays and during holidays, the therapist checks incoming messages twice a day and, where appropriate, replies to them.

The quantitative examination concerns only the messages sent by patients, since it was not possible to obtain parameters that would also make the therapists’ replies assessable, conditioned as they are in their contents, their timing and their characteristics by the former; the exchanges of messages, on the other hand, were submitted to analysis, examining the link between the type of solicitation and the reply within the therapeutic relationship. The therapists were asked to give the reasons for the reply they sent; the results of this part of the investigation will be set out in the form of commented examples of typical SMS exchanges.

Quantitative analysis of the SMS received by the therapists

Number of SMS messages and sex of the senders

Therapist A, a psychiatrist, received 112 messages (91 from 18 female patients and 21 from 7 male patients) in four months, with an average of 0.93 messages per day; therapist B, a psychologist, received 53 messages in three months (42 from 20 female patients and 11 from 6 male patients), with an average of 0.59 messages per day.

Table 1 – Total number of patients and by sex; total number of SMS and by sex of the senders; daily average of SMS received. (The eight tables of the original article were presented as images, today unavailable; their captions are kept here, the numerical data being taken up in the body of the text.)

The numerical ratio between men and women reflects the composition of the two professionals’ clientele.

The daily average of SMS, apparently low, is in fact calculated over the total number of days, including non-working days, of the seven months taken into consideration in all. It may be noted that therapist A, a medical psychiatrist and psychotherapist, with an equivalent number of patients and a similar distribution by sex, receives nearly 40% more messages than therapist B, a psychologist and psychotherapist.

Table 2 – SMS by sex of the senders: percentage of the total number of SMS and average per sender.

It appears that female patients make greater use of the possibility of communication offered by SMS, sending 40% more messages than men; but a closer examination makes it possible to rule out that the higher number of messages received by therapist A, a man, compared with B, a woman, depends on the sex of the therapist or on that of the senders.

Table 3 – Table by therapist, with the numerical distribution of messages per sender.

The table brings out a different distribution, between the two therapists, of the number of messages received: A receives a single message from half as many patients as B, while certain senders send him a great many more (from 8 to 23 each!), a phenomenon that does not occur among B’s patients.

Content of the messages

The content of the messages was classified into four broad categories according to theme: M (questions about medication), A (cancellation of an appointment), S (request for an appointment, including for a telephone contact), I (request for or communication of information concerning the therapy), Ps (message connected with therapeutic interventions carried out during the sessions, and elaboration of these).

Table 4 – SMS by content: number and percentage of the total.

It appears that, although one of the therapists is a medical psychiatrist, messages concerning medication are rare, fewer than those cancelling or requesting appointments; the content of the SMS is in any case linked above all to the interventions carried out during the psychotherapy sessions and to the events related to them.

Diagnosis

The professionals were asked to classify the senders of the messages, their patients, into four broad diagnostic areas: mood disorders, disorders of ideation, neurotic disorders and personality disorders. The choice not to resort to an external evaluation or to the use of diagnostic tests is justified by the decision not to interfere with the therapeutic process; the limitation to these four broad diagnostic areas should in any case reduce the risks linked to the subjectivity of the evaluator and to their involvement in the relationship.

Table 5 – SMS by diagnostic area and by therapist.

The cases followed by therapist A, a psychiatrist as well as a psychotherapist, are assessed as belonging to diagnostic areas liable to present disorders that are, if not more serious, at least exposed to more frequent acute crises; therapist B, a psychologist, also has patients of this kind, but fewer of them.

Emergencies

Those SMS that presented indications of serious and immediate risk to the health of the sender or of others – suicidal intentions, threats of violence, the intention to move to undesirable behaviours – were considered urgent by an external evaluator, on the basis of an examination of the context (time, day of the week, presence of other messages), of the content and of the way in which the content is expressed in the message.

Table 6 – SMS presenting emergency characteristics.

Therapist A receives SMS presenting emergency characteristics from different patients, at least once a month, a phenomenon that does not occur with therapist B. The fact that the emergencies concern various patients, and not repetitive forms of contact, leads to their being considered as deserving to be taken seriously.

Times

SMS carry beneath the text the indication of the time of sending. Since the therapists guarantee telephone availability from 9 a.m. to 8 p.m., an analysis was made of the messages sent outside those hours, from 8 p.m. to 9 a.m., and of their authors. In particular, the percentage weight of the messages received by each of the therapists was considered; the number of senders in relation to their total per therapist; the maximum and minimum frequency of recourse to out-of-hours messages. The therapists generally replied the following morning.

Table 7 – SMS sent outside hours (after 8 p.m. and before 9 a.m.): number and percentages of messages and of senders per therapist.

No significant differences are detected between the two therapists in the reception of “out-of-hours” messages as regards the number of senders; A receives more messages than B, but this is due to a small number of patients who send a higher quantity of messages.

Public holidays and the eves of public holidays

Besides the time, SMS come with an indication of the day of sending. Since the therapists do not work on Saturdays, on Sundays or during holiday periods, and since they agree with patients on telephone availability until 8 p.m. on Saturdays and on the reception of messages on the other days, we included in the research an examination of the messages arriving on the eves of public holidays and on public holidays, when the availability of the professionals is reduced or non-existent, in order to see whether this brought about any variation indicating a particular function of SMS in the therapeutic relationship when the possibilities of contact are reduced. For each therapist, therefore, weighting differently the holiday days taken in the period examined, a total count and a separate count were made of the SMS of the eves of public holidays and of public holidays; a percentage evaluation of the number of messages out of the total received; a count of the number of patients who had recourse to this communication resource.

Table 8 – SMS sent on the eves of public holidays and on public holidays: number and percentages per therapist.

It is observed that therapist A receives far more messages on the eves of public holidays and on public holidays, almost four times as many as B; the patients who send them to him are more numerous; the percentage of the total number of messages is almost double.

On the whole, it may be concluded that therapist A – a psychiatrist as well as a psychotherapist, male and older – receives, for an equal number of patients, more messages during the week and above all outside hours, on the eves of public holidays and on public holidays, as well as messages presenting emergency characteristics, compared with B, a psychologist and psychotherapist, female and younger. The difference is due to a higher number of messages sent by certain patients, belonging to diagnostic categories that imply greater clinical severity; on the other hand, it is independent of the sex of the sender and of that of the therapist. The content of the messages is different too: few concern prescriptions of medication, A receiving rather a greater number of communications relating to the course and the progress of the psychotherapeutic intervention, more oriented towards a request for a “prolongation” of the sessions.

Given that therapist A tends in general to see his patients less frequently than therapist B, and that a good number of them are affected by more serious pathologies often calling for urgent interventions, it may be thought that this same therapist A uses SMS as confirmation or monitoring of the therapeutic process more assiduously than B, who more often makes a use of them oriented towards the practical management of the therapy and towards psychological support.

This hypothesis of two possible, distinct and legitimate uses of SMS can only be confirmed by a qualitative examination of the exchanges, comparing a few messages received by each of the two therapists and the replies they gave to them.

Examples of SMS exchanges between patients and therapists

First example: the patient Francesca and therapist A

She is a 31-year-old nurse, at her fifth psychotherapy consultation for depressive disorders, with a suicide attempt by ingestion of medication and a borderline personality disorder. She lives alone; the suicide attempt followed the end of a love relationship with a very problematic man, unfaithful and violent, but also demanding and despotic.

At a meeting two days earlier, F. had reported that Richard had again drawn closer to her and that she was experiencing serious emotional difficulties; A’s aim is to remain a point of reference, including between sessions, in an initial phase of the therapeutic relationship in which it has not yet been possible to establish a bond solid enough to offer guarantees against the repetition of self-aggressive behaviours. One alarm factor is the time of the first message, as well as the mention, in the third, of the day spent in bed, that is to say without going to work and alone at home. The therapist’s messages respond to F.’s request not to be left alone; at the same time, they pursue a line of intervention begun during the last interview, aiming to modify the image of Richard as a unique and irreplaceable Prince Charming, and to look in the patient’s personality characteristics and history for the motivations of her distress, as a way of reducing her reactivity to uncontrollable external stimuli such as Richard’s comings and goings.

Second example: the patient Claudia and therapist B

Claudia is 22, and has been in therapy for two years for bulimic crises; this problem having been eliminated, the therapy has for a year been oriented towards resolving problems of growing up that have blocked the development of Claudia’s life, both in the field of her studies and in that of social and affective relationships. The message responds to a period of support for the resumption of regular university attendance. The therapist does not only want to give value to the result obtained by the patient, but to have her acquire through it a greater confidence in qualities of character of which she feels deprived. At the same time, the therapist plays down her own role in obtaining the result, accepts a partially adoptive relationship, solicited through the hug, but tempers it with a with warm regards; she confirms the next appointment, implicitly guaranteeing that for the moment there is no risk of her withdrawing if the patient makes progress.

The message therefore aims at a therapeutic support that goes beyond the positive result and extends to a reorganisation of character.

Third example: the patient Tilde and therapist A

Tilde presented delusional disorders of bodily transformation, currently contained by a rigid defence based on obsessional rituals; in therapy for a few months, she constantly asks the therapist for guarantees, in an obsessional mode, and he does not reply to all the messages but only to some, in an attempt – once the disorders of ideation have been contained – to make less rigid some compulsive defences that are also very limiting for everyday life. A’s reply aims, on the one hand, to provide the guarantee sought; on the other, in connection with the absence of a reply to the previous SMS, to encourage a better control of anxiety.

Fourth example: the patient Luigi and therapist B

The SMS link agreed upon during the session before departure allows the patient, who suffers from panic attacks, to face a plane journey with his partner and a few friends. The success of the undertaking can help to increase the patient’s self-confidence and to reduce the risks of a recurrence of panic attacks, also avoiding the appearance of problems in the affective relationship and in the social group of reference. The therapist’s reply confirms her protective interest, without burdening the patient with too much responsibility, thereby bringing the experience he has gone through back within a framework of normality.

A few examples of the most frequent SMS, by type of content

Medication

Cancellation

The therapist’s reply is welcoming, but it underlines that it is not for the patient to decide the date and time of appointments, inviting him to agree on the new date together.

Information and monitoring

To the messages that inform them of difficulties and of progress, allowing a monitoring of what happens between sessions, the therapists reply with an involvement that supports their patients in the hardest moments and reinforces them positively in those of a deserved success.

Psychotherapy

The therapist accepts the request for encouragement, but she announces the theme of the next session, inviting the patient to a greater commitment and initiating an intervention on the therapeutic relationship, understood as support or as an alliance with a view to change.

The therapist notes the dramatic character, accentuated even in the writing of the message in capitals, which contrasts with the reserve of keeping to herself until the following morning the privilege of coming at the appointed time or later: he refuses to relieve the patient of responsibility, while guaranteeing her his availability, and he creates the premises for proposing at the following session the need genuinely to treat her alcoholism, rather than feeling sorry for herself and being pitied for her own incapacity. He deliberately chooses to reply very briefly and using only lower-case letters, in order to underline the exhibitionist component of the message received.

Here is a very brief exchange that brings into play an ironic reflection on the repetition of a problem and on the therapeutic relationship, a reflection that could take place in the course of any therapy session.

Request for an appointment, for a meeting or for a telephone conversation

The therapeutic writing of SMS

The way in which SMS are written must never be considered fortuitous, both for those that arrive and for those sent by the therapists.

In the previous example, one of the messages, written entirely in capitals, appears wholly coherent with a diagnosis of histrionic personality, both in its characters and in its contents: it therefore already carries a diagnostic suggestion.

Many messages, moreover, reach the therapists without a signature, as if the patient expected to be recognised immediately or, better still, to be unique for their therapist; in that case the therapist, by replying with a message that merely points out the absence of a signature, at once re-establishes a reality principle in the therapeutic relationship, while being spared the work of identifying the sender by consulting the address book.

Sometimes the messages received contain incoherences and contradictions that can be pointed out immediately and then examined in therapy by the therapist, so as to create an activation in the patient and to train them in psychological inquiry.

An expressive, if not consciously rhetorical, use of SMS is also attested by the use of punctuation, as in the following example, where one sees how far the patient seeks to communicate the news in a striking way:

The therapist too must, for each SMS received, make stylistic choices of reply suited to the content, so as to confirm it and reinforce it with persuasive elements (16): to reply to a cancellation, for example, they may choose a neutral tone, or a concerned one, or even an indifferent one, according to the meaning they attribute to the cancellation, the moment of the therapeutic process and their intentions regarding the intervention.

Using the patient’s first name can be a way of giving greater personalisation to the message, making the written word less cold. The place of the first name in the message can express different nuances of meaning: for example, Giovanni, you have done something silly is more understanding and less accusing than You have done something silly, Giovanni!, where the contiguity with the end of the sentence, all the more so if there is an exclamation mark, seems to imply a reprimand rather than a consoling solidarity. The latter can in turn be accentuated simply by the use of punctuation: Giovanni, you have done something silly… It may be said that the organisation of the sentence, the distribution of words, the punctuation, the sonority that resonates in us as we read and other resources also give the written message that connotative aspect of meanings that the pragmatics of communication attributes to the analogical component of language (23).

That therapists should always sign their messages, spelled out or with initials, is therefore not only a debt of courtesy and a sign of good manners: an ending such as Dr E. B. (initial of the first name, surname spelled out) or G. A. (initials) represents in any case a context marker, indicating that this is a message inscribed within a professional relationship, which reduces the risks of an excess of familiarity.

In cases where the therapist considers that they are receiving too many messages, or wants to underline for therapeutic purposes the imbalance of the relationship, they may use various means: reply with an SMS that underlines the excess, not reply, or reply only after a delay long enough to make the patient fear that they have gone too far, keep the messages in the phone’s memory and use them at the next session to make them a theme of work on the relationship…

For the therapist, the choice of the appropriate terms to create in the patient the desired psychological effect is a commitment, of varying degree, but one that must not be underestimated: a simple encouragement is indeed not the same depending on whether it is expressed by Well done! or by See you soon. A joke or a playful comment can confirm a particular understanding in certain situations: for example, Congratulations, a prestigious result that will bring you credit… and clients!; in others, it is appropriate to use more general expressions, for example: I am happy that you have obtained such a good result.

A story told through SMS

On the basis of what has been said about the non-fortuitous use of messages, it should be possible to see the therapeutic story as it evolves by bringing together all the SMS sent by a patient over a prolonged period, alongside the therapy sessions, together with the therapist’s replies.

Example: Luciano, 43, is a company director affected by narcissistic personality disorders, with occasional impulsive and risky reactions, in a depressive phase following a stormy separation that could compromise his professional and financial situation; he has two young children whom their mother intends to take to another region, a prospect of loss he cannot manage to accept.

The second sequence of messages presents a coherent narrative evolution, even though it consists of exchanges spaced out in time, and a therapeutic meaning based on the proposal of a story of altruistic and suffering redemption, addressed to a depressed and confused man and father. The messages punctuate the evolution of the story developed in the therapy sessions, integrating themselves into it, reinforcing it, summing it up and setting it going again in moments of difficulty, but also condensing it into a moral that announces a deepening, in therapy, of the work on the personality disorder.

A borderline case

This exchange of messages, sent to a third therapist, relates to a situation that is in no way unusual, but is such as to alarm younger therapists in particular. These are SMS sent anonymously, by computer, with messages of love coming from a presumed patient.

The therapist waits until Monday morning to send her reply, so as not to give the impression of having been too disturbed personally or in her family life. She knows that she brought the patient significant help, even though she was at the time young and not very experienced, and she formulates a reply that helps him to pick up the threads of an interrupted therapeutic discourse.

Jacopo is a young man whose case the therapist in question followed until two years ago. Obese (around 120 kg for 165 cm), he suffered from very severe panic attacks with agoraphobia; enrolled with excellent results at the school of nursing, he had suddenly broken off his studies and all social relations. He had never gone out with a girl; the family had sporadically found itself caught in serious difficulties.

In the therapy a serious situation quickly appeared, complicated by alcohol abuse (at night and alone), the progressive reduction of all social activity and the appearance of ideas of reference. He had sometimes come to the session with both arms covered in clean, deep cuts, declaring suicidal intentions.

A third child, born after and in compensation for the premature death, at 5, of a sister named Jacopina, he had always been a model boy, kind and good, overprotected by parents devastated by the death of their daughter. The eldest sister had left home, with great difficulties of disengagement, two years earlier. The psychotherapy had lasted about two years; Jacopo had not resumed his studies, but he had begun to see a few friends again. He looked after a little dog and sometimes helped his father with the work in the fields; he ran errands on his parents’ behalf.

He no longer had panic attacks, no longer cut himself and no longer drank alcohol; the obesity, however, persisted.

Once the most acute symptoms had been overcome, at the beginning of a deepening of the work on the personality disorders, Jacopo had begun to say that he came only because he was in love with the therapist and, after a few months, he had dropped out, saying that he preferred to stop. The parents, at that point, had also broken off contact.

The therapist observes the distress behind the contents and the sending times of the messages, and she uses the opportunity offered to propose once again the possibility of resuming the therapy, even with others, rather than confiding in fantasies or in infantile hopes of affective adoption. Indeed, Jacopo seeks the solution to his problem of reduced personal autonomy – to which a serious personality disorder corresponds – in the fantasy of being saved by the love of an angelic woman, a masculine version of the role of Prince Charming in fairy tales for little girls.

The therapist thus overcomes the disquiet created by the anonymous messages by using them to redefine the patient’s transference.

Incidents of this kind are fairly common in the life of psychotherapists, and leaving the patient one’s mobile number can worry the youngest and least experienced; on the other hand, it is worse to be reachable on the home telephone or to find anonymous messages there. The mobile phone is always, and in any case, a work telephone, less private than the landline; it can easily be switched off, and it is also possible to have two numbers on the same device, one private and the other public, with even different ringtones.

Conclusions

The messages that can be sent and received by means of the mobile phone can represent a significant resource for psychotherapists; it is an economical and concise way of communicating, almost in real time. A few years ago it seemed that the spread of the Internet was going to overturn completely the way psychotherapy is practised, going beyond the model founded on face-to-face dialogue; today we can observe that there may be different ways of including electronic mail and therapeutic exercises in the course of therapies (14), and even of building sections of a training programme for psychotherapists, in Norway and in Latin America, drawing on a virtual interaction; but also that the therapeutic relationship demands a personal involvement that can hardly do without the direct and close meeting of two or more people.

The SMS message does not require the use of a laptop or of sitting down in front of a desktop computer; it does not involve the risk of scattering the content in excessively long e-mails; it guarantees that the therapist can be reached immediately, while leaving them free to control the times and forms of their reply; it does not require devoting excessively long periods to reading and deciphering the communications received, then organising and writing the replies.

To be sure, it does not replace therapeutic meetings, but it can make it possible to space them out over time, and it can prolong and reinforce their action beyond the narrow limits of the hour of the session.

Moreover, it makes it possible to manage situations of risk by offering a possibility of rapid contact in emergencies; to monitor the taking of medication in the initial phases of treatment; and to support patients who are trying to overcome difficulties created by symptoms in real life, taking part from a distance, in a minimally intrusive way, in their efforts to change. It can be used differently according to the patient’s needs and the therapist’s objectives, giving prominence to aspects of support, of monitoring and of stimulation, or by introducing on the spot, with speed and power of synthesis, interpretative or humorous elements or, in any case, elements endowed with a power of redefinition which, on their own, may already have a psychotherapeutic value.

The problem of the possible development of an excessive dependence on the therapist, who becomes always or almost always accessible to the patient, as if the mobile phone came to represent a psychological umbilical cord, is no greater than the one that a larger number of direct meetings to manage the same situation would induce, and it constitutes a constant risk of the therapeutic relationship.

Like all useful instruments, SMS demand of the therapist who makes conscious use of them attention, promptness, commitment and responsibility; they reward them with greater effectiveness and with a saving of time of direct contact with each patient, thus enabling them to increase the number of their patients and to reduce the costs of their therapies, with benefits for everyone in the end, not only economic but also social.