Discussion of note writing in Recovery In The Bin

Help needed! I am a trainee therapist with prior lived experience of the mental health system including forced treatment and serious iatrogenic harm. There were lots of reasons I decided to train as a therapist, partly because I believe in the power of storytelling, meaning making, witnessing and a providing a safe space for someone to speak their truth, and partly because therapy was the core thing that helped me reclaim my sense of power and allowed me to heal.
Also, I guess because as a peer-support worker I got fucking sick of not being taken seriously or given any support by mental health services in my work with people, and my comments about the injustice of the system being constantly discredited as me having a ‘chip on my shoulder’.

Things are going well in my training thus far. I’m now in my first placement, but have hit a roadblock. I am finding it extremely hard to write notes about clients (which I am legally and ethically obliged to do) in a way that I’m comfortable with, and sits right with me from a power and social justice perspective.
I am finding just the simple act of sitting down and writing *about* my clients to be an act of objectification and it feels like a huge power imbalance. Why should I be the one who defines how things are going, what progress is being made? Why am I the one who gets to record our journey together, who gets to write history? I also remember how much anxiety I felt about my own case notes when I was in the MH system, and how acutely powerless and voiceless that big brown file made me feel.

So… I am mulling over the idea of co-writing my case notes with my clients at the end of each session, rather than writing them alone once the session has ended as I am being trained to do.

My thinking in how to do this practically, is that I will keep the amount of therapeutic time exactly the same so people don’t feel they are losing out on time to talk, but to extend the session to 55 minutes rather than 50 in order to write a brief summary of the session together in the final 5 minutes. I imagine the process being quite informal, but me just asking the person I’m working with what they felt the key themes or ideas of the session were, that felt important to them, and then for me to share my take on things, and then we collaboratively agree a way of wording this that we are both comfortable with as a written summary of the session.

I am a bit concerned about what I would do if a client is upset or experiencing a strong emotion at the end of the session (which currently seems to happen about 10% of the time) where switching to reflective mode could be counter-productive. I was thinking that in those instances I might call a ‘raincheck’ on the note-writing for that week, then do my side of the notes alone and then share those at the start of the next session, when things have settled down, and ask if there was anything they might add before we begin.

I am genuinely interested in what people in this group think about this as an idea. How would you feel if your therapist, (or CPN, support worker, psychiatrist etc.) asked you to be an active participant in writing your case notes with them? Would this feel helpful or overwhelming? A burden or empowering? What would be your hopes, as well as your fears or concerns?

I am interested in hearing genuine reactions as I am not attached to this as an idea yet (nor the way I’m thinking about going about it) I’m just exploring this as an option right now.
What do you reckon? Feedback would be so much appreciated!

– I would want a therapist to take notes. As a patient I would find it overwhelming to help with this, usually just wanna leg it and have space. Had a million therapists and only one was good.

– I totally get this. I think in my own journey there would have been times when I would have found the process of co-writing empowering and times I would not have been able to cope. Would you like to have been given the option to co-write them, even if you ultimately turned it down as not being right for you? Or would even being asked feel like too much?

– I think I would just see it as the therapists work.

– That’s really helpful. I appreciate you sharing your perspective.

– For example, I had a therapist who obviously couldn’t remember our last session, he tried the best he could to manipulate it into a weird thing where he wanted to understand why I couldn’t remember, little did he know that I can very rarely rember conversations. Then finally I just asked him if he could tell me, and he couldn’t, as he didn’t take notes. Didn’t pay him and left.

– I am not surprised you did not pay him. I can understand a therapist not remembering a specific detail from a session because even with taking notes you can only record so much, and many people are loathed to put too much detail about the content of the session in their notes because of concerns about confidentiality and also therapeutic notes are increasingly being called on for use in court cases, so many therapists are anxious about writing too much in case it is later used against their client. If you have 20 clients it is hard to hold lots of detail in your head, it’s not an easy task to remember so many names, events timelines etc.

Also the nature of memory is that in a conversation of 2 people, both will remember the elements that felt most important to them, which are very rarely the same (one of the reasons that co-writing feels interesting to me) So I have found that that in my own practice I am prone to sometimes forgetting specific details, or if a client starts a session with something like ‘what you said last week was really interesting’ it is amazing how often I assume they are talking about something different to what they remember as important.

However when this happens I try to be honest and just apologise that I can’t always remember details as clearly as I would like in an ideal world. However all too often I have seen professionals try to avoid seeming ‘incompetent’ by doing something like your therapist did and turn their lack of recollection into a problem with the client. Also your story demonstrates why notes are important. I’m not anti-note taking I feel they’re essential so that important information isn’t lost. I guess I’m trying to get the spirit right in the way I go about writing them.

– Is the problem not that you are working with too many people? Ratios is a difficult thing to manage…. I remember once upon a time being a play worker and our ratio could be 40-1 at times, for an adventure playground. Safe to say it was manic. Problem is that it was state funded and it was affected by austerity, which had adverse effects on both our well being as workers and the kids quality of fun and attention and safeguarding.

– Wow that does sound manic! No currently I am only working with between 2 to 4 clients at any one time as I am training, but even at that ratio a HUGE amount of information can get disclosed in the average therapeutic hour. I do think that ratio becomes a problem for qualified therapists though, especially those working in the NHS. The average caseload for a therapist who has qualified is around 15-20 people weekly, and I can imagine even from working with 2-4 people that after a while that must become impossible to hold so much detail in your head.

But I think my problem here is less about memory recall and more about the power-politics of the situation. I’m genuinely interested in moving away from institutional, medical-model driven approach in the finer detail of my practice, and so often case-notes are written in this spirit. I’m also interested in exploring ways of working which don’t assume the therapist is the ‘expert’ in the situation or the only one with the power to interpret, plan and record information. Of course I have professional skills and of course the power imbalance is also a reality I can’t escape from, but I do want to work in a way that sits well with me and does the least harm.

– I think it’s a good idea to give people a range of options, I’d really like that from you doing notes and the person not seeing them, to joint writing, or the person seeing your notes at different points and adding or amending. I think you’re being thoughtful and I like your thinking.

– That sounds great. If that kind of reassurance could be portrayed in the sessions it would be ace, I agree with what ….. says above

– I really love the idea of a range of options. That hadn’t occurred to me and seems a lovely potential solution to me. I’ve found your feedback so helpful, thank you.

– Think ……has a good idea in the therapist writing notes that a person has the option to look over together with you at intervals… Depending on the person that may be set increments of time when you ask if they’d like to reflect because you feel it has been a significant period of change and you want to check in with if the sense you have is shared so the records are accurate, or if a person is in a frame of mind to be more proactive in the process then it could be left up to them when these intervals occur. I’m just thinking out loud. I love that you are asking these questions.

– Thanks your thinking out loud is very helpful and it’s good to hear so many different perspectives on this issue, I’m finding the feedback I’m getting so valuable. I think balancing the administration with the therapeutic process (which by definition constantly changes) is going to be the challenge, but it just feels like flexibility and good communication will be the keys to navigating this. It is going to be an interesting learning curve for both me and my clients and I’m sure in the beginning I’ll make mistakes and be a little clumsy in my handling of all this, but I find people are remarkably forgiving of mistakes if I can own them and just apologise when I get it wrong. I am excited by people’s feedback and excited about the possibility of a slightly different way of working. Feeling grateful to RITB right now!!

– Definitely, people appreciate the effort

– Best therapist I had made notes throughout our session, photocopied them and put them in the mail to me. Getting them a couple of days later at home where I could read them when I was ready to, reflect, work through anything I needed to and bring back anything it raised or I wasn’t sure about. Absolutely brilliant and I still have some of them over 10 years later!

– I do not feel qualified to comment on any case but my own, but if I was lucky enough to have someone like you as my therapist I would be pleased to be involved in the write up. In my case what talking therapy I have had has not been painful or even a chore. Perhaps it is significant that I have had no serious professional help for some 20 years when I looked forward to my visits with an excellent psychiatric nurse. SRMN. Your approach as you describe it reminds me of these sessions. All the talking help I have had or feel I can get now is likely to be a student or zero hours unqualified worker reading exercises from mindfulness books or the ridiculous online CBT. Perhaps at the moment though I do not need any help as I am functioning OK in the ESA support group being left entirely alone (for now). I do want to wish you well and tell you that I found your post refreshing and encouraging.

-Thank you for your thoughts & feedback. I too had a CPN with an amazing perspective who made a big difference to me. I worked with him for 4 years when I was in my 20’s and before I was remotely ready for therapy. It is sad to me how much CPN time is being cut back and how the therapeutic aspect of the CPN role is being reduced and reduced and reduced into being a box ticking exercise in micromanagement.

Also agreed about the current state of therapy, the idea of an online self-help website being ‘therapy’ is a nonsense to me (not that self help can’t be helpful but that is what it is!) and yes the mindfulness bandwaggon grates on me too. I am lucky enough to be practicing in a placement which provides free therapy for trauma survivors but such services are few and far between and our waiting lists are too long. I also have zero idea how I will manage to work with the people who most need it once I have qualified and need to earn money from at least some of my work, there are so many issues around the power structures of access to therapy that need addressing!

– Giving the client options sounds good. I like this idea but know at the end of some psychotherapy sessions I was desperate to leave, or needed to hold on to my feelings so stopping for notes wouldn’t have worked. Equally at the beginning of sessions there may be a burning issue, which notes would distract from. I think though that having an appropriately timed ‘admin’ session with advance notice where the client has the option to add to / amend notes would be helpful – for me that would’ve helped stop that fear that I was falsely represented in my file. It may have also been too overwhelming though. Difficult to gauge and everyone will be different but it’s reassuring that you feel this way.

– Yes, I think that it would be a more accurate or honest reflection of each encounter/session if you were to write notes with the clients…not all therapists write notes as far as I’m aware. If you do write notes I think it is better not to speculate! All the best in your work.

– You’ve got to watch that false info doesn’t make it into your notes. My ex-husband maliciously made a false allegation of domestic violence against me and that ended up in my notes as a “fact”.

– Notes should only be about and from the person in my view. Another suggestion would be if the person wanted to have input but not every week, that a monthly or whatever frequency could be on offer for a read through

– Yes, inaccurate notes can be hurtful – damaging…

– Ritb group rules! sooooo anti therapy due to all the crap ones, ace to read this thread and it sounds positive.

– I’ve just realised that I put my faith in someone as a therapist who is a nice enough person but…zzz…my mental health is no better for seeing him. People are very limited and it is a mistake sometimes (often) to do as I did.

– It’s really important therapists have good social awareness it’s just not good enough when they see claimants/people in poor conditioned low paid work and don’t get what that means, “I don’t know much about that”, maybe that should be part of training

– Yes, some therapists would appear to be in ivory towers (of sorts)…I read a book ages ago titled: “Therapy Means Change”. The writer argued that society needs to change, not the individual.

– Yup the ivory tower thing is a very real problem. I think there are huge equality issues about even accessing therapy training, especially in the humanistic or psychoanalytic traditions. Mine costs £10,000 each year for 4 years, the total costs of my training including foundation diplomas will be close to 50 grand. There are no loans or bursaries available which makes it systematically impossible for people in difficult financial circumstances to qualify as a therapist. Not to mention barriers because of health, disability, having kids, or other factors.

Counselling training is a little more doable because loans are available for some courses and the training is a bit less intense / lengthy but even that is too much for many people with lived experience. I am very unusual in my training group not only because of my MH history (quite a lot of therapists will have had some form of MH issue but I am unusual in having more longstanding issues and experience of psychosis etc) also I am from a reasonably working class background, comprehensive school education etc when many of my peers are both very southern and private / public school educated. I lucked out because my husband who I’ve been with since my teens did a PhD and now works as a lecturer and we don’t have kids. If it wasn’t for his salary training simply would not have been an option for me. I’m still having to work 2 jobs to pay for it but it is actually possible where as for many other skilled peer support workers and SU activists I’ve worked with it simply wouldn’t have been even though they had skills in abundance. I am so aware I’m in a very privileged / fortunate position. The ivory tower thing is a reality as much to do with the class/social backgrounds of most therapists rather than something inherent to the role. It makes me so angry it is this way and it needs to change!!

– Need more like you

– Trainee therapist with NHS?, because if you practice privately you don’t have to write notes.

– Need some surely unless you have a photographic memory

– My therapist never does, and we both feel liberated about it.

– Wow impressive

– It depends on whether the therapist is accredited and who they are accredited by. Because I am registered and being trained it is part of my ethical code that I am bound to that I need to keep some form of record of the sessions, and if I did not keep them I could face being de-registered. However not all therapists are accredited and there are different accrediting bodies, with different rules and expectations on this issue. Also, I personally have slight memory issues due to damage from meds and my own trauma history so I personally wouldn’t be comfortable going entirely note free, although I know some people who would not work any other way.

I think it really depends on your own skills and capabilities, and your stance on this sort of thing. A nice thing about therapy in general is that we do still have freedom to be flexible in our approach to these things. It’s nice to be able to ask a group like RITB and get feedback I can actually utilise in my practice. Not many professions have the same flexibility.

– Writing notes could actually breach confidentiality/confidence/trust…it all depends upon who else reads them (if anyone).

– I don’t disagree. It’s why it’s so important to me that I give this maximum thought and careful attention. Because so much damage is done by carelessness even when there are good intentions, and through not considering the impact on the person.

– I remember when Bradford Home Treatment team gave Survivors the option of writing and keeping their notes at home.

– I did not know that – was this something you had direct experience of? Did it pan out well in practice? I would be so interested to know the impact it had.

– No, I didn’t have direct experience but knew it was something team offered. The service won a beacon award back in the day and Service User satisfaction was high.

– Thanks for the info I will investigate more about this 🙂

– Oh yes I remember that

– I would like the option personally, though I wouldn’t always take it. Even just being given the option would make me feel safer and more respected and seen and empowered.

In terms of the content of the notes, I agree that sticking to what actually comes up and is discussed in session without speculation is best. One of the most triggering things for me in seeing past clinical notes was my psychiatrist taking careful notes on how I looked/ nonverbal actions and speculating (wrongly) on what they meant in terms of my mental state. I’m autistic and being perceived as more anxious or depressed or “worse off” because of not making eye contact or stimming more, which for me are actually signs that I feel more comfortable and trust the person I’m with, felt super invalidating. I wish she would have asked what my actions meant for me as opposed to just assuming. I was also really bothered by the demarcation of notes into “subjective” (my narrative) and “objective” (my psychiatrist’s interpretations). I was really offended that her often wrong or incomplete interpretations got to be classified as “objective”. She was the first psychiatrist I had that I actually liked and trusted so seeing those notes at the end of our relationship felt like a betrayal and it made it harder for me to trust therapists/ psychiatrists.

– This is such helpful feedback and touches on so much I’m afraid of in the potential harm of writing notes – that a pretty healthy relationship can become invalidating by this kind of practice, and I’m sorry to hear that an experience that was previously positive got tainted by the experience of reading your notes. I too would have felt betrayed in that situation, and your experiences are at the very heart of the issue for me.

The form of notes you refer to are generally called SOAP notes, which split between objective and subjective and they are just so dangerous in the implicit idea that the therapist has the ability to be objective and to step in neutral position of defining what is ‘fact’. I’m training as a therapist, which at its heart rejects the idea there is such thing as objective truth or that any one person can possess it. So the idea of writing SOAP notes (which are becoming increasingly popular as a format and used by many placements) is not only counter to my ethical principles but all the theories at the heart of my therapeutic training, so I refuse to use that format full stop.

– Such good points

– There’s no such thing as objectivity with human distress and relationships no one can be in possession of an unquestionable truth

– Yep. This is my entire stance and to me is at the heart of this issue. The idea that having done a bit of training and got a certificate that I can suddenly be objective whilst my client can only ever be subjective is ridiculous. We are both absolutely bound by our own subjectivity in that situation, as you say human distress and relationships are so complex they can never be fully pinned down, and both therapist and client will be profoundly influenced by their culture, personal relationships, their own history, social and spiritual background and world view when making meaning of a situation and it can never be any other way. It is my belief that neither client nor therapist can ever be anything but subjective, but what we can do is try to understand the other’s perspective as fully as we are able.

– Of course ……..is right about objectivity being a misnomer…

– The aim is to have “unconditional positive regard” isn’t it? Some people have this ability but most people are more prejudiced than they would feel alright about admitting/acknowledging…Jiddu Krishnamurti talked a lot about “can there be an ‘I’ free from prejudice”…

– Therapists probably worry about failing their clients – especially those who have more serious MH problems. So most people who have the benefit of long-term individual analysis would appear to be the “worried well”. I am in the position right now of feeling that I have failed my therapist…a difficult position to be in really. My tendency is to put people on pedestals and not see that failure in those terms involves 2 people – the analyst and the analysand.

– …An interesting conv. Thanks. I hope y’all are having a good day in spite of this highly oppressive ‘political’ climate…more later. ‘bye 4 now, 🙂

– Always good to try and quote Survivors in notes as much as humanely possible.

– Might be useful to have a few key facts from person, note of something tough coming up so to remember to enquire

– Yes, as a memory aid I can see the value for some people of keeping notes.

– Keeping notes is deemed an ethical requirement, the organisation who govern the course I am training on, so for now at least I am bound to their code of ethics in my training contract and therefore ethically obliged to keep records. Once I have qualified I will have more freedom but for now it’s the system I have to work with. Thank you for your input that’s really appreciated.

– I just had my last session (over 8 months) with my therapist yesterday because she is being redeployed. I don’t think I would like to write notes at the end of a session because I am always shattered and have lost focus at that point. I would have liked to see notes from the previous session maybe halfway through the next (after exhausting the current burning issue and before moving on to other stuff) to comment on or revise them

– This is great feedback, thanks. I think what is becoming clear is that it will vary from person to person what works best in practice, but that the option of co-working and transparency feels helpful to people.

– My instincts are you will make a very good therapist because of your determination to try and get things right between you and the people who you support.

– Thank you that has made me smile so much. 🙂

– I think that notes written by a therapist working outside the NHS particularly a CMHT would bother me far less than those produced by the system. If I was working with a therapist I respected I would trust them to write what notes they wanted and not enquire. I also think 5 mins at the end of the session could feel like the mandatory questionnaires iapt use to demonstrate outcomes. What if a client didn’t want any notes to exist at all as that could then feel coercive. Being flexible over the 50 minutes would be more worthwhile as otherwise it just feels like we should sod off and not take up a minute longer of the therapists time

– There is no FOI when it comes to therapists in the private sector. I’ve had some unhelpful therapist encounters but mostly put them down to experience. I think it depends on how the notes are to be used as that is where power comes in. I also used to feel a bit uneasy at times re any prospect of my case being discussed with a supervisor in case that was due to being perceived as difficult. I know that’s just professional practice though

– When I was in practice, I put almost nothing in the notes. Literally. This was for the protection of the individuals I was seeing. If my notes were ever subsequently subpoenaed, the court wouldn’t get much. I let folks know I did this and why. Sometimes they did co-write notes with me if it felt right to do it at the particular time. In those cases, I continued to keep it minimal but included things they specifically requested, letting them know the risks of including same if I thought there were any. No one ever complained and no one was ever convicted of anything based on anything I wrote either. It feels like a good day’s work in retrospect.

– Very

– Thanks means a good bit coming from a ……..

– Ruff

– What a great thread this has been

– I was not in a position to contribute to notes during my last rounds of therapy, but feel totally disempowered that professionals are issuing their opinions about me to each other and i have no recourse as it was decided I wasn’t able to handle reading my notes (fair, but I’ve moved on a bit). From those notes I might not agree with may come a treatment plan which will cause harm to me in the long term as misinterpretation is rife.

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