Writing therapy notes
Plus: smartphones and mental health, the limits of advice giving & more
Happy Thursday! I’m Eleanor Cummins (aka The Overthinker) and this is The Small Q, a round-up of news-worthy topics in psychotherapy. Have a question for The Overthinker? Share it with asktheoverthinker@gmail.com and it might be included in the next edition.
“Stunned. Ambushed. Traumatized.”
These are the words that kicked off a recent story in The New York Times about . . . therapy notes. After a recent update to federal law, a growing number of patients are opening up MyChart to find not only their antibiotic prescription and their glucose test results, but everything their therapist has ever written about them. And what they read isn’t always flattering.
Jeffrey, one of the Times’ sources, discovered his psychologist had labeled his insight “fair” and his judgment “poor.” Lisa, another source, discovered her therapist had created a list of his personal goals for her: To stop crying so often and be more productive at work. “It felt like a real betrayal,” she told the paper.
What’s a therapist to do?
It’s important to distinguish between types of notes. There are “progress notes,” a mandatory recap of each individual session. These are very procedural, documenting things like the interventions offered in-session, and observations on how the client is responding to treatment. It’s often said, “if it’s not in the progress note, it didn’t happen.” But therapists may also keep “private notes,” in which they record their private thoughts and feelings, jot down their hypotheses about the case, and even journal about their counter-transference.
Additionally, the Times story is referring to the 21st Century Cures Act, which as of 2021 requires all healthcare systems to make patient progress notes electronically accessible at no cost. Notably, this law doesn’t apply to private practice psychotherapists to the same degree! Therefore, many therapists’ progress notes will not be appearing, unbidden, in their client’s health app.
That said, clients have always had the right to read their notes. All they have to do is ask. Most don’t. But healthcare lawyers say a therapist should write their progress notes as if the patient, and their trial attorney, and their insurance company were all reading over their shoulder. Because all of those entities can, in theory, get access to your documentation.
Crucially, these same lawyers also advise that therapists should not write private notes at all. This is, for some practicing professionals, inconceivable. Their personal notes are an integral part of their process. But experts say the risk of a breach of confidentiality outweighs any reward. Jeffrey, the patient in The New York Times article, would certainly agree.
🗣️ How do you write your notes? What’s the best advice you’ve received on note-writing? If a client asked for their notes, how would you feel handing them over? Share your thoughts in the comments!
From the archives: A 2022 Slate article on how patients can approach their therapist’s notes.
Seeking continuing education on the logistics and ethics of note-taking? Check out this webinar.
Other worthwhile reads:
From Psychiatry at the Margins, why therapy ≉ advice
I love this quote: “In fact, the purpose of psychotherapy might be to find out why advice has such a high failure rate.”
In The New Yorker, a long and absolutely devastating read on the links between adolescent suicides and smartphones
The TL;DR: Teen suicide is on the rise, but “I have conducted dozens of interviews with young survivors of suicide attempts, and few mentioned social media as a factor,” Andrew Solomon writes. “They pointed to a sense of impotence and purposelessness; climate change; the brutal language of modern politics; intolerance for their gender, race, or sexuality; bleak financial prospects and diminished social mobility; an inability ever to feel that they had caught up, as though their brains were slower than their lives; and acute loneliness, even among those who appeared not to be lonely.”
The New York Times asked therapists what seven mental health memoirs they think everyone should read. 🗣️ What’s your answer!? Share below!
ICYMI: Back in August, ProPublica published its investigation into the abysmal status of insurance coverage for mental healthcare in the U.S.
Key point for advocacy: “Almost every state has a law that requires insurers to quickly reimburse for treatment claims, but the strength and enforcement of those laws varies greatly. Providers said they sometimes had to wait years to get paid.” This is the kind of policy work social workers are made for!
Anything I missed? Send your recent reads to asktheoverthinker@gmail.com or comment below.