The Poetics of Progress Notes
Using Your Imagination with Tough Cases
by Brad Sachs
Like many therapists, I know what it's like to dread having to write up case notes after my sessions, and how tempting it is to find ways to put off the task. But through the years, I've discovered that because of the many overlaps between psychotherapy and writing, broadening the definition of what it means to "write up case notes" can actually heighten my awareness of what's happening in my work.
While we're generally trained to focus on preparing notes that are clinical and objective, confining ourselves to this format severely restricts the creative potential of the process. It's interesting to consider, in fact, that although many clinicians encourage their patients to keep a journal, draft real or imaginary letters to family members, and compose poetry, few clinicians use creative writing in their own work.
The act of writing is, in its most elemental form, an act of self-discovery. At its core, it brings into awareness a conversation between what's alive and what's dying in ourselves, what's limiting and free, what's observable and shadowy. Writing isn't just a transcription of what we know; it can also reveal to us what we don't know, what we don't know that we know, and what we don't want to know. When it comes to progress notes, delving into our reluctance to write about a particular client has the potential to help us think about a case in new and clinically valuable ways, rather than simply making us feel guilty.
There are many ways to write progress notes that tap a therapist's imagination and enhance what goes on in therapy. One is what I call the Reverie Poem. As clinicians, all of us have had the experience of having our minds drift during a session. With practice and self-discipline, most of us learn to gently nudge ourselves out of our reveries. But another approach involves being more attentive to our inner meanderings to see whether they lead to useful clinical clues.
I was once treating a woman, Wendy, with whom I was having great difficulty empathizing. Despite the litany of quite legitimate complaints she had about her life--a callous, philandering father; a mother who was simultaneously clingy and rejecting; a thwarted escape from her family into a dismal marriage with a remote alcoholic who absolved himself of almost all childrearing responsibilities--during sessions, I'd almost instantly find myself reflecting upon anything but what she was saying.
Writing up my sessions with Wendy was a further exercise in futility. I remembered very little about what she'd said as I struggled to implement some kind of treatment plan. Then, after one particularly frustrating session, I wrote the following poem to try to make sense of the trancelike musings that overtook me in Wendy's presence:
Three Minutes of Therapy
It's like I can't feel
I can't even feel
The feeling of not feeling
The O'Keeffe on my wall
Its glowing wombs
When I'm with my kids
It's as if I'm not with them
They could be anyone's kids
The mocha drink in the fridge
I'm like my own mother with them,
So cut off, so remote
I despise her
But I'm just like her
It's all I can do to get through the afternoons
And I'm desperate for my glass of wine
A glass of red wine
The late afternoon sun
Will I ever return to Italy?
dizzy with wine
Until I can get them off to bed
And then the emptiness
The sandwich I made for my lunch
So much earlier this morning
It's just me and my husband
Did I bring the rice?
Although he's so busy with the computer
I can avoid him more easily
Than the kids
My daughter fell asleep before I got to say goodnight to her
Because I was too busy on the phone
asleep before he even gets upstairs
And then he's gone before I wake up
9:55, halfway through
months, I guess,
I don't even think about it anymore
I don't even think he thinks about it anymore
Yes, I believe the rice is there,
I know I brought it
divorce, but would I be better off?
What would it accomplish?
The O'Keeffe on my wall
The glowing, empty wombs . . .
Reading the poem afterward, I became aware that my personal wool-gathering had to do with profound emptiness --the wombs in the O'Keeffe painting on my wall, the incessant focus on food and drink, the absence of contact with my own child (playing the role of my patient's callous father, "philandering" with whomever I'd been on the phone with when my daughter was ready and waiting for me to tuck her in). I realized that it was my own fears of encountering my patient's profound emptiness that kept me so disengaged from her.
Reading the poem inspired by my session with Wendy crystallized for me how dutiful she was. She was essentially raising her two children as a single mother while tending to her adolescent-acting husband. She volunteered at the children's school and was team manager for her girls' lacrosse teams. She also regularly fielded her mother's calls for medical advice and made herself available to drive her to appointments, even though they lived almost an hour apart.
Perhaps, it occurred to me, her responsibilities were so oppressive that they were oppressing me, prompting me to avoid attending to her by allowing my own attention to roam. My reverie may have been serving the same purpose for me that her drinking did for her--allowing for a momentary break from a suffocating reality. After this insight, I was able to rouse myself from my previous torpor and focus on our sessions with more clarity. I helped Wendy begin to examine her ambivalence about setting limits with her children, her husband, and her mother. I encouraged her to start looking for ways to nourish and gratify herself that didn't rely entirely on meeting others' needs.
Thinking more about her own needs, she joined a senior swim team, and insisted that her husband be home the two evenings a week she practiced to supervise the girls' homework and nighttime routine, which, to her surprise, he agreed to do. She made some calls to a senior-support services center in her mom's neighborhood, and found that they offered free transportation for local seniors' medical appointments, which unburdened her as well. She also began attending Al-Anon meetings.
In retrospect, my poetic exploration of my own absentmindedness enabled me to enter Wendy's psychic landscape more fully than I'd have otherwise been able to. Connecting with her in this new way changed the whole direction of our work together.
Since then, I've explored other ways of using writing to offer fresh perspectives on a case. Sometimes I've written a reverie-based poem, along the lines of the one I wrote about Wendy, but from the patient's viewpoint, imagining the subnarrative that might be going on within her during a session. Other times I've interviewed my inner censor in an effort to ascertain why I'm reluctant to write about a patient, posing questions like:
What do you want from me?
What do you want to keep me from ?
Who do you remind me of?
Who does this patient remind me of?
How might we become partners, rather than adversaries?
What keeps me separated from my patient, making me unable to write about him/her?
How could I honor you and still write what needs to be written?
What would I lose by being freed to write about this patient?
What would I gain by being freed to write about this patient?
Therapists have often asked me whether it's ever a good idea to share their creative progress notes with their patients. I've never done so, although I've been tempted to many times. I suppose it's a judgment call, much like any form of personal disclosure during treatment--there are times when it's certainly warranted and can be quite illuminating, but it also can be hazardous.
Whether shared with patients or not, though, whenever therapists find new and imaginative ways to invest in clinical documentation, the process generally pays handsome dividends. In some sense, it's really just another form of clinical supervision, but one in which the supervisor is inside us. n
Brad Sachs, Ph.D., is a family psychologist in Columbia, Maryland, and the father of three children. He's the author of The Good Enough Child: How to Have an Imperfect Family and Be Perfectly Satisfied . His poetry books include Blind Date; In the Desperate Kingdom of Love ; and I Have Told You This to Make You Grieve . Contact: firstname.lastname@example.org. Letters to the Editor about this article may be e-mailed to email@example.com.