Thank you to everyone who responded to our August Clinician's Quandary. Here are some of the top responses! Submit to next month's Clinician's Quandary here.
August Quandary: I often take notes during therapy. It helps me better digest what my clients are saying and helps me recall detailed information. However, I sense that some clients are bothered by it. Sometimes they get distracted when I start writing. Recently, in the middle of a note, one client asked whether I’d just heard what he said. Another asked what I was writing and was bold enough to ask if he could see my notes! I’d hate to give up this valuable tool, but worry that it sometimes impedes therapy. What should I do?
1) Giving Your Full Attention
In the Seinfeld episode “The Package,” Elaine goes to the doctor to receive treatment for a rash. While waiting in the doctor’s office alone, she sneaks a look at her medical chart only to read that he’s labelled her “difficult” based on a consultation where she’d refused to wear the paper-like surgical gown. The doctor enters, proclaiming, “You shouldn’t be reading that.” Elaine inquires with the doctor about being difficult, and he pretends to erase the label, which was written in pen. “You fake erased,” Elaine says. Elaine’s chart and label of “difficult” follows her from doctor to doctor. She receives no treatment for the rash.
Taking notes is a common part of psychotherapy and a tool I’ve utilized in my clinical social work practice with adolescents and families. Notes can help us prepare for subsequent sessions and mark an important statement we may wish to revisit further. Still, there are some pitfalls with note-taking, as well as strategies for mitigating ruptures to the therapeutic relationship because of them.
While our clients provide informed consent to participate in therapy, we can also unpack our note-taking. I let people know that my memory isn’t always great, and I simply like to record what’s going on. I keep this note-taking to a minimum and use the client’s direct words often. I find it helps transfer the client’s voice to paper. I also let clients know that if they’d like to read my notes, they can. Working with young people, I sometimes see them at school, in my office, or outdoors. But no matter the setting, I try to position my notepad in a way that the client can see what I’m writing. I’ve never had a client ask for a thorough read of these notes, but I’d have no problem sharing them.
When writing about our clients or talking about them in supervision, it’s important that we never say anything we wouldn’t say to their face. To do otherwise is to gossip. Like the Elaine example, referring to those we work with as difficult, resistant, unmotivated, in denial, or precontemplative removes us from the relationship, causing further division in power and potentially straining the alliance. Psychotherapy’s effectiveness is based on the alliance constructed by two people. Positioning ourselves as an expert with privileged knowledge and the client as a novice creates further inequality.
I am mindful that, when putting the pen to paper, the client may not have my full attention. Clients’ experiences should be heard and validated. Our processes must focus on the provision of care, not on methods such as note-taking. Some clients may care, others may not. But it’s important to be open and transparent regardless, focusing on reducing the power differential wherever possible.
I recently surveyed my psychotherapy colleagues about the best portrayal of a psychotherapist in a movie or TV show. The most common answers were Robin Williams’ portrayal of Sean Maguire in Good Will Hunting and Lorraine Bracco’s portrayal of Dr. Jennifer Melfi in The Sopranos. Both built what seemed to be genuine, authentic relationships. Neither took notes.
Will Dobud, PhD, MSW(AP), BSW
Wagga Wagga, Australia
2) What True Presence Looks Like
Why are bartenders and hairdressers more likely to hear deeply personal revelations from their clientele than in any other profession? I believe it’s simple: it’s because they’re listening.
Yes, they may be busy at their craft, but they’re still attending, acknowledging, focusing, and fully present with the person in front of them. When we well intentioned therapists take notes during sessions, a crucial connection is lost—the connection that says “I am here for you. I’m not busy writing right in front of you. I’m not distracted on my tablet. I am not half attending to you.”
Therapy is most helpful when humans connect on an emotional level. Note-writing makes it businesslike, formal, and clinically cold. People need to feel heard and acknowledged, not as though they’re simply being documented or tracked. What do you feel when you go to the doctor? For me, it’s become a most uncaring experience because my doctor takes notes often. The computer that swings out from the wall becomes his central focus. My health history and a place to take notes may be necessary, but it’s a major distraction that leaves me feeling uncared for. In the process of record-keeping, he’s not an attending, listening, caring healthcare professional. Meanwhile, I’m in the room feeling exposed, vulnerable, and sometimes scared. The same may be true for a client in therapy. Many clients need their therapist’s full attention.
It’s been well documented that positive therapy outcomes depend on the quality of the genuine therapeutic relationship. Note-writing in session may be a time-saver, and I fully admit that I am old school, but I ask that you to do what we’re all challenged to do as therapists: try to see things from your client’s experience. Have empathy. Be fully present. And have tissues at the ready!
Sally James, MA, LPC-S, NCC
3) A Therapeutic Shortcut
I never used to take many notes in my sessions, but as I’ve gotten older (I’ve been practicing for 35 years) I feel that taking notes is important to effective practice and is simply a part of my process. In intake sessions, I always inform clients that I prefer to take notes, ask for permission to do so, and check to see if they have any reservations about note-taking. I’ve never had a client say outright that it makes them uncomfortable, although I have at later times had several ask me what I’m writing and why. I have no problem sharing what I’m writing, but rather than handing them my notes, I offer to read what I’ve written. I don’t omit anything when I read. However, I do include tone and inflection so the client not only hears the words I’ve written, but the meaning and context behind them as well. Afterward, I check in with them to see if they have any concerns with what I have written. I watch their expressions and body language very closely so that I can observe any possible reactions. This allows me to address those concerns immediately rather than have them arise down the road and potentially impede our work together.
With clients who are curious about my note-taking, I also ask about possible concerns or fears about what I’m writing. Their reactions can reveal trust issues, shame, vulnerability, and concerns about safety. I’ve found that clients who fear I might be writing something negative sometimes project negative feelings about themselves onto me.
When I ask how clients feel about my note-taking, it often leads to a fruitful dialogue that might have taken much more time to reach. Sometimes, discussions about notes can be a shortcut to valuable therapeutic material. I believe that exploring all client reactions brings us closer to understanding the ideas, beliefs, and fears that cause them trouble. It creates an opportunity for us to work with issues that lie beneath the surface.
Lauren Murphy Payne, LCSW
4) Trust the Process
Whether you should or shouldn’t take notes largely depends on your theoretical framework. There was a time in my work where I used a laptop during assessments, taking notes to make sure I was ticking all the necessary boxes. But I never felt comfortable with this model. It felt as if, while busily typing, I was missing all sorts of client cues. My therapeutic focus felt restricted by the administrative demands of my employer.
When I transitioned to working as a psychodynamic psychotherapist, I felt enormous relief since I was taught to be present in the here and now in sessions, and to learn to recall conversations without relying on notes. My focus became the client, the unconscious dynamics at play, and my bodily responses. I could finally work in the transference without being pulled out of it to take notes.
Many therapists who follow different models often ask me how I can recall session details without notes. The truth is it’s taken years of training to master. I find it helps to try to write up an approximate transcript of the session after it’s ended. Doing so has helped me realize just how much information we can recall without the aid of in-session notes. Now, I rely solely on the transference and countertransference that comes up in sessions as my guide to complete a write-up.
In sessions, instead of using silence or breaks in the conversations to take notes, I sit with the silence. I listen to my body and feel the unspoken narrative, all of which I missed when I used to have a laptop or notepad with me. Since clients now have my undivided attention, they feel at ease, like the room is their safe space. It’s made the whole process of therapy much more efficient.
To this clinician wondering whether he or she should take notes, I’d simply suggest that they follow their instinct. It seems like taking notes is a key part of their practice and they wish to retain it. Perhaps it’s a matter of having an open conversation about notes and their rationale for taking them. I’d advise that this therapist communicate that note-taking is a caring gesture, a way of keeping track of the important points the client makes so that they can deliver the best support possible.
However, it also sounds as if this clinician might be ready to explore a different way of working, one that doesn’t include notes. It doesn’t necessarily mean abandoning their therapeutic model, but perhaps adapting it to fit their needs and those of his or her clients. This could lead to a beautiful journey where the clinician discovers their own unique style and methods.
5) A Learning Opportunity
This Quandary brought back memories of my first therapist, who took notes. I remember how uncomfortable her note-taking made me feel. It felt as if she wasn’t fully with me, as if she was dividing her attention between me and her notes. While I didn’t like it and found it very distracting, I didn’t know how to say this to her because I thought it would be disrespectful. Thankfully, I was able to find a new therapist who didn’t take notes during our sessions.
In my work, I tell clients that I’ll only be taking notes only during the initial assessment, just so that I can remember the most basic information they’re providing. This lets my clients know what to expect. I’ve actually had two clients tell me after the fact how uncomfortable taking notes would make them feel. I suspect more clients feel this way but, as I felt with my own therapist, they probably don’t feel like they can voice their discomfort.
I see this therapist’s experience with this client as a learning opportunity for him or her, a chance to be more proactive around this issue. They seem to be very clear as to the purpose of their note-taking. I wonder if they’ve ever considered simply being transparent with their clients and telling them directly, “I take notes because it helps me better digest what you’re saying and remember some of the details you share.” They could even a go a step further by saying something like, “If you ever feel uncomfortable with me taking notes, please let me know and I’ll see what I can do. I want you to feel comfortable. And if you’re curious about what I’m writing, please let me know that, too. I’d be happy to share what I’ve written with you and discuss whether I accurately captured what you were expressing.” I think these statements would also serve the purpose of communicating to clients that therapy is collaborative, and that their feedback is welcomed.
Renee Sandler, RP, RMFT
Next Month’s Quandary: I have a client who’s been estranged from his mother for 15 years. He’s recently brought up wanting to be in touch with her. I’m not sure how best to support him in this effort, as the mother lives across the country and there is a history of abuse there.
Photo © iStock/hanabeni
Topic: Professional Development