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 case 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.
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. This 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. 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, was team manager for her girls' lacrosse teams, and even made herself available to drive her mother to doctor’s appointments, even though she lived almost an hour away.
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.
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.
This blog is excerpted from “The Poetics of Progress Notes” Read the full article here. >>
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