Documenting Psychotherapy

Essentials for Mental Health Practitioners

Mary E. Moline, George T. Williams, Kenneth M. Austin

• Publisher: SAGE Publications, Inc
• Year: 1997
• Print ISBN: 9780803946927, 9780803946910
• eBook ISBN: 9781506319636
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy
• Index: Psychology

Avoid malpractice for keeping inadequate records and be prepared to respond to a professional peer review by using Documenting Psychotherapy, a practical volume that examines what is necessary in order to keep adequate records that meet current standards of care. This highly readable volume explores issues such as the limits of confidentiality, retention and disposition of records, documentation of safety issues, client access to records, treatment of minors, and the clinical record as it pertains to working with individuals, family couples and groups, as well as supervision and training issues are discussed in detail. Legal cases, vignettes and professional commentary are used throughout the book in order to help guide the reader in thinking through legal and ethical situations. Documenting Psychotherapy belongs on the book shelf of every mental health practitioner and will prove invaluable to professionals in clinical/counseling psychology, social work, psychology, interpersonal violence, and nursing.

PART I

THE IMPORTANCE
OF RECORD KEEPING
IN PSYCHOTHERAPY

This section is divided into two chapters. Chapter 1 covers therapist attitudes about record keeping and protecting both the client and the therapist. Chapter 2 focuses on the limits of confidentiality and mandatory reporting.

CHAPTER 1

Protecting the Client and the Therapist

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Record keeping has become an imperative in clinical work. This chapter emphasizes that keeping records is significant not only for the therapist, but the client as well. The significance of keeping records has both ethical and legal considerations. The legal considerations become paramount when the clinician’s records are subpoenaed, and in this chapter we discuss some helpful hints on how to deal with a subpoena. We will conclude with relevant legal cases, vignettes, and questions to further stimulate your thinking. We do not answer questions posed, for our intent was to take you beyond the boundaries of each chapter. If you find that you do not have answers, we hope you will discuss the questions with colleagues, professors, and fellow students.

Do you keep records on each of your clients? Are you confused about what you need to write down in your client’s records? Could the following case represent you if your records were subpoenaed?

You have been seeing a client for over a year. You have helped her overcome a suicidal period, work through her issues of abuse, and become a better parent. You also helped her decide to leave a relationship (an extramarital affair) she had for the past year. You did not treat her husband nor her children. In addition, your record keeping was brief and somewhat sloppy. You were not sure how to organize your thoughts and actions but that did not concern you until you received a subpoena for her records. The subpoena was submitted on her husband’s behalf. He is currently requesting a divorce. He wishes to prove that his wife is an unfit mother so he can obtain custody of their children.

What do you do? How do you evaluate your method of keeping records? Do you erase any of what you wrote down or add to it? Do you notify your client that you have been issued a subpoena for her records? Do you feel somewhat embarrassed as to how you kept records and wonder how the legal system might interpret them? Are you concerned about the manner in which you addressed her issues of suicide, abuse, and the affair? Do you have any idea what to do once you have been subpoenaed? If these are questions you would like to have answered, you will find this book an appropriate resource.

We hope to increase your awareness of how your record-keeping procedures can determine the outcome of a legal case brought against you. Although such a case is not likely to be due to inadequate record keeping, such practice could negatively affect the outcome of your case. Some therapists view it as unwise to keep detailed records about their clients. However, if you become involved in a lawsuit, you are likely to be deemed as behaving unprofessionally if you have not kept adequate records (Austin, Moline, & Williams, 1990).

Attitudes About Record Keeping

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Before writing the book, we asked therapists what they thought was the significance of keeping records. Moreover, we asked if they believed it was important to keep records. Persons informally surveyed suggested two main rationales for not maintaining any client records: It is a method for protecting their clients, and it is a method to protect themselves against ligitation. We were fascinated to learn of their decision, as various professional associations advise psychotherapists to keep records, and there has been a sharp increase in malpractice suits. Even with the number of complaints from licensing boards and ethics committees on the rise, respondents nonetheless argued against keeping records.

Arguments Against

Although controversy exists among some mental health professionals about keeping records in psychotherapy, we have been unable to find any written commentary against keeping written records. Arguments presented here are largely taken from verbal comments related by various psychotherapists too numerous to credit or who are reluctant to be identified as being opposed to record keeping. The reasons given for not keeping records are listed in Table 1.1.

Arguments For

The reasons for good record keeping in psychotherapy are numerous. Table 1.2 lists some of the major reasons we have discovered, not only in our own practices but in reading and researching various resources, that record keeping is good practice.

Protecting the Client

The most common explanation for not keeping records is from therapists who feel keeping records breaches client confidentiality and privileged communication. These therapists may have good intentions, but they are also operating on the faulty premise that clients cannot protect themselves. Clients have certain rights which protect what they communicate to their therapists. Their records cannot be shared unless they waive their rights and give permission for records to be viewed by outside resources or a release is ordered by a judge.

TABLE 1.1 Arguments for Therapists Not Keeping Records

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	Therapists believe they can better maintain confidentiality with their clients by not keeping records.
	Some clients request that their therapists keep no records.
	Therapists fear someone (e.g., client, attorney, insurance company) might take issue with what is stated in the record.
	Since it is impossible to write down everything a client says, the therapist who keeps records might have to justify why something from a session did not get recorded.
	Some therapists want to keep process notes (e.g., the client’s fantasies and feelings; the therapist’s reactions and hypotheses formed). They argue that such “working notes” do not belong in a client’s record and feel any disclosure (to the client or court) is an invasion of the therapist’s privacy.
	Some therapists claim that accurate record keeping is very time consuming.
	No record is better than an inadequate record. Some therapists seem unsure of what is contained in a good record.
	Records are only to protect the therapist in litigation. Since the therapist does not intend to do anything wrong, there is no need to keep records.
	We have heard this message from therapists: “It is in my client’s best interest not to keep records.”
	One therapist even said that keeping records would make him accountable, and he wasn’t going to be accountable to anyone. (We think he forgot about the state board that issued his license.)

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Confidentiality can also be protected by consciously being aware of what is written into client records. Act as if others will be reading the records as you write about your client(s). Without being untruthful, write only the critical pieces of information, not words that might be embarrassing. What would you want your clients to observe by reading your account of them?

Record keeping assures your clients that appropriate procedures are being followed. Records are a method by which you can follow the direction of treatment in a meticulous and meaningful manner. If you have a full client case load, you might not remember what various hypotheses were generated and followed, what medication has been prescribed and the amount, or what ...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Contents
• Preface
• Acknowledgments
• PART I The Importance of Record Keeping in Psychotherapy
• PART II The Clinical Record
• PART III: Documentation of Safety Issues
• PART IV Special Topics Relevant to Record Keeping
• PART V Appendixes
• References
• Index
• About the Authors