Transparency in Therapy: How Therapists Keep Notes on Progress and Symptom Management
Many individuals hesitate to engage in therapy due to concerns about being judged or discussed overly privately. However, detailed progress notes taken by therapists serve a crucial role in the therapeutic process. This article aims to clarify the purpose and methods of progress note-taking in therapy.
Why Therapists Keep Notes During Sessions
Personal details such as crying, looking down, or exhibiting specific symptoms are often documented by therapists in their records. These notes are not intended to be reviewed by the client during the session. Instead, they provide valuable insights that can aid in the overall effectiveness of the therapy.
I, as a therapist, record such observations as part of progress notes, not during the session itself. These notes include a range of details, from eye contact and emotional responses to specific symptoms. Such observations are just as important as numerical assessments, such as mood scales, in gauging a client's progress.
Progress Notes and Their Importance
Progress notes are an integral part of a therapist's practice. They document the client's behavior, emotional state, and any symptoms that arise during the session. For instance, if a client appears to be isolating, angry, or using profanity, or if they are tearful, these are all documented in the progress notes. These observations are crucial for understanding the client's inner world and tailoring the therapy approach accordingly.
The Bates Island Recall Procedure (BIRP) format is one popular method used in my practice. It consists of four parts: Behavior, Interventions, Response, and Plan. In the Behavior section, notes are made about the client's behavior and the context provided by their words and actions. For example: 'Client reports that he is isolating again and appears angry today as evidenced by a clenched jaw, liberal use of profanity, and by session content.' In the Response and Plan sections, interventions and next steps are documented.
Diagnosis vs. Progress Notes
It is important to distinguish between the use of progress notes and the making of a diagnosis. Diagnoses are based on a comprehensive assessment, which includes a detailed history-taking, symptom checklists, and standardized measures like the Depression Anxiety Stress Scale (DASS) and the Impact of Event Scale (IES). Progress notes do not diagnose but rather track the client's journey through therapy.
Therapists use progress notes to remember important details that might be relevant in future sessions. Such notes help in planning the next steps and ensuring that any issues or behaviors are addressed appropriately. However, these notes are not intended to be a record of clients' private conversations and should not be taken as an indication of criticism or misunderstanding.
Conclusion
This article aims to provide clarity on the practice of progress notes in therapy. It is important for clients to understand that these notes serve as a tool for the therapist to better understand and support their progress. By doing so, therapy can be more effective and beneficial for the client. For those seeking more information or professional advice, please contact a licensed mental health professional in your area.
The information provided in this article does not constitute or substitute professional mental health advice. Please seek guidance from a licensed mental health professional if you have concerns about your or a loved one's mental health.