Major Depression Inventory (MDI) in psychotherapy

Counseling Competencies – The Application of Ethical Guidelines and Laws to Record Keeping Counseling Competencies – The Application of Ethical Guidelines and Laws to Record Keeping Program Transcript NARRATOR: In this video program, Doctors Tiffany Rush-Wilson, Matthew Buckley, Jason Patton, and Stacee Reicherzer discuss the importance of record keeping of counseling sessions. TIFFANY RUSH-WILSON: How has record keeping been integrated into your practice? How do you know what to record and what not to record? What if you’re not sure, how do you make that decision? JASON PATTON: The primary thing that I want to get down is if I had to transfer this case, if this person had to be admitted to some hospital or needed some other kind of level of care, I want whomever is taking on this client’s case to have a good idea of what we’ve done together, to have a good idea of my conceptualization of this client’s stuff. And it shouldn’t be put in a way that is in any way belittling of the client’s experience. It shouldn’t be– my notes are not necessarily in incredibly clinical terms, although I have to use diagnoses. But I do a lot of contextual stuff to my notes. But everything that I put in my notes is always about client stated or my client noted. Because it’s not that I’m making a clinical interpretation of what this client came in as depressed. He told me he was depressed. Those are important things that I’d like to get down in my notes because I don’t want someone to misinterpret what we did together as something other than what it was. TIFFANY RUSH-WILSON: You mentioned something quite interesting. You mentioned writing your notes for potentially another clinician reading in the future. Who is the audience when you write the note? It’s not always another clinician. It might be the legal system. It might be, I don’t know who else it might be, but it could be someone other than another clinician. So do you write your notes with the idea that someone will read them in mind? JASON PATTON: Most of my notes don’t tend to use overly clinical language, I don’t think. And that tends to be because I want this client to be able to get a copy of their notes, if they want a copy of their notes, if they want their medical records. And they need to be able to see what I’ve written. If they so choose, they need to know what I thought about it. And this is not a secret for me. Major Depression Inventory (MDI) in psychotherapy

And I don’t know that every clinician takes it that way. But in particular, it’s that I want whomever this client wants these notes to be released to I want them to be able to interpret it in some way. It may have a diagnosis that’s specific to the DSM, but you should be able to reference that with the DSM. © 2016 Laureate Education, Inc. 1 Counseling Competencies – The Application of Ethical Guidelines and Laws to Record Keeping MATTHEW BUCKLEY: I think an important aspect of this conversation is really what your professional experience dictates or how that’s informed you. Because oftentimes counselors who work in agency settings have a very definite protocol of what needs to go into a client record. If you’re working in private practice, which I have done most of my professional life, I write my notes to remind me and to keep a continuity of the work that I’m doing and not for any particular other audience including my clients. It’s to help me remember the important details, important aspects of what occurred in the session and how it’s adding to the treatment plan. I would feel awkward and I would also feel like it would border on unethical practice of me if I wrote my notes with fear that some lawyer or some judge was going to be reading this, and so I needed to have some complete and accurate running record of what my client and I did in session. And I hear what you’re saying about the example that you used, about the notes from this particular clinician helped her avoid some litigation. But I think that it’s important to be responsible, I really appreciate what you said just said, Jason, about being able to use the kind of terminology that you use that helps inform you. But if we write our clinical notes with the fear that we’re going to be sued, it’s going to greatly influence what we do in our records and it actually might end up hurting our clients. TIFFANY RUSH-WILSON: That’s very interesting. , We were actively taught after this huge case, it was a really big case it was even covered on a national news magazine to write our notes with the legal system in mind by our practices attorney. So I think it probably is best to instruct our students to check in with the rules and dictates and norms of the places where they’re working, in order to write their notes, whatever types of notes they are being asked to keep. MATTHEW BUCKLEY: And I think that’s a really important point that I certainly don’t want to promote the idea that students shouldn’t be responsible in how they keep their clinical notes. And this is a great example of how the profession evolves. Because we really do live in a litigious society. And so in order to protect ourselves, which ultimately protects our ability to practice, continue to practice responsibly, we have to be aware of what we need to include. And so I think it’s a good idea to have attorney friends and colleagues that we can consult with on a regular basis around these types of issues. TIFFANY RUSH-WILSON: I think it’s imperative. As a private practitioner, we always have to have an attorney connected to the practice because we don’t have a big agency to help guide us. So we need to have independent relationships with attorneys. Major Depression Inventory (MDI) in psychotherapy

© 2016 Laureate Education, Inc. 2 Counseling Competencies – The Application of Ethical Guidelines and Laws to Record Keeping MATTHEW BUCKLEY: And with each other too, being able to consult with one another. STACEE REICHERZER: My perspective is a little bit different than Matt’s because I think I want to write my notes in a way that with an understanding that these could be read by a lot of different people at any time. And so for me, transparency means that I write things in the clearest way possible. And so whether I’m using a SOAP formula or a DAP formula, it’s important to be formulaic in how I do this. Because this could be information that at some point I’m trying to send on to a psychiatrist or to somebody else based on whatever’s needed in the client record. Or it maybe something that the client sees, as Jason pointed, out it could be something that’s part of the legal system later on. So I’m really very focused on making sure that in that even though I’m in private practice, It’s likely that I’ll be the only person who’s going to ever read this. This could be read by a lot of people far down the road, based on whatever happens in the person’s experience. And I really care about that. And I try to maintain that focus in all the work that I’m doing with my clients. TIFFANY RUSH-WILSON: I think this is really an important discussion. Before we move on, I want to say that our students have struggled a little bit with understanding what to include in the record. Sometimes they’ll believe that a particular detail is too important or too personal to include in the record. So I want them to understand and be able to reflect on what to include and what not to include in. MATTHEW BUCKLEY: I think what Jason said about what the client said, I don’t think it needs to be necessarily a verbatim record, but there may be some key phrases that a client uses that would be very useful to illustrate something. Depending on some formulas, there there’s usually a kind of a clinical impression section where the counselor will, where I will share what my clinical impressions are of what’s going on, and then my plan and what I plan to do and follow up with. Also I like to include consults that I may have had with others about something that’s going on, so that it’s part of the record that I acted responsibly and I consulted with another professional. So I think those are important elements. Major Depression Inventory (MDI) in psychotherapy

Obviously diagnostic impressions are part of that. If a client makes a suicidal gesture, that’s something that you want to note and that you’ve done some follow up with. JASON PATTON: Not to get off point with that, but it is it’s important for me to tell a client that I’m going to be making notes about their session, that there will be a © 2016 Laureate Education, Inc. 3 Counseling Competencies – The Application of Ethical Guidelines and Laws to Record Keeping record of our work together. And that’s part of our disclosure statement. That’s part of how we inform them and they consent to that. I often say, what kinds of things do you want people to know about you? There may be things that, they’re like I’m telling you this in confidence, and it’s has no legal implications. It’s something I want you just to think about right at this moment. And he may want to tell me that. It may not be something that I need to remember in a future session. But I do want the client to know that there will be a record of whatever we’re talking about. And we should talk about that before we actually get there. MATTHEW BUCKLEY: I think it’s important how that’s communicated to clients because what I would not want to communicate to a client is that I’m making a record and anybody could read this. Because what would happen is that would actually, I think, prove detrimental. It make kind of close them down. And particularly with some clients who have had these types of experiences, where they’ve been with someone who has maybe tendencies to feel a little paranoid about things. That would not be something that would go over very well with them. So I think that it’s important to communicate that this is part of my professional practice, that there may be some instances where others may need to know what happens here. But I want you to know that those would be instances that I would communicate with you around when. TIFFANY RUSH-WILSON: That leads me to the last point I wanted to make. Group and family therapy, I work with eating disorders and primarily I work with the person who has the eating disorder, not with their family, sometimes in a group setting, but not typically with the family. How do you distinguish the differences between group and family therapy? Who is the client? Who has access to the record? Can anybody in the family read the record? Can anybody in a group read the record? How do we make distinctions between those two processes and the relationships we see within those two settings? JASON PATTON: Well I think one similarity that should be noted probably even before breaking them down is that we can’t guarantee the confidentiality that the group members or family members have. So if something is shared in the room with others present, that same level of confidentiality that we have as counselors is not necessarily going to be upheld, although I have full expectation that they will do so. And I ask them to do so. I can’t guarantee that. Major Depression Inventory (MDI) in psychotherapy

And that’s something I always want to set out in the very beginning. Now for me, the biggest difference between group and family therapy is that in a family system there are already alliances set up. There are already © 2016 Laureate Education, Inc. 4 Counseling Competencies – The Application of Ethical Guidelines and Laws to Record Keeping mom and daughter kind of team up against so-and-so, or mom and son do so. Or it’s experienced that that’s the case. So there are already things happening before you’re in the room. With group, hopefully that’s not the case. And so you want to name those things with early on to say, I want to come in and talk to each other. And we may be naming that there’s a dynamic already in place. And we may be talking about it. And we want to hopefully, name it if it comes up in the group as well, but they shouldn’t already be in place. TIFFANY RUSH-WILSON: Can they all have access to the record? Can anybody in the group or anybody in the family have access? JASON PATTON: Well say, for instance in a group, a group member doesn’t have access to another group member’s notes at all. And if I’m making notes about a particular group member, that’s the only group members name that I make in that group member’s notes. In a family, the family may be the group that I’m seeing. I’m seeing this family as a whole, where with the group that’s not the case. STACEE REICHERZER: I’m a believer when working with a couple or a family that there’s value to maintaining separate files. And this is particularly one of the things that comes up in couples work for example. When people go through divorces, there’s all kinds of weird stuff that they try to do. And so, if I’m working with a couple, Darren and Terry, In Darren’s file, I’m going to just simply say T or partner or something like that. Darren reported that partner was not responding to his blah, blah, blah, whatever that might be. But I don’t want Terry’s name to be prominently featured throughout the file. And there’s a lot of reasons for that. Because with confidentiality, Darren has a right to his record and he can sign the release and have me send over files to his doctor, things like that. But Terry has her own rights to release. And so Darren can’t just sign paperwork that I can send all of the stuff over and there’s Terry stuff in there because then I’ve just broken Terry’s confidentiality. And so it’s very important with couples work that there are separate files kept, and that we’re just making a note, using T, using whatever it is, so that there’s not another person’s identifying information in client one’s file. That’s a major issue for print for protection and to avoid litigation. MATTHEW BUCKLEY: Regarding the group, the keeping of group notes, I think it’s an important practice that I do when I do group notes, is I’ll write what a particular individual has said in a particular group. Major Depression Inventory (MDI) in psychotherapy

But I won’t necessarily write © 2016 Laureate Education, Inc. 5 Counseling Competencies – The Application of Ethical Guidelines and Laws to Record Keeping how others responded or those types of things. Because the focus is on what work that person is doing. Now if there’s a particular interaction that’s relevant to that, I certainly don’t want to name anyone else in that particular record. But I think part of what you’re asking about also is just the differences and the similarities with groups and families. And I like really what Jason said about families already having those established dynamics and groups not. As people come together in a group they’re sort of getting to know each other and they don’t really have those family relationships well established. But what I’ve noticed in groups that’s also interesting is that people in groups will play out their family dynamics very, very, very strongly. And I really liked something that Irwin Yalom said. And that is that people don’t remain indifferent to each other in a group for very long. As they begin to get in, as they begin to interact, those family of origin issues will come up and really make themselves manifest in a very dynamic way. And so that’s where I think that groups and families are similar is that we’re always sort of acting out our family experiences in those types of relationships. TIFFANY RUSH-WILSON: Can I go back to one thing you said before about groups? If you have a group of eight people, are you keeping eight records for that group or are you keeping a one record on the entire group? MATTHEW BUCKLEY: My particular practice is that I keep a record on the group. And I don’t particularly do– I’ve done a lot of group work, but I don’t particularly do a lot of group work now where I would keep separate records. I inform myself, I keep a good sense of what’s going on, so that if there is a need somewhere along the line that someone subpoenas a record that I can go back and I can take a look. And then I can go ahead and create a treatment summary for a particular group member. But I would not keep eight separate files. Now that may not necessarily be best practice, but that’s something that I do. And I think it’s important to check, to consult with others, other professionals to see how they do it. To consult with an attorney. And this is where it gets into how individual counselors keep their records. JASON PATTON: It’s going to really depend on your setting. I know that in agency work in my past when I have done group work, it was required that we have a specific file for each person. If a person is also doing individual, that their group be separate from their individual therapy as well. But my general way of doing it was a personal preference. © 2016 Laureate Education, Inc. 6 Counseling Competencies – The Application of Ethical Guidelines and Laws to Record Keeping There is an overall group content that’s not specific to the person. And then there’s a specific node about what happened with the specific client. And although it is a lengthy process, it is one that met the needs of this particular agency. Major Depression Inventory (MDI) in psychotherapy

STACEE REICHERZER: And see my background, because I came to it from an agency administrator’s perspective, I was a clinical director and worked in this agency setting for a long time. So I never divorced myself from the need and logic of keeping eight separate files. And so my notes were obviously not as lengthy as they would be in individual, simply because– for a lot of reasons, obviously. Couldn’t be doing this all night long. But also for the fact that within an hour and a half group session, there was going to be a whole lot less content and a lot less process that’s necessary. So it may be just two or three short sentences that describe the situation very, very briefly and summarize it within group. But I wanted the eight separate files because I wanted to also maintain that these were eight individuals. And I didn’t want things getting overlooked. That way also I’ve had a very good perspective, each week. If Sharon is never talking in group, I was really noting Sharon was silent again last week. And that she seems to only do this when Terry brings up x, y, z. So there’s important things to being able to do that. But I also again, from an administration perspective tend to look at things from the possibility that these could be subpoenaed. These are things that I might need to pull together rapidly. And I want the flexibility to do that and to respond to whatever it may be happening in a moment’s notice. TIFFANY RUSH-WILSON: So it’s almost a protective thing. It’s a formulaic approach that allows you to see patterns and also to have a consistent way to present the notes if ever they need to be seen by another party. MATTHEW BUCKLEY: Well I think if you’re talking about best practice, that’s best practice. That’s best practice. STACEE REICHERZER: And for me, it’s not ever that I feel you know paranoid or weird or oh my god, who’s going to read these notes? Major Depression Inventory (MDI) in psychotherapy

It’s that I always understand that I’m a professional. I’m in the profession of working with people, helping them move through their experiences, and I’m also a business woman who has the responsibility to protect the public and to protect her professional practice. And those are things that are always going to be all going on for me at once. So you know it keeps me focused and it keeps my work with clients, it keeps an emphasis and a structure around it that I think is necessary. © 2016 Laureate Education, Inc. 7 Counseling Competencies – The Application of Ethical Guidelines and Laws to Record Keeping TIFFANY RUSH-WILSON: So these notes help protect the public, the professional, and the profession itself. STACEE REICHERZER: Very well said. Yes. MATTHEW BUCKLEY: Exactly. You said the word focus. And I think that’s a really important distinction is that I’ll just be honest, there are a lot of things to keep track of early on. And as a new professional, it’s going to s … Major Depression Inventory (MDI) in psychotherapy