Group counseling notes: What you need to know

Are you a therapist who recently decided to start a group, or is even just considering it, and then thought, “Wait — How do I write the note?”

I’m here to give you the basics so you feel confident documenting those group experiences.

The first thing to remember is that group notes really aren’t that different from individual therapy notes. Phew, right? So breathe deep and relax, because you can do this. The notes are pretty much the same and some parts are *exactly* the same, and that will help you save time.

The biggest difference in notes from group therapy is that you need to document the individual interactions and the group interactions. And the good news about THAT is: it’s pretty easy.

Step One:

Follow your normal notes template. Whichever one you use — DAP, SOAP, GIRP, PAIP, or your own format — and make sure you include all those components in how the individual client acted, how they interacted with the group, how the group reacted to and interacted with them, how they influenced the group, and how the group influenced them.

It sounds like a lot, but I promise, it really isn’t.

Step Two:

My biggest advice for therapists writing group notes is:

DON’T WRITE ANYTHING TWICE!

This means you can sort of “cheat” a little in group notes, and this is where you start saving time. How? Well as you work with the group you might provide an intervention for the whole group, and you definitely don’t need to write that five or ten times. Write it once, and then copy and paste into everyone’s individual note.

I heard that little sigh, even though the computer.

Yes, you do still need to write individual notes for each member, because they are each still individual clients and should have separate records.

So you’ll have a portion of the note that deals with the whole group, interventions you provided, the things you did that apply to everyone, and another few sentences specific to that client.

Easy enough, right?

Use your template and take advantage of those little tricks to save yourself time: copy and paste what you can, and then add the individual components highlighting how the group is different for each person.

That’s it. You’re done!

Are you doing group therapy? What tips and tricks do you use?

If you want more information on the notes templates listed above, or aren’t feeling confident with your individual notes yet, check out my FREE Private Practice Paperwork Crash Course. For more in-depth help with note-writing, check out the Meaningful Documentation Academy, which is full of trainings on notes, treatment planning, time management, and more.

The 2 Biggest Blocks to Writing Progress Notes

Today I’m going to tell you a juicy secret.

What kind of secret? I’m going to share the two most common things I hear from therapists about what blocks them from writing their progress notes.

I know you’re thinking that if I hear it all the time, it’s not a secret, right? Well it’s a secret therapists keep from each other, and I’m here to air it out so we know we’re all dealing with the same issues.

Issue #1

FEAR

Yup, fear. Fear is a huge block. Lots of therapists become paralyzed when they sit down to write progress notes because they don’t know what to write.

They worry about who will read a note and what they might say about it. Even if a therapist has never had a note critiqued, never had a negative comment, never had a note read in court, so many are afraid that those things are lying in wait, just around the next corner.

People sit down to write, or they think about writing, and this fear actually stops them from writing altogether.

Other things therapists are afraid of are audits or client record requests. The idea of a client reading notes, even if they’re written, can be terrifying. Embarrassment about the idea of notes making people look bad or un-professional can also keep someone from writing notes or being as thorough as they should be.

Issue #2

Perfectionism

This is huge for a lot of therapists, people who have Masters or Doctorates, so they are used to doing things well! And when it comes to notes, we don’t typically get a lot of training in writing notes, and there isn’t a lot of information out there about writing notes, or even a general criteria therapists can refer to if they want to be sure they’re covering the right bases and writing really good notes.

That freaks a lot of people out.

So a lot of us think our notes have to be perfect, and I know from experience there are therapists spending 25-30 minutes on ONE note for ONE client!

If you see ten clients, that’s already FIVE hours a week of note-writing, and if you’re only getting paid for ten hours of work. No one should be doing 50% more work than they’re getting paid for, right? But a lot of therapists agonize over every word in a note.

Usually that agony is really about a lack of knowledge about what needs to be in the note.

I’ve also seen people paralyzed with worry over writing the right thing. They’re so concerned that they don’t write the notes at all, which is super common if someone is behind in their notes, because the idea of writing the wrong thing is so anxiety-provoking that they just don’t write the note at all.

Now we need a solution, though, right?

So I’m also going to share with you the one thing that I’ve seen help therapists overcome both of those issues: having a community and a push to get those notes done.

My challenge to you today is to find that community and that push. Whether this blog is the push you needed, or you get together with some therapist friends or coworkers to get through your notes, or you join the Meaningful Documentation Academy and take advantage of our WEEKLY Get Notes Done hours and monthly Get Notes Done days, find an option that works for you.

Accountability and support are key to solving this problem. Leave me a comment below about your biggest block. Take the leap of putting that out there into the world right here, where there’s no judgment, ever.

What is the thing that makes you dread writing your notes?

Do it Right--Progress Notes and Online Text Therapy Platforms

These days therapy isn’t necessarily hour-long sessions with a client in your office.

That’s SO 2014. Now we have video therapy and text therapy through apps, which are an amazing tool for you and your clients, and introduce a few new considerations for therapists, particularly around progress notes.

First of all, let’s define ‘text therapy.’ It’s a pretty simple definition but we always want to be clear when we’re talking documentation, right?

Text therapy is providing therapy through any format where texting or online chatting are your main form of communication. This can happen through apps like TalkSpace, BetterHelp, and more. Sometimes you’ll combine video, phone, and texting, and the same considerations would apply to those combos.

Personally I LOVE these formats!

Still, there are a few big points to think through when you’re either considering offering counseling through these platforms or already are offering services through these platforms.

Assessment, support, and information

So first, you want to assess your level of risk and figure out how comfortable you are with it. Some people love trying new things and find it easy to think through all the issues and come to a decision. Some have a harder time, and might not love the idea of being dependent on someone else (the app) for record-keeping, etc.

Second, you want to make sure you have a solid support network of other therapists to consult. If you don’t have that network in place, please get working on that before you engage in these new platforms. If you’ve already started, get that network together now.

Third, You’ll need to be aware that you probably won’t have a lot of access to your client information. These platforms are great for anonymity, which can be a really awesome tool for your clients. Some of them will feel more comfortable sharing and being honest because they know you have limited info. Some of them may never have considered therapy without the choice to remain anonymous.

Anonymity can be excellent for the therapy process, but it does come with some issues for you to be thinking about:

  1. You want and need basic client information, like name, phone number, and address.
    Why? Because sometimes you get cut-off mid phone call, or the app might stop working, and you’ll need to be able to communicate with your clients if that happens. A client might start exhibiting suicidal ideations or you may realize they’re in danger, and you’ll need an address. Now plenty of your clients will be happy to give you the basics, so just ask them.
    
And then, if needed, keep asking. 

    I’m not saying harass them about it, but as the information is relevant, make a point to ask them again if they’ll share those three things.

  2. Who keeps the records?
    You’ll get to the root of the problem and get the answer you need by simply asking your platform provider what happens in case of a records request. For your own peace of mind and for your clients’, you’ll need to know whose responsibility it is get the clients their records and what is revealed in the process. 
If the app says, ‘Well we don’t have anything to give them,” then you know they aren’t keeping records at all, and you’ll need to keep a full record to CYA. On the other hand, if they say they can hand over entire transcripts of conversations, then you know that what’s being said isn’t completely private, and you need to pass that information on to clients.

And then there’s the notes question.
Where do you write progress notes? How?


Well, you’ll need to know where you’re tracking access to the data you do have on clients. Maybe you’ll keep your own record on the side, or maybe you’ll feel more comfortable keeping a full record. It depends what you have access to through the app.

Either way, keep your notes wherever you have access to the rest of a client’s info. You’ll need access to them in order to protect your clients and yourself, to write reports if a client requests them, etc.

And of course, you need to write notes for EVERY session. If you have specific sessions by chat where you are 100% focused on the client for an hour, write your progress notes as usual after each session.

If you’re texting back and forth all the time instead you’ll want to do daily or weekly summary notes. So maybe you spend ten minutes talking on Monday, and five on Wednesday, and then a few minutes Thursday, Friday, and Saturday, and you write a weekly progress note.

Maybe you spend lots of time on texting in between video sessions, in which case you’ll need a regular note for the video session and a summary of what’s going on in the texts. This way you’ll be able to refer back to what you’re working through, what techniques you’ve used, and what progress a client is making, even if it’s not happening in a traditional way.

There you have it: If you’re considering starting text therapy, think all of this through ahead of time. If you’re already doing it, make sure the processes you have in place cover everything.

Looking for more information on notes? Check out my Therapy Notes FAQ, the basics you need for process notes, and the Comprehensive Note Writing Guide for Therapists, or sign up for the Private Practice Paperwork Crash Course.

The Things You Carry, Part Two

Guest Post by Christina Kaake

As therapists, here’s a concept you know and love, right?

Well for those of you who have stuff to write, and particularly if you have trouble with writing anxiety, boundaries are your BEST writing friend! Set yourself some keyboard-related boundaries because they give you an incredible edge in finishing what you start and, importantly, making sure you finish strong.

I’m sure some of you are excited about even the concept of a new boundary to set (amiright?) and some of you think this makes no sense at all, so let’s get down to hard rules. Maelisa recently asked a bunch of you who are currently working on writing projects what your writing weaknesses are.

This week I promised to talk more about The Things You Carry—those issues people have mentioned to us that keep them from finishing a writing project and weigh you down.

Writing too much can be an issue (and I would know—word counts are SERIOUS business in journalism), or getting distracted, or simply taking too long. So in our last installment of the Writing Boundaries series, I want to cover those concerns, as well as some general tips.

1001, 1002, 1003, 1004….

First thing first, if you feel like you write too much…well, welcome to the club. You know how I mentioned above that word counts are serious business in journalism? I have agonized over cutting 100 words from a piece, and I have hated it and been sure it’s ruining everything.

Yes, I tend toward the dramatic when I’m stressed.

But the thing is, it doesn’t matter how much I hate it, what matters is that the word count is there for a reason. Sometimes I know the reason—space limits, attention-span limits, consistency—and sometimes I don’t. It doesn’t matter. What matters is I’ve been given a task and, honestly, my writing has been better for it. I’m forced to make sentences tighter and refine ideas. It’s a fantastic exercise, and I’m about to drop it on YOU.

Give yourself a word count.

Catching up on notes? Set a limit and see if you can stick to it—if not, ask yourself why. Are you including unnecessary information, or was the limit unrealistic? I once had an editor tell me to go back and add words because she decided the limit she gave didn’t work for the story. Check the average length of your notes against a colleague, and see where you might be able to trim, or if you’re right on target. If you are, use that average as your limit from now on, unless there’s an anomaly in a session.

Working on a book or scholarly article? Maybe you don’t want to limit yourself, but once you’ve started writing and are ready to re-read a few hours’ work, force yourself to cut 20% of the words and see how it turns out.

Squirrel!

Shiny distractions keep us all from our work.

Sometimes you open a browser window and a suggested article pops up and…two hours later you never actually started your work. Not that I speak from experience. Or you work from home, and kids and spouses interrupt you or make it hard to focus. Maybe you have so many projects that one piece of work is distracting you from another.

If you don’t absolutely need the internet, turn the wifi off on your computer. I know it’s hard. I promise, I’ve been there. But it helps! Put your phone on silent in another room. Without Facebook, Twitter, and those Firefox reading suggestions (again, totally hypothetical), you stand a better chance.

For me, music and headphones help. Headphones serve to focus my mind (although I have no idea why) and some good music in the background just makes me feel like I’m in work mode. Music may not be your thing, but headphones can keep us from noticing what’s going on elsewhere in a crowded office space, coffee shop, or around the house.

Too many projects vying for your attention? Set a specific time to work on each one. Knowing that you have two hours scheduled for project B tomorrow morning can help you stay on project A now. If the two share a deadline, or both have no deadline, then feel free to work on whichever one is inspiring you, but still block out separate time to work on the other. Keep an open document on your computer or a notepad nearby, and write down ideas as they come, but then get right back to what you were doing.

That will keep you from losing any fantastic ideas you have and also allow you to stay on task.

“Cross this line and you’re DEAD”

I had a writing professor who LOVED to say this to us in college. Annoying? YES. Accurate? Yup. Deadlines exist for a reason, and they’re rarely arbitrary. Set yourself a deadline that makes sense for every project you start, and tell yourself over and over that crossing that line is NOT acceptable. I know it’s tempting to ignore self-imposed deadlines, but honoring your deadlines means respecting your own time as a professional.

Keep that in mind, create deadlines, and make a practice of sticking to them.

A final note…

Some people just aren’t writers, and that’s okay! I would be remiss if I didn’t mention that there are lots of excellent professionals who can help you. Consider working with a ghost-writer if you have too much writing to do or your skills aren’t up to scratch. We’re very discreet :)

If all you need is a little polish, you can hire a copywriter to check your work for consistent tone, voice, grammar, etc. If you want to do the writing yourself and have confidence in your skills but need some help with structure, consistency, or staying on track, hire a writing coach.

In all of these cases you can try someone’s services before committing to a long-term contract (although you absolutely must pay them for their time—imagine if your clients asked for a free month of sessions to make sure you’re a good fit). If a ghostwriter sends you a chapter you don’t like, or a coach just isn’t getting your style, move on.

Give yourself the freedom to ask for professional help.

Once again I’ll ask you to consider your own profession: your clients need tools, or they need a helping hand using the tools they already have, or maybe they’re overwhelmed and just need someone to shoulder some of the burden. Just as you wouldn’t want clients judging themselves for needing help, or wanting help, and you would be aghast at someone else judging them, you should never judge yourself if you want or need help with the writing tasks you’ve set yourself. I promise you, professional writers won’t judge you, they’ll just step in where needed and give you a hand, and they’ll be happy to step back out again if you feel like you don’t need them anymore.

This is the official end of the series on instituting boundaries in your writing, but if you have a concern that hasn’t been addressed, never fear! We’re always around, so comment here or send us an email and we’ll get back to you with the perfect boundary.

Go! WRITE!

The Edit Remix

Guest Post by Christina Kaake

Boundaries!

As therapists, here’s a concept you know and love, right?

Well for those of you who have stuff to write, and particularly if you have trouble with writing anxiety, boundaries are your BEST writing friend! Set yourself some keyboard-related boundaries because they give you an incredible edge in finishing what you start and, importantly, making sure you finish strong.

I’m sure some of you are excited about even the concept of a new boundary to set (amiright?) and some of you think this makes no sense at all, so let’s get down to hard rules. Maelisa recently asked a bunch of you who are currently working on writing projects and your writing weaknesses.

We’ve already covered getting your writing started and some common concerns, so this week we’re taking time to talk about the things that ails us most:

The absolute most common issue was over-editing yourselves.

Oh that age-old editing problem. You just can’t stop yourself from tweaking one more word, from checking your comma usage a fourth time, from re-reading it again even though you meant to finish it yesterday.

I'm guessing as therapists most of you fall into one of two categories: either you are writing for your own website/audience and publishing your posts yourself, or you have a chance to send work to an editor (if you're writing for someone else's site, publishing a book, etc.). In either case, you’re worrying more than necessary.

The audience for your websites/blogs/notes (ahem) is less interested in your grammatical prowess than your content. Sure, you might get the odd reader annoyed with comma placement or mentally correcting who's to whose. But those people will have forgotten your editing faux pas within minutes. Seriously! What sticks with us (yes, I’m one of them) is errors in major publications like the New York Times, and even then we know an editor let it slip because they were overworked.

As a professional writer and reader, I have never stopped reading a blog or other interesting content because of editing issues. But your flawlessly-written piece with no punctuation errors and the perfectly-constructed sentences? Those tend to be so over-written as to lose focus, interest, and readability. Remind yourself that the point of your writing is to tell a story, and keep that front and center as you read and edit.

If you're really concerned, use a free online grammar checker. Truth bomb—Even those of us who get paid to write for other people do it sometimes. In fact, I know freelancers who use one for every piece, because the more you re-read something, the less likely you are to catch errors.

For those lucky writers sending their work to someone else for publishing, you HAVE an editor, and it’s their job to find and fix both stylistic and grammatical problems. Stop worrying—they get paid for this!

Since "stop worrying about it," is rarely actionable advice, your best bet is to start by setting yourself an *absolute* limit, and sticking to it. Allow yourself three drafts/edits of a piece of writing, and then STOP. No more. When you get to a 4th read-through, you are no longer editing for clarity or consistency. You are 100% missing any actual problems (science backs me up on this--your brain fills in the right letters and words when you know what SHOULD be there) and simply re-writing. In general I've found that when someone re-writes several times, they either add or remove so much that they lose their original point.

In the end, if you edit too much, you are not producing usable material (if for no other reason than you *aren't using* it). Set yourself a limit, and force yourself to stick to it. Hit the publish button and accept the tiny frisson of anxiety we writers still feel every single time. And if you're still worried, know that I once re-read a resumé I sent in for a writing job and was horrified by the mistakes I found in matching tenses. The editor who wanted to hire me? He didn't care.

Next week, we’ll get back to more of The Things You Carry, so if you have a specific concern you’d like addressed, leave it in the comments!

The Things You Carry

Guest Post by Christina Kaake

Boundaries!

As therapists, here’s a concept you know and love, right?

Well for those of you who have stuff to write, and particularly if you have trouble with writing anxiety, boundaries are your BEST writing friend! Set yourself some keyboard-related boundaries because they give you an incredible edge in finishing what you start and, importantly, making sure you finish strong.

I’m sure some of you are excited about even the concept of a new boundary to set (amiright?) and some of you think this makes no sense at all, so let’s get down to hard rules. Maelisa recently asked a bunch of you who are currently working on writing projects what your writing weaknesses are.

Concerns that came up a lot were overthinking what you write and/or writing too much.

We also heard from people who are too personal or too vague, and from a few of you who love exclamation points (ahem, Maelisa). Over the next few weeks, we’re going to address all of those problems, and every single one has — you guessed it — a corresponding boundary!

Last week we talked about getting your writing off the ground. This week we’re addressing some of your specific concerns, what I’m calling The Things You Carry.

Punctuation

Some of you overuse exclamation points! You use them a lot!! They are your BEST!!! FRIENDS!!!! This one is simple. You now have a one-exclamation-point-per-piece rule. What constitutes a piece? A blog post, a short article, or a chapter in a book. In a longer article, limit yourself to one per section of your article, and *try* not to use them in consecutive sections. Let your passion and excitement show through your work, not through your punctuation.

When you’re just…vague.

We’ve all been there. You know you have a great point to make, but you can’t quite get to it. You’ve been writing in circles, coming close without ever getting into the details. The easiest way to go from vague to specific is by giving an example.

Here’s an example (see what I did there?): If you were a designer giving someone a color scheme, you wouldn’t say, “I recommend maybe a few shades in warm tones and one or two cooler options, along with one surprising neutral.” You’d say, “What I’m thinking is coral, mustard, and olive with navy accents, using a pale pink for your neutral.”

Do the same in your writing. There’s a reason we use the adage, “show, don’t tell.” It’s because it works! So if you want to talk about why HIPAA compliance is important, tell me a story about what happens when I’m not compliant. Worried about confidentiality? Make up a phony client and give them a real problem. And if you once overcame exactly the issue you’re talking about, give me an outline of how you did it and what your life/business looked like after you did. That leads me right into how personal is “too” personal.

Or when you go way beyond vague

Maelisa addressed this with some great encouragement. When you get personal, you connect with your readers in a special way, and they will absolutely love it. For some of us though, the boundaries between personal and professional are sacrosanct.

That’s okay! You can be personal and set yourself a few limits to keep your privacy intact. First, run your story past a trusted colleague, because they’ll have a better sense than you will of how personal it really is. When we have lived something, and then we write it, we feel vulnerable and exposed in ways we might not really be exposed, because we know all the background. Fresh eyes and ears will help.

Second, if you can remove specific details without hurting the story arc, do it. I know that tapping into anger was helpful to me in my divorce, and I use some quirky details to engage readers, like how I blistered my fingers mopping the floor while thinking about our marriage. I can refer to the imaginary conversations I had with my ex about exactly which actions hurt me, and how, and why I was angry. I spent hours having that imaginary conversation, racking up the charges I had been minimizing for years in an attempt to make my marriage work. I got MAD. That anger helped me reclaim my story by focusing on how my decisions made me feel strong and in control.

In that story I haven’t referred to the specific ways I was hurting, but I’ve still made my point. The details about blistering my hands (true!), and referring to the imaginary conversation, which so many people engage in, make the story personal and give it staying power without making me feel vulnerable.

Too vague and too personal are opposite sides of the same coin, but I promise you that with practice, it gets easier, and honestly most of us are our own worst critics (another one of those very true clichés). So get another set of eyes, and then listen to their evaluation.

I know some of you are saying, but what about my issue? Never fear! We’ll address more of the Things You Carry next week!

Boundaries, Writers! (A four-part series)

Guest Post by Christina Kaake

As therapists, here’s a concept you know and love, right?

Well for those of you who have stuff to write, and particularly if you have trouble with writing anxiety, boundaries are your BEST writing friend! Set yourself some keyboard-related boundaries because they give you an incredible edge in finishing what you start and, importantly, making sure you finish strong.

I’m sure some of you are excited about even the concept of a new boundary to set (amiright?) and some of you think this makes no sense at all, so let’s get down to hard rules. Maelisa recently asked a bunch of you who are currently working on writing projects what your writing weaknesses are.

Concerns that came up a lot were overthinking what you write and/or writing too much.

We also heard from people who are too personal or too vague, and from a few of you who love exclamation points (ahem, Maelisa). Over the next few weeks, we’re going to address all of those problems, and every single one has — you guessed it — a corresponding boundary!

Get the Party Started—Part One

I’ve been there: The blank computer screen and the 1001 excuses not to focus on it. I think every writer (or college student) has been there. There’s always something else you could be doing, another project that needs your attention, and the nagging self-doubt that always seems to win those internal arguments.

If you have trouble starting there are boundaries and tips to get you over the hump.

A few of the boundaries are simple, so we’ll start with those.

Make It Happen

Set yourself a schedule. Whether you write daily, weekly, or monthly, or you tackle your projects for one hour or eight, successful professional writers know that you need to treat writing like any other job.

Create your schedule and stick to it just like you ask your clients to do.

You probably won’t charge yourself for a skipped appointment with your laptop, but you should remember that a note left unfinished could rear its ugly head with real-life consequences and web copy left unpublished results every day in missed sales and missed income.

Once you’ve got your schedule, make sure you set a specific goal every time you sit down to write.

I’m not talking goals like, “I will start my book today,” or “I will catch up on notes.” You want to sit down with a plan for a topic you’ll deal with or a number of words you’ll write. For example, “Today I will explain how I’ve used a reward system to get through a task that was difficult for me to stay focused on and finish in a timely manner.”

If that’s not enough to get you started, try some writer-tested, writer-approved techniques for breaking free of writer’s block.

Free writing and writing prompts are two techniques that work just as well for your professional work as they do for fiction writing. Using the example from above, if I know I want to explain how my reward system has worked but I’m still having trouble getting into it, I can free write about goals, rewards, and do a little journaling about the experience I want to relay to you.

Even if you go off track, allow yourself the freedom to do that.

Stick to your boundaries by setting a timer for your free writing exercise. When the timer goes off re-read what you’ve got and start pulling the important points out to expand on them.

If prompts are more your style, write some for yourself. Think of the question you get asked most often, and how you answer it or why it’s so difficult to answer for people.

What research is needed to tailor the answer to a person? Or what is frustrating about the question? Once you get stuck into answering those prompts, you may just find yourself with a blog post ready for editing. If you’re writing notes, try prompting yourself by asking what stuck out to you most from the session, and why.

If you’re still having trouble, try combining your new boundaries with a little excitement.

Treat Yo’self

How we all feel about this 21st century advice is probably a topic with enough oomph for its own entire set of blog posts. But I’m not advising that you go out and buy a new video game or purse, or have a night out at an expensive restaurant every time you write.

I’m talking about a small system of goals and rewards.

A few years ago I was regularly reviewing books, which in case you’re wondering, is a compulsive reader’s dream. Unless, of course, the book is badly written. The thing about journalism is that it includes a deadline for every project, which means having a hard time getting started is a Very Bad Problem.

One day, as I was trying to convince myself to read a particularly onerous book because the review was due the next day, I came up with a system. I knew what I really wanted to do was binge-watch my favorite show on Netflix. So I made a deal with myself that I could watch one episode for every two chapters I read.

Having that small reward to look forward to was truly a weight off my shoulders.

I could commit to two chapters at a time and in fact, most of the time I could get through four or five before stopping. I was able to finish the book on time, and the review, and I also gave myself permission to rest and relax.

If your writing project fills you with dread, give yourself permission to chill when you reach small goals.

Make sure they’re treats you really will be able to enjoy, and that will give you a true break from your work. If you’re a social media junkie, give yourself 15 minutes to zone out on Insta once you finish five notes. If you’ve got a new murder mystery on the bookshelf, let yourself read two chapters for every 500 words you write. If you love to bake, try out a bread recipe that requires resting and kneading, and work in between.

Regardless of what you choose, the excitement of getting that time to do something you love will keep you motivated and give you new energy to re-focus when you come back to your writing.

What tips and tricks have you used to get yourself on track?

If you need some help making your writing projects happen, consider joining the Therapist Writer’s Support Group. You got an email about it last week if you’re on the QA Prep mailing list and if you’re not already on the list, you can sign up here!

You can also check out some of Maelisa’s past blogs about writing notes here and here.

Avoid Fraud When You Diagnose

Here’s a common scenario: A new client comes in, obviously in need of your services. You want them to be able to use insurance because you know how important therapy is and want to make sure they get what they need. So you diagnose them with something —anything— to make it happen. 

You think you’ve done them a favor, but what you’re really doing is committing FRAUD.

It happens every day, and most therapist don’t even realize they’re breaking the law. I’m here to help you avoid fraud! That’s why I want to talk about the major mistakes people make when giving a diagnosis for insurance. 

Watch the video to find out more or keep reading below…

The first thing to remember is that any diagnosis you give, for any reason, must be real and accurate. So get out that DSM and make sure!

Even when I was diagnosing people every day as part of an agency job, I always double-checked the criteria for every diagnosis, every time. Why? Because even when we think we know a diagnosis inside and out, the DSM offers crucial guidance to getting it right. And unless you have a photographic memory, you probably don’t remember every single component of every diagnosis. 

The two big mistakes people make in a diagnosis that often lead to fraud are over-diagnosing and under-diagnosing. 

Let’s look at a common diagnosis to see how this works in practice: Adjustment Disorder.

Under-diagnosing


In under-diagnosing a client, you’re probably forgetting the ‘rule of severity.’ One of the main criteria for adjustment disorder is that if someone meets the criteria for another, ‘more significant’ disorder, you *must* diagnose them with the other disorder.

For instance, you may have a new client who fits the criteria for Bipolar Disorder and sought you out while in the middle of a Major Depressive Episode. If that’s the case, you are not allowed either legally OR ethically to diagnose them with Adjustment Disorder.

Sometimes we therapists worry about documenting something like Bipolar Disorder, concerned the diagnosis might do harm to our client.

In those cases, our job is to remember how important it is for our clients to have accurate medical records for their own health, as well as for us to be doing the best job possible providing the services our clients need. We fail at both of those if we don’t diagnose properly.

Over-Diagnosing


Over-diagnosing looks like this common scenario: a client comes to you in major distress, even though they don’t meet the criteria for any specific disorder. They could be experiencing a major transition or experiencing stress related to job loss, a major move, etc. In cases like this many therapists will ‘fudge’ a diagnosis; after all, everyone meets the criteria for adjustment disorder, right?

Well as much as I like fudge to eat, it’s a bad idea for diagnoses!

You don’t want to give someone a mental health diagnosis if they don’t actually meet the criteria, because you have no idea how it might impact them in the future. It’s just as bad as under-diagnosing to avoid what you might consider a ‘harmful’ diagnosis.  

Basically, therapists should never (ever!) give a diagnosis to a client unless they meet the criteria.

If you want to keep the insurance companies happy, clients happy, and yourself protected, diagnosis is just one part of what you need to consider for clients who use insurance. Click here to check out everything you need to know about insurance and medical necessity. 

Documenting Text Messages and Emails

“Do I need to copy and paste all emails from clients into their file?”

“How do I document or save text messages with clients?”

These are concerns that usually come up for mental health therapists after they start seeing clients, and after they’ve reviewed policies and procedures with them. It’s okay though, even if your client starts texting you out of the blue and you had no policy around this, you have plenty of options for documenting this conversation… easily and simply.

Let’s review some tips for documenting text messages and emails with your counseling clients:

Think of texts and emails like voicemail.

Remember when all you did was talk on the phone? Life was so much simpler then… in some ways.

The problem is that we often over-complicate things when they are new, and texting or emailing with clients is still relatively new in the world of mental health.

But when you think about it, texts and emails are commonly replacing communication that would have happened over the phone 20 years ago… so a good question to ask yourself is, “What would I do if this were a voicemail?”

You’d likely write a brief note about the interaction. For example, you might write something like:

“Client left voicemail cancelling session due to being sick. I called her back and she will attend next session on xx/yy/zz.”

That’s it! Easy!!

Same thing with a text or email communicating the same type of information. Simply write a brief note in the file so you remember what happened and it’s documented for good.

Summarize, summarize, summarize

I really don’t believe it’s necessary to copy and paste most emails or text messages with clients. The key is to make sure you do have the communication documented in some way, and the easiest way to do this is to summarize in a brief note, like the example above.

Don’t overwhelm yourself!

Tracking and copying all this information may be unrealistic but it doesn’t mean you’re being unethical or not able to document the important aspect of the communication.

And if you prefer to have ALL the back and forth communication with your clients, there are actually some cool apps available that will save this information for you. They offer a secure way to text with clients and the ability to print out or review any text messages.

The added benefit of email and text communication with your therapy clients is that, when needed, you actually can copy and paste the entire communication.

While I don’t recommend doing this every time, it can be very helpful when ethical dilemmas arise or when there is confusion about the communication.

So, in my opinion, these types of communication can actually be more useful than voicemails! It is unlikely you’d want to save a full voicemail from a client, but copying and pasting a long email into your EHR takes about 30 seconds… and gives you a secure way to save potentially important communication.

Let us know in the comments below:

Do you save all your emails or text messages with clients? Do you use an app to communicate with clients and save all the data?

Remember, there’s no right or wrong answer here and we can all help one another by sharing.

Writing Court Letters in Private Practice

There are few things that stress out therapists as much as dealing with a subpoena or a request for records. Most of us prefer to avoid anything court-related at all costs.

However, many counselors unknowingly get involved with court cases through one simple step: Writing a letter that is used in a court case.

While a letter is often preferable to releasing all the psychotherapy records, it’s important to remember that letters can also have significance and we should be careful about what we write. We also need to make sure we review the potential consequences of letters with our clients.

You might be thinking, “What can be so harmful about writing a simple letter?”

Well, it is not so much the letter itself, but the potential for blurring lines of competence that can get therapists into trouble.

Let’s review a common scenario for writing a court letter…


We'll call our imaginary therapist in this scenario "Mary Muggle, LMFT." Mary has been seeing children and adolescents in a private practice setting for about 10 years and has been licensed for about 12 years.

>> It's important to note here that experienced clinicians appear to be more at risk in these areas. During extensive research into common board violations among various practitioners, I found very few examples of newer therapists making a violation. 

Mary begins seeing a 10-year-old boy we'll call Dudley. Dudley's parents are going through a divorce and over the last two months his grades have been dropping and he started getting in fights at school. His mother brings him to treatment and explains that Dudley's father travels frequently for work and is aware that Dudley will be getting counseling but doesn't want to be involved.

Mary asks for custody paperwork and Dudley's mother brings in a form that isn't very clear but it appears that the parents have equal custody for now. Mary files this with her records and begins seeing Dudley for weekly therapy. She does leave a voicemail for Dudley's father to see if he can come in for an appointment but she never hears back.

During his sessions Dudley often reports missing his father because he sees him very irregularly now that his parents are no longer living together. He reports visits with his father being sporadic and including lots of take-out or junk food and very little discipline or structure. His father also does not seem to approve of Dudley being in therapy and says things like, "Fighting isn't a problem. Not sticking up for yourself is a problem. Don't let them turn you into a pansy."

After about three months of weekly sessions Dudley has made some improvement in school and seems to enjoy his weekly sessions but admits to Mary that he feels embarrassed to talk about them with his father.

It is around this time that Dudley's mother asks Mary to write a letter for an upcoming court date.

She is worried that Dudley's father will ask for therapy to be discontinued. She also confides that she is concerned his father will request more time with Dudley now that he is done with the work project that required so much travel. 

Mary writes a letter summarizing Dudley's reason for referral, his goals and progress to date, as well as Dudley’s concerns about his father not supporting the therapy process. She highlights in the letter that this can be detrimental to therapeutic rapport, Dudley's ongoing progress in school, and she reports that Dudley's father has been uninvolved and may be a negative influence. She also recommends Dudley's mother remain the primary caregiver.


Writing a letter about Dudley's treatment is perfectly acceptable, but Mary makes two critical mistakes in this scenario:

  1. She provides an opinion about Dudley's father without ever talking to Dudley's father.

  2. She provides a recommendation related to custody without being appointed (or even trained) to do so.

These mistakes are critical errors because Mary is practicing outside her scope of practice and has a potentially harmful dual relationship.

Let’s dig into each of these issues…

The Ethics of Dual Relationships and Scope of Practice

As mental health professionals, we often see into the very vulnerable parts of individuals and families. We also form a connection with our clients. We like to use the term “therapeutic rapport” to sound more academic but it is often a basic, human connection we have with our clients.

This connection is important for counseling to provide a healing environment where clients can be vulnerable. However, this connection impairs our ability to be objective.

That is why, for example, it is usually unethical for me as a psychologist to do psychological testing with someone who is also a therapy client. Or to test someone whom I already know well.

No matter how objective psychological tests are, my interpretation or evaluation report is very likely to be influenced by my prior knowledge of the person’s abilities, history, etc.

Likewise, our relationship with our clients can impair our ability to objectively look at other situations, such as custody agreements. This applies when your client is the child, as well as when your client is one of the parents.

Custody situations are often very emotionally charged for all involved and this makes objectivity that much harder.

So it is generally considered unethical to provide an opinion about custody unless you are specifically trained in providing such assessments (which often have very specific legal guidelines and ramifications) and have no prior relationship with members of the family involved.

Are there exceptions to these guidelines? Always!

For example, if you live in a rural area and there are very few providers, you might be the only person available to provide such an assessment, despite some type of prior relationship with the family involved.

This is where we must consult our ethical guidelines, consult with colleagues who can offer guidance, and disclose all the potential things that might be impacting our objectivity.

So what do we do about writing court letters?

Keep writing them!

(Or don’t… more on that in a minute)

Yes, keep writing them but always keep in mind that letters can have a significant impact and…

It is not your role as the therapist to make legal determinations for your clients.

>> Should your client be excused from work because of the significant stress it is causing? Your role is to assist the client through this process and potentially, provide a letter explaining their current symptoms and stressors.

>> Should your client receive social security disability because of their diagnosis? Your role is (usually) to report the symptoms, history of these symptoms, impact of the diagnosis, and the prognosis based on your ongoing professional assessment.

>> Should your client who loves his children have custody of them because their mother (his ex-wife) is an alcoholic and currently in jail? Your role is to simply report your client’s progress in treatment, regardless of the circumstances.

Most counselors are well-meaning and genuinely think the recommendations they include in letters will benefit their clients, and the others involved.

We became mental health professionals because we want to help people! And it often seems unfair when we can’t help our clients the way we want.

However, you can help your clients when they are experiencing any of the above scenarios.

Here are some general guidelines for writing letters that might be requested by an attorney, sent to an evaluator, or used to determine a client’s role or benefits in some way:

  • Discuss with your client the limitations and potential ramifications of writing such a letter and that you cannot guarantee any type of result, positive or negative.

  • Stick to the facts. All of your statements should be backed by data (whether that’s your own clinical assessment, reports by others, observation, etc.).

  • Report on what is observable and provide examples or quotes, if needed. Keep in mind that your client’s statements about the situation or anything you have observed might be relevant here.

  • Keep your opinions about anyone or anything that is not your client out of the letter. For example, Mary could certainly write that Dudley’s father has been unresponsive to her attempts to reach out and therefore uninvolved in treatment. Those are facts based on her experience, not an opinion.

  • Keep it simple. Stick with symptoms and/or reason for referral, progress to date, and perhaps, prognosis for treatment.

  • Don’t be afraid to say no or to charge for your time. Writing letters is stressful and it does take time, but it’s also not required, unless you have a subpoena or some other type of court order. You have every right to say no or to charge a reasonable fee for your time. Just make sure this is outlined in your policies!

Keep in mind these guidelines are generalized and you must always consult your own state laws and professional ethics!

Using these guidelines should help you stay ethical, provide excellent care for your clients, and create a less stressful experience for you as the treating therapist.

How do you handle requests for letters from clients? Let us know in the comments below!

Therapy Interventions Cheat Sheet for Case Notes

You may have heard me mention that I don’t usually recommend treatment planners for notes and other documentation.

That’s because these planners rarely save time. In fact, I hear from many counselors who tell me they actually end up taking more time and definitely create more confusion.

These planners also don’t help you personalize your progress notes. That’s why I created this video!

In this video I not only walk you through the benefits of creating your own cheat sheet, but I’m actually sharing 10 therapy interventions that you can still and add to your cheat sheet right away.

Not into watching a video?

Well, you’ll miss out on the examples of how to implement a lot of these, but I’m listing them here for your convenience!

These are 10 therapy interventions that pretty much ANY mental health counselor needs to have in their writing arsenal:

  1. Assessed

  2. Challenged

  3. Demonstrated

  4. Evaluated

  5. Explored

  6. Identified

  7. Labeled

  8. Normalized

  9. Reflected

  10. Processed

Now tell us!

Do you use a cheat sheet for your notes? Which interventions do you plan to use in your cheat sheet?

Process Notes: What You MUST Know

Maybe you’ve heard some of these terms and are confused about how they are different (or the same!)…

  • Process notes

  • Progress notes

  • Psychotherapy notes

  • Case notes

  • Clinical notes

What do all these terms mean?!

Fear not, amazing therapist, I am clearing this up in the video below!

And in case you’re not into videos, here’s a snap shot of what I cover:

  1. “Psychotherapy notes” and “process notes” are the same thing, we all just tend to use different terms. The term “psychotherapy notes” was created specifically for HIPAA so this impacts how we use this term.

  2. Process notes are totally optional! Yup, there is no requirement to write them, so it’s totally up to you.

  3. Process notes don’t even have to be legible. You can draw, use shorthand and abbreviations. In short, you can do what you want since they are just for you.

But most importantly, process notes are NOT a place to hide important clinical information that may be needed for treatment.

Your progress notes should always document treatment and should be able to stand alone to tell the story of your client’s journey in therapy.

Now, let us know! Do you use process notes? Why or why not?

Credit Card Fees and Private Practice: Can I Pass the Fee to My Client?

Credit cards are pretty standard practice in the world of mental health these days. And, in my opinion, that’s a good thing.

Credit cards mean it’s easier for clients to pay for services, you can be assured that you’ll be paid, and clients can often use Flexible Spending Accounts to save money and pay for therapy.

However, credit card processing is NOT free so someone has to pay for these companies to create massive firewalls and protect our client’s personal data… but who pays?

In this video I explain you shouldn’t pass the fee on to your clients… but I also explain how to do this without losing money yourself.

Because yes, having a modern therapy practice does cost a bit more these days, but it’s totally worth it.

I mentioned IvyPay in the video and yes, if you click on the link below you’ll get $1,000 free in initial credit card fees! Yay, thanks, IvyPay!

Click here to check it out.

You can learn more about all the things to consider with credit cards by checking out this blog post on Credit Cards: Your Questions Answered.

Let us know in the comments below! Do you factor in credit card fees when creating your own fee for counseling services?

How To Catch Up On Notes

One of the most common concerns I hear from therapists is that they are having trouble staying on top of their notes.

This is a big concern and the problem can get out of hand very quickly. 

That's why my approach to helping counselors catch up on progress notes consists of two things:

1. Create a sustainable strategy for staying on top of current notes.

2. Create a realistic plan for catching up on older notes.

Once these two things are mastered, you're good to go! The hard part is getting there...

That's why I recorded the following videos with steps on each strategy.

One caveat: It is tempting to jump to the catch up plan because that may be the immediate need that is causing stress. Don't do this!

It is sooooo important to create a sustainable schedule for yourself first so that we break the cycle of falling behind. So, make sure you watch Part 1 and really focus on trying out this strategy for a week or two before you jump to Part 2.

How To Catch Up On Notes (Part 1)

Create a sustainable schedule for ongoing notes

 

How To Catch Up On Notes (Part 2)

Create your catch up plan

Do you want extra support to get some notes done ASAP?

Click here to sign up for the Summer Paperwork Blitz!

More of My Favorite Intake Assessment Questions

You may have already read about My 4 Favorite Assessment Questions but let's get into some more! In this video I'm sharing four more questions I recommend you ask your clients during the intake process.

These questions will help you get the necessary historical data to treat them best but also help you make a connection more easily.

Still have questions about the intake assessment process? Then check out this blog post on Assessment Dilemmas and FAQ's to get some tips on how to simplify the process. 

Let us know in the comments below what your favorite questions are to build rapport with clients and get the information you need to provide them the best therapy possible. 

What is the BEST Case Note Template?

There are many different progress note templates to choose from and I often find that people are using a template they don't like... so what do I recommend? Well, that depends on you!

The Bad News: The best note template will vary with each clinician.

The Good News: The best note template will vary with each clinician... so you can make some quick changes right now that will improve your notes!

Watch the video below or read the summary underneath for some details on how you can do this today.

Here are some quick things to consider before adjusting your template:

  1. What sections of my note do I like?
  2. What sections seem insufficient?
  3. What do I write that doesn't seem to fit in one of my current template sections?

Then look at ways you can easily make adjustments to just these sections. You don't need to change the whole template! Add a section, take a section away, etc. Do what works for you.

Next, add checkboxes... but do it carefully and thoughtfully.

For the interventions section:

Don't go off someone else's list. Sure, you might use a list to gather ideas but don't include every possible intervention. If you're ignoring something all the time it is just getting in your way- delete it and move on!

For your client's response section:

Particularly if you work with similar types of clients, you will often have similar responses over time. Again, if these come up often then create checkboxes. If not, you can ignore this part... do what works for you ;) 

For the plan section:

You likely have common recommendations for your clients so why not create checkboxes that will make your life easier? You can always leave blank spaces to provide more detail on things like dates or specific recommendations.

Want to see some examples?

Click here to sign up for the FREE Private Practice Paperwork Crash Course and you'll get immediate access to video trainings, templates and note examples.

What is Medical Necessity?

Medical necessity is a term that is based on the medical model of treatment but is also applied to mental health treatment. Sometimes that can be confusing for those of us who are counselors, therapists, social workers and psychologists!

In this video I explain:

  • The three main components of medical necessity 
  • Why insurance companies use medical necessity for mental health
  • Where you want to highlight medical necessity in your documentation

Click here to submit a question for a future live Q&A video!

And let us know what you think in the comments below. Are there other strategies you use to talk with insurance companies? Does this seem to cover what is needed for your client notes?

Quick Clinical Case Notes (Collaborative Documentation Q&A)

Recently I've been getting a lot of questions about a somewhat controversial topic- collaborative documentation.  While I don't think everyone should use this strategy, I definitely think it's worth considering. 

Collaborative documentation (sometimes called concurrent documentation) can actually look very different for different therapists!

In this video I review four ways you can incorporate this strategy in your counseling practice right now:

  • Writing notes with clients in session
  • Writing part of the note with clients during session
  • Sharing notes with clients after they are written
  • Having clients complete intake paperwork before the initial session

I also go through some of the benefits and potential drawbacks of this technique:

  • Less time writing notes (the most obvious benefit!)
  • Increased communication and connection with your clients
  • Reduction of errors in documentation
  • Better engagement of "resistant" clients

If you’d like to submit a question for me to answer on a future YouTube Live Q&A, then click here.

>> Subscribe to my YouTube channel and click the bell for notifications so you don’t miss the next Live Q&A! 

I'm on every Monday at 12pm Pacific Time.

If you’re still looking for help with your documentation, click here to check out the FREE Private Practice Paperwork Crash Course

Do Therapists Really Get Disciplined for Failing to Take Notes?

One of the biggest concerns I hear from counselors about their documentation is whether or not their notes will be read by someone else. Usually they are most concerned by a potential court case Their concern is that the notes will somehow harm their client in this case.

Click here to read about whether or not I think limiting your note content can help you or your clients with court cases.

Secondly, the concern is about others reading their notes and that they will be deemed an incompetent or negligent clinician when the notes are revealed. 

Why are so many therapists worried about their notes somehow revealing poor practices? 

I find that the lack of clarity about what to write in therapy notes contributes to a LOT of worry. That worry builds when counselors seek out information about how to write progress notes and they find a myriad of conflicting information from seemingly reliable sources. 

The worry grows exponentially when that same counselor falls behind in their notes and needs to catch up on paperwork

Then you add to that a horror story of another counselor being put on probation or losing a contract due to poor note writing and this becomes a real concern!

But is it true that psychotherapists get disciplined for poor record keeping? Does this really happen?

Yes!

I find this commonly happens when some other catalyst creates a client complaint or Board investigation.

When the Board begins to investigate and requests records, they often find two additional problems (other than the original complaint):

  1. The clinician failed to obtain proper informed consent.

  2. The clinician failed to maintain adequate records.

Keep in mind that these common scenarios are regardless of whether or not the therapist is actually found to be at fault regarding the original complaint. 

So, let's dive in to each of these two scenarios and see how to avoid these common issues...

The clinician failed to obtain proper informed consent.

1) This often occurs when therapists are providing services to children and adolescents. The therapist may fail to inform the parents when it is required or may fail to obtain consent from the correct party (or both parties, if required). Similarly, this can also happen when a dependent adult is being treated.

2) I've also seen cases of this when a psychologist failed to obtain proper consent for psychological testing or did not adequately document reviewing the differences between a testing and a therapeutic counseling relationship. 

3) There are also scenarios where the therapist does not actually review the informed consent process at the beginning of therapy. Instead, they simply make sure forms are signed and don't review any policies or procedures, potential limits to confidentiality, or describe the therapeutic process.

When counselors are too lax about the intake process and jump right in to the therapy process they set themselves and their clients up for a potential disaster and significant harm to therapeutic rapport.   

4) Lastly, the counselor may simply fail to document that they obtained consent for treatment. I always recommend you document in an intake note that you reviewed necessary policies, potential limits to confidentiality and obtained consent for treatment.

The clinician failed to maintain adequate records.

1) One common problem here is that the therapist simply has incomplete records. They may be missing case notes, informed consent documents or other necessary paperwork, such as releases of information.

2) Another common problem is that the therapist has case notes but no other supporting documentation, such as a treatment plan or intake paperwork.

3) Lastly, the issue might be around quality of documentation. For example, the counselor only includes such brief information in their case notes that the Board cannot adequately determine if their actions are justified. Or the counselor may fail to document things like important phone calls or missed appointments that corroborate their side of the story. 

>> It's important to note here that experienced clinicians appear to be more at risk in these areas. I found very few examples of newer therapists being disciplined for these concerns. 

What can you do to avoid these potential problems?

Two ongoing things are critical for every licensed psychotherapist in every discipline, state and country:

So, just reading this blog post you are already on the right track! You're making ongoing learning a priority for your career. 

And despite the fact that you may hear different opinions about documentation practices, regularly discussing these practices with other clinicians, along with educating yourself on best practices, will help you gain the critical thinking needed to decide for yourself what you will do in your practice. 

If you're looking for a community of other therapists with whom you can consult, as well as a place to obtain continuing education credits and learn about individualized documentation techniques, then click here check out the Meaningful Documentation Academy

The Academy incorporates community and education to make sure you are prepared and confident about all things documentation.

How to Review Notes by Other Therapists

If you're a supervisor then you know it can feel like a daunting task to sit down and review notes for other therapists. 

Or maybe you've tried to do this for your own notes and found that you're not sure where to start, what to look for, or how to use the feedback you obtain.

Well, this quick video will help alleviate that confusion! 

I'm going to share with you how to structure your review and provide some tips so that you can make it a meaningful experience for yourself and your supervisee. 

And if you're looking for a simple tool you can use to make sure notes have all their necessary components, click below to sign up for my weekly emails and you'll also receive a Notes Checklist.

We keep your information secure via our Privacy Policy.