Is Culture Part of Your Documentation?

Integrating culture is now the standard in treating clients as a therapist. Many of us received special training in this in grad school or we take continuing education classes that focus on the role of various cultures in therapy and mental health dynamics. But have you ever thought about the role culture plays in your documentation? 

There are lots of things to consider, particularly if you tend to work with specific cultural groups. Do you tend to see women only? Do you see families who are monolingual Spanish-speaking? Focus on military populations or LGBQ or Trans populations? All of these groups of people have a slightly different view of the world based on their common experience and there are many things a therapist can include in his or her paperwork that will help to build rapport and make clients feel understood.

  1. Consider the terms you use. Do you tend to work with groups who may not appreciate a gender section? Should your form be available in multiple languages? Think about how your typical or ideal clients describes things and use those terms. This is your opportunity to connect with your clients right from the beginning. Be professional but be real!
  2. Personalize your intake paperwork. Ask questions on your intake form/initial assessment that speak to your clients. If you specialize in sexual issues, ask about sex! If you specialize in children, have a (brief and kid-friendly) form for the child and one for the parent. If you specialize in military families, ask about deployments and current rank. The purpose of this document is to give you necessary information on your client and get them thinking about what they want work on with you. Make it a valuable use of time for both of you.
  3. Create policies that make sense for your clients. Do you specialize in working with elderly clients who would prefer to write a check or do you work with 20-somethings who never carry a checkbook? Do you work in a downtown area with professionals who travel and need flexibility with scheduling? Consider your ideal client and consider the policies the make sense for your business. It may not matter what your colleagues are doing but you know what does matter- having the policy written down and reviewing it in person with your clients.

Culture plays a part in every aspect of our work with clients. Make sure your documentation and your policies reflect that. Go through your intake forms and note where you could change the language so it applies better to your clients. Think about additional questions you commonly ask that you could add to your forms. Better yet, think about the questions no one answers or the ones you overlook and take them out!

If you want more help in creating your forms, check out my Clinical Documentation online program. We go in depth on this topic over two weeks. You can also check out my free Crash Course for an intro to the necessary components of private practice paperwork. 

But in the meantime, I'm interested in hearing from you! How do you incorporate culture into your documentation right now? Any steps you plan to take after reading this article or any tips you'd like to add?