Have you ever felt unsure about how to document questionable behavior exhibited by your clients? Or unsure about whether or not you should document past criminal activity? Well, you're not alone!
This time we're continuing the FAQ series with a more specific topic- documenting criminal activity and/or questionable behavior of your clients. Although this is a shorter series of questions, I actually do receive these questions pretty often and thought they were important to address in the documentation FAQ series.
So, let's dive in to the questions!
"Documenting crimes committed- Do you? Don't you? How to?"
The short answer is YES. However, there are things to consider when documenting your client's criminal history.
First, let me explain some reasons why this answer is a clear YES...
- CYA (cover your assets). You want to know what type of client you are seeing. There are obviously varying levels of criminal behavior and in some cases this won't impact your treatment or be very significant. However, it can easily become significant. For example, if you share a common waiting room with other therapists and you see adults but they see children, it would be important to know if your client could potentially pose a risk to any other clients in the waiting area.
- This is objective information as part of an assessment. A criminal record is one of the most basic and objective pieces of information you can gather. It is public information. It is fairly straightforward (although circumstances can certainly make a huge difference) and it is likely relevant to your client's psychosocial history.
- It is clinically relevant. Significant events in your client's life are always important to document as part of a good clinical history. It's important to have these as baseline questions for all clients and to never assume that a client does or does not have any type of criminal history.
- Your documentation is not meant to hide historical data about your client. One of most common misconceptions in mental health is that confidentiality rules somehow mean we are supposed to hide information that could potentially be harmful to our client. Not so! Confidentiality protects our client's privacy and information to an extent. However, that does not mean we are to hide, downplay, or embellish any client information. Don't muddy the waters in your clinical relationship.
So, yes, you document any reported criminal history. And I recommend you specifically ask about criminal history- ALWAYS.
This is when it's important to review your paperwork with clients and make sure they know that you keep records, that they can access those records, and when those records may be requested or seen by others. It's also important to reiterate your commitment to their privacy and confidentiality.
"A client is involved in a criminal act like theft. Is it reportable?"
The short answer here is NO.
Regardless of the severity of the crime, past activity is typically not reportable... unless it falls under a separate reportable category like child abuse or unless someone is telling you about a crime they intend to commit in the future.
These are very important distinctions.
For example, I once had a client tell me they shot someone. However, there was no future identifiable victim, no child abuse, etc. Perhaps fortunately, this happened before I was licensed and I was able to consult with my supervisors and make sure we had considered all the potential reporting scenarios.
If you're unsure or have an uneasy feeling in your gut, consult with a colleague (or two) about the situation. Make sure you're aware of applicable state law and your ethical guidelines. Carefully consider and then document your rationale for reporting or not reporting a crime.
I hope this helps you if you're ever in doubt about whether or not something is reportable and how to document when your client tells you about past actions.
Remember to stay as objective as possible in all your documentation, particularly related to biopsychosocial history and anything that could later be used in a court matter.
Unless you are specifically trained in criminal behavior and potential for recidivism, avoid statements about whether or not you think a client will commit another offense. Stick to the facts, things like...
- Client reports being sober for the last 20 years
- Client reports attending support groups for the last five years
- Client reports no prior offense
- Client reports feeling very remorseful about behavior
- Client's spouse reports they are now "a different person" and they have not seen any similar behavior over the last five years
Now, tell us! What other tips do you have to add and when have you felt confident about documenting criminal activity? Comment below.