What Notes Do Therapists Take During Sessions?

Therapists employ various strategies to take notes during sessions, some lean heavily on documentation, while others maintain minimalism. This article explores the viewpoints of different therapists and the reasons behind their note-taking practices, helping clients understand and communicate with their therapists effectively.

Minimalist Note-Taking

Some therapists opt for minimalistic note-taking, focusing on concise, relevant information.

For example, a therapist might jot down brief bullet points such as 'Annoyed mother', 'Feeling depressed', or even a single symbol to capture a fleeting emotion. Before the session, the therapist typically fills out an intake sheet that includes common emotions, self-harm, suicidal ideation, appetite, sleep, medication changes, phone numbers, and any new activities or issues since the last session. This process is efficient, allowing the therapist to jot down essential information quickly and pay full attention to the client.

Process-Oriented Note-Taking

Art therapists, for instance, may use a different approach. They sometimes jot down key quotes from clients to return to later, making process drawings when clients engage in artistic, dance, or sand tray activities. These notes serve as essential reminders and tools for review. Any thoughts or interpretations are documented in a private supervision journal afterward, ensuring the confidentiality of the client's information. In cases where full case notes are required due to institutional obligations, therapists often write these notes from memory, including relevant quotes to help the treatment team understand the client's needs.

Balanced Note-Taking

Some therapists take a balanced approach, balancing the need for thorough documentation with the client's comfort. For example, if a client expresses concern about the therapist taking detailed notes, the therapist might suggest that they document the session after the session. This approach respects the client's boundaries while ensuring timely and accurate documentation. Here's an example from an art therapist:

During my sessions, I may jot down a few key quotes or make process drawings when clients engage in creative activities. These notes are to remind me of essential details and to help us review together. Any interpretation of what might be happening is documented in a private supervision journal afterward.

The Purpose of Notes in Therapy

The primary purpose of notes in therapy is to aid in understanding and processing complex emotions and issues. Intake notes, for instance, are essential at the beginning of a treatment plan to identify immediate goals and areas that require focus. During the session, therapists may note significant points for discussion, while subsequent notes might include interpretations or conclusions drawn from these discussions. This process helps both the therapist and the client to reflect on progress and align on the next steps.

Conclusion

Therapists employ various note-taking practices that range from minimal to detailed, depending on their approach and the setting. The key is to find a balance that respects the client's comfort and benefits the therapeutic process. Clients should feel comfortable discussing their notes and any concerns they may have about the note-taking process. Whether minimalist, process-oriented, or balanced, the aim is always to support the client's mental health and facilitate effective therapy.