38. 记录咨询会话

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38 Keeping records of counselling sessions We, like many counsellors, find the administrative and clerical duties associated with counselling a chore. However, it pays to keep detailed and up-to-date records on each counselling session. Ideally, report writing should be done immediately after the counselling session, while all the relevant information is fresh in the counsellor’s mind, and before other inputs have had time to intrude. In today’s society we can either type or dictate records using speech recognition software directly into a computer. Alternatively, we can keep handwritten records on printed forms or cards. Where records are computerised, adequate security measures are required to protect confidentiality. Similarly, handwritten records need to he kept in secure locations (see Chapter 40). IDENTIFYING THE PERSON SEEKING HELP Records of people seeking help need to he clearly identified so that there can be no confusion, because in large agencies it is not unusual to find two people with the same name. Identifiers might include: • family name (surname) • other names • date of birth (if known) • address • contact phone numbers. Where handwritten records are kept, it can be an advantage to label each page of the record with the person’s full name so that the possibility of pages being inadvertently placed in the wrong file is minimised. ADDITIONAL DEMOGRAPHIC INFORMATION ABOUT THE PERSON SEEKING HELP Commonly, when the information is available, records may include any of the following: • marital status • name of partner or spouse • names and ages of children • referral source.

NOTES ABOUT EACH COUNSELLING SESSION The notes for each counselling session may include: 1 date of the session 2 factual information given by the person 3 details of the person’s problems, issues or dilemmas 4 notes on the process that occurred during the session 5 notes on the outcome of the counselling session 6 notes on interventions used by the counsellor 7 notes on any goals identified 8 notes on any contract between the person and the counsellor 9 notes on matters to be considered at subsequent sessions 10 notes on the counsellor’s own feelings relating to the person and the counselling process 11 the counsellor’s initials or signature. We will now describe the content of the notes in more detail under the headings listed above. However, although these headings are discussed individually, in practice, notes often How together as the headings overlap. Handwritten notes need to be legible so that if a person transfers to another counsellor for some reason, notes can easily be read, with the person’s permission. DATE OF THE SESSION This heading is self-explanatory, When reviewing progress over time, it’s very useful to know the dates of counselling sessions. FACTUAL INFORMATION GIVEN BY THE PERSON SEEKING HELP During a counselling session the person seeking help is likely to divulge factual information, which may be useful in subsequent sessions. Sometimes small facts, person’s mind, or could, if remembered, provide the counsellor with a clearer included in a counsellor’s notes could be: She has been married for 13 years and during that time left her husband twice, once two years ago for a period of two weeks, and secondly six months ago for a longer unspecified period. She has considerable financial resources, Lacks a social support system, had an affair some years ago and has kept this a secret from her husband. DETAILS OF THE PERSON'S PROBLEMS, ISSUES OR DILEMMAS Keep the record brief, so that it can be read quickly when required this part of the record would be: Mary suspects that her husband may be sexually involved with another woman, is afraid to ask her husband whether this is so, and is confused about her attitudes to him. She can't decide whether to pluck up courage and confront him, to leave him now or to continue in what she experiences as an unsatisfactory relationship with him. She is not willing to consider relationship counselling with her husband.

NOTES ON THE PROCESS THAT OCCURRED DURING THE SESSION t he process is independent of the facts presented and of the person’s issues, and is concerned with what occurred during the counselling session, particularly in the person-to-person counselling interaction. For example: He initially had difficulty talking freely, but as the counselling relationship developed he was able to explore his confusion and look at his options. Although he was unable to decide which option to pursue, he seemed pleased by his ability to see his situation more clearly. NOTES ON THE OUTCOME OF THE COUNSELLING SESSION The outcome could be that a decision was made, or that the person remained stuck or that a dilemma was identified. Alternatively, the outcome might be described in terms of the person’s feelings at the end of the session. Examples of notes under this heading are: She decided to confront her husband. She left feeling sad and determined. She said that she could now see things clearly. NOTES ON INTERVENTIONS USED BY THE COUNSELLOR Notes under this section are intended to remind the counsellor of particular interventions used. For example, the notes might say: Taught relaxation. Coached in the use of assertive statements. Discussed the anger control chart. NOTES ON ANY GOALS IDENTIFIED These may be goals for the person to achieve in the world outside, or in counselling, for example: He wants to learn to be more assertive. She wants to use the counselling process to sort out her confusion and make a decision regarding her marriage. She wants to experiment by taking risks.

NOTES ON ANY CONTRACT BETWEEN THE PERSON AND THE COUNSELLOR It is important to remember any agreements that are made with the person seeking help. These may be with regard to future counselling sessions, for example: She contracted to come for counselling at fortnightly intervals for three sessions and then review progress. It was agreed that counselling sessions would be used to explore his relationships with the opposite sex. I contracted to teach relaxation during the next session. NOTES ON MATTERS TO BE CONSIDERED AT SUBSEQUENT SESSIONS Often during the last few minutes of a counselling session a person will bring up an important matter that is causing pain and is difficult to talk about. If this is noted in the record, then the counsellor can remind the person at the start of the next session, enabling them to deal with the issue in question, if they wish. Sometimes, as a counsellor, you will realise at the end of a session that aspects of a person s situation need further exploration. It can be useful to make a note as a reminder. NOTES ON THE COUNSELLOR'S OWN FEELINGS RELATING TO THE PERSON AND THE COUNSELLING PROCESS These are required to help the counsellor avoid letting their own feelings inappropriately interfere with the counselling process in future sessions. Such notes can be invaluable in the counsellor's own supervision, and may be useful in helping them to improve their understanding of the counselling process. An example is: I felt angry when he (the person seeking help) continually blamed others and failed to accept responsibility for his own actions. THE COUNSELLOR'S INITIALS OR SIGNATURE By initialling or signing case notes, a counsellor takes responsibility for what is written in them. In many agencies, counsellors work together with other counselling team members. In such agencies, over a period of time more than one counsellor may see a particular person. Also, a person may come back to an agency for further counselling after a particular counsellor has left. In such situations it can be helpful for the person if their counselling history is available, subject to the normal constraints of confidentiality7. As stated previously, writing records of counselling sessions can be a chore. However, a counsellor who does this diligently will quickly become aware of the advantages. The effectiveness of future counselling sessions may be improved if the counsellor reads the record of previous counselling sessions relating to a person before meeting with them each time. By doing this the counsellor is able to ‘tune in’ to the person right from the start of the interview and will not waste time on unnecessary repetition. Clearly, records need to be detailed, accurate and legible if they are to be maximally useful. However, when writing records, be aware of the confidentiality issue (see Chapter 40) and of the possibility that the legal system may demand that such records be made available to a court. Also, bear in mind when writing records that the person they relate to may later ask to read them. Clearly, a person seeking help has the right to read their own records if they wish to do so.

Learning summary Ideally, report writing should be done immediately after a counselling session. Records need to include: » the date » factual information and details of the person's issues » notes on the process and outcome of the session » notes regarding interventions used, goals set, contracts made and matters to be considered in the future » notes regarding the counsellor's own feelings. Writing records can seem a chore, but a counsellor who keeps diligent records quickly becomes aware of the advantages. Further reading Bor, R. & Watts, M. 2010, The Trainee Handbook: A Guide for Counselling & Psychotherapy Trainees^ 3rd edn, SAGEh London.