March 21, 2022

Now Modern Therapists Need to Document Every F*cking Thing in Our Progress Notes?!?

36 minutes

Curt and Katie discuss a recent citation from the California Board of Behavioral Sciences (BBS) to a therapist for cursing while in session. We explore: How do we document ruptures during the therapy session? Is the BBS over-reaching by controlling what therapists document? What are the best practices for note taking? All of this and more in the episode.

In this podcast episode we talk about appropriate documentation practices for modern therapists

As therapists it’s important that we take accurate notes. But what is important to include in the notes, and how much should we really be documenting?

Wait – Is it alright to use curse words in session?

Therapists should be first and foremost aware of the client and their potential reaction.

Note the therapeutic relationship with the client, their history, and how the client empowers themself when making language selections.

If considering using casual language, consider the client’s vernacular.

Follow the client’s lead when it comes to their language in session, including cursing.

The BBS has no specific statute related to cursing or swearing.

What should modern therapists document in clinical notes?

It is important to document any bold interventions or ruptures in the therapeutic relationship and repair attempts for ruptures.

In note taking, it is important to follow the clinical loop: assessment, diagnosis, treatment plan, intervention, use of intervention, and the client’s reaction and progress.

Your notes will be a balance of covering your liability and creating notes that help you remember the session.

Therapists should consider documenting the use of any language that could be deemed not clinically appropriate, even positive statements like “I’m proud of you,” or “Yes, my dear.”

Does the California Board of Behavioral Sciences (BBS) outline what we should say in our notes?

In the 300-page PDF outlining the statutes for LPCCs, LMFTs, LCSWs, and Educational Psychologists, notes are only mentioned 10 times.

There is no mention in the statutes of what can be said and what can’t be said in notes.

Some agencies and institutions will stress writing very little to ensure protection from liability, but as this citation showcases, this might not be best practice.

The BBS wants to ensure the protection of clients and you might need to justify your words, just as you would justify the use of an intervention.

This is a reminder that the BBS can and do look at therapist’s notes.

Support The Modern Therapist’s Survival Guide on Patreon!

If you love our content and would like to bring the conversations deeper, please support us on our Patreon. For as little as $2 per month we're able to bring you more content, exclusive offerings, and more opportunities to engage in our growing modern therapist community. These contributions help us to expand our offerings for continuing education events and a whole lot more. If you don't think you can make a monthly contribution – no worries – we also have a buy me a coffee profile for one-time donations support us at whatever level you can today it really helps us out. You can find us at patreon.com/mtsgpodcast or buymeacoffee.com/moderntherapist. Thanks everyone.

...more

View all episodes

By Curt Widhalm, LMFT and Katie Vernoy, LMFT

4.4

235235 ratings