Case Notes: Task or Tool?

Fields of Knowledge_Case Notes

If you have been providing therapy to clients with any longevity you have at some point questioned whether your approach to a given case was the culprit responsible for therapeutic stagnation. You may have chosen to switch your approach, integrate tenants of other models or refer the client(s) elsewhere.

You’re not alone in your desire to be the one who gets to witness a client’s transformation. However, most therapists understand that there is inevitably a time where they are not adequately equipped to handle a specific case. Unless there is an ethical dilemma with a particular client, therapists should (using good judgment) accept the clients that arrive for help.

I believe this because the person seeking help is present and in action. Any time a client leaves there is no guarantee that they will be back. Likewise, once a client is turned-away there is no guarantee they will contribute a similar effort again.

With this said, it is incumbent upon therapists to be equipped to supply the demand. At the least, the consultation process should include active listening, empathy and the sharing of hope and optimism. Whether the next step is session number two or a referral, therapists should feel that they have done everything possible to leave the client with a realistic impression of the therapeutic process.

Sometimes it’s further along than the initial consultation when therapists come to the realization that they are in over their head. Before throwing in the towel, therapists may seek guidance and advice from colleagues, mentors and other helping professionals.

Therapists can often learn a great deal from understanding how their colleagues’ approaches differ from their own. Even when colleagues share that their approach would have been the same, they may still be able to provide suggestions for your consideration.

I suggest that this dialogue, which is essentially a version of professional development, involve evaluating the effectiveness of your approach to tell the client’s story. In essence, this is a method for understanding how your therapeutic approach depicts your client(s). If your approach does not tell the client’s story, perhaps you can make a special effort to address the gaps in future sessions.

With the permission of your client(s), have a colleague review a version of your case notes, which outlines what approach and tools you have used and the effects that you hoped to, have gained. Have your colleague explain (back brief) the family’s situation as they see it as described by your notes, almost as if they were introducing you to the client(s) or transferring the case to you.

The picture they paint of the family may give you insights on the validity of the therapeutic model and techniques you have employed. Here are two examples using differing therapeutic approaches addressing a single vignette. Do the respective approaches to therapy tell the same story about the family? As we all know, there is rarely a single approach that can be considered “best”. However, you are always making the right decision when you approach a given case ethically, efficiently and effectively.

So while the model of therapy you have chosen to work with may not be wrong, you may be employing it ineffectively and thus having little effect assisting the client with positive change. These types of reviews assist clinicians with evaluating the effectiveness of their approach, and can be accomplished with a colleague or alone.

Example Case Notes – A

By implementing a structural approach, I understood that the relationship hierarchy needed to adjust significantly before the family’s optimal functionality could be attained. As a combined result of Jack devoting so much of his time at work, and Jill being the parent who has been more consistently present, of course Johnny would develop a more closely emotional relationship with his mother. However, this relationship is magnified because Jill has spousified Johnny in order for her to fill the emotional vacancy caused by Jack’s frequent absence, so obviously a large portion of Johnny’s anxiety results from his mother’s “need” for him to be present for her own functionality in the family. Also, a possibility for John’s extended absence could be the result of the fact that, with all of the children now away at school, he is experiencing his own anxiety as this will be the first time in twenty four years that he and Jill have been the sole members of the household.

The primary objective has been to eliminate Johnny’s panic attacks regarding his beginning college by minimizing his anxiety about being separated from the home. With the ideal situation being that the foundation is established for all relationships in this system to progress toward a healthy functionality. To accomplish this, a restructuring of the family is necessary. The relationship between Jack and Jill must become more developed. Jill must allow Jack to fill his spousal role—the role that she has encouraged Johnny to occupy. This will be done by basically reacquainting Jack and Jill, as well as reestablishing what their needs and goals are in their marital relationship, not simply their roles as parents. Boundaries should then be determined in order to stabilize each newly restructured role. An aspect of this technique that would be beneficial to use regarding Johnny’s anxiety would be to strengthen his relationships with his siblings. Since both Sue and Carl have years of experience away from home and in a college environment, their guidance would be tremendously helpful for Johnny’s elimination of his separation anxiety.

Example Case Notes – B

I have chosen to utilize Psychodynamic/Family of Origin therapy with this particular family. In the most basic triangle of this family, Johnny and Jill are the closest relationship with Jack as the outsider. By having knowledge of Jill’s position in her family of origin, it is understood that her own emotional over-involvement with Johnny has resulted from her attachment to her own mother, whom she could never obtain an ideal relationship with as she was consistently vying for her mother’s attention against her step-father and other siblings, so she is now severely attached to Johnny—the most constant figure in the home. Jack’s position in his family of origin placed him as a likely caregiver and source of support for his younger siblings, so he most likely feels a strong sense of responsibility to provide adequately for his nuclear family. Thus, he allows himself to spend an increasing amount of time involved with work.

The overall goal would be to establish positive functionality for this system by developing each member’s differentiation of self, and adjusting the emotional triangles. The initial technique to implement would be to sketch a comprehensive genogram in order for each member to understand the origins of the system’s emotionality. This would allow Johnny, Sue, and Carl to objectively view Jill and Jack’s familial positions and relationships with their respective families of origin, and provide them with a new understanding behind their current system’s functionality. Jack, Jill, and Johnny will all need treatment to improve their levels of differentiation in order to prevent their emotional dependencies from creating a multigenerational pattern. I plan to have Jack, Jill, and Johnny voice what their wishes are for their relationships and then be confronted with aspects of their situation which they may be oblivious. I believe that this will be an effective technique for this family as it seems apparent that they may not currently acknowledge to themselves what their needs are in each of the relationships.

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You can see how, despite the use of varying approaches to working with this family, that items such as the family dynamics are synonymous in each. Adversely, the priorities, techniques and goals differ and in such light, differing details regarding the family are presented in each set of notes. These types of notes give enough detail to your colleague to enable them to relay back to you “how they see the clients,” and may spur a discussion involving “what I would try is….”

At any course, your colleague is immediately able to pick up on your therapeutic hypothesis and the techniques you have, or plan to employ, as well as the family dynamics, presenting problems, and direction of therapy.

It is through the dialogue that follows where you may learn from the assumptions about the family that your colleague makes based on your notes. Likewise, you may find that their concerns for the client(s) may not align with your own. Perhaps your colleague has questions for you regarding the client(s) of which you don’t have answers.

You may also be enlightened to the fact that your colleague or mentor would prioritize the goals of therapy different than you and the client(s) have. In addition to being used as a tool to garner support from other professionals, these types of notes are a great way to provide yourself with a summation of your and your client’s work.

Atlas Concepts, LLC_Jordache WilliamsJordache Williams is currently based in Rock Hill, SC and is the Program Manager for Atlas Concepts, LLC. He is a Certified Life Coach and holds a Master’s Degree in Human Services.

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