Some of you know that I have Wonder Woman all over my waiting room. Wait, scratch that. Some of you may know that I have Wonder Women all over my waiting room. I have artist renditions of different kinds of women — fat, thin, young, old, hip and matronly, different ethnicities — all as Wonder Woman. Some of them are very serious and dignified and some of them are silly. They are all awesome.
When I was first decorating my office I went back and forth about hanging them all up. If you’ve been to many therapist offices then you know that most of them are pretty neutral and I wondered if it would be too much of me there in the waiting room. I thought maybe I should go with a tasteful Pottery Barn neutrality or maybe just a touch of Ikea blank hipness. I thought about having, you know, a gentle beach landscape on my wall.
But then I decided that I am not really a neutral therapist. I mean, I crack jokes a lot. I’m not always all that dignified, much to my chagrin. So I figured that since the research says that our success depends on the relationship that we build together then we would all be better off if my clients knew what they were getting right up front and what they’re getting is someone who thinks it’s appropriate to have a comic book character all over her waiting room.
So why Wonder Woman? Why not Bat Girl? Or Buffy? Or some other out-sized heroine of justice and truth? Here is why.
When I was a kid my mom had a Wonder Woman picture hanging in our kitchen. (You can see it in my waiting room now — it’s the one on the wall you’re facing when you are heading into my play therapy room.) I wasn’t much for comic books and if I was reading a comic book it was much more likely to be Sabrina the Teenage Witch but I liked that Wonder Woman picture. I liked the TV show, too, and I liked the Saturday morning Super Friends episodes with her in them the most. I liked the idea of her. I used to run around my neighborhood pretending I was this character I made up, Shadow the Midnight Panther, leaping off my Huffy bike to fight the powers of evil. I’m not so sure that I would have invented Shadow if I hadn’t had Wonder Woman as an example. (The reason I was not actually Wonder Woman is that I really wanted a cape — Shadow had a cape — and I liked cats a lot and panthers are super cool.)
Later when I was a loud young feminist my mom mentioned that Wonder Woman was on the very first issue of Ms. Magazine. That’s when I realized that Wonder Woman meant something to a lot of women — not just to my mother and not just to me. I still liked her only now I liked that she was a touchstone. I liked that she reminded me of the terrible 70s fashion of my youth and of the specific feminism that I grew up with. (When I was little I would read Ms. and flip to the No Comment in back, then the “click” letters in the front and finally to Stories for Free Children.) That specific feminism taught me that it was OK to be angry, to be strong, to be outspoken and to have a sense of humor.
All of that is to say that Wonder Woman is hanging in my office as a way to share that I’m a feminist therapist. Now you don’t have to be a feminist to come see me — that’s the great thing about feminism, it very clearly says that we all get to be who and what we want and need to be — but I want people to know that they’re seeing a feminist therapist because, again, you should know what you’re getting right up front if you’re thinking about seeing me.
Very often clients will tell me that they saw a Wonder Woman thing — the book that just came out, a doll, a t-shirt — and they’ll say, “I thought of you!” But I’ll tell you the truth, I really hope that someday my clients will see Wonder Woman and think of themselves, of what they worked at and what they learned in our time together. I have all of these Wonder Women in my office because I want my clients to see their own strength and power and heroism. I want them to see themselves reflected in the Wonder Women on my walls.
I’ll add that while I do see men in my practice I mostly see women and kids — boys and girls. Someone — not a client — asked me why I don’t have male super heroes on my walls and my answer to that is that we get to see lots of male super heroes everyplace else. We get to see them at the movies and on television and on the shelves in our toy stores. I have nothing against male super heroes — I especially like Spider-Man — and you’ll find them in my sand tray toys. But I like to do my part to even out the representation in the world a little bit, which is why Wonder Woman gets the prime real estate in my office.
Note: I haven’t blogged the last two weeks because as some of you know I slipped on the ice and jammed my finger by sliding hand first into a curb. I think the technical term for what I did to my finger is “stoved.” It was my middle finger, which made wearing a splint super hilarious since just by wearing it I was inadvertently flipping the entire world off. The most annoying thing about it was not being able to type. Years from now when I’m filing away my client case notes I will notice that two weeks worth are all lower case, terse and filled with typos. I will see them and remember, “Oh yes, those were the splint weeks!” And I will once again be reminded to always be grateful for spring.
Recently I’ve talked to folks who are confused about what counselors can talk about when it comes to helping courts make custody decisions and I wanted to explain what we can and can’t say.
In general, therapists don’t make custody recommendations for ongoing clients, period.
A child custody evaluation is a very specific service that requires very specific training and it’s not the kind of thing a therapist could do for ongoing clients. Most of the people who do them are psychologists (although social workers and counselors are able to do the work as well).
Those of us who are regular old therapists don’t do custody evaluations and we definitely do not do them for current clients.
If I’m seeing a child or a parent for therapy I’ve entered a confidential, goal-oriented relationship that necessarily carries some bias. If I’m seeing a client who is having friction with a spouse I will only have access to her version of events even if I have a session or two with her partner. A couple of sessions with one partner in the context of a therapeutic relationship with the other isn’t going to do much to off-set any bias I carry. Obviously I cannot then say whether or not she would make the best parent.
Likewise if I’m seeing the children I’m not going to be able to look at the parents objectively because in a treatment-focused counseling relationship with a child I’m joining the family system and working with the members to change the system. Even if the child is my primary client, when I work with younger kids I am also working with the parents.
When I’m working with teens I have less parental contact — parents rarely join us for a session — but the issues of bias are still relevant.
So you can see why stepping outside of that therapist role and becoming an objective evaluator would be impossible; there’s no way I could get the distance necessary to see the family without prejudice. Sure, I might have an opinion but it’s not ethical or appropriate for me to share that opinion in a court of law.
Therapists are often asked to testify in custody cases but what we can ethically say is limited. Per Ohio law (that’s a link to a pdf) we absolutely should not make custody recommendations even when asked point blank by a judge. We can only testify to facts such as:
- How often the client(s) came to treatment;
- Whether or not the client(s) completed the treatment plan;
- Which parent brought the child(ren) to treatment or attended sessions.
Basically the kinds of facts that can be corroborated.
According to a recent training I attended led by legal counsel for the Ohio Counselor, Social Work and Marriage & Family Therapist Board, a whole bunch of us are getting in trouble for misunderstanding our scope of practice when it comes to custody issues. Part of that is that we get nervous on the stand and maybe say more than we ought to and part of it is that some of us just don’t know better, which is why it’s a good idea for us to get our own legal representation should we get a subpoena. That way we understand what we can and can’t ethically say when called to testify.
Whether or not we must disclose information about a client without his or her permission — such as the contents of our sessions — depends on what the court says. But it’s important to know that lawyers can subpoena therapy case notes for a divorce case. While a therapist can and should fight to protect a client’s confidentiality, her hands may be tied legally. Therapists should make sure clients understand the limits of confidentiality during intake.
With kids, confidentiality belongs to the parents. Parents have a right to their children’s clinical case notes because they have rights to all of their medical records. When a divorce is happening this gets way more complicated. As that link shares, which parent has the right to the child’s case notes will depend on who has legal say over the child’s medical decisions.
If you have questions about your rights or your child’s rights when it comes to divorce and confidentiality, talk to the counselor and talk to a lawyer. But do know that you can’t ask your or your child’s counselor to recommend that you get custody of your children.
I think Russell Crowe ought to play Sondheim if they ever decide to do a biopic. What do you think?
I thought I’d tell you about how I write my clinical case notes because it’s the kind of thing was interested in before I became a counselor and I still like learning how other people write theirs. (Treatment plans, too, but that’s a topic for another day.)
When I think about writing case notes I think about turning one of Sondheim‘s writing rules on its head. Stephen Sondheim says that writing lyrics for musical theater comes down to these three principles: Content dictates form; less is more; and god is in the details. In writing case notes I think that form often dictates content. In other words, I write to a form and it directs my train of thought thus dictating the content.
Like a lot of therapists, I use a modified version of what’s called a SOAP format. SOAP is an acronym that stands for Subjective, Objective, Assessment and Plan. For example, if I was counseling, say, Mama Bear of Goldilocks and the Three Bears, and she was telling me about her frustration cooking breakfast for her picky family, I might write:
Client was present with therapist. Client discussed her challenges in cooking breakfast. Client says her husband likes his food much hotter than she does but cooler than her son prefers it. Client says she ends up having to cook three different breakfasts and gets up several hours early to do so. Client reports feeling “resentful” towards her family. Therapist asked client about her previous plan to serve family cold cereal. Client says she feels guilty when she does this. Therapist and client discussed her feelings of guilt. Therapist asked if client’s feelings of resentment may come out with her family in other ways. Client identified that when she feels resentful she has trouble being pleasant on the family’s morning walks in the forest. Client says that in many ways her guilt about feeling resentful is worse than the guilt of serving cold cereal.
That’s the Subjective part of the case note, which basically means it’s what the client has to say and what I had to say. Now here’s the Objective part:
Client appeared extremely tired as evidenced by her repeated yawning during the session. Client had her apron on backward, her fur was uncombed and she had to ask therapist to repeat herself several times.
Notice there isn’t any opinion in there. I wouldn’t write, “Client is clearly being run ragged by her selfish family” or “Client needs to get it together and focus.”
In the Assessment piece I look back at our treatment plan and see if Mama Bear is making progress towards her goals. In Mama Bear’s case, she might have said that two of her goals are to make more time for herself and help her family become more self-sufficient. In this case I would say that Mama Bear is making progress because she is starting to think about the ways that her resentment towards her family is more of a problem for her than feeding them cold cereal. Even though she hasn’t changed her routine and even though she’s still having trouble putting her needs first, she’s thinking in ways that are moving her forward. I would note that like this:
Client is thinking critically about her choices and beginning to consider how taking care of herself might serve the family, too.
Finally there’s the Plan part of the SOAP note. Here I would write what our plans were whether they’re to meet again in a week, to have Mama Bear keep a diary of her feelings around breakfast or to ask her to ask Papa Bear to take one morning over this week.
What’s interesting to me about writing up the case notes is that using the SOAP format orients me to see the progress we’ve made in the session and in our counseling relationship as a whole. That’s the Sondheim-ish, “Form dictates content.” Writing our sessions in such a detached format gives me the perspective I need to really understand what it is that we’re doing together. When I’m in session, I try to stay present with my client. Writing up case notes after our time together gives me the chance to think back and reconsider my experience, which gives me new insight.
The second reason I keep things so bland is that case notes are confidential except when they’re not. Clients are (obviously) allowed to access their files and sometimes courts are allowed to access them, too. If this happens I want to protect the client (by keeping my opinion out of things — imagine the difference between sharing that Mama Bear’s apron is on backwards and saying something like, “Mama Bear sure didn’t know where her head was at that day” if she ends up in a heated custody battle) and I want to protect myself. I do that best by stating just the facts, ma’am.