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No guarantees in therapy

shutterstock_105731375Therapy is an investment of time and of money and it’d be nice if it came with guarantees but it doesn’t. There are just too many variables to make any promises about how therapy will work for any individual but there are some things you can do to get the most out of your time in the counselor’s office.

  1. Find the right counselor. Remember your progress comes down to the therapeutic relationship that you build with your therapist. If you want a more touchie-feelie counselor or a less touchie-feelie counselor then go find that person. Whether you want someone with lots of fiddle toys in a comfy overstuffed office or one who keeps everything streamlined and clinical, then go find that person. There are lots of different counselors in the world because there are lots of different people so when you call someone to check them out, don’t be afraid to ask them any weird question you feel you need to ask to feel comfortable.
  2. Leave the wrong counselor. If you’re working with someone and you just don’t feel comfortable or safe, switch. It’s ok. You’re the client and you get to decide what works for you.
  3. And if the counselor is almost right? Help them become all the way right. If you have an issue with your therapist and are afraid to bring it up, please give it a shot before you quit therapy. We therapists aren’t psychic so if we’re doing something that isn’t working for you we’d love for you to let us know. I know it’s scary but remember what I said, you’re the client and you get to decide what works for you. Besides it’s good practice for asserting your needs in the rest of your life.
  4. Show up. Sometimes we have to miss our therapy appointments because our cars don’t start or our kids spike fevers or our bosses move up our deadlines. That’s all true. And then sometimes we miss our therapy appointments because it’s just easier not to go. But therapy only works if we get ourselves into the office and into that chair to talk and listen so even when it’s hard — especially when it’s hard. And you know, you can tell your therapist how hard it was to get there that day; she’ll appreciate knowing.
  5. Stick to it. Speaking of how hard it is to come, please don’t drop out completely when therapy becomes tough. Sometimes we have to feel worse before we feel better. Growing is hard and sometimes it’s painful, which is why so many of us don’t do it. But you know what? It’s really worth it. I promise.

Anatomy of Clinical Case Notes

Stephen Sondheim

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.


Why your brain needs to be dreaming

sleepygirl-insideDid you know that dreaming is a little like defragmenting your brain?

I don’t have to defragment my computer anymore (does anyone? or is it just a Mac thing that my computer does it for me when I’m not looking?) but I used to like doing it because I liked watching everything get consolidated on the progress screen.

This is how my friend Mart explained computer defragmentation to me. I don’t know if this is his metaphor or not but it’s a good one.

Let’s say you wrote a 500 page paper. It takes up a tidy little space on your desk in your office, it’s all consolidated and in order and you can read through it quickly to find exactly the information that you need.

Now let’s say that you take those 500 pages and you head out to a football field. You toss all of the paper up into the air and the wind catches it and blows it all over the field. Now can you read it easily? Can you find the information you need quickly and easily?

When you defrag your hard drive, you re-consolidate all of the information so your computer runs more quickly and more smoothly.

I listened to this old show from Radiolab awhile back on Sleep and they describe dreaming a little bit like Mart described defragging your hard drive. At least that’s the way I heard it.

See, you only have so much room for memory in your brain and you are like a little PacMan during the day, eating up events and storing them in your head. At the end of the day you sleep and your brain defrags your brain to make room for the things you need. It discards little things (the name of your server at the restaurant you ate at that morning, the color of socks your co-worker was wearing) and consolidates the things you paid more attention to. The more attention you pay to something, the stronger the signal that this is something for your brain to hold onto.

Radiolab explains that this is why a musician can practice a song all day, trying to get it right, and then wake up the next morning and play it perfectly. It’s why sometimes you might go to bed at night fretting about a project you’re working on and wake up knowing exactly how to tackle it.

As our brain quietly re-organizes itself, it puts the pieces back together so that the thoughts that persevered through our day — through chit-chat with the server whose name you forgot, through your overview of your co-worker’s outfit right down to the socks — are finally reunited and you are better able to tackle the things that matter to you and that you’ve been working on and thinking on.

When you think of dreams this way they make more sense, too. It’s your dream mind rummaging through your day’s events — every little thing you did or said or thought — and rearranging them. No wonder your sixth-grade crush might show up sitting next to the canned ham you put aside for the food bank on the boat you’re thinking of renting for next year’s vacation.

Now isn’t that interesting? And see why you need to make sure you’re getting that all important REM sleep?

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