This is the first of what I plan to be a series of short videos about my thoughts on psychotherapy service delivery, with a special focus on service provision to children and young people who have experienced relational and developmental trauma. In this video, I address the issue of case noting. I hope you like it.

Transcript

In addition to your ethical responsibilities to keep good case notes of your sessions with your clients, they’re actually really important in keeping track of and monitoring progress in psychotherapy.

In terms of what I think are really important things to include in my case notes, first thing I do is I keep very good records of how a client presents.

Now, my clients are primarily children and young people who are recovering from a tough start to life. Mostly, that has taken the form of relational and developmental trauma when they are in the care of their mum and or their dad. I keep very good notes of how they present each time they come to see me. That includes how they’re dressed, how the care that they’ve taken around their appearance, how they respond to me arriving in the waiting room, how readily they separate from whoever brings them along to their sessions with me, how well they engage with me in the session, and particularly what their verbal output is like, what their emotional presentation is like throughout the session. Do they converse freely with me or is their verbal output restricted? What their emotions are like, are they animated and expressive? Are their emotions congruent with content and context? How well do they regulate or respond to co-regulation by me?

I’m also interested in their defensive behaviours during the session. Do they try to set the agenda, both in terms of activities we do and conversations we have? Because my approach to psychotherapy is highly relational, and I’ll talk about why that is the case in another short video, what transferential behaviours am I seeing?

Of course, I also keep a record of the interventions that I have delivered during the session. I’m quite interested in how they go at the end of the session. Do they seek to delay or extend the session or do they go easily?

Now, all of this is predicated on having a good, solid theoretical framework that you’re working in relation to. I’ll talk more about that in another video like this. Having a good, solid, coherent theoretical framework from which to reflect on your client’s presentation and behaviour, particular transferential behaviour and approach to the therapeutic relationship during the consultation, is really important also in having an idea of what changes you are expecting to see as part of an effective delivery of a psychotherapy service.

Okay, back to case noting, and I’ll see you in the next one.