On the HBO forums there has been considerable discussion of the note-taking issue. And we saw this week that after seeing April, Paul sat down to write some notes. Which we know from what he said to Mia when they met to discuss the lawsuit taking session notes is not his usual practice. So why now?
The answer is simple -- anxiety.
The whole issue of session notes is related more to risk management and insurance company requirements than it is to good care and the best interests of the patient. In fact. until fairly recently, it was up to the therapist what kind of notes if any notes would be taken. And, depending on licensing requirements and whether or not one accepts third party payment, it is still up to the therapist on this issue. Some therapists document via a short notation the occurrence of a session combined with billing records. Others take notes during the session. There is nothing in these approaches or any other that correlates to skill or outcome.
In a paper presented to the APA, Martin Williams explains how what starts as a way to manage risk morphs into standard of care -- and sometimes into mandated requirement:
Paul opens the door and sees Kate who has an envelope of financial aid material for Rosie. They start to have a spat. Paul asks her please not to come to his therapist's again. Tammy comes out again and they greet. She apologizes for interrupting last week.
Paul starts mentioning Tammy and Gina says they can't talk about that. Paul says he cannot be in therapy with her now. Gina says she is sorry but she respects his decision. She gets up to go and says he can stay there till the kids arrive. Paul looks unhappy. Gina asks if he wanted her to argue with him. He wants an hour of conversation, that he will pay her. She says she doesn't charge for conversation. Paul wants her to stay and talk. Paul starts to complain about his week. He looks miserable. Gina says okay, just for a few minutes.
He mentions he thought about Tammy Kent when they were 17 and wonders why he did that. Gina says he could work on that in therapy. He tells her that the lawyers are deposing Laura this week. Gina asks if he is worried that she will try to get back at him. Paul says he doesn't want to talk about his past because it his present that is causing him problems. Gina says it occurs to her that he thinks about Tammy because there is something incomplete from that period in his life when his father left his mother and when she died.
Paul closes the sleep sofa while his daughter, Rosie, is talking to her mother on the phone. There is a knock -- a messenger has an envelope from the law firm for Paul. His daughter guesses that he is being sued. Rosie asks who he can talk about it with. Paul says it is under control. She says he is condemning himself to a life of loneliness and she wonders why. She refuses his hug, because she says she won't hug him until he comes home. Paul tells her that isn't going to happen and they hug. She sees the turtle on the shelf. -- the turtle Oliver was afraid he would fail to care for.
Walter begins by saying he is sure that this week Paul has read up about him. Paul says he read about the industry but not about him. Walter believes a reporter at the Times is after him. Paul asks if it is coming from within the company. And apparently that is a possibility. He is worried that the articles are putting his daughter in jeopardy. Paul suggests maybe his anxiety is getting the better of him. Paul observes that he sounds quite confident given the circumstances.
Oliver and his parents are in the waiting room, each listening to their iPod. Alone together. And this is a good image of how they are relating to each other.
Oliver asks Paul if they are going to play another game. Paul says he has been learning about the rules of blackjack. Oliver wonders why. Paul tells him he wants to learn about the things that Oliver does and likes. Oliver says his teachers don't think he is smart, that all of them hate him because he falls asleep in class. School is boring he says. He says none of it is about real stuff. He says they are reading Lord of the Flies which is lame -- because you don't have to crash on an island for kids to be mean. Then he shows Paul the turtle he has to take home and take care of. And if he doesn't take good care of him, he will fail. And he assumes he will forget something and the turtle will die.
Paul observes his backpack is crowded. Oliver carries all of his books in case he goes to his father's, but he doesn't go there. Paul wonders why he is so tired, even at his mother's house. He says he has trouble sleeping. Paul suggests there are very stressful things in his life and wonders if there is anyone he can talk to. He says if he tells his mom, she calls his dad and then they argue. That day his mom said he isn't getting enough sleep and his dad said he isn't healthy which means fat -- because he is fat. Paul guesses he is upset about being fat. All the kids at school talk about it. They call him Piggy after the fat character in the book. Oliver tells Paul about hiding out during a party. He doesn't tell anyone about this. He says he doesn't tell his mom because she'll tell his dad and then they will fight and he doesn't want it to be his fault that they get a divorce. He wants to know if Paul can make his parents happy. Paul says he can't make them happy but he can help them to get along better. Then he invites the parents in.
April is talking on her cell phone in the hall and sounds angry. Paul is in his kitchen reading the paper when he hears her. He steps over to the door and listens a moments then goes into his office.
Paul tells April he is glad she is there. She contacted him by email. She wants to know if he has an iPhone charger. He says no and she asks to use the phone but agrees to wait until the session is over.
April has a tremor in her hand. She tells Paul that it runs in her family, getting a tremor when she is angry. She says it would help if she could use the phone. Paul tried again to get her to wait.
She is angry at Sienna who is Kyle's new girlfriend. April told Kyle she has cancer, he broke her confidence by telling Sienna who offered to pay for her treatment. She wants to be able to call Sienna back so she can hang up on her. Paul gets the phone. She asks Paul to give her a moment so he leaves the room. He waits a moment or two and then she comes to the door and they return to his office. The tremor has stopped.
Mia shows up at Paul's office very early in the morning. She starts off commenting that their positions are reversed -- he used to be in Manhattan and she in Brooklyn. Then says it is strange to be back and comments on the couch, saying the old one was black and blue and that she thought that was funny.
She apologizes for her behavior last week. And that is the reason for this visit. Paul reminds her that she waited until Friday to call for an appointment. Mia agrees with Paul that she set up their last meeting because she had wanted to needle him a bit and impress him. Paul asks if she and Bennett are involved because he noticed her manner changed when he came into the room. Bennett is married. They have been involved for over a year. He has told her he wants to leave his wife and be with her but he hasn't. Mia says she doesn't need a therapist, she needs a matchmaker. Then says he does owe her.
Mia keeps asserting she is not really a patient and she asks about Paul's marriage, if he had an affair. She has been wondering what would happen if she ran into him somewhere but she imagines he already has a girlfriend. She tells him how hard it is to find an available man. Paul asks if she is asking if he would be attracted to her. She does not respond and then talks again about Bennett.