Week 2: Issues

Photo of Paul

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:

“Why wouldn’t you want to take notes about your session? …

Some psychologists—many more, I think, back a few decades ago and fewer today—do not think of what we do as medical, or as a treatment, or as something for which written documentation is appropriate. We see our work as forming relationships with patients, relationships that are unlike that of doctor-patient, but more like teacher-student, consultant, clergy-parishioner, or simply peers. Some of us believe that medicalizing that relationship by writing notes about how “the patient is progressing” or even about what happened during the session creates a barrier between the two people who are engaged in a personal journey together. Along those same lines, some of us eschew diagnosis and treatment plans.

It doesn’t really matter whether you agree with this Humanistic approach to psychotherapy. It serves as a good example of how risk management evolves to become the standard of care. Somewhere along the line, psychologists thought it would be a good idea to document what you did in therapy as a way of protecting yourself from certain claims, especially claims that you failed to do something. If someone claims you failed to ask your patient if he or she was still feeling suicidal, and your notes show that you did ask that question, bingo, you’re protected. If the patient later suicided, but after the session you wrote a note documenting the reasons that you believed the patient was not suicidal, and those reasons make sense to a later adjudicator, you have a degree of protection that you wouldn’t have had you just reconstructed that session from memory—subject to the skeptic’s view that your memory had been conveniently altered and rearranged to diminish your liability.

So it makes sense that those of us who want more protection would minimize their risk by taking notes, taking notes to document that we did all those things that someone later might claim we failed to do—a fine risk management idea. Fast forward to 2002 and we find that record keeping is no longer about risk management. It has become the standard of care…

One no longer keeps records to protect oneself. Now, one keeps records because not doing so is considered unethical in and of itself. Risk management evolves to become the standard of care.”

Ultimately each therapist has to decide where he or she stands on this issue. If one does not accept third party payment, it is a little easier because there are not then concerns about insurers demanding to inspect files, which they have the right to do for covered patients. The therapist must weigh duty to protect the patient’s interests and confidentiality vs. risk management. Consider also that patient files can be subpoenaed in other legal actions such as divorce cases and the confidentiality issue can be quite significant.

So Paul, now anxious about the lawsuit filed by Alex’s father, is taking notes after seeing April, not because it makes him a better therapist but because of his fears. It isn’t clear whether he is also taking notes on other patients. 

This is a difficult issue. Before therapy was routinely covered or expected to be covered by insurance, risk management and these kinds of records requirements were rare for therapists. And given the low incidence of lawsuits against therapists, the fear generated by risk management folks is disproportionate. Years ago in response to someone asking how he felt about insurance coverage for analysis, a well-known Jungian analyst said that we must remember that he who pays the piper picks the tune. We do well to bear this in mind as third parties become more a part of what we do.

“Psychoanalysis cannot be considered a method of education if by education we mean the topiary art of clipping a tree into a beautiful artificial shape. But those who have a higher conception of education will prize most the method of cultivating a tree so that it fulfils to perfection its own natural conditions of growth.” Jung C W, vol. 4, para. 442

Week 1: Oliver

Oliver picture

Oliver and Paul are sitting on the couch. Oliver asks if they have to wait for his mother and father. They decide to play cards while they wait. Oliver suggests blackjack and expertly shuffles the deck. He gives Paul the rules. Oliver says Paul sucks at the game and he wonders why if he sucks at it, why play? Oliver doesn’t really know why he is there. Paul tells him that his parents are getting divorced. Oliver denies the divorce — he says his dad has moved out but it doesn’t mean they are divorcing. He finds it annoying that his dad has moved out. Paul tells him they are meeting to help work out a solution to the problem that Oliver refuses to stay at his father’s apartment.

Oliver doesn’t like the food at his dad’s or his friends or that it takes longer to get to school. Paul says maybe they can help get things to change at his dad’s and make it easier for him to stay there. His mother arrives with Oliver’s snack and complaints about the father and where he lives. She doesn’t want to wait in the waiting room until the father arrives. We can see his mother is reluctant to have Oliver stay with his dad. 

The father arrives in a rush. The parents complain about each other to Paul. Paul asks Oliver to wait in the waiting room while he talks with the parents.

Paul tells the parents they need some ground rules and that Oliver doesn’t really know they are getting divorced. Each of them blames this on the other. The dad wants Paul to explain to Oliver but Paul refuses because it is important for them to tell him these uncomfortable things. Luke, the father, believes that by allowing Oliver to choose his own food from take-out menus he is teaching him self-sufficiency. Paul explains that what Oliver may be saying is that he is not getting enough nurturance.

Paul picks up that both parents are using Oliver to get information about the other parent and tells them this is not good for Oliver. Paul proposes separate meetings and both refuse because they want to know what the other says. Oliver creates a distraction and they invite him in. Oliver tells his dad that it’s hard when his friends come on school nights. And dad agrees to change that. They also come up with a solution for after school snacks. Oliver says he doesn’t want to stay with his father and the mother says he doesn’t have to. The father leaves. Then they all leave.

Oliver is around the same age as Paul’s youngest child so we have to wonder if Oliver’s unhappiness makes Paul think about his son and the effect of his divorce on his children.

In this case, Paul has a complex dance to do — helping Oliver and gaining the cooperation of the warring parents. This is never easy. The parents are not interested in being seen as a couple, which is too bad because they could perhaps become better able to work together as parents if they did. So he has to try to get them to make agreements while steering around their long standing conflicts. 

Parents are the hardest part of working with children.

I liked the way Paul let Oliver explain the rules of the card game to him. Playing games with a child in therapy is never about the game but what the game allows the child to reveal about himself and the issues he struggles with. So Paul pays attention the way Oliver explains the rules. And we learn something important about him when Oliver asks of Paul what is the point in playing something if you suck at it — we should not be surprised if we learn that Oliver feels he is no good at sports or other games that  maybe his father enjoys. And note that Oliver did not seem excited by the football his dad gave him when he arrived. It was when he was playing with the football in the waiting room that he knocked over the plant. It looks like Oliver is struggling with some things in addition to his parents’ divorce.

Week 1: April

April picture

A young woman, April, is sitting in the waiting area. Paul opens the door and invites her in.

Paul’s office has large bay windows and is comfortably furnished. April walks around looking and admires the office, mentioning she is an architecture student. She asks if he did it himself or used a decorator and when he says he did it, she congratulates him.

April tells him she is 23, a student in architecture and urban planning at Pratt. She is recently single, having just broken up with a long time boyfriend. Paul asks if that is why she has come and she says no, the breakup was fine. She says she found his name online because she wanted to see someone near Pratt who would take her insurance. She tells him no one had commented and she had assumed it was a new practice. He tells her he recently moved there. Paul tells her she needn’t apologize for questions and that she needn’t censor herself to spare his feelings. He asks if she has seen a therapist before and she says she had —  through student health. She speaks scornfully of the previous therapist. She felt that that therapist saw her as a complete waste of time. She  tells Paul that the therapist had told her the same joke twice. Paul asks about it and she tells him. April stopped going and never spoke to the therapist despite receiving many telephone calls from her. She says she did not return the calls or tell her because she didn’t ant to hurt her feelings. April gets angry and defensive at Paul’s questions about her previous therapist.

Paul reflects to her that he knows now that she doesn’t want him to tell her things twice, not to feed her platitudes, that if he fails to engage her she will leave him without telling him even if he calls her 87 times.

She likes that and asks how many people come to her because of something really big. He tells her she can tell him anything — a rape or death. She tells him she was not raped and she is trying to tell him. Then she asks if she can write it down and he says of course. She writes and she is clearly upset. She hands him the paper. She looks terribly ad and so does Paul. He asks how she feels  — she replies she is tired. He asks what type of cancer it is. She says she doesn’t want to talk about it. She just wanted to tell someone and she rushes into telling him all the things she has to do. He asks if she is getting sleep and she says no, she has terrible night sweats which are a symptom of lymphoma. He asks how she found out. She tells him she had a cough that wouldn’t go away. She went to the health center but what they gave her did not help. Her father is a doctor in the Army and she couldn’t reach him. Her symptoms got worse so she returned to the health center. Finally she was sent for further tests and she was diagnosed. She has a big mass behind her spine. She tells him to never get a bone marrow biopsy and describes how bad the experience was. She has met with an oncologist. He asks if she was alone when she did and she says she was. He asks if she has told her parents or friends. And she says she has only told him and a construction worker who harassed her on the street. She says she wanted to talk someone who is objective and won’t care what she does so she can talk about what she wants. She says her mother would become hysterical as would her father. Her brother, who is autistic, she says would become violent. Paul asks if she came to him looking for someone who would tell her it’s okay not to get treatment and she says no. Paul asks her if she really believes she has cancer, does she believe what she knows?

April tells him the oncologist said she was at stage 3 and she should start chemotherapy immediately. Paul challenges her resistance to starting treatment. Paul suggests to April that the other therapist told her the same story twice as a way to tell her it’s okay to need help. Paul says she needs to tell the oncologist what she is contemplating and that she needs to tell her parents as well. April gets angry and wants to leave. Paul offers her another time and presses to schedule another. She says she will call him. Paul is worried. She leaves.

April presents Paul with some interesting issues. He knows she will leave if he does not meet her expectations for his behavior, if she feels he has not listened and really heard her. And she is also in denial about the seriousness of her illness and the necessity to allow people to help her and to engage her in treatment. So he must find the line between listening and confrontation that will allow her to stay. The threat of abrupt termination is hanging over the therapy from the outset and Paul knows this.

Notice how Paul understood from what April told him about the first therapist and her scorn for her that she was telling him what would lead her to similarly reject him. And in fact she is primed to reject him because she is deeply ambivalent about getting help of any kind. It is not uncommon for patients to tell us how we will fail them, and we often do exactly that because it is an unconscious agenda for the therapy. The trick is in getting the patient to be willing to work through what they feel as a failure of empathy in order to see the greater complexity of the issue.

Paul is hoping April will come back. He stepped on the mine when he bluntly told her she needed to allow herself to be helped and to tell her parents. But he also earned some credibility in her eyes when he got what she was saying about the previous therapist. The odds favor her return. But it was a gamble he had to take on the chance that she did not return, a chance which was present from the very first moment of their meeting.