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One of the strange things about paying to bare your soul to a stranger is the very one-sided intimacy in the room. If you haven’t experienced it yourself, ask any of your friends who have been in therapy for any period of time—you want your therapist to like you. And if she picks up a pen after you say something, it’s tempting to ask yourself: What is she writing?
But if you worry that your therapist is judging you, that your therapist is doodling out of boredom, that your therapist is extrapolating an Oedipal complex from an offhand comment about your mom—relax. I talked to a dozen therapists and experts around the country to get a sense of just what they are writing down in those notepads, and I can safely say: Your therapist’s notes almost definitely aren’t as interesting as you might think.
First, it’s worth noting that many therapists take notes only for your first meeting (what they call the “intake session”). Most of those I spoke to said they jot down information about symptoms, demographics, treatment history, and personal history during that first meeting so as to get a sense of both what potential issues they’ll be tackling and who the patient is more generally.
But those therapists often avoid taking notes in any subsequent sessions (though some take notes privately, just after the session ends). Their reasoning for this, for the most part, had to do with trust-building: Many believe their clients feel more comfortable with and open up more to a therapist who appears to be giving them eye contact and their full attention. Many therapists also choose to take as few notes as possible out of concern that people may be a little anxious about the notes (especially with patients exhibiting signs of paranoia or intense anxiety). Others also think the note-taking process itself can influence the patient too much. “It can begin to shape what they talk about,” Julie Ribaudo, a clinical professor of social work at the University of Michigan, said. “ ‘That’s important or not important, so that’s what I’ll talk about.’ ”
But the therapist’s notepad isn’t entirely an invention of pop culture, and there are certainly some who like to take note of both factual information and thoughts as they pop up in a conversation.
Any quick notes taken after the first session will likely relate to a small fact your therapist might normally have a hard time remembering: the date of your loved one’s death, for example, or a change in dosage to a medication. Some states have specific requirements for what a licensed therapist must keep in these notes. (Florida, for example, mandates that clinical therapists include, among other things, the patient’s basic demographic information, symptoms or reason for coming in, types of services provided, “what transpired” in the session, test data, medications, “possible sensitive matters like threats,” and written consent for the therapy.) And some therapists, aware of the remote but real possibility that their notes could become relevant in legal issues, have personal rules for more serious issues. “I have patients with ongoing suicidal thoughts, so I note in every session the degree to which they’re ongoing,” Aaron Fisher, a psychology professor at the University of California, Berkeley, said. “But most of us keep those notes vague for brevity, and also because we don’t want to betray the patient.”
A therapist’s note-taking practice can also relate to her theoretical orientation. (Not every therapist has a theoretical background, and some pick and choose from more than one. Many social workers take more of a patient-centered approach focused on supportive therapy, which emphasizes empathetic listening and a supportive relationship with the patient. Many psychiatrists—medical doctors who can prescribe medication—also are less steeped in psychological theories.) Broadly, those with more of a background in cognitive behavioral therapy target a patient’s thoughts and behaviors and try to coach clients into more healthy patterns. These therapists are therefore more likely to track the patient’s distress, the steps assigned, and progress made to tackle a particular problem. For example, according to Fisher, if you come to a therapist for a fear of dogs, they might suggest exposure therapy to build a more positive association. First, the therapist might create a “fear hierarchy” with a scale for what the patient considers the most to least frightening type of dog. Then, the therapist might create a week-by-week plan and, at each step of exposure, take notes on the patient’s reported response.
Then there’s the psychodynamic area of therapy, which is a more Freudian mode. As the American Psychological Association explains, “this approach focuses on changing problematic behaviors, feelings, and thoughts by discovering their unconscious meanings and motivations.” These therapists may take more in-session notes about relationships and about specific phrasing and ideas a patient has used. So a therapist might draw out a kind of genogram, or family tree, with information about the social relationships between the members.
One therapist who pulls from the psychodynamic approach, among others, told Slate that while she will jot down dates and names, she also uses her notepad to record flashes of insight or repeated specific phrasings a patient uses, to help her understand how the patient conceptualizes a problem. Another said she’s careful to watch for potential hidden meanings behind some phrasing. “A client is saying, ‘These last few months have been so difficult and stressful, when I get off work, I want to drive my car into a wall,’ ” Jennifer Noble, a psychologist in Los Angeles, said. “I might jot down a note like Explore deeper? Suicidal thoughts? It sounds like a joke, but it might not be. And you might not want to alert the person [in the moment], but you shouldn’t ignore it.” And still another therapist said she might note potential patterns in relationships and ways of thinking. For example, she may write down partner distant, like father? as a possible idea to explore later. (“It’s a cliché, but it comes up.”)
Note-taking also depends on context and practicalities. A psychotherapist treating someone compelled by a court will often take more thorough notes. Therapists might take more extensive notes for clients with more complicated or severe conditions, particularly when trying to settle on a diagnosis. Someone who needs to establish disability would also require a different set of notes. And then there’s the variation among demographics. Teenagers often feel particularly anxious and uncomfortable in a counseling setting, so their counselors might refrain from taking notes. And sometimes, therapists just need more help with specific patients. “Periodically, if I have a client that jumps around a lot, I might ask [to take notes],” La-Toya Gaines, a psychologist in Southfield, Michigan, said. “It helps me see how the client is connecting things, how they’re relating things together.”
A couples or family therapist will treat the relationship between people rather than the individuals themselves and adjust their focus, and notes, accordingly. Dug Lee, a couples and family psychologist in Atlanta, said she takes notes of a client’s specific phrasing to make sure to come to a common definition. “They may think I and their partner know what they’re talking about, and we could all three have different understandings of a phrase.”
The APA has recommended that therapists discuss their note-taking with their clients beforehand, and most therapists I spoke to said they would forgo the practice if a patient expressed discomfort. Several said they would willingly share their notes with the patient, and some even already do so to reassure patients or even ask them for collaboration or feedback. But others cautioned against sharing notes with patients. “Psychiatrists and social workers speak their own language,” Antonia Caretto, a psychologist in Farmington Hills, Michigan, warned. “A ‘fantasy’ just means a wish, a thought, or a desire. If someone documents something about a patient’s ‘fantasy,’ it could be misconstrued by someone reading their own medical record. And a ‘narcissistic injury’ is a commonly used phrase that refers to a blow to the ego. But when you see ‘narcissistic,’ you can get upset.”
Your clinical notes are considered a medical record, which you have a right to see. Some therapists keep separate personal notes with questions and thoughts they have during sessions, and you’re not guaranteed to see those. You can always ask, of course. Many therapists are trained to assume their patients will read their notes and will be therefore comfortable handing them over for you to review.
But before you ask, you should stop to think whether you really want to see your therapist’s notes. On online forums dedicated to discussions of talk therapy, some patients have reported feeling embarrassed or ashamed to see descriptions of them so starkly laid out. Others have felt a sense of betrayal, or at least a profound disappointment, at seeing their relationship with their therapist reduced to such clinical terms. “After I read the notes, I felt really defensive,” one person said in a message. “I had the tendency to interpret every comment as criticism, and simply seeing the descriptions of the emotions I showed made me feel threatened and like I was being made fun of.”
Not all patients have regretted the experience, though. Marie Laigneau, a 38-year-old French woman currently living in London, recalled an experience several years ago with a therapist in Chicago. She had been seeing the therapist for a couple of years, and she decided she wanted to look at her therapist’s notes to get a sense of the progress she had made. The therapist warned her that the notes would not make much sense to her. But she insisted, and she was shocked to see the therapist hadn’t made note of a certain self-harm incident. “I actually took offense at it,” she said. “’It’s important to me, but it doesn’t seem important to you?’” But she talked it over with her therapist and thought the conversation helped them get on the same page. And she came out of the experience with greater trust in her therapist and insight into how she had grown. She also saw the same themes and patterns, repeating over again. “It helps, because sometimes, in this process of therapy, you don’t take a step back and really assess.”
But Laigneau also knew that the notes could be painful. In a different, more psychiatric setting, she once saw notes intended only for clinicians. They included a diagnosis she hadn’t heard yet, and she felt wounded. Sometimes, she said, notes carry something of a risk, given that a therapist might casually jot down a tentative diagnosis. “It’s tricky, because you can be faced with comments that are half-made,” she said. “But overall, I think there’s quite little risk, and if you’re smart enough, it’s fine, because therapy is a safe space where you can discuss anything that’s been thought about you. But I think it’s better to do it when you have already established a very good relationship with your therapist, when there is no risk for rupture.”
While ethically a therapist is prohibited from discussing your notes with anyone else without your permission, there’s no guarantee they will remain private. Most therapists will almost certainly challenge a subpoena for their records, but a court can compel it in some situations. Insurers, too, have a right to see those clinical notes, as they would for any medical record, and there are other third parties, like clinical supervisors, who are often authorized to view them as well.
According to the APA, best practice for a therapist is therefore to take only perfunctory clinical notes tracking diagnoses and treatments—in part so a patient can hand the record off to another therapist if necessary—with the option of a separate set of private and more detailed therapy notes containing the more sensitive information, if the therapist thinks she needs it for her own memory. But still, even under that guideline, there’s room for interpretation. Grace Kim, a psychologist in Minneapolis, said she keeps only minimal clinical notes and no separate detailed ones out of a fear that they could be collected with a subpoena.
“If you have a question about what I’m thinking, just ask,” Kim said. “People get anxious about notes, so if that comes up as a clinical issue, we’ll go over those notes and talk about them and read them together. It can be part of the therapy process. It doesn’t have to be this mysterious thing.”
State of Mind is a partnership of Slate and Arizona State University that offers a practical look at our mental health system—and how to make it better.
