To note or not to note? That is the question.

Note taking can be a contentious issue in therapy, with some experts advocating not taking notes at all during sessions (because it may break the rapport between a counsellor and client) others take notes sparingly and still others make copious notes. Incredulously, there have even hear stories of newly trained psychologists typing continuously on a laptop as their client speaks…

In this brief article we will consider best practice, guidance, and evidence in relation to note taking and consider the perspectives of both clients and counsellors.

Bernardi (2015) considered note taking from both the therapists’ and clients’ perspectives, comparing note taking, note taking with reviewing, reviewing only and no note taking, and found no difference in ‘clinical judgement’. However, he also found that reviewing notes improved interview recall for the counsellors in that they were clearly better able to recall the session via reading their notes versus not.

Historical research on the impact of note taking in therapy is interesting. Back in 1984, a study by Hickling and colleagues showed a clear detrimental effect of note taking on clients’ perception of the counsellor. Later Miller (1992) assessed a number of variables in clients who experienced no note taking versus note taking and found ‘willingness to return’ was significantly lower in the note taking condition. The authors conclude that not giving full attention to the client was likely to be the factor affecting this. Conversely, Christie and colleagues (2015) found no negative effects of note taking on the clients’ perception of the counsellor.

Despite the appeal, and even necessity, for such note taking, there is arguably a need for prudence in relation to taking notes within sessions, so as to avoid damage to rapport. One clear technique is for the counsellor to explain, albeit briefly, the reason for taking notes; to keep a record of what is discussed and setting goals for counselling. This in turn can help keep both client and counsellor stay on track. Also, the timing of when you take notes in a session is important. For example, when a client reveals the ages or names of their children during a session, it would not seem strange or unreasonable for a counsellor to note this. If conversely, the client was to make a joke, in an effort to lighten the mood or make rapport between themself and the counsellor, the client might panic if the counsellor decided to start jotting things down at this point!

Interestingly the grandfather of psychoanalysis, Sigmund Freud, took the view that notes should not be taken during a session (although he also acknowledged that not all therapists would have the same memory as he did).

‘he (Freud) advises against doing this (note taking) in the session, not only because of “the unfavourable impression which this makes on some patients” (p. 112) but also because it would compromise the nature and quality of his attention, a point he had made in an earlier paper in commenting on the difficulties the physician has conducting: ‘six or eight psychotherapeutic treatments of the sort in a day, and [who] cannot make notes during the actual session with the patient for fear of shaking the patient’s confidence and of disturbing his own view of the material under observation’. (in Tudor & Gledhill, 2022)

Eric Berne, the originator of Transactional Analysis, makes a similar point on note taking during sessions:

‘If the therapist is distracted during the meeting by trying to remember what he is going to put in his notes, to that extent his therapeutic efficiency is diminished, and probably his effectiveness also’ (in Tudor & Gledhill, 2022).

An interesting alternative to ‘regular’ note taking is a collaborative approach where the client gets to see, and even have input into, what is written down. A study carried out by Perlich and colleagues in 2018 sought to identify whether the ‘Tele Board’ digital white board system would be ‘comfortable’ for therapists and save time in terms of producing official reports etc. The therapists therefore involved their clients in the note taking process. The therapists developed a positive feeling when using the collaborative white board (although the perspective of the clients was not captured) and the authors suggest that the approach saved practitioners 60% of the time they would normally spend writing reports to insurance providers.

Does note taking differ by mode of counselling?

It may well be that note taking is greater in modes such as Cognitive Behavioural Therapy (CBT) or Rational Emotive Therapy, where the notes could also form a part of the intervention. For example, in an exercise to identify automatic (and perhaps negative) thinking, the client will identify thoughts and triggers and also alternative challenging thoughts. This then becomes a key element of the therapist’s notes. Conversely, in person centred counselling, few or no notes are likely to be taken during the session as the practitioner is likely to feel this interferes with rapport between client and therapist.

Additionally, a counsellor may take process notes as well as session notes. Process notes capture the reflections, feelings and observations of the counsellor (and of course may well be very useful in supervision sessions). Whereas session notes should be factual and record objectively what was said in the session rather than the therapist’s opinion or interpretation.

Legislative Implication for note taking

Not all helping professions have a legal requirement for note taking and this is of course important in cases where courts of law might subpoena therapists for their client’s notes. There is no actual legal requirement for counsellors to take notes in Australia, despite the strong recommendations from governing bodies such as the ACA and PAFCA that counsellors do take notes. If you do take notes, you can see how the necessity for factual, accurate, and clear details are essential. Nobody wants to lose a client to suicide or any other cause, but if a patient has died, the coroner’s court often ask for a counsellor’s notes. So, again we need clarity and objectivity over what has been recorded/carried out within sessions for accurate reporting.

Templates for note taking

Psychologists and counsellors working within organisations may have specific guidance over note taking and what needs to be recorded to meet local policies. Here we cover several popular note taking templates, SOAP, RPT, DAP and SIRP.

We will firstly look at SOAP as one of the more favoured styles of notetaking.
 

  • S – Subjective: This is what the client has to say about why they are here to see a description of their issues and may include direct quotes from them.
  • O – Objective: here you would record the clients appearance mood, demeanour and any kind of diagnosis if appropriate.
  • A – Assessment: Here you document what you record such as mood (perhaps via a scale such as Depressions, Anxiety and Stress Scale, DASS 21) also could include your assessment of risk of harm and any progress made between/during sessions.
  • P – Plan The plan of course clarifies the way forward, details your any ‘homework’ a how often you will meet for therapy, approaches used (e.g. ACT or CBT etc).

There are numerous popular formats for note taking aside from SOAP, practitioners also use RPT, for example, is a three stage note format and the sections relate to: Report, Progress and Treatment.

Report includes the client’s report of where they are up to/what is happening in relation to their problem(s), it could be an update if treatment is ongoing or else their ‘story’ if it is an intake session.

Progress might include the therapist’s observations, hypotheses etc.

Treatment will relate to what the clients next steps are- for example it may be that during the session a CBT exercise has been discussed/trialled, and this forms the next treatment between sessions.

A further template comes in the form of DAP notes, DAP is Data, Assessment and Plan.

Data
This section records the client’s and your own observations from the session.

Assessment
This section is to record your clinical observations, any questionnaire data you’ve recorded (e.g. Depressions, Anxiety, Stress scale or Impact of Events Scale for examples).

Plan
This section is to document what is happening between this and the next session and/or plan for the following session.

Finally, there is SIRP, or Situation, Intervention, Response and Plan:

Situation is essentially the clients condition/problem/complaint it clarifies why they are here to see you for counselling.

Intervention
This identifies the measures caried out (questionnaires completed/therapeutic intervention e.g. CBT or Person-Centred Counselling for examples).

Response
This section captures receipt of interventions essentially how the client has responded to the actions carried out.

Plan
This section is about moving forward, with identified work to do on the part of the client, or cross referral to other agencies and/or planning of future sessions and their content.

Conclusion

Where opinion is expressed, it is again prudent to be clear about this and perhaps minimise opinion whilst offering an interpretation that could be corroborated with the client. For example, a counsellor noting that two issues may be connected might ask the client: ‘I can’t help but notice the similarity between this relationship and the way your mother was- what do you think?’ is particularly helpful in terms of collaborative working rather than making some form of diagnostic statement which is essentially ‘secret’ within your notes.

Care should be taken when it comes to what is noted, asking yourself; are your notes objective? Or are you diagnosing inappropriately? E.g. ‘Julia seems depressed’ is opinion, but ‘Julia’s DAS score equals 20 for depression 8 for anxiety and 9 for stress which suggests extremely severe, severe and mild respectively’ is objective information. Note, this is not a clinical diagnosis, it is merely indicative of Julia’s condition at the moment, and offers objective data for cross-referral, treatment plans etc.

In conclusion, it appears that note taking is important for numerous reasons, including necessity for the body you work for, the possibility of providing notes for other practitioners or (with permission) legal entities, courts/solicitors etc. and of course not least for the counsellor to review prior to a next session to recall details of where the client was up to. The issue appears to be when and how notes are taken rather than if they are taken. There is a risk that notes taken during a session can affect the rapport between the client and counsellor even to the point of reducing likelihood the client will return. Some leading exponents (including Sigmund Freud and Eric Berne) suggest note taking at the end of a counselling session. Responses differ between practitioners but when it comes to not note taking, it always seems to boil down to the way in which we choose to develop the therapeutic relationship between client and practitioner.

Further reading
Interesting perspectives can also be found by reviewing various blogs of counsellors and psychologists commenting on their commitment to taking or not taking notes.

For example:
https://nathandriskell.com/dont-take-notes-therapy-session/
https://www.goodtherapy.com.au/flex/is-it-normal-for-a-counsellor-to-write-copious-amounts-of-notes-during-sessions/548/1

References

Bernardi, F. (2015). Note-taking during counselling sessions: A mixed-methods research on the client’s perspective (Doctoral dissertation, City University London).

Christie, C. D., Bemister, T. B., & Dobson, K. S. (2015). Record-informing and note-taking: A continuation of the debate about their impact on client perceptions. Canadian Psychology / Psychologie canadienne, 56(1), 118–122. https://doi.org/10.1037/a0037860

Hickling, L. P., Hickling, E. J., Sison, G. F. P., & Radetsky, S. (1984). The Effect of Note-Taking on a Simulated Clinical Interview. The Journal of Psychology, 116(2), 235–240.
https://doi.org/10.1080/00223980.1984.9923641

Miller, M. J. (1992). Effects of note-taking on perceived counselor social influence during a career counseling session. Journal of Counseling Psychology, 39(3), 317–320. https://doi.org/10.1037/0022-0167.39.3.317

Perlich, A., & Meinel, C. (2018, September). Cooperative note-taking in psychotherapy sessions: An evaluation of the therapist’s user experience with tele-board MED. In 2018 IEEE 20th International Conference on e-Health Networking, Applications and Services (Healthcom) (pp. 1-6). IEEE.

Tudor, K., & Gledhill, K. (2022). Notes on notes. Ata: Journal of Psychotherapy Aotearoa New Zealand, 26(2), 123-144. 10.9791/ajpanz.2022.12