TRANSCRIPT
I’ve been thinking lately about the subject of psychotherapy notes. Of psychotherapists writing notes about their client after each session, writing intake evaluations the first time they meet a new client or potential new client, and how I question the value of these notes, the necessity of these notes. They’re considered a definite basic necessity of the psychotherapeutic relationship. It’s considered a basic responsibility of the therapist to write down what happens or the progress or something that happens in every single psychotherapy session to document it. They can get in trouble; they can be held liable if they don’t write notes and don’t write proper effective notes.
Well, in contemplating this subject, I go back about six years in time. I remember the date actually that this story took place: March 1st, 2017. It was the seven-year anniversary of me closing my private psychotherapy practice. I had had that private psychotherapy practice for eight years, the last six years of that being full-time. On that seven-year anniversary of closing my psychotherapy practice, I closed it March 1st, 2010. I had been wrapping it up for a year. Seven years later to the day, I sat in front of a shredder, a little plastic and metal machine that shreds paper. I opened up a large lock box that I had that had a really strong padlock, took the padlock off, opened it up, and had a big thick pile of papers. One by one, I put the papers into the shredder and shredded them. It was eight years of private practice psychotherapy notes and intakes. I was finally allowed to get rid of those notes legally. Actually, I found out later New York State only required me to wait six years, a minimum of six years, but I waited seven. I actually mistook the date.
But I remember how it felt to shred those notes because I looked at them. I didn’t read; it was way too much to read. Probably, you know, hundreds of thousands of words of notes that I’d typed in and printed out and signed and dated. But reading these names of these people, so many people, people who I loved, many, many of these people who I’d seen, some of them for years, in all sorts of different contexts and ways, and talking about all sorts of different things. Just reading snippets of the notes and snippets of the intakes and shredding them, and I felt so mixed. It was like another stage, a big stage, a final stage in a way of letting go of my relationship with being a therapist, but also saying goodbye at another level to these former clients of mine. These people who I had done my best to nurture and help to grow and listened to.
So I did have sadness, the letting go process, but also it was a wonderful sense of relief, a sense of letting go of this powerful responsibility of holding on to all this massive amount of private information. Also, a sense of respect for the clients, all these human beings, these people. A sense that now I no longer am holding on to a record of your life, your privacy, your intimate experiences, sometimes very horrible and traumatic and terrible things as expressed in these notes. There was a part of me that just felt it was wrong that I, who had not been in touch with many of these people, most of them, almost all of them for years and years and years, that I should be holding on to this.
And also, the most poignant, most painful, I suppose in a strange way, was, well, I think of looking, holding on to the intake evaluations of some of the people who I had seen 15 years earlier, right at the beginning of my private practice. Because some of these people only came one or two times, maybe once. I only saw them once. I asked them a lot of personal questions about their lives, as I needed to do as a therapist, but I was documenting it also as I was required to do. And some of the people, I couldn’t remember their face anymore. It had faded, meeting one person for an hour 15 years earlier. And here I was, the guardian of all this incredibly personal information: history of being molested as children perhaps, or suicide attempts, or deaths in their family, or terrible painful things that they may have remembered or had done or had witnessed. And I’m holding on to this. It’s like, why should I? I didn’t feel it was right. I felt sort of like it was wrong that I had this information.
And then I thought of these people out there who I wondered, did they think about me having written down all this information? Because I told them that I would do this. They had actually signed a consent form for me to write down all this information. This was part of the process I had explained to them. But how did they feel that 15 years later, some person that they may have actually forgotten, they may not have remembered me at all, that I had their social security number, their birthday, their name, all this stuff, an emergency contact? And that, like, why should I have this? It really brought these thoughts to my mind also as I was shredding these notes.
And it took hours, like hours, to just shred, you know, hundreds and hundreds and hundreds of pages of notes. Many points I teared up. Some of the people I was actually shredding their notes, they had died. Some of them had HIV and had died, or died of cancer, or a heart attack. And here I’m like the guardian of, in a way, probably the closest thing anybody had to their life story. And it was like, how strange. But a thought that came to my mind is me having been in psychotherapy, me having gone to a few therapists who I’m confident to say didn’t like me, weren’t loving toward me, didn’t have positive regard for me, not of the variety that I had toward these people who came and bared their souls to me.
So I was the guardian of information of people whom I loved. But I thought about a couple of therapists in particular. One who fired me straight out, and then I had another one, you know, while another one got back when I was a teenager. I’ve talked about her, a rotten person. She just threatened me. What did she write in the notes about me? What terrible things might she have written? Probably she wrote, is that record still there somewhere? Or another therapist who I saw for two years, who I fired because I finally figured out she doesn’t understand me, she doesn’t like me, she’s cruel and crude in many ways. And yet I tried to get her to like me for so long because while I was playing out my hope that my mother and my father would like me and finally love me, and finally I could win someone who was a parental figure. And I bared my soul and told her all the deepest, darkest secrets and hopes and desires and fantasies of my life. And she could never live up to that expectation.
And I think she felt ashamed of herself when she unconsciously realized that she couldn’t be what I wanted and wasn’t healthy enough to be. And then I started getting angry and started calling her out for it, like many of my clients called me out. But when they called me out, I felt that what a beautiful thing. They’re being honest. Let me live up to it. Let me respect them more. Let’s bring it back to their history and learn about them and let me try to grow. That’s not what happened with her. She resented me more and more and more. And it’s like, ugh, I showed a light on her limitations. And I’m sure she expressed that in the notes. I’m sure she wrote things about me that weren’t loving. And I, as I shredded those notes, I thought, is she holding on to this record of what she wrote about me? This record in which she had the legal authority, the medical authority, authority to write the truth in those notes? And what she wrote was considered fact, even though it was her opinion or maybe her twisted ideas. Or this other guy therapist I had who fired me, and I’m sure he wrote nasty, nasty things about me: immature and this and this and that. And I was this and this. And it was like, really? Because I emotionally threatened him because I called him out for being so immature and stupid.
Did he write about me? And I wondered, should I go through the formal process of requesting a copy of my medical records, my notes, my intake that they took on me, so I can see what they wrote about me? So I can witness it and know for myself.
And then it just went through my mind, “Don’t do it, Daniel. Why read cruel and harsh things that people you don’t really respect wrote about you?” Whereas a therapist, because I know it—I was a therapist. I’ve read so many other therapists’ notes about my clients. They can write harsh things. They can twist it and make it really mean. Or what they can do is not write the loving stuff, not write the caring stuff, not write the strengths of the clients, but instead focus on the weaknesses, focus on the problems, focus on the pathology, the medical pathology, focus on the symptoms of the diagnosis. Let it go. Just like that’s how I finally resolved it in my mind.
And I’ve thought about this many, many, many times since. And even sometimes, even a little bit before, out of curiosity, “What did they write?” But then I thought, “This is just going to make me angry and want to fight with those people.” And then I think since then, and even before then, sometimes from time to time, a person reaches out to me on the Internet or in various forms in the world and says, “You know, I’d like to get my medical records from a past therapist to see what they said.” And I usually don’t recommend it. Sometimes it might be interesting. Other times, people have told me they did get hold of their medical records. They did get hold of their psychotherapy notes, and they were shocked. Sometimes they said they learned some things, but sometimes they were shocked to discover how cruel, how vicious even their psychotherapist or psychotherapists were about them in the notes, writing about them. Is this disturbed being the client in a way that the client wasn’t?
I’ve actually had that happen in psychotherapy with these clients sometimes, where while in therapy with me—this happened in the past—they got hold of their medical records and saw and were devastated sometimes by saying things like, “I thought that past therapist of mine, he or she loved me.” And then when I read the notes, I think, “This person really not only didn’t love me, but really was like spitting on me, being nasty about me, saying such hurtful things. I never would have gone back to this person if I knew what they were writing about me in the notes.” Well, as I was shredding the notes, also many, many moments of gratitude for something I’d learned along the way—that was the more I loved my clients, the more I realized, write these notes for the clients, for their betterment. Write these notes with the intention that the client will most definitely read them.
And in that year when I started closing my practice, I told all my clients, I said, “If you wish to have a copy of everything I’ve ever written about you, just tell me, and I will photocopy them, and you can have them.” And it was fascinating, actually, how people responded to this offer of mine. Now, I know legally I was allowed to say, “And you have to pay me,” so for the photocopying, but I didn’t do that. I just said, “Let me do it for you. I want to give it as a gift. I feel actually you should own these more than I should. You should see what I’ve written about you because it’s all about you.”
Well, when I offer this to my clients, I noticed right away that they fell into one of two categories, and it was very interesting because there were definite sides of both categories. The first category was the clients who immediately said, “Oh my God, yeah, I’d love to read my notes. I didn’t know I was allowed to.” And almost all of the clients that fell into that first category were people who had not previously been in psychotherapy, and I was the only therapist that they knew. And what had happened, I realized, as a result of our relationship, months or years of working together, was that they just trusted me inherently. They thought I was a good—they knew actually that I was a good force for growth in their life, and they made the assumption that my therapy notes reflected that. And guess what? They were right.
So I made copies, they read them, and most of these clients came back immediately, were like, “Oh my God, awesome, thank you! It’s like a biography of my life. You wrote it respectfully, you wrote it kindly, you were taking my side clearly in these notes. You didn’t write so much personal information that it could hurt me. You didn’t make me look troubled and disturbed, blah blah blah blah.” And I put a lot of effort into writing the notes as a record of what happened such that it wouldn’t hurt the client or even hurt other people in their lives. I could be kind of vague about other things that might really cause damage if someone else in their life were to read this.
Because also, I’ve seen this—didn’t happen to me, but I know a few stories through my years of being a therapist, and certainly I’ve heard it since—of a psychotherapy client who killed him or herself, committed suicide, and suddenly people in their lives, family members, got hold of their psychotherapy notes and their intake, and they read stuff, and they learned stuff. And sometimes it was devastating private information family members could read about molestations, things between siblings, perhaps things that the client had never told anyone and never intended for their family members or greater family members to know about. It could wreak pain and havoc in their relationships—things that clients maybe never ever wanted other people to know. And yet, because of the notes getting out, it came out. So I was very careful about what I wrote in those notes.
So that’s the first category. Also, the other thing is some people in that first category of clients who wanted their notes immediately were people who had been in therapy before, maybe even hadn’t trusted past therapists, but trusted me. But basically, it was the category of trust.
Then there was the second category of people who were like, “I don’t know that I want to see my notes. What did you write about me?” And that was shocking to me because I was like, “Wait, let’s say we’ve worked together for years. Haven’t I proven to you? I thought it was just assumed that I’d proved to you that I’m on your side and I’m fighting for you, and of course it’s going to be reflected in the notes that my notes are an expression of my love for you, my caring for you, my fighting for you.” And what I learned from some clients is that they had been burned so badly by sometimes having read past psychotherapy notes that they didn’t really even trust me deeply.
And then I was like, “No, I actually want you to read these notes. Even if I don’t give you a copy, please look at them. At least see that it wasn’t the same.” And some of those clients read the notes, and they’re like, “Oh my God, I wished I’d read this before. I had no idea that there was such a thing as a loving, caring psychotherapy note.” And that opened up discussion—fascinating discussion sometimes. Sometimes I was really glad it happened, you know, six months or a year before my therapy practice closed. And my clients told me stories, um, former psychotherapists of them writing horrible, ugly diagnoses that the clients didn’t even realize they had. They thought maybe they had some mild diagnosis. Instead, they’re being diagnosed with psychotic disorders or pathological personality disorders that really were embarrassing and shameful—notes written that were very harsh, learning that sometimes psychotherapists secretly hated them, pretended they liked them so the person would keep coming back, but was expressing their rage and hatred through the side lens of writing in these private psychotherapy notes.
And how do they even find those notes? Some of my clients told me, “Well, you know, my therapist went to the bathroom in the middle of the session, and I saw my chart, so I peeked at it, and I started reading it, and I saw these horrible things written about me.” Hmm. Another thing is I’ve read clients’ notes sometimes when I was at clinics. I would inherit that word that they used.
Inherit a client when a psychotherapist would leave. I would get their whole chart, and I would look through the notes. I would read these things that psychotherapists—sometimes psychotherapists who I knew, sometimes psychotherapists who I’d never met from the years past. I read their notes, and it was like, oh, sometimes they could be really harsh and cruel. I thought probably better that this client doesn’t know what this person wrote about them. But then I had part of me thought they should know this. They should know about who they sat with sometimes and paid money to for years.
Then this stuff, and then I think back early on in my time as a psychotherapist when a supervisor of mine—I think it was my second year of being a psychotherapy intern—I had a lot of clients. I was asking a supervisor of mine, “Well, how should I write these notes? What should I put in there?” The supervisor of mine, a kind of a cunning person, said to me, “Wow, you should always consider that your psychotherapy clients might read the notes. So consider that they’re sitting on one shoulder, peeking at the notes you’re writing over one shoulder. But on the other shoulder, remember there could always be a lawyer who someday will read these notes and could come and try to get you in trouble legally.” So imagine a lawyer, a hostile lawyer, sitting on the other shoulder reading everything you write because it’s a legal document that could end up in court. They could go after your license. So make sure you write them very, very carefully to protect yourself from liability.
And what a sad thing! What a sad thing to even have to consider from the perspective of a psychotherapist that here you are trying to help someone grow, and yet in your legal required documentation, you are having to protect yourself from getting your livelihood and your life destroyed because you might write something that makes you look bad. And I’m like, how can that be a part of a healing relationship? Which makes me question the idea, maybe no notes are better at all. It certainly would increase confidentiality if nothing was being written down, not even the client’s name at all.
And on that subject of confidentiality of psychotherapy notes, yes, psychotherapists are required to keep all their notes under lock and key for a minimum, in New York State, of six years, perhaps longer elsewhere. But I think of some of the psychotherapy clinics where I worked, where there was a locked room where the notes and the intakes were kept. But how locked really was it? Who had access to those rooms? I think sometimes of going into those rooms in the clinics where I’ve worked and seeing people reading notes of clients who are not their own out of curiosity. The directors of the clinic going and just reading notes about some client. The people who were on the staff of clinics maybe reading notes about a client, maybe out of curiosity. Maybe the janitor went in and read the notes when he or she was cleaning the room because he or she was allowed to be in that room after hours. It’s like, how locked really were those rooms?
I thought about that for myself. It’s like, who could read the notes that those past psychotherapists of mine wrote about me? Pardon, foreign just the thought of that made my throat tighten. I think that’s why I just coughed. It’s a very unpleasant burning sensation and thought. It’s like, how private was that relationship? And those relationships of ultimate privacy? We’re back in school when I was studying to be a therapist. They talked about the extremely high value of confidentiality, except when confidentiality was broken for X and Y and Z reason.
I also thought sometimes about back when I was a therapist, when psychotherapy clients of mine, or past psychotherapy clients of mine, sent me a request for information because they were getting divorced and they needed their psychotherapy notes to prove XYZ about their relationship with their soon-to-be ex-wife or soon-to-be ex-husband. Or they were having some legal problem with a car accident, and they needed their psychotherapy notes or some summary of it. And it was like they were allowing confidentiality to be broken. But it’s like, I didn’t like that. I would talk to them and say, “I don’t think that’s a good idea. I don’t think really this is a good idea.” But then again, sometimes I had to do it. They requested it. Sometimes I could get away with just writing up a summary, but sometimes that detailed stuff in there, no matter how lovingly it was written, it’s like I think it’s a bad idea for that to get out into the world.
And just the fact that it might get out into the world, it really puts the therapist into a very weird position where they become more than just a healer in their relationship with the client. Again, having to think about that lawyer sitting over their shoulder, and not more in a better way, but it’s like more in a cunning way, more in a twisted way. But they have to have another part of them that’s always thinking and thinking about what’s going to happen and how is this going to be used. Maybe if they’re loving, outwardly loving, used against the client. But many psychotherapists I know are not so outwardly loving. If they are self-protective, this is their business. This is their livelihood. This is the livelihood of their family. So they’re always being protective of what they say.
And sometimes, in many cases I know it to be true, many psychotherapists write things that can be harsh about a client in order to protect the therapist’s own self. Well, what if it comes back, you know, to bite the therapist? Oh, you didn’t send them to a psychiatrist for meds, or you did send them to a psychiatrist for meds, or you gave them this, you know, extreme diagnosis. You had better prove that they are officially crazy or officially pathological. And you have to constantly document in the notes how pathological they are to justify that you’ve given them this extreme diagnosis. And sometimes they gave them this extreme diagnosis so that they could bill for a longer period of time to the insurance company so that they could be paid. So they gave a high diagnosis, and then the notes have to reflect that diagnosis. And this is troubling. This is like not therapeutic.
So yes, maybe there can be a real value in documenting some aspect of the psychotherapy in some way. But the way that it happens nowadays, it’s so tainted. It’s so twisted. It’s so much risk of loss of confidentiality, so much risk of actually causing harm to a human being or to many human beings. I think, huh, I think maybe we’d be better without psychotherapy notes at all. No written documentation. Often I think it would be better for the whole therapeutic world. And I think the incredible relief I had when I looked at that lock box when it was totally empty, when I just had a huge mound or several bags from what I remember of just shredded notes, and I threw them away. No one could ever piece them together. No one could ever figure out what they once said. That sense of relief, that feeling of freedom that I got all those years after being a therapist. And I thought, hmm, maybe it would have been more therapeutic for me, and I would have been able to have been a better therapist if that lock box from the very beginning had always been empty.
[Music]