[Trace14]

Has anyone ever gotten their therapy notes, like to take to another T? My last T wouldn't give them to me but would send them to the new T. The VA wouldn't scan them into my file so this T gave them to me. I read over them and it was so blah and looked like a lot of copy and paste. I know we talked about more things. I wonder if T's have a copy of more detailed notes somewhere else, and these generic notes are the ones they share.

Had an appointment with the T today. We talked more about stuff we needed to talk about than we ever had. She agreed that this portion of the DBT was dealing with people but wanted me to come back once the Mindfulness session started. My last T sent my notes to this current T. Next apt Oct 17th......over a month away.

[ThisWayOut]

Generally, notes are kept as vague as possible for privacy and legal concerns. They ate deliberately uninteresting and lacking specifics.
I've never asked for my t's notes, but I have looked at them on occasion. Private t's notes are a bit more substantive than the t's I've seen at clinics. The t's I've seen at sexual assault counseling centers were the most vague because they worked a lot with law enforcement. Outside of official statements, most notes were asking the lines of "client spoke about mood and symptoms. Client and therapist agreed on plan of action for the week.".... I saw one for the better part of a year, sometimes more than once a week, and her entire notes at the end of therapy fit onto one legal sized piece of paper (front and back) in my file...

It sounds line this session was a bit more... helpful? Real? Substantial? I'm sorry the next one is so fast away. How do you feel about the thought of returning to dbt again? I know you had mentioned concerns beyond just the lack of relevance...

[Lauliza]

T notes are not supposed to contain too many details and definitely no opinions. So rather than saying "it appears x is depressed" they world write "x presents with a flattened affect" or "x reports feeling depressed". Just observations and what was reported to them. Some Ts may differ but that's how you're trained. Some may keep a second set for themselves that includes more but that would be in a personal file (I yet to come across any that have said they actually do this).

[Trace14]

Originally Posted by ThisWayOut

Generally, notes are kept as vague as possible for privacy and legal concerns. They ate deliberately uninteresting and lacking specifics.
I've never asked for my t's notes, but I have looked at them on occasion. Private t's notes are a bit more substantive than the t's I've seen at clinics. The t's I've seen at sexual assault counseling centers were the most vague because they worked a lot with law enforcement. Outside of official statements, most notes were asking the lines of "client spoke about mood and symptoms. Client and therapist agreed on plan of action for the week.".... I saw one for the better part of a year, sometimes more than once a week, and her entire notes at the end of therapy fit onto one legal sized piece of paper (front and back) in my file...

It sounds line this session was a bit more... helpful? Real? Substantial? I'm sorry the next one is so fast away. How do you feel about the thought of returning to dbt again? I know you had mentioned concerns beyond just the lack of relevance...

That explains a lot. Though you would think if you were sending these notes to another T they would be more detailed. But I guess in the big picture it makes sense. Thanks for explaining that.
Yes, this last session the T seemed to be more in tune with inquiring about why I feel the way I do, instead of let's just address the surface depression and then all will be well. I hope she can keep on this train of thought and maybe we will get somewhere. She wants me to come back to the DBT, next session, which is mindfulness, that may actually pertain to me and I think might be helpful. I will give it a try. At this point I will try about anything, ya know? Even thought about hypnosis. Thanks for responding back and have a great weekend. I'm suppose to go on vacation but the thought of leaving is making me sick to my stomach. Maybe with some Pepto on board I can get through this.

[Trace14]

Originally Posted by Lauliza

T notes are not supposed to contain too many details and definitely no opinions. So rather than saying "it appears x is depressed" they world write "x presents with a flattened affect" or "x reports feeling depressed". Just observations and what was reported to them. Some Ts may differ but that's how you're trained. Some may keep a second set for themselves that includes more but that would be in a personal file (I yet to come across any that have said they actually do this).

I can understand this to some extent. But what if someone is applying for disability. Notes like what I saw would not support the claim. Like I said so much just seemed copy and paste. Maybe SS or whoever needed the information would ask more detailed questions of the T.
I mean, it is comforting ,I guess, to know your conversations are so guarded. But from what I saw it wasn't worth the $20 to have them sent to the current T.

[Lauliza]

Where I live SS gives providers specific forms to complete, so actual therapy notes wouldn't be handed over. They would be more likely to use notes for help in completing the forms. Otherwise SS uses documentation of official diagnosis and testing results if there are any. Then they would ask for a summary explaining how the diagnosis affects their overall functioning.

With notes, the general school of thought in the field is to keep things succinct and factual. Therapy notes can be subpoenaed, and clinicians who put too much detail or opinion in their notes can probably do more harm then good.

[Trace14]

Originally Posted by Lauliza

Where I live SS gives providers specific forms to complete, so T actual therapy notes wouldn't be handed over. They would be more likely to use notes for help in completing the forms. Otherwise they use documentation of official diagnosis and testing results if there are any. Then they would give a write up on the forms explaining how the diagnosis affects their functioning. The general school of thought in the field is to keep things succinct and factual. And to stay vague enough so nothing can ever be used against a client legally.

Okay, thanks for this clarification.