As mentioned in previous posts, collaborative documentation is a new approach to the way in which counselors produce their clinical documentation. Simply put, the clinician “collaborates” with the client when it comes time to write the progress note. Although there are definite benefits to doing this, counselors need to think about how to introduce this concept to their clients.
I have found that my clients have viewed me as “the expert”. Usually clients are looking to the clinician to determine what they need to do to function better, to feel better, and to be better. This, of course, is reasonable as the client is paying for the service the counselor provides. Given this, clients may be confused (and even frustrated) if the counselor asks them to be a part of the progress note-taking process. (After all, isn’t the client paying the therapist figure out what to do?). Clients may also be unhappy about giving up some of their therapy time to stop, reflect on the session and have the counselor write the progress note. Therefore, counselors need to be mindful about how they ask their clients to be involved in the collaborative documentation process. Following are a few suggestions for how to talk with clients about this.
- Explain to the client that you, as the counselor, want to provide the best care possible. Given this, you want to make sure that you are clear about what the client thinks, feels and experiences during the therapeutic session. To best do this, you want to spend the last 10 to 15 minutes of each session going over the highlights of the work the two of you did together.
- Also share with the client that therapy works best when the client is engaged in his or her treatment. Collaborating on the notes that you take will help ensure that you and the client are “on the same page” as to what is working and what is not working during the therapy sessions.
- Another reason to engage in collaborative documentation is so that you, as the counselor, can gain further insights about what the client needs to move forward or make progress in therapy. The goal of counseling is to work with the client so that skills are gained, insights are realized and functioning improves, so taking time to reflect on what transpired during the session can help you both discover the interventions, tools and processes that have the most positive impact on the client.
- A fourth reason to use collaborative documentation is to empower the client. Having the client process what she or he experienced during therapy will help the client realize the progress she or he is making and will enhance the insights gained. The client may be able to leave the therapy session with a sense of direction, a feeling of accomplishment and a deeper understanding of how counseling is working for him or her.
It may take a while for a client to get accustomed to engaging in this type of reflection with the counselor at the end of a session, but more than likely this will strengthen both the therapeutic alliance between the client and the counselor as well as help the client move through therapy with more success.
Stay tuned for how to use an organized, step-by-step method for your collaborative documentation approach. Having a system for how to take progress notes will help both counselor and client use the last few minutes of the therapy session in an efficient and effective manner.