Have you ever thought about the language you use in your progress notes and what it conveys? “Language” refers to a body of words and the systems for their use common to a people who are of the same community” (reference: dictionary.com). Languages vary among different fields, and one of the most important ways in which a profession distinguishes itself as a unique field is through the language it uses. Various professionals “speak their own language”. For example, medical doctors have certain terms they use as do attorneys (think of the times you have tried to understand a medical diagnosis or interpret a legal contract).
For counselors, clinical language is utilized in documentation that pertains to the mental health of the clients being served. Think about the word, “clinical.” This word is used fairly often. For example, commercials are often making statements about how something has been “clinically proven” to eliminate germs, reduce pain symptoms, or improve something. “Clinical” refers to the observation and treatment of clients; the words used are objective, analytical and unemotional. Both the verbal conversation and the non-verbal behaviors of the client are recorded in the progress note so as to ascertain aspects of the client such as her or his current functioning, reasons for therapy, progress towards goals, engagement in the therapeutic process, and mental, emotional, and physical state.
Clinical language includes impartial impressions the therapist has of the client. The words used to refer to what the mental health practitioner observes are objective and factual. An example of a clinical impression would be as follows:
Client is a 47 year old biracial male who exhibits flat affect and speech is anergic. Appearance is disheveled, unkempt and mood is dysphoric. Client reports no prior mental health treatment and denies any suicidal or homicidal ideation. Client reports drinking one to two beers a week, denies any drug use, and states he has never smoked.
What would this mean in non-clinical language? A 47 year-old biracial man has presented as someone who shows little to no emotional expression as he discusses his issues with the therapist (flat affect). He also has little to no expression or energy when he talks (anergic). He appears untidy; clothes may not be clean, hair may not be washed or brushed; and he may also not have bathed or engaged in normal self-care recently (disheveled and unkempt). In terms of how the client appears emotionally, he appears unwell and/or unhappy (dysphoric).
As the session progresses, the therapist needs to think about how he or she is engaging with the client in terms of the therapy modality and the interventions utilized. For example, if the therapist is one who uses cognitive-behavior therapy, some of the clinical language in the progress note should reflect this. The counselor may note statements such as:
- Identified negative thinking patterns the client has about his supervisor, his work and his career;
- Reframed negative thoughts about current situation client is experiencing with his work;
- Identified positive thoughts client has about himself and his skills as well as the positive aspects of his job;
- Challenged client to think three positive thoughts at the beginning of his day and writing down three positive things that happened at the end of the day.
Interventions also need to be recorded in a progress note. Interventions the therapist may have used during this session could be:
- Guided client through a self-talk exercise so as to note changes in mood when positive statements were used;
- Exhibited how cognitive distortions can be challenged with negative thoughts;
- Identified three cognitive distortions the client uses on a regular basis (mind reading, all-or-nothing thinking and fortune telling error); and
- Demonstrated how client could use assertive language with his supervisor so as to better express his thoughts and feelings in a professional manner.
Knowledge and use of clinical language is imperative when documenting one’s therapeutic work with clients. These terms exhibit an understanding of what the clinician is observing. The clinical terms give structure to therapeutic work that may, at times, appear unstructured and difficult to follow. Knowing terms that are distinctively used in the mental health profession conveys the knowledge of the practitioner as well as the uniqueness of the profession. To assist counselors with learning more of these terms, as well providing guidance for progress notes and other forms of clinical documentation, a new book entitled The Counselor’s STEPs for Progress Notes: A Guide to Clinical Language and Documentation is available on Amazon at: http://www.amazon.com/Counselors-STEPs-Progress-Notes-Documentation/dp/1514643588/
Being aware of and using the clinical language that is shared by those who work in counseling and therapy environments helps others understand and respect the professional nature of the mental health field. This language should be applied throughout the progress notes and other forms of documentation kept by therapists as it signifies the specialized nature of the counseling discipline.