Ethics and Case Note Writing

1. Ethics and Case Note Writing Caitlin J. McCredie March 4/2014

2. Introduction Imagine your client who was sexually abused is in court testifying against a sexual abuser. You have been seeing your client for a year since the incident. All of your counselling files has been subpoenaed and are being used in the defences case. Your client has disclosed much of her life regarding her relationships with others, drug and alcohol use among other things. Your client has had 2 abortions. All of this is documented in your case notes which are now being used a hook for the defence. This is how ugly things can get when ethical case note writing is not practiced. Ethical dilemmas of what to write or what not to write can happen all the time in the counselling field. However, if proper guidelines are followed there are ways to protect your client, and yourself.

3. The Counsellors Responsibility “Counsellors have a primary responsibility to respect the integrity and promote the welfare of their clients. They work collaboratively with clients to devise integrated, individualized counselling plans that offer reasonable promise of success and are consistent with the abilities and circumstances of clients.” (McMahon, Schulz, & Sheppard, 2007)

4. Ethical Dilemma/Area of Research The ethical dilemma that I will be discussing in this presentation is how much or how little is ethically correct to record in client case notes and client files in counselling. I will do this by discussing my experiences with case note writing in my internships, using information from the CCPA, discussing the importance of case note writing, defining confidentiality and its limits, going through practice ethical dilemmas, including a presentation on ethical case note writing I was able to attend, and presenting questions open for discussion.

5. Ethical Case Note Writing First, I would just like to explain why this topic is important to me and why I chose to research it. I did not know much about case note writing when I entered my internships, and I did not really have to do any of it in my junior internship. It was really shocking to me that when I began my senior internship I was totally out of the loop. It seems to me that there is so much gray area regarding case notes and client files, and this can be quite alarming. As a counsellor, client confidentiality and safety should be at the forefront of practice. This includes what goes into a client file. To be able to write case notes ethically is a challenge. I also thought this would be a good topic since everyone will have had different experiences with what was required at their agency.

6. Why keep client files? In most counselling agencies, case notes are taken recording sessions with clients. This is helpful for the counsellor to be able to reflect on the session, keep thoughts organized, and to create a treatment/session plan for their clients. These files can also serve as evidence that the counsellor is in good practice, and demonstrating positive change in the client. Other things that may be in a client file are: contact information, address, occupational information, health information and the informed consent and confidentiality agreement between that counsellor and client. Typically, this is a document which is signed in the first or second session with a client. According to the CCPA, it is a counsellors responsibility to keep up to date notes on their clients, “Counsellors maintain records in sufficient detail to track the sequence and nature of professional services rendered and consistent with any legal, regulatory, agency, or institutional requirement. They secure the safety of such records and create, maintain, transfer, and dispose of them in a manner compliant with the requirements of confidentiality and the other articles of this Code of Ethics.” (McMahon, Schulz, & Sheppard, 2007)

7. What are The Limits of Confidentiality? “The CCPA Code of Ethics lists the limits of confidentiality: Counselling relationships and information resulting therefrom are kept confidential. However, there are the following exceptions to confidentiality: (i) when disclosure is required to prevent clear and imminent danger to the client or others; (ii) when legal requirements demand that confidential material be revealed; (iii) when a child is in need of protection.” (McMahon, Schulz, & Sheppard, 2007)

8. When Confidentiality Must Be Breached: After reviewing what the CCPA lists as the limitations of confidentiality, we can see that there are many situations that counsellors will come into contact with in which they may be facing this ethical dilemma. No counsellor wants to damage the rapport that they have developed with their client. This can be painful for the client and the counsellor, and can damage the therapeutic relationship that has grown between them. Thankfully most counsellors can rely on their agency for support for themselves and their client when confidentiality must be breached. (McMahon, Schulz, & Sheppard, 2007) However, I would like to focus on the second point in the CCPA code of Ethics definition of limits of confidentiality, “when legal requirements demand that confidential material be revealed” (McMahon, Schulz, & Sheppard, 2007). This is not something that ever happened to me in my internships, but it was something I talked a lot with my supervisor about. What would happen if the files a counsellor has kept on their client were subpoenaed by the courts? Would this counsellor be in some kind of trouble? Would the client? How can what a counsellor keeps record of be dangerous to the client?

9. What We Write Down Matters? Yes, ethically speaking, the types of things you write in your clients case notes matter. The language in which a counsellor writes their case notes matters. And, the amount of detail or lack of detail certainly matters. As counsellors it is our responsibility to keep our clients safe, and we can do that by using ethical case note writing when documenting client sessions. So how can what we write about our clients harm them? Why cant we just write everything the client said in the session down? We cannot do this because if for some reason that file were to be read in court, that would be very harmful to client. On the other hand if we write down fewer details and keep things concise, some of our clients privacy can be protected.

10. A Practice Situation Your 25 year old female client comes in for her weekly session and it is proceeding as normal. You decide to do a genogram with your client. Your client discloses years of alcohol and drug abuse by nearly all members of the family. The client explains that her mother was drinking while she was pregnant with a child and miscarried. This was very traumatic for your client, but you have created a very safe space and your client is happy to share their past with you. Your client also talks about the many years she spent as a child feeling like there was little to eat around the home, and they way her mother and father had done little to ensure that their children were clothed and fed. Your client has a relationship with her parents today. You decide to do a therapeutic drawing exercise to get grounded before ending the session and your client draws a picture of a cat. Before going on to the next side, think about what kind of detail you would include in a case note about this session.

11. Which of these is right? Few Details Theme of session was childhood and family trauma. Client reflected on meaningful past experiences. Grounding exercise was completed. Many Details Client disclosed watching her parents abuse alcohol for much of her young life. She reported having been hungry and uncared for by her parents and remains sad about this. The client said she saw her mother have a miscarriage that was caused by alcohol consumption.

12. Which of these is right? There is no right or wrong answer. Before proceeding, reflect on your experience writing case notes, and consider which style best protects your clients right to confidentiality.

13. How to Write Ethical Case Notes I was able to take in a presentation on Ethical Case Note Writing by Dawn McBride last semester. She is an associate professor at the U of L and is a private practice psychologist. During her presentations she covered 13 areas that should be considered to avoid ethical dilemmas with clients and case note writing. Her job previously has been to work in court when counsellor files are subpoenaed. It is important to remember that any form of recorded information is considered to be a record that can be subpoenaed.

14. How to Write Ethical Case Notes It is important to only record the information that you absolutely need. Keep in mind when writing case notes on a client, that this is YOUR case note and it should be written for yourself, not for an audience. Less is more in a case note because it should only trigger your memory of details. Don’t ever state that something your client said is a fact in their case notes. Use words like, “Client stated,” or “he explained.” This is important because you don’t know if what your client told you is true, and you don’t want to be held accountable for this. (McBride, 2013)

15. How to Write Ethical Case Notes 3. Keep this case notes private to the best of your ability. Ensure that the printer you use is also private. 4. Describe your clients behaviour but don’t diagnosis it. Say things like, client displaying anxiety by______. Don’t say, “client was experiencing an anxiety attack.” 5. Take notes during the session to ensure accuracy. 6. Don’t use long paragraphs to explain a story. 7. Do not record names of your clients in your daytimer. (McBride, 2013)

16. How to Write Ethical Case Notes 8. Don’t keep two sets of notes. This means, if you have taken informal notes in a meeting, relay them into your formal notes and destroy the informal ones. 9. Keep separate files for all client involvement in your agency. (Individual/group/couple/family counselling should all be separate notes.) 10. Record any phone contact you have with your client. 11. If you receive a disclosure of abuse, but sure to record the action you took. (CPS/Police/SRO) 12. Don’t include the clients narrative of their life or “diary” into the case note. 13. Ensure you always record harm to self or others. (McBride, 2013)

17. Putting it All Together So how does this relate to addictions counselling? It is important to have a case note writing format in your agency or practice, to ensure the protection of yourself and your client. Lets look at another practice situation and using the steps provided from the ethical case note writing seminar, create a session summary.

18. Putting it All Together Practice situation: You have been seeing a client for several weeks now in your private practice. This female has issues with alcohol and drugs, and has just disclosed that she prostitutes herself in order to fund her addiction. This female is 24 years old and has suffered much trauma since her childhood which she disclosed to you during this session. This client also disclosed to you that she was a witness to a crime many years ago, and this bothers her often. You decide to use some creative art therapy for grounding, and play with some clay. She moulds the clay into what looks like a baby. You ask her to explain her piece and she says she recently had an abortion, but she has not disclosed this to family or her partner. Session ends and you are due to see her again in 1 weeks time.

19. What do you think? If this was your client, what would you include in the case note? Have you ever had to write case notes? Does/did your agency have a policy/template for case notes? Do you think case notes should include all details, or be kept to themes and generalizations? If you have not had to write case notes before, what were your thoughts before this presentation on what case notes should look like?

20. Conclusion Thank you for viewing my presentation. Case note writing was a huge challenge for me in my senior internship and I learned a lot during that time. I hope that you can take something from this presentation with you and I hope I can answer any questions the class might have from this presentation.

21. References McBride, D. (2013, October). Ethics: consent & record keeping in counselling. Professional development. Lecture conducted from the University of Lethbridge, Lethbridge, Alta. McMahon, S., & Schulz, W., & Sheppard, G. (2007). The code of ethics: Canadian Counselling and Psychotherapy Association. Retrieved from https://moodle.uleth.ca/201401/pluginfile.php/46 858/course/section/1064/CCPA%20CodeofEthics_ en_new.pdf