Tag Archives: process notes

Observation Skills

(Pfäfflin & Adshead, 2004) suggest that from a neurobiological perspective the process of affect regulation inexorably links nonverbal and verbal representational domains in the human brain.  This relationship may serve to facilitate the transfer of implicit information in the right hemisphere to explicit or declarative systems in the left.  (Pfäfflin & Adshead, 2004, p. 136)  One might deduce that it would be subsequently impossible to separate verbal behavior from nonverbal behavior.  Recognizing this connection, in my opinion, is the key to improving our observational skills.  No action, verbal or nonverbal, should go un-scrutinized… every action (no matter how small) means something.

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Despite our recognition that nonverbal communication is as important, or more important, than verbal communication; “there is no dictionary of nonverbal communication.”  (Riggio & Feldman, 2005, p. xiii)  There is no standard by which we can judge the inherent meaning of an averted gaze.  Even basic facial expressions that convey emotion are subject to the trials of context and individual differences.  And so, we would be well served to recognize that individual and multicultural issues are paramount in the interpretation of behavior.  Furthermore, the interpretations of those expressions are governed by our own selective attention.  (Ivey, Ivey, & Zalaquett, 2010, p. 124)  “Be careful not to assign your own ideas about what is ‘standard’ and appropriate nonverbal communication.”  (Ivey et al., 2010, p. 125)

I would suggest that we be cognizant of the perceived deficits that our potential clients bring to the table, especially if they have a history of interpersonal problems.  We should approach our observations with a healthy scientific skepticism and mindful that we can not always trust what we see.  Furthermore, we would be well served to approach the perspectives of our clients with the same distance and objectivity.  Take the case a client whom demonstrates deficits in decoding facial expressions…

One can speculate that many interpersonal problems might result from a deficit in decoding facial expression… the most obvious problem is the difficulty in identifying the internal states of others: their desires, emotions, or intentions.  Such information is essential for the understanding of others, of the meaning of their behavior in general as well as during social interaction.  Relating to someone whose intentions and emotions are obscure is virtually impossible.  (Philippot, Douilliez, Pham, Foisy, & Kornreich, 2004, p. 18)

Furthermore, research suggests that both nonverbal and paralinguistic communication play an important role in the retrieval of knowledge in trans-active memory systems.  (Borman, Ilgen, & Klimoski, 2003, p. 348)  Almost invariably, it seems as though individuals will “look up and to their left” when they are retrieving information from long-term memory.  Although I do not recall the specific source, I recall that left handed people actually do the opposite (look up and to their right).  When interpreting the memory retrieval of our clients, we would be well served to know which hand they write with.

You mentioned note taking… which is important not only for our benefit of reviewing previous sessions, but for our ability to self access and determine if we have left a stone unturned.  Process notes really are an art, not a science.  In his blog, Bowden Mcelroy (2005) suggests a couple of different formats for process notes that you may find helpful in your practice.  He terms the first one ‘BIRP.’

B: Behavior. What did the client do?

I: Intervention. How did the therapist intervene?

R: What was the client’s Response to the intervention?

P: What is the Plan? Where does treatment go from here?

A second suggestion, one that is in relatively wide use in the field, is called ‘SOAP.’  (As a sidebar, this is also a great method for self-assessment) (Mcelroy, 2005)

S: Subjective: What did the client say?

O: Objective: What did the therapist observe?

A: Assessment (or, Analysis): What does the therapist think is going on?

P: As always, P stands for Plan.

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Borman, W. C., Ilgen, D. R., & Klimoski, R. J. (Eds.). (2003). Handbook of psychology (Vols. 1-12). Hoboken, NJ: John Wiley & Sons.

Ivey, A. E., Ivey, M. B., & Zalaquett, C. P. (2010). Intentional interviewing & counseling (7th ed.). Belmont, CA: Brooks/Cole.

Mcelroy, B. (2005, Nov. 10). How to write counseling notes [Web log message]. Retrieved from http://mcelroycounseling.com/how-to-write-counseling-notes/

Pfäfflin, F., & Adshead, G. (Eds.). (2004). A matter of security: The application of attachment theory to forensic psychiatry and psychotherapy. New York, NY: Jessica Kingsley Publishers.

Philippot, P., Douilliez, C., Pham, T., Foisy, M., & Kornreich, C. (2004). Facial expression decoding deficits in clinical populations with interpersonal relationship dysfunctions. In R. E. Riggio & R. S. Feldman (Eds.), Applications of nonverbal communication (pp. 17-37). Mahwah, NJ: Lawrence Erlbaum Associates.

Riggio, R. E., & Feldman, R. S. (Eds.). (2005). Applications of nonverbal communication. Mahwah, NJ: Lawrence Erlbaum Associates.

Supervision: Self-report, process notes, audio recording, video recording, and live supervision

Self-report is described as the most widely used supervisory model.  Self-report within the context of a supervisory relationship is troublesome for the same reasons that self-reporting is troublesome in the context of a therapeutic relationship… it’s not always “objective.”  I don’t think people purposely misuse the self-reporting tool, but it is potentially an issue when the person reporting has a lack of insight or intuition.  The potential issues we need to be most aware of are those that are in motion and are totally unforeseen.  Because of the potential for lack of awareness, due mostly to inexperience, I would anticipate that self-report would leave all parties vulnerable to the inexperience of the supervisee.  Potential benefit is the relative ease of conducting this method, provider there is a relationship of trust and understanding between and among the supervisor and the supervisee.

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Without, self-report is likely a method we will employ during our supervision process, but it should not be the only method we employ.  Process notes build on the self-reporting process by adding written record regarding content and interactions in the therapeutic process.  I support the concept that “if it’s not documented, it didn’t happen.”  I am already what you might consider a “documentation junkie”… so this is likely to be my strong suit.  We are required to keep detailed notes in both the clinical record and the case notes, so this should come easily to most competent clinicians.  It still has the drawback of the content having been filtered through a relatively inexperienced clinician… but I honestly believe that writing is a process that demands the inexperienced clinician reflect on, and subsequently justify, specific processes, strategies, questions, concerns, etc.  The second layer of documentation, when added to an oral self-report, gives the newly trained clinician the benefit of hindsight when and if a similar situation arises in the future… thereby making the experience more valuable for long term growth and development.

Recording, whether audio or video, is a valuable tool in that is allows for direct assessment that is not “filtered” by an untrained mind.  In my opinion, this is the single most effective (and time constraint friendly) way to get feedback from a supervisor directly.  Understanding that supervisors have their own caseloads, and their own lives outside of work… even the most dedicated supervisor can’t be expected to conduct live supervision (the most accurate and most valuable form of supervision) often.  Recording gives the supervisor the opportunity to review the content at their leisure, and without the pressure of having to serve a client “right this second” like live supervision.  It is a good balance between autonomy (on the part of the supervisee) and oversight (on the part of the supervisor).  I like this opinion… it would be my first choice among the methods of supervision.

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