Perhaps a New Technique for Child Therapists: Writing Process Notes with your Child Patient following his or her Therapy Session
Andrew Guthrie, Ph.D, TCPP dipl.
I came across this technique out of pure coincidence and a bit of lazyness. Child therapists are rarely able to write their notes about what occurs in a therapy session during the session itself, as child therapy often involves playing and physical action which does not permit this distraction. Instead, we usually write our notes following the sessions, in the five or ten minute gap between patients. In my job at the Children’s Aid Society, I often see up to ten children in one day, which occasionally necessitates some time-saving measures such as writing my notes with the child in the room at the end of their session. In this way, I came across this “technique” for my own time-saving reasons, before realizing its therapeutic value. I do not use this technique regularly, and I would not do it with every child I see, but depending on the child, the potential usefulness of writing notes with the child, and the type of day I am having, writing my process notes with my patients happens from time to time. Each time it does occur, it has always turned into a significant intervention that can forward the progress of the therapy, which explains why I felt it was important to write a few words on it here.
An example of what it looks like to share one’s process notes with a patient might help. Let’s say there are five minutes left in a session with a seven year old child. I might say, “I’m going to sit down and write about what we did today.” The child almost always shows some curiousity about recording what we did together, and may sit beside me or stay nearby playing quietly with toys as I begin to write my notes and speak them aloud. Often the child hangs in the background and sort of overhears what I am thinking, writing and saying – this is actually part of what makes this intervention especially useful, since the child is provided emotional distance from the emotional experience I am describing and saying. This distance seems to enable the child to listen and take in what I am thinking without needing to shut down or defend against the intense feelings that can be created in therapy.
In response to the child’s interest in my recording the sessions I might say, “Yeah, I always write down what we do together, maybe you didn’t know that. I don’t show other people what we do, but it helps me to remember what we did, and I like to remember.” This statement reassures the child about the privacy of the notes and the sessions. It also communicates that I find the sessions and the child to be valuable and worth remembering, which seems to help children understand that I think about them, remember them, value them, and so on. A child knowing how I feel about him or her can begin to help the child feel differently about himself or herself, can shift his or her perception of me and significant others, and may begin to cause change – therapeutic and developmental change – which, of course, is the goal of therapy.
With the child I will then begin to write and speak aloud what I am writing: “When we met in the waiting room she didn’t look too happy to see me and seemed unsure if she wanted to come with me to the room. I was a bit worried about her. I wondered if she was sad or mad or scared – she looked sad to me but also a bit scared I thought. Inside I said she seemed down and she agreed she was sad but didn’t know why. Then she didn’t want to talk of that anymore. We played castle . . .”
Often I do not share all of what I write in the process notes – for example I usually do not share my interpretation of the meaning of the child’s symbolic play (i.e. the sad princess who lost her mother was symbolically my patient, etc) as I have rarely found that this understanding helps the child very much (nor are children usually interested in how their play can mean “something else”). If I think a child may react sensitively or defensively to one of the observations I would normally make in my notes I would omit this as well. Most children can only take in a few things at a time: it is the therapist’s capacity to judge the learning and attention threshold of each child which may largely determine if the therapist can help that child.
The important thing to note in my observations above are what I am observing in the child emotionally - sadness and fear – since this can begin to help the child understand her own feeling states. Just as important is the fact of my observing anything at all, by which I mean that my observation of her generally connotes that I care, that I have her in mind, and that she is tolerable and observable, or worthy of observation. This may positively affect self-esteem, but also gives her the sense that people can think about each other, empathize or put oneself in the other’s shoes. Feelings can be read – people can be read – and this can create positive feelings in oneself and within relationships with others. Emotional intimacy and attachment with others can ultimately be experienced through the mutual, incremental reading of the others feeling states. Reading one’s notes aloud with a child is one way to facilitate this process.
Back to the session notes: “I knew she had not seen her mother in many weeks, and I wondered if she was missing her. She said she was, and seemed sad. I said I knew she was sad, that it was ok to be sad here, and that I would help her with this. Then she seemed a bit happier and started to play again.”
This part is important since it connects her feelings with a specific event or experience – a crucial aspect of making sense of the world and what happens to us. This capacity is what so many patients in psychotherapy lack and require help with: feelings often make sense, but this requires a sense-maker, or a thinking, empathic person who has the child in mind. The therapist can be this person for the child, and reading this in a process note in front of the child re-confirms what the child already sensed or felt: that you cared, that you think about them, that you are curious about them and want to help them feel better.
Sometimes, reading process notes aloud to a child can make explicit what was implicit in the session. For example, I might say (as I write): “He seemed mad at me when I would not let him cut the puppet, but it seemed like he was afraid to be mad at me, maybe because he was worried about what I would do back to him.” If I had said nothing of the child’s feelings during the session, perhaps because it was too tense or anxious, this would be the child’s first experience of knowing that I thought about him and was getting to know him a bit – good and therapeutic things for patients to know.
Reading to the child my sense of him creates very little anxiety at the moment of writing the note because it feels like a very different event from the kind of relating that occurs during a therapy session. The use of the computer and the formalized act of writing and speaking create a somewhat private experience for me-the-therapist that the child almost overhears, or eavesdrops on, usually without being an active participant in the writing. As I noted previously, this seems to create a feeling of distance and safety for some children, when it is much easier to hear things about themselves that they otherwise might need to shut out. In this way, the therapist broadcasts his thoughts about the child at the end of the session in a formalized way, and the child tunes in, listens and invariably uses the information for some, often growth promoting purpose. Broadcasting one’s thoughts in this way represents a kind of transparency that can also reduce the patient’s potential reluctance or fear of the therapist. The child can see and hear your thoughts, which is especially helpful for abused children who may actively fear what you are thinking and feeling about them. Distortions such as the child feeling that you do not like him or her can quite easily be corrected them (“I really enjoyed playing with him today – his story was interesting and creative”), and the relationship with the child often strengthens and can become less ambivalent and more openly positive.
I would not necessarily recommend this technique to other therapists, as I came across it in my own strange way, although it does seem to be an interesting, effective, non-intrusive, and perhaps novel way of getting across thoughts to our patients, which is so much a part of what we do. How we get our subjective experience across is limited only by our creativity and fear of experimentation and failure. Tentative exploration of new ways of understanding and communicating with our patients may lead to tentative new results in our therapies, which can ultimately benefit our patients. This is, after all, why we do what we do.
Sharing process notes with our patients can be one of many therapeutic actions we make in a session. Therapeutic acts go on all the time, inside and outside of our awareness (with more experience, therapeutic acts become more ingrained who we are personally and professionally), and broadcasting our understanding of a patient in a more formalized way can be added to the ongoing and never-ending expansion of our therapeutic action armamentarium.
