My penmanship blows, by the way

We talk in therapy, right? So what’s with all the scribbling?

A reader asked a question about the written word that’s too good to erase. It pertains to the value of longhand in the therapy office, which sounds like prime Mailbag material. Again, this is a disguised and distorted letter from an unidentifiable and possibly fictional reader:

I love therapy and can’t imagine where I’d be without it. I just started with the third therapist in my life and it’s good to be growing again. Only one small problem. She has her notepad out each session and writes as we talk. She keeps eye contact and doesn’t write down everything, but it’s still a distraction, and I feel distant when she’s writing. Is this a normal thing for therapists, and should I accept it or say something?

Even if you’re a therapy neophyte you’ve seen the caricature: patient lying on a couch, talking to the ceiling, therapist sitting silently out of sight, notepad perched on crossed legs, either taking notes or falling asleep. In the least flattering portrayals the notepad is filled with a shopping list or juvenile doodles. The notepad is as much a part of the lore of therapy as the clock, the couch, and the bottomless box of Kleenex. But is it really a therapy staple?

No, it isn’t. Many psychotherapists go without the notepad in weekly sessions. They set the pen aside and spend the hour focused on talking and listening, believing that notes prevent them from fully engaging with the client.

Of course, there would seem to be some practical value to note-taking in session – collecting data, recording details, staying on topic, etc. - yet it’s not a given in the consultation room. So why wouldn’t a therapist take notes?

It’s distracting: Regardless of a therapist’s Olympic-caliber multi-tasking skills, they’re going to lose some of the client’s thoughts as they debate “your” vs. “you’re” or blast through the “i before e except after c” ditty. You just can’t fully attend to a client while formulating and writing a summary. Also, most therapy conversations travel a non-linear path, so a session outline won’t follow the MLA handbook.

Does it help memory?: Something happens when you write something down – it removes the pressure to remember. That’s why journaling is so effective for anxious people who have difficulty at bedtime, by the way. If you have it in the written record, why work to repeat it in the 3 lbs of fat between your ears? But in therapy, if the therapist isn’t returning to the notes to digest every word, the notes may actually reduce the amount of information the therapist remembers. A recent study showed that note taking alone doesn’t actually benefit recall.

We already take real notes: The notes taken during the session are typically jumbled fragments of data. Whether we take notes or not, we still need to write a coherent, legally binding note at the conclusion of the session. In-session notes may help us recall certain minutia, but it records trees, not forest.

It’s a barrier: That 8.5” x 11” cardboard and paper legal pad can feel like the Great Wall of China to the relationship. The client may wonder what their therapist is writing about, or not writing about, they could worry about where those notes go, or they may feel more judged or evaluated than heard. Therapists may feel pulled to attend to the notes instead of the client. The appropriate therapeutic response to “I lost my dog Rover when I was 7” is concern and compassion with congruent body language, not: “is that Rover with one V or two?”

Of course, there are some exceptions. There are always exceptions. Here are some times when a therapist may choose to take notes in therapy:

Intakes/legal issues: Early sessions tend to be heavy in history and description of the symptoms the client experiences. Therapists often jot down the significant dates, names of important people, and descriptions of symptoms. This becomes even more important when documenting information that could be written up in an abuse report or other legal proceedings. Most therapists who take notes during early sessions set the pen aside after gathering the history, but not everyone.

Therapeutic modality: Some forms of therapy (typically of the CBT variety) rely on a written record of thoughts, feelings, subjective units of distress (SUDs), or the classic psychoanalysis lying-on-the-couch scenario mentioned above. These therapists have been trained to take notes during the session, so they’re just following their guidelines.

Dreams: Some therapists eschew the notepad for most sessions, but it magically appears whenever a dream enters the room. These shrinks respect dreams to the point of wanting to record them verbatim in order to dissect it for symbolism and meaning.

Anxiety: Something I heard from a therapist last week: “I like to have my notepad nearby to give me something to focus on during intense sessions. I write more during the session with clients who make me feel uncomfortable.” Yup, therapists are people too, and sometimes they are drawn to the notes as a way to organize a lot of content or as a buffer for emotionally heavy material. I'm not saying this is ideal, I'm just saying it happens. 

Habit: Some therapists learned from a professor, supervisor, or their own therapist that the pen is co-therapist. Like we all tend to do, they may be repeating a habit without evaluating its function or consequences.

So what is best, notes or no notes? It depends from therapist to therapist, client to client. I personally choose not to take notes in session after the initial intake, a stance that is supported by seasoned clinician and In Therapy contributor Glen O. Gabbard:

“… note taking during a psychotherapy session may interfere with the development of rapport and empathy. It may also disrupt the therapist’s immersion in the countertransference produced by the patient so that important information for the therapy becomes obscured. Therapists may want to jot down a few notes for supervision about key interventions they made or themes that the patient brought up. These notes, however, are best done after the session before the next patient arrives or later in the day.”

My advice for Fictional Reader above should be no surprise if you’ve followed this blog: talk about it. You’re allowed to say anything in therapy, and this is a great example. If your therapist’s notepad makes you feel uncomfortable, detached from your therapist, or overly curious about what is being written, you have every right to raise this concern. Something like “I’ve been meaning to bring up the fact that you’re often taking notes in our sessions. I find myself feeling (distracted, confused, distant, judged, etc.) when you do this. Can we talk about this?” would be a very diplomatic way to raise the topic. You have every right to say “Hey! Ditch the notes!” but that’s only if you like conflict.

Check the next post for the pros and cons of clients taking notes in therapy. 

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Fans of the written word are welcome to peruse my facebook page and website. You’re also invited to listen to, and take notes of, my new podcast: The Mental Health Happy Hour (iTunes or website).

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