“We camouflage our true being before others to protect ourselves against criticism or rejection. This protection comes at a steep price. When we are not truly known by the other people in our lives, we are misunderstood. When we are misunderstood, especially by family and friends, we join the "lonely crowd." Worse, when we succeed in hiding our being from others, we tend to lose touch with our real selves. This loss of self contributes to illness in its myriad forms.
” - Sidney Jourard
Here are a series of forms that I use almost every session with clients, or for screening and orientation at the start of therapy:
Summary sheet - at the end of virtually every session with a client I move my chair round to sit beside them and, using a clipboard to press on, I write out a summary sheet. Under the sheet is a second "No carbon required" (NCR) sheet, so when I hand them the summary, I have a copy which I put into their notes. It would probably be cheaper, but a little more fiddly, to use a sheet of carbon paper to make the copy. Summary sheets seem to be useful in a whole series of ways. They can emphasise key points and highlight ‘homework' assignments. We refer to them early in the next session together, encouraging linking from appointment to appointment, and making it more likely that homework will be discussed. The summary sheets also mean I don't have to keep many notes during the session itself (the sheet acts as the notes), so I can give more attention to the client. A further benefit is if there is a subsequent muddle about the time of the next appointment, the date and time have been written at the top right of the summary sheet and it can be checked back to. Finally, I typically give clients an A4 folder at the first or second session with me and suggest they keep all the handouts, summary sheets and reflection sheets in their folder. I'm fairly regularly told by clients that they get a good deal of benefit going over these folders - even years later, when maybe they are facing another difficult time in their life.
Reflection on session - I usually hand one of these sheets to clients at the end of each session with me. I ask them to fill it in and bring it back with them to the next session. I tell them that they are probably going to get most benefit from this exercise if they fill in the sheet within a few hours after the end of the session. At the start of the next session my usual sequence is to collect and score (and put onto their progress chart) any assessment questionnaires that we're using to monitor their anxiety or depression or other difficulties. I then look at the summary sheet from the previous session - usually using their top sheet as it tends to be easier to read than my NCR sheet. I then look at their reflection sheet(s). This is only a typical sequence and sometimes (for example if they come in looking pretty distressed) I will use other sequences in how we start sessions.
Reflection on recording - if there were one thing I would change about my one-to-one work with clients over the last decade or so, high on the list would be to have started recording sessions sooner. I've only been being doing this for a few years now and it seems very helpful. As you can see, there's a question on the "reflection on tape" sheet asking (0 to 10) how useful they found it having a tape of the session. Clients typically score the usefulness somewhere around 7, 8 or 9. What I do is tape almost every session with clients (not usually the history-gathering first session) and hand them the tape at the end of the session with the request to listen to it at least once at some point before the next session and then fill in the ‘reflection on tape' sheet. Where the session has involved quite powerful emotional work (e.g. with PTSD) I might encourage them to listen to the tape several times or even daily. Occasionally they will let others (e.g. their partner) listen to part or all of their tape - to help the other person understand particular issues better. Mostly they bring the tape to their next session and we simply recycle it by recording the next session over it. I say that, if there are any sessions where they want to keep the tape indefinitely, they are welcome to do so. With my summary sheet, the reflections sheets, the tapes, and other personal material, I suggest they take care that they store this material securely.
We're at a somewhat difficult transition phase technologically. I could record sessions on a digital voice recorder and then send the recording to the client later in the day via email. This isn't really realistic for me. I'm often hugely busy and sorting out attachments and emails like this at the end of every day with clients just doesn't make good sense. Similarly actual session time is full enough as it is, without adding in time for transcribing digital recordings to CD's or other media. I use a simple Sony tape recorder and a small microphone. This duo works well together. I've tried small tieclip style microphones as well, but any added pick-up quality isn't worth the cost of impeded movement for me (I move my chair around during the session to be at an angle (usually), facing, or beside the client). Most people can dig an old tape recorder out of their attic, or somewhere, to listen to the tapes. I keep a few Sony Walkman personal tape players that I can lend out or sell to people who don't have a tape player at home. Occasionally someone will prefer to bring in their own digital recording equipment instead. If you are going to see a therapist who doesn't record sessions for you, I recommend you consider taking in your own recording equipment. Nearly always any sense of artificiality about being recorded or nervousness about listening to one's own voice rapidly dissipates with a few minutes use. Adding to these comments in 2012, I would point out that lots of clients now carry smart phones which have perfectly adequate voice recorder/voice memo modes and very reasonable built in microphones. This is ideal because they can then listen to the recording - for example through headphones - in their own time. I also now stock a few cheap digital dictaphones as well as a few analogue personal tape players, so I can lend out gadgets for either of these formats.
Reflection on therapy overall - I probably don't use these overviewing reflections sheets as much as would be most helpful. I do use them occasionally though - at the end of a sequence of therapy sessions or at other review times.
Reflection on reading - another sheet to encourage reflection.
Learning circle of experience - a Powerpoint slide handout that I occasionally use with clients when we're discussing the importance of both active engagement and reflection in the process of therapy.
Making therapy as helpful as possible for you - an important orientation handout that I give to nearly all new clients at the end our first session together.
M.I.N.I. screen and other questionnaires - I regularly use the M.I.N.I. screen, typically in the latter part of the first session with a new client. The M.I.N.I. screen is an abbreviated version of the full Mini International Neuropsychiatric Interview (M.I.N.I.) - "the most widely used psychiatric structured diagnostic interview instrument in the world. The M.I.N.I. has been translated into 43 languages and is used by mental health professionals and health organizations in more than 100 countries." I find this very useful - for example in picking up significant comorbid problems that I've missed in the initial interview. Unfortunately, in its most recent version 6.0, it is no longer free, but at a once off fee of less than $20 it ain't bad! See the Medical Outcome Systems website.
Attitudes to therapy scale - I use this to monitor confidence and empathy. Both are crucially important for effective therapy.
Expectancy & credibility scale - downloadable as both a PDF file and as a Word doc.
Progress charts - I use these charts to monitor clients' progress. Usually at the first or second session together we will have come up with one, two, possibly three, rarely four, assessment questionnaires that seem particularly relevant for tracking progress with difficulties that are important to the client. Examples are questionnaires assessing anxiety and depression levels, more specific assessments of PTSD, OCD, panic, etc, severity, measures of functioning & disability, measures of wellbeing & happiness, and at times just "bog standard" measures using simple 0 to 10 scales to assess the severity of problems that are not easily covered by standard questionnaires. I usually start using a week-to-a-square progress chart and, when therapy sessions become more widely spaced, I may move on to fortnight-to-a-square, month-to-a-square, or even two-month-to-a-square charts. I find this charting hugely useful. I typically keep questionnaires that clients fill in at the start of therapy (partly to refer back to later on to highlight changes), but with all subsequent questionnaires I usually transfer relevant scores to the chart and destroy the questionnaire (it helps to reduce endless paper storage). The visual picture presented by the chart seems much more helpful than scores that are presented just as a series of numbers. If we're making good progress, this shows clearly on the chart and tends to boost a client's optimism and commitment to the work we're doing. If we're not making adequate progress, this too shows on the chart and helps to underline the importance of adding additional therapy components (e.g. medication to psychotherapy or vice-versa) or other changes. We can also put other information onto the charts such as changes of job or other life circumstance.
