A New Development: The After Visit Summary

The latest good idea I’ve had about counseling I got from visiting my allergist.

I have allergies. If you ever sat with me in a counseling session and I had tears in my eyes, it might have been due to what you were saying; sometimes I am deeply moved. But probably my allergies were responsible. I went to see an allergist to determine if there was something I could do about it. He gave me a bunch of tests and told me there was. All I had to do was…

“Got it?” the allergist asked.

“I understand,” I claimed.

Then he showed me the printed after visit summary where he had written out the instructions. I learned that I had not understood. Not at all. I had them all screwed up.

The incident got me thinking about all the times I’ve had people in my office and watched them arrive at an important insight, only to forget about it as soon as they leave. I might prevent that from happening simply by writing an After Visit Summary just as my allergist had.

In this document, he summarized the things I had said about my allergies. He gave the test results. He listed the steps I could take to treat them. It seemed easy enough. I could do it, too.

After each session is complete, I write a summary note it anyway. All I had to do was share it with the client. Maybe I can’t produce it on the spot as my allergist had; I don’t want to have to write during the session, but I could send it later.

It proved to not be as easy as it sounds. First of all, a clinical note is a highly technical document, full of mysterious jargon, alienating, and objectifying of the patient. When I worked in a community mental health clinic, the lawyers and the insurance companies had inserted themselves into our note writing and forced us to fill the records with so much legal mumbo jumbo that it was impossible to find the point. I could never simply share a clinical note with a client and have it be helpful and understandable. It would have to be written respectfully, clearly, simply, and concisely; not because clients are idiots, far from it, but because the point of writing an After Visit Summary is to communicate.

Ordinary clinical notes are not written to communicate. No one ever reads them.

To be honest, I have not been the first to share notes with clients. Writing therapeutic letters reflecting on sessions is a pretty standard technique in narrative therapy. I tried doing this years ago, writing thoughtful letters to each client after every session. I might have continued, but it was time consuming. The clinic where I worked also required the usual clinical note. Then there was all the fuss and expense of stamps, envelopes, and printing. I soon abandoned the practice and forgot all about it until that day at the allergist.

Conditions are different now. I’m in private practice and I can adopt practices that suit me and my clients. Also, I don’t have to rely on the post office. We have the internet.

Getting the internet to work towards the objective of communicating with clients is another story, a long, involved one, with which I will not bore you. Suffice it to say that ordinary email is not secure enough to send summaries of sessions by. I had to enroll in an electronic medical record system that included an encrypted patient portal, but, luckily the technology is out there.

So, there you have it, my new development. We’ll have to see if it helps people progress faster in therapy or if it just causes new problems.

Here’s one. Just how do you summarize, organize, and interpret fifty minutes of conflict, fears, and angst? How do you pack it away in a manageable bundle?

That’s what therapy is anyway.

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