And my take on Dr Melfi and Tony Soprano
The best idea I’ve had about how to conduct psychotherapy, I got from visiting my allergist.
Whenever I have tears in my eyes during a session, it might be because of what the client was saying; sometimes I’m deeply moved, but probably my allergies were responsible. I once 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 I had not understood. Not at all. I was completely confused.
The incident got me thinking about all the times I’ve had people in my office and watched them arrive at an important insight or learn an important skill, only to forget about them as soon as they left. Many of my interventions, interpretations, recommendations, and homework assignments also get forgotten. 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 note anyway. All I had to do was share something like that with the client. Maybe I couldn’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.
I knew I had to change the way I was writing my notes because I didn’t want to have to write two sets, one for the chart and one for the client. 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 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. It would not be helpful to share a clinical note with a client as they are usually written. It would have to be written respectfully, clearly, simply, and concisely, because the point of writing an After Visit Summary is to communicate. Ordinary clinical notes are not written to communicate.
I would not be the first to write therapeutic letters reflecting on sessions to clients. It’s a standard technique in narrative therapy. I tried doing it years before, writing thoughtful letters 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 methods that suit me. Also, I don’t have to rely on the post office. We have the internet, and my clients have a secure patient portal.
I started writing After Visit Summaries eight years ago, giving me ample time to get ready for a law Congress later passed in 2021, the 21st Century Cures Act. In it, they prohibited the blocking of most clinical notes from patients who would like to read them. Many therapists had not been prepared to have their clients read their notes and have found the prospect to be very threatening. Rather than have them read mystifying clinical notes, I send my clients a record that clarifies the session they’ve just experienced. This gives them an opportunity to give feedback on what I’m writing about them and shape the course of their therapy.
An Illustration
To illustrate how I write an After Visit Summary so that it combines the needs of the chart and the needs of the client, let me show you one I would have written for Tony Soprano after his first session, had I been his therapist, Dr Jennifer Melfi.
Name: Anthony (Tony) Soprano
DOB: August 22, 1959
Provider: Jennifer Melfi, MD
Appointment: Individual appointment on January 10, 1999
3:00-4:00 pm, 60 minutes
Assessment, 90791
Diagnosis: Deferred
AFTER VISIT SUMMARY
What you said:
You were referred by your neighbor and doctor, Dr Cusamano, after you collapsed at a family barbeque. All you remember was that just prior, you watched the ducks you had adopted, fly away. You then felt like ginger ale was fizzing inside your skull.
Dr Cusamano ordered some blood work and neurological tests that came back negative. He concluded you suffered a panic attack. You disagree and characterize the issue as stress arising from family life, work, and cultural changes. You’re disturbed by cultural changes. The young don’t take things seriously and standards have slipped. You blame modern peoples’ preoccupation with feelings and admire men like Gary Cooper who kept his feelings to himself. You’re not keen on psychotherapy because you believe it’ll make you weak.
You describe yourself as a waste management consultant and have done very well. You were raised by both parents in New Jersey. Your father has died, and you’re concerned that your mother is not getting out of the house and living life fully. She has a negative attitude about everything. You’re married, with two adolescent children. Both you and your wife are Catholic, but she is more religious and has the priest over at the house a lot, which bothers you. She and your daughter don’t get along. You work in a family business, headed by your uncle. You disagree with some of his business decisions. When you were young, he humiliated you by telling your girl cousins you would never be a varsity athlete.
You admitted to feeling depressed since the ducks left. As soon as you did so, you became agitated and ended the session before our time was up.
My Remarks:
At one point, you began to describe having to deal with someone in debt to your uncle. I interrupted and warned you that information you share with me is confidential, but I must report any violence you plan to the authorities.
I also said that panic attacks are a psychiatric condition that should be taken seriously. You could have one when driving and get into an accident.
The Plan:
You’re welcome to resume our conversation by making another appointment.
Please write back or tell me the next time we meet what you most want to remember about our session, and what you would most like to forget.
This document contains confidential information about your therapy. It is provided directly to you for your personal, private use only.
Let me go through the entire summary and tell you what I had in mind when I wrote it.
The Heading
The session was cut short before I would have been able to make a definitive diagnosis. He had been referred for depression and an associated panic disorder, but that doesn’t mean I must agree. If he had been an insurance client, I would have been forced to include a DSM diagnosis if I wanted to be paid, so I would have made a provisional one of “adjustment disorder with mixed emotional features”. I would then need to establish how I came up with that diagnosis and the medical necessity of treatment in the body of the note. As it is, since insurance was probably not involved, I would have deferred the diagnosis until we could complete the evaluation.
Tony used the session to debate what to call his collapse. He resisted the notion of panic because it made him appear weak. Admitting depression seemed to have triggered such a sense of shame that he ended the session. A mafia capo cannot appear weak, nor have shame, but he was willing to admit he’d been under stress. Tony used the word as a kind of cover story that is broad enough to explain everything, but vague enough to explain nothing.
Dr Melfi seems to be committed to speaking the language of psychiatry, rather than adopting the patient’s own language. This establishes her as an authority in an arcane field of knowledge. It can be therapeutic to introduce clients to new ways of thinking. Having panic disorder and depression does not have to mean you are weak.
On the other hand, forcing others to adopt our terms makes it hard for people to come to us and feel heard. I always try to hit the edge of the client’s hermeneutic horizon, that sweet spot between what they already know and what they cannot accept or understand. If I introduce something too far beyond, it, at best, goes nowhere; at worse, it alienates them and becomes a barrier between us.
For example, the jargon I just used, hermeneutic horizon, could be an example of a term just beyond your hermeneutic horizon if you’re not familiar with it. Your eyes may have glazed over or concluded I was a pedantic windbag. Either way, I’d lose you. On the other hand, hermeneutic horizon refers to a concept that’s important to know. If you don’t know what hermeneutics are, let me come within the horizon of your understanding and explain what is just over the hill.
Tony had a very limited ability to understanding his own feelings. The only word he had for what bothered him was stress and he was barely able to talk about his stress. He knew the words depression and panic, but he only knew them as weakness. The therapist’s job, as I conceive it, is to help him improve his capacity to talk about his feelings, so that he can have more choice about what to do with them. Hermeneutics is a fancy word for helping you understand what you previously didn’t.
A therapy session is all about hermeneutics. Both the client and the therapist have a limited range of understanding. Dr Melfi may have the advantage of years of training and experience, but she doesn’t know what it’s like to be Tony Soprano. It’s her job to open herself up to understand Tony Soprano, just as she shares her points of view with him. The relationship is reciprocal. It doesn’t work unless it’s reciprocal. If I don’t know what you already know, I can’t teach you anything new.
What You Said
The section of my After Visit Summary labeled What You Said is the client’s receipt of what he said. In this case, it’s what I gathered of Tony Soprano from Tony Soprano’s point of view. Tony gave his point of view in the session. Here, I’m demonstrating what I heard. In the eight years I’ve been writing After Visit Summaries for clients, I feel very gratified when they say they felt heard when they read this section. Sometimes it’s the only time they have even felt heard. Something good happens when people feel heard. They don’t need to keep saying what they’ve been saying. Then they can open up and take in new information. They can broaden their horizons.
In some cases, I don’t hear things right. When that happens, I hope the client will correct me and trust me to try again. I’m glad I share these After Visit Summaries, for otherwise I might go on thinking I get understand when I don’t.
In all cases, when the client reads my summary of what they said, it will sound different than when they said it, even when it’s correct. For one thing, it’s shorter. I condense what is sometimes fifty minutes into a couple of paragraphs. I’m always afraid, in doing so, I’m doing violence to the heart of what they are trying to say. But the feedback my clients give is that it gets to the heart and cuts out the extraneous matter. It packages all their angst into a more readily handled container.
Some have told me they learned to think differently when they read what they said in a session. This could happen if Tony reads the sentence I wrote about Gary Cooper. He might see this, and the preceding sentences, recognize he sounds like a grumpy old man, and become more open to societal change. I don’t have to shame him by saying he sounds like a grumpy old man if he can see it on his own. In a like manner, he could read the accomplishments he mentioned, and they could sink in better, so that he feels grateful for his resources and success and not just bothered by the stress they bring.
My Remarks
The next section, My Remarks, summarizes the important things I said in the session. In this case, I have Dr Melfi repeat the privileges and limits of confidentiality. It is of utmost importance that every client understands this, not just mafia capos, for that’s what enables them to trust me. I don’t rely on a sentence or two during a session to communicate issues of confidentiality, or a form on intake that most sign without reading. I reiterate it in my summaries.
I also have Dr Melfi repeat what she said about panic attacks because she obviously wants Tony to accept the term. I don’t think I would have put this in the summary if Tony met with me. I generally leave out the things I say in the session that don’t seem to go anywhere, unless I believe they are absolutely crucial. I don’t think it’s crucial that we call his collapse a panic attack, versus stress, as long as we get a chance to unpack the meaning of stress. It’s more important that we find common ground upon which to communicate early in the course of therapy.
A good illustration of why it’s important to accept the client’s language occurred at the end of the session when Dr Melfi asked about his depression, and he walked out. Tony seems to have been overcome by feelings he couldn’t handle when she broached the subject. We will never know what would have happened if she approached it differently. Tony seems to be a good candidate for a therapist to take a strengths-based approach, as opposed to focusing on weaknesses, as therapy is usually conducted. A strengths-based approach does more than just flatter alpha males like Tony, it gives them a way they can talk about their weaknesses while saving face.
Often, when I write a summary after a session, I get a chance to reflect and identify mistakes I made in the session. Sometimes, I just make a mental note, but in Tony’s case, I’d write something in this section that could change the direction the session took. I would say something like:
I didn’t get a chance to say this before you left, but I’m impressed by your achievements. You’re a success in your vocation, have a good family, many friends, and close kinship ties. You love animals. You have done a brave thing by coming to see me. I hope, if you come back, that you would tell me how you’ve been able to overcome the challenges you’ve faced so far, and we can talk about how you will overcome the stress you feel now.
It’s only manipulative if it’s not true. I sincerely feel this way about Tony Soprano and believe this approach would disarm his resistance.
There’s a lot that is not recorded in the After Visit Summary that occurred in the session. There were the attempts Tony made to get to know Dr Melfi better. It is evident that he regards her as a sexual object, and he has already attempted a conquest. The second is that Dr Melfi figured out what Tony really does for a living, but they colluded in avoiding the subject. These two issues will be the elephant in the therapy room for most of their course of therapy.
I generally don’t try to take on elephants in an After Visit Summary. If an issue was present, but not discussed in the session, I won’t introduce it in writing. The limitation with After Visit Summaries, and all textual communication, is I don’t know the frame of mind readers will be in when they read it. When I talk about a difficult subject in real time, I can observe whether the client can be receptive that moment and shape my words around how they receive them. Nonetheless, I would make a private note of these issues and commit myself to bringing them up after more trust is established.
The Plan
Dr Melfi couldn’t write much in this section because Tony left before they could plan. Towards the end of most first sessions, I ask the client to put in a sentence what their objective is in coming to see me. If I have a particular approach I want to use, I describe it in this section. I include links to helpful articles, podcasts, or videos. If there are recommendations I made in the session, if there is a homework assignment, or if we’ve scheduled another appointment I document it here, so it’s not forgotten.
The Postscript
The part in italics at the very end is added to every After Visit Summary. In it, I mean to solicit feedback on my performance and invite the client to co-author their therapy. I also believe that lessons they learned in a session will be reinforced if they repeat them back to me.
Most clients do not choose to give explicit feedback on therapy here, or with any other method I’ve tried. I still ask for it, though, both in a formal way, such as here, and in a more informal manner by utilizing reflective listening.
The last statement, which reads like a lawyer wrote it, is something a lawyer wrote, to cut down the chance the summary will be used out of context in court, for which it was never intended.
A Summary About the Summaries
In the eight years I’ve replaced my clinical notes with After Visit Summaries, most clients have said good things about them, but I haven’t been able to set up a more rigorous research study into their efficacy. Perhaps if more therapists used, some researcher could do so.
Some clients have found that reading their summaries is not for them. Some say it “feels weird” to see their sessions documented, others obsess over every line. More often, I get people who can’t be bothered, either because they already live busy, chaotic lives, or they conceive of therapy as something they do for an hour every week or two, and don’t want to devote more time to it. In those cases, I can accept they are not interested and am happy not to send them. I still write them, though. I’ve found that charting in this form orients me more towards their world and reminds me that I must find common ground upon which to communicate if I am to connect at all during a session. This is very different from writing the usual clinical note which orients me towards explaining my client to other therapists and is preoccupied with meeting the needs of third parties. It gets me back to what I think therapy is supposed to be, a connection that fosters human growth.
Keith R Wilson 