How to Write Psychotherapy Progress Notes (continued...)
Patricia C., Ph.D.
3) Closing a File: The Termination Summary or Termination Report
At the conclusion of a psychotherapy treatment mental health professionals should provide an overview of the treatment received and the nature of termination of the therapy. Such a Treatment Summary or Termination Report is essential to write regardless of the length of the treatment and/or the nature of the termination. In what follows is a description of the structure of a Treatment Summary with a brief description of what might be included in such a report. Please Click Here for a sample Treatment Summary loosely based on a case I had seen several years ago.
Summary of the Presenting Difficulties:
To being the treatment or termination summary, you should begin by briefly restating the issues and difficulties that brought the client to treatment. You might here simply restate what you included in the corresponding section of your original Intake Report.
Other Areas Addressed During Treatment:
Next, it is important to include a short description of any other issues, problems or difficulties that emerged during the course of treatment. For instance, “Though the client’s presenting difficulties involved a depressive reaction to a recent job loss, during the course of treatment it became evident that the client was also struggling with a number of characterological difficulties that interfered with her ability to establish and maintain friendships with others. These difficulties were also addressed through the course of the treatment”.
Overview of the Treatment Process:
It is in this section where the clinician describes the main features, characteristics and development of the treatment process. In the case of long-term treatment durations, it may be helpful to organize this section into “initial phase of the treatment”, “middle phase of the treatment” and “termination phase or late phase ”. Another helpful way of organizing this section may involve structuring the content around the different problem areas addressed (e.g., treatment of the client’s binge eating, the treatment and evolution of the client’s interpersonal difficulties, the treatment and evolution of the client’s post-traumatic stress disorder, the client’s work-related coping etc.) or around the different aspects of the treatment process (e.g, the nature and development of the therapeutic alliance, the evolution of the relationship with the therapist, significant dream work, the exploration and resolution of core conflicts etc.).
It is important to keep the focus on the development of the treatment itself (those interventions and processes that were part of the treatment) and not solely on the development of the client. That is, you want to here document how and in what way your work with the client was initiated, maintained and progressed over the course of the psychotherapy.
As I have emphasized elsewhere, it is also important here to distinguish between what you observed directly from the client versus your own professional hypotheses, conjectures, or inferences. It can be helpful to begin statements with phrases such as “It appeared that….” “It is likely that…”, “There was some suggestion that….”, “This suggests that…, “It seems possible that…” “The client appeared to experience this as ……”
Nature of the Termination:
In this section you first describe why and how the termination came about (i.e., “It was mutually decided by client and therapist that the goals of the treatment were sufficiently met and that therapy is no longer indicated” or “As the client did not appear to be further benefiting from the treatment, the possibility of terminating the treatment was raised with the client who agreed to setting an end date” or “The treatment was terminated abruptly by the client who called and stated that she not longer wants to attend therapy as she feels uncomfortable discussing her personal problems with a man. After discussing the issue with her on the phone, it was decided that she be referred to a woman therapist”. Next, you may then go on to describe the termination process itself. For instance, this may include the client’s reactions to ending the treatment (e.g, anger, sadness, fear, excitement, a feeling of accomplishment etc.), any further issues that were stimulated by the ending of the relationship with the therapist (e.g., revisiting feelings of mourning and loss, fears of independence and loneliness etc.), any problematic features of the termination (e.g. “The client explained that she was too distressed to attend the last session and cancelled at the last minute”), as well as positive features of the termination (e.g., ”The client expressed deep appreciation for the therapy process”, “The client experienced the termination as a symbolic graduation and beginning of a new journey in his life” etc.).
Gains and Progress Made:
In this section, the clinician outlines all of the gains and progress made by the client throughout the course of treatment. It is important to include both what the client perceived and may have stated as gains and progress as well as what you as a clinician have observed in the client (the two need not always be the same, though there is usually some correspondence between the two). Be sure to include concrete examples of changes and progress made when deemed appropriate and fitting.
Limitations of the Treatment:
It is important to make some statement regarding any limitations of the treatment. No treatment meets all the therapeutic needs of a client and not all clients can benefit from a recommended treatment. It is in this section that the clinician turns an evaluative eye on the treatment conducted and describes the ways in which it was not able to address the treatment goals. Be careful here not slip into a tone that inadvertently blames the client for the limitations of the treatment. Again, the focus is on the treatment itself and not the “limitations” of clients.
Remaining Difficulties and/or Concerns:
In this section, you briefly describe and discuss any remaining difficulties that were either not addressed during the treatment or that were not sufficiently addressed and resolved during the course of treatment. In addition, it is here that you may raise any concerns you have regarding the client’s ongoing and future functioning and/or life situation.
Following from the last section, the clinician here makes any necessary recommendations that may benefit the client. For instance, you may recommend that the client pursue a different form of therapy in the future, or you may suggest that the client will continue to benefit from some form of psychotherapeutic support in the community, or you may simply state that no further recommendations appear indicated. If you have made follow-up recommendations, you should also explain that you have discussed these with the client or relevant person involved (e.g., his or her GP) and the measures you took or are taking to facilitate the recommendation when appropriate. Again, as with all documentation in a client’s file, be sure to include your signature line and remember to sign the Termination Summary shortly after printing.
_______________________________ Patricia C., Ph. D. Psychologist
Note: Recommendations and examples presented are intended to provide a general overview of how to write psychotherapy progress notes and do not constitute nor can they substitute for legal counsel or official guidelines mandated by any particular professional order or other regulatory body; please be sure to consult and familiarize yourself with the guidelines and rules regarding record keeping in your particular mental health field and/or as stipulated by your profession.