THE FLESH MADE WORD: THE RELATIONSHIP BETWEEN WHAT IS
SPOKEN AND WHAT IS WRITTEN IN MENTAL HEALTH THERAPY
Joanne Me Lain
B.A., University of Colorado at Denver, 1981
M.A., University of Colorado at Denver, 1985
A thesis submitted to the
University of Colorado at Denver
in partial fulfillment
of the requirements for the degree of
Doctor of Philosophy
Educational Leadership and Innovation
This thesis for the Doctor of Philosophy
Joanne Me Lain
has been approved
Me Lain, Joanne (Ph.D., Educational Leadership and Innovation)
The Flesh Made Word: The Relationship Between What is Spoken and
What is Written in Mental Health Therapy
Thesis directed by Associate Professor W. Alan Davis
Clinical documentation is vital to the practice of mental health therapy but its
relationship to the spoken aspects of therapy is not well studied. This study
looks at how therapists and clients view the intake assessment and
documentation process, how therapists choose what is important to record
and how the tool (document) constrains the communication, thinking and
This study follows the basic tenets of Multi-level Action Research. There is
consideration of various levels of scale, from the individual therapist, to the
therapist-client relationship, through the peer review process, the
organizational dynamics of the agency, and implications for the mental
health field. The impact of the research on my own practice and beliefs is
examined and activities for systems change are pursued.
My primary research questions are: How does the spoken intake session
relate to the intake summary written by the therapist after that session?
How well does the client believe the intake summary describes her life?
How does the written intake summary influence the spoken therapeutic
relationship? How does the agency function to encourage or constrain
therapists strategies for writing intake summaries?
In order to study this process from a variety of viewpoints, I recruited two
therapists, each of whom engaged in therapy sessions with a client. I
conducted interviews, recorded therapy sessions, and ran focus groups, so
that I had two series of data sources, one series about each therapist-client
pair. This ensured that I would record the voices of client, therapist and peers
regarding the same therapeutic session and the same document.
Three consistent themes emerged from the data: it is important to incorporate
the clients voice into the clinical record along with the therapists voice;
recontextualization of the clients story into clinical language is important for
analysis and synthesis but needs to remain close to the clients voice; and the
constraints of documentation can be beneficial to the therapeutic process but
can also interfere with therapeutic rapport-building. The potential for
reification of the chart or diagnosis may be reduced if the therapist-writer
includes the clients voice in the record.
It is important to train new therapists how to incorporate the concepts of
voice, recontextualization and reification in their clinical writing. These
concepts should also be reviewed after a therapist has some experience in
the field. Further research on the relevance of these concepts at other stages
of therapy, particularly during service planning would be useful, as well as
studying their application during intake sessions in other settings. Agencies
should be encouraged to consider the tensions between the limited time
available for intake sessions and summary writing, and the therapists need to
establish therapeutic rapport as well as collect data.
This abstract accurately represents the conte/it of the candidates thesis,
recommend its publication.
W. Alan Davis
This dissertation is dedicated to my parents, who encouraged me from the
beginning: I wish you could be here with me at the end.
It is also dedicated to my husband, William C. Thomas, who provided
emotional and technical support throughout the process.
And, finally, it is dedicated to my children, lain Me Lain Thomas (I hope he
has learned the value of persistence while watching me), and Ceiturin Me
Lain Thomas, who attended doctoral labs before she started preschool.
This study could never have been completed without the support of my
agency, referred to as Prairie Mental Health Center, and all of its dedicated
employees. 1 particularly appreciate the therapists who were brave enough to
volunteer for this study and the clients who shared their life stories to enrich
Janice Me Lain provided extensive assistance with transcription, and Bill
Thomas edited multiple drafts. John Klein provided time, energy, expertise
I would also like to thank Alan Davis, my advisor, and all of the members of
the Lab of Learning and Activity for the conversation that never ends.
Developing the Theme.................................1
Theoretical Framework: Setting the Scene............10
Methodological Overview: Defining the Action........15
2. REVIEW OF THE LITERATURE: FORESHADOWING................17
The Purpose of Documentation........................17
Recontextualization: the Flesh Becomes Word.........19
Reification: the Word becomes Flesh.................27
Voice: Bringing the Client into the Record..........28
3. METHODOLOGY: THE PLOT AND CHARACTERS...................32
Data Series ........................................35
Selection of Participants.......................... 35
Data Collection Steps...............................37
Description of the Intake Summary Document..........42
Overview of the Process.............................46
Series One: Steven and Denise.......................48
Steven Graham, Therapist............................48
Intake Session Between Steven and Denise............57
The Flesh Becomes Word: Denises Story is Written into
the Intake Summary..................................67
The Second Session of Steven and Denise.............78
Interview with Denise...............................85
The Final Interview with Steven.....................88
The First Focus Group...............................93
Summary of the First Series: Steven and Denise.....104
Series Two: Paula and Carol........................107
Paula Weiss, Therapist.............................107
Intake Session: Paula and Carol....................113
Writing Carols Stories into the Record............129
The Second Focus Group.............................138
The Final Interview with Paula.....................150
Summary of the Second Series: Paula and Carol......157
Interview with the Third Therapist.................159
Summary of the Analysis: Tying Together the Threads
of the Stories.....................................160
5. DISCUSSION: CRISIS AND RESOLUTION.....................163
The Flesh Within the Word..........................163
Voice: Teaching the Record to Speak................165
Recontextualization: Editing the Record............167
Avoiding Reification: How to Keep the Actor in the Story.. 171
The Relationship Between What is Spoken and What
Sequels: Looking to the Future.....................176
A. Intake Summary Prairie Mental Health ...........178
B. Intake Summary..................................183
C. Instructions to Focus Group Moderator...........186
3.1 Series of Events ..........................................41
3.2 Cross-Comparisons .........................................41
Developing the Theme
Why write a paper about paperwork? What is the fascination about the
clinical phrases that therapists use to document services delivered in
community mental health centers? We have walls full of folders in my office,
each with the institutional record of every person who came seeking
therapy, or was sent involuntarily to be given therapy, during all of the years
the office has existed. There are too many folders, with information no one
reads, unless the person returns to therapy or goes to another institution
where staff feel the need to request historical documentation. We set up a
shredder and set a support staff person to tear down the walls of paper.
The regulations of the state specify that we must keep clinical records for
certain periods of time (seven or ten years, depending on which
bureaucracy regulates the chart), but we had records that were almost thirty
years old. Before the shredder removed them from reality, I read a few of
them, to see how standards and styles of documentation changed overtime.
Most of the records were little more than bureaucratic words on paper, but
some held stories about real people. Shredding those had emotional
impact. What stood out the most about the records generally was the
gradually increasing complexity and length of narrative they contained.
When I started working in community mental health, in the 1980s, I did part
of my internship at a chronic team in Denver. Each client had a chart that
included basic demographic data, billing information, a brief initial paragraph
that served as a clinical summary, and progress notes that read like
postcards from one staff member to another. Visited Lilly at her home
appeared stable, neat and clean, no hallucinations, one might read. The
next might state: Art GroupLilly needed redirecting, rude to other clients,
talked to self. Need med adjustment? That might be followed by a
psychiatrists note about medication changes. The brief, staccato notes
followed each other across the page.
Since that time, there have been what amount to philosophical changes
about the nature of good documentation. Sometimes we were told to write
at great length, with a lot of details about subjective impressions. At other
times, the fashion was brief, terse and objective. A persons mental status
was described in one or two word statements, such as short-term memory
was adequate. There was a time (when I had a computer to write intake
summaries on) that I wrote a macro to type the word appropriate for me, so
I didnt have to type it myself, over and over.
During the past decade or so, there has been a growing organization of
consumers of mental health services: people with severe and persistent
mental illnesses who prefer not to be called clients. This has started
systemic changes that influence every aspect of community mental health
services, including how services are documented. If both parties in the
therapeutic process are to share responsibility for the process, then
consumer involvement at the clinical level means that we believe
responsible behaviors can be expected from all players more often than not,
and that joint problem solving succeeds where unilateral treatment decisions
fail (Smith, 2000). The format of documentation has undergone changes to
better reflect the changing relationship of the therapeutic process, but this
may be reflected differently in the spoken discourse than in the written text.
This potential difference has not often been discussed in the literature.
Even the basic choice of the term consumer instead of client has multiple
implications. The mental health field originally borrowed the medical word
patient to describe a person receiving services. One definition of patient
is one that is acted upon (Mish, 1988). The root derivation is from the
Latin pati, to suffer. The word client came into use to avoid the overly
medical and hierarchical connotations of patient. It means a person who
engages the professional advice or services of another but it is not a term
free from paternalism: another meaning is one that is under the protection
of another, and the word was derived from the Latin clinare, to lean (Mish,
1988). Groups such as the National Alliance for the Mentally III (NAMI)
chose to call themselves consumers in order to show that they were
purchasing services from therapists, not just passive recipients of services,
which gave them the power to choose how those services were provided.
They were using the definition one that utilizes economic goods, but
ignored the other definitions of consume that mean to use up, to do
away with completely, and to spend wastefully (Mish, 1988). In order to
avoid a paternalistic term, they have turned to one that emphasizes the
limited nature of the good provided.
There does not appear to be a term that describes the person who engages
in a therapeutic relationship that is free from negative connotations. Another
consideration is that consumer is not a term generally used in substance
abuse counseling, in part because of the unfortunate implications that occur
through comparison with the consumption of alcohol. At the risk of violating
political correctness, throughout this work I will use the term client, in part
because it is the most familiar word for many who might read it, but also in
an effort to honestly portray my own view on this subject. If words convey
meaning, then I prefer to use the word that seems to me to be the least
limiting of the choices available.
The consumer movement of people who live with mental illness brought
about other changes in the use of words in the mental health field. Instead
of a consistent problem focus, we were asked to also write about strengths
and supports, not just problems and attempts to mitigate them. This has
been a major benefit to the practice, and is worthy of examination in a paper
about the use of words, as well.
Two events triggered my reflection on clinical documentation; both were
instances when I found myself defending a point of view about a client I did
not know well, using primarily what was documented in the chart. One
occurred during a call from a woman who worked at the state mental health
office, who was auditing our charts. She was reading information in one
chart that concerned her. Why doesnt this woman have court-ordered
medications? she asked. I argued that she was not gravely disabled,
therefore it was her choice to take medications or not, even though she
wound up in the hospital periodically as a consequence. Neither of us knew
the woman we discussed (although I had met her a few times, briefly); we
were arguing over the evidence of her life as documented in the chart.
The second event occurred when I was ordered by the court to bring the
chart of a client I had never met (I brought it because I was nearer to the
court than the office where the client had been seen). The judge asked me
to give my opinion about what sort of facility the client should be sent to,
even though he knew that I was not the therapist of record. I found myself
speculating from what I had read in the record. The judge used that as a
major basis for his ruling, and the client went to a residential treatment
Both of those stories demonstrate the reification of the clinical chart. The
chart became more real, more central to vital decisions about the clients
life, than the flesh-and-blood client. I became curious about how this
happens in a human-service profession, what purposes it serves, and what
constraints it places upon the people involved.
In my business, mental health, words are the core of the work. We may talk
about the importance of nonverbal cues, but it is wordsthe clients, our
peers, our ownthat lead the way through the tangled forests toward the
light. We are blind without them, but, in the nature of all light, we may be
blinded by the words we choose. There are two versions of words in the
mental health field: those spoken in a therapeutic session and those written
in the documentation of that session. They reflect each other, but they are
not the same.
There are skills involved in the transformation of therapy into documentation;
we may create a word picture so powerful it brings life to the page, or we
may just muddle through. We may not even be fully accurate in our view,
but in some ways, that ceases to matter. The flesh-and-blood client
becomes reformulated into text, but then the words take on flesh: the chart
is reified and becomes the client.
People who work in the mental health field generally share certain
assumptions that many have not thought through. One assumption is: If it
isnt documented, it wasnt done, a statement that is common throughout
healthcare fields. Another is that ethical therapy requires careful
documentation. A third is that observers can accurately judge the quality of
treatment by reading the chart (Mitchell, 2001). I dont disbelieve these
assumptions (there are practical reasons for each), I just question the
thoroughness of the reasoning underlying them. If we dont really
understand how we arrived at these assumptions, we cant really
understand the relationship between the spoken words of therapy and the
written words that document it.
Another word choice that I am making in this paper is the use of spoken
when referring to what is said in therapy sessions. The custom among
people who study the use of language is to use the term oral in reference
to speech, but, given the connotations of that word within the mental health
field, I prefer to avoid the unintended meanings it would convey.
Good charting has sometimes been compared to a novel: there is an
introduction, setting of scene, development of characters, and a plot that
builds to a climax, then resolution and conclusion. There is a narrative flow
that helps the reader understand the purpose and progress of therapy. The
implication is that if the writer/therapist can produce a coherent therapeutic
narrative, he or she has a good grasp of the flow and progress of therapy. If
the narrative is choppy, incomplete, rambling or nonsensical, the therapy
was too. We assume a direct connection between the spoken and the
written words without defining how that relationship occurs.
New practitioners of mental health treatment are taught how to document
their clinical work and they are told general reasons why they should
document, but the contributions of documentation to clinical practice are
rarely discussed in depth. Some therapists develop a reflective practice in
their documentation, and charting is frequently a source of discussion in
supervision, but, in practice, its use is limited to what is directly stated in the
chart. There is rarely discussion about how we decide what is important,
and how it relates to the larger picture of what is done in behavioral
The discourse is limited to the practical aspects of what was said by whom,
what behavior or affect the client displayed, how that reflects diagnostic
patterns and what is the plan for the next session. Mitchell (2001, p. 33)
writes that most counselors are qualified for the professional parts of their
job, but few have training in the area of keeping records. This statement
implies that record-keeping is not a professional part of a counselors job.
Perhaps if the process of documentation were not subordinated in this
manner, discussions about it would provide more therapeutic insight. The
genre of clinical writing shapes what can be said about the client (or about
the therapist), therefore it constrains what can be thought about the
When I ask therapists why they document therapy, the answers (after the
standard because I have to) usually relate to legal issues (evidence for
court, Social Services, etc.) and standards of the field. Most mental health
centers gauge the productivity of clinical staff by documented direct service
time. Some therapists mention the need for quality assurance (auditing
charts). Some, but not all, mention charting as a means of remembering
what was done and what the goals are from session to session (something
like journalling). A few mention charting as a means of communicating from
one professional to another (like writing a letter). I have never heard anyone
mention charting as directly useful to the client (e.g.: so the client can see
what has been done and what the goals are).
As St. George and Wulff (1998) point out,
writing clinical case reports is often viewed as a necessary but
undesirable professional activity for therapists. Case reports are
approached more as an administrative chore rather than something
that could have therapeutic potential. Despite this less-than-exciting
reputation, the case report is probably one of the most enduring
legacies of therapy. Reports may remain influential in clients lives for
years after the therapy sessions have ended.
The enduring nature of clinical documentation places an ethical burden upon
the therapist-writer to ensure that what is written closely reflects what was
said. Written words often have a more lasting effect than words that are
spoken; they present an artifact that can be read, and reread, years after the
events they memorialize (Olson, 1994). The document provides a voice that
neither the client nor the therapist can easily contradict once it is placed in
the chart and the people move on. St. George and Wulf emphasize the
importance of deliberately representing the clients voice in the record, both
to ensure accuracy and to increase the clients involvement in the
The field of mental health is based upon the humanistic assumption that the
relationship of two (or more) people talking to each other can produce
positive change. Yet in the course of routinely documenting the process of
therapy, the chart frequently becomes the client: the written material is
treated as if that is the primary source of information about what is done in
therapy and about the basic nature of the client. Auditors read the charts;
they dont often talk to the client when determining whether appropriate
services have been provided. Other agencies ask for written reports and
evaluations; they dont ask to talk to the client. The reader may mistake the
map for the territory, to use one of Batesons (1972/2000) phrases; or the
script takes on the life of the actor.
We design documentation to convey information efficiently but when do we
take the time to reflect on the impact of what we write and what we choose
not to write? When do we reflect on the process of the writing instead of just
I am interested in how these pieces fit together and what happens to the
flesh- and-blood client (and therapist) in this process. I want to know what
stories people tell to explain this and the different roles people play in the
process. How do therapists choose what is important to record? How does
the tool (document) constrain the communication/thinking/relationship? How
do we use words as tools to create an image that is real enough to stand in"
for the flesh-and-blood client? How do the forms and formats (tools) we
design shape the way we view clinical practice, our role in it, and the role of
the client? In what ways are these constraints beneficial to the practice and
in what ways are they detrimental?
Writing and reading are actions that influence the patterns of practice and
relationships. When therapists document their practice, whom are they
writing for? What do they think their writing will achieve? How do third-party
voices and readers (the state, insurance companies, lawyers, consumer
advocacy groups) affect what is written and how it is read? How can the
practice of documentation be shaped to retain its efficiency yet allow the
voices of clients and therapists to embody the text?
Theoretical Framework: Setting the Scene
Writing is a tool we use to structure meaning; it is not just a method of
recording reality. Meaning that is structured through writing is different than
meaning structured through speech: it is more static, specific, and longer-
lasting, with complex pieces making a whole pattern. When a therapist has
a conversation with a consumer, structured as an intake interview, and then
writes an intake summary, the therapist is shaping the conversation into a
pattern through a certain focus. That pattern becomes the basis for the
service plan, another document that structures the therapeutic relationship.
These two documents play a fundamental role in guiding what occurs in
My conceptual framework has been shaped by the systemic view of Gregory
Bateson (1972/2000), since I am interested in the recursive feedback loops
that develop into a therapeutic relationship, and the context of therapist,
client, paperwork, agency and third parties. This study is an extension of
the idea that psychotherapy itself is a context of multilevel communication,
with exploration of the ambiguous lines between the literal and metaphoric,
or reality and fantasy (Bateson, 1972/2000, p. 224). Some of the levels of
communication involve writing, both directly and indirectly, since the
therapist must consider what he or she will write about the therapeutic
session, while still talking with the client during the session.
Psychotherapeutic analysis and interpretation involves the translation of the
contextually-grounded language the client brings to the session into the
metaphorical terminology of clinical theory. In particular, I am interested in
how the format of required documentation constrains the verbal therapeutic
relationship. Bateson wrote that we prefer exact records since we believe
that how a schizophrenic talks depends greatly on how another person talks
to him; it is most difficult to estimate what was really occurring in a
therapeutic interview if one has only a description of it, especially if the
description is already in theoretical terms (1972/2000, p 225). The context
of the therapeutic relationship itself alters how participants perceive
themselves and the world; writing a clinical description of that therapeutic
relationship, in the format of an intake interview, alters it further. The pattern
is recursive, as each level of communication informs the others, flowing in
spirals so that it is impossible to define a starting or ending point other than
the arbitrary cutoffs of date of first contact and date of termination for the
It is not my purpose in this paper to bring conscious structure to aspects of
the therapeutic process that function well without it. I believe, as Gregory
Bateson did, that it is a distortion when it is commonly assumed that it
would be somehow better if what is unconscious were made conscious... as
though such an increase in conscious knowledge and control would be both
possible and, of course, an improvement (1972/2000, p. 136). One of my
primary goals is to provide therapists with tools for reflection on their
practice (as well as my reflection on my own practice). Not all of this
reflection will result in products that can be defined in a simple list.
Mary Catherine Bateson writes that the mental imposition of a pattern of
meaning is the only way to encounter the world (1994, p.53). I am looking
at the role of documentation, in a pattern with the role of the verbal
therapeutic relationship, to gain a richer understanding of the process of
therapy in a mental health center. I am imposing a pattern of meaning by
defining the first therapeutic session between a therapist and a client as a
starting point, since each participant in the process brings a lifetime of
meaning to that conversation. Speaking and writing in the process of intake
sessions can function like jazz musicians improvising together, both
repetitive and innovative, where the therapist must learn to combine and
vary familiar components to say something new to fit a particular response,
sometimes something of very great beauty or significance, but always
improvisational and always adaptive (1990, p. 3). Conducting an intake
session and writing intake summaries are artistic processes in that there are
no step-by-step guides that ensure a quality end product, and they require
practice to develop a skilled performance.
Wertsch (1998) writes about the reciprocal process of tool use, in which the
tool-maker shapes the tool, then, through using the tool, becomes shaped
by it, leading to refinements of the tool. Because humans express
themselves through stories, the structure of historical texts as cultural tools
both empower and constrain those who use them (1998, p. 80). Clinical
documentation is a tool that both records and shapes the therapeutic
relationship, and how that relationship is viewed by third parties. The
process of therapy then leads to refinement of the documentation in order to
provide records that serve goals that may be defined by a variety of
interested parties, from state agencies to the therapist or client.
The act of writing as a cultural tool is described by Cole: With writing one
gets systematic knowledge, scientific concepts, and schools as enculturating
institutions where the young acquire the ability to mediate their interactions
in the world through codified, reified speech structured in the appropriate
fashion by scientific knowledge (1996, p. 114). Clinical documentation
reflects the training of those enculturating institutions; the preferred
language is often both codified and reified into what is considered to be
Translating therapeutic discourse into writing is a structured process that
therapists are trained to follow. The client is not trained to speak, think or
write in the same manner, resulting in a style of communication that
deShazer (1994) describes as a productive series of miscommunications.
The process of therapy is full of questions. The therapist asks them in order
to form an understanding of the client and the clients situation, the pattern.
But questions do not always produce clear answers.
Making sense of something is a cumulative process rather than a
specific act limited to a particular moment. Therefore, at any
particular moment, misunderstanding is more likely than
understanding. Furthermore, such misunderstandings constitute
conversations and, in fact, misunderstandings make conversations
possible. That is, if we simply (radically) understood each other, we
would have nothing to talk about. If a client were to say I am
depressed and we understood what he meant (i.e., the common
sense view), there would be no reason to ask him any questions. We
would know precisely and exactly the past, present and future of his
condition... Fortunately, even our fields most positivistic endeavors
(such as the DSM) recognize that things are not that clear-cut. So we
ask questions because we know that we do not understand what our
patient means when he says that he is depressed (de Shazer, 1994,
It is important that we also question our documentation of that conversation
From Olson I gain a theory about the relationship between written and
spoken language. He states To interpret, then, and to have a concept of
interpretation are two different things. The concept or theory of
interpretation is what makes the process of interpretation conscious and
subject to rational considerations (1994, p. 116). The therapist interprets
what the consumer says, in the process of writing what was spoken, but the
therapist may not be fully conscious of the process of interpretation that
takes place. Ong (1982, p. 78) also provides insight into the relationship
between spoken and written language: Without writing, the literate mind
would not and could not think as it does, not only when engaged in writing
but normally even when it is composing its thoughts in oral form. The
format of documentation structures the questions asked in the intake
interview, before the words are even structured for the page. Havelock
(1986) and Goody (1987) added to my understanding of the historical
relationships between spoken and written language in various cultures.
Bureaucratic texts have a devastating potential to marginalize and
dehumanize the people they document (Taylor, 1996). Texts also can take
the place of the experience as it was lived; the written documentation
eventually stands in for the spoken therapy session, reifying the words on
the page to become the consumer in the minds of auditors, other third
parties, and even the therapist. Documentation is much like field notes:
Reading a field text allows us to tap into a base of memories of field
experience... But field texts are as much memory transformers as they are
memory signposts. To begin with, the writing of field texts shapes the
experience. Furthermore, as one reads and rereads them over time, they
become less of a signpost to the field experience and become all that is left
of it (Clandinin & Connelly, 2000, p. 143). The relationship between a
therapeutic session and the form that documents it is complex, with
implications that go far beyond simple record-keeping.
Methodological Overview: Defining the Action
This project follows the basic tenets of Multi-level Action Research. There is
consideration of various levels of scale, from the individual therapist, to the
therapist-client relationship, through the peer review process, the
organizational dynamics of the agency, and implications for the mental
health field. The impact of the research on my own practice and beliefs is a
fundamental thread of the process that is woven throughout the overall
tapestry. Beyond the basic interest in learning how documentation relates to
spoken therapy, this project is a change effort, a sustained activity
mediated by tools (LoLA lab fact sheet, 2002), that attempts to create an
environment where everyones learning is valued.
My primary research questions are: How does the spoken intake session
relate to the intake summary written by the therapist after that session?
How well does the client believe the intake summary describes her life?
How does the written intake summary influence the spoken therapeutic
relationship? How does the agency function to encourage or constrain
therapists strategies for writing intake summaries?
At Prairie Mental Health Center the intake summary (a semistructured
narrative) is written by the therapist after the first therapy session with a
consumer. It includes a diagnostic section, but there are also sections for
recording referral information (why the client is there), psychosocial history,
development (including issues of aging), substance use/abuse, mental
status, medical, strengths, needs, cultural issues and a plan for treatment.
Recently (during the course of this project), the intake summary was
changed to place more emphasis on synthesis (summary and integration of
the information provided in all other sections), and to add a state-required
section regarding the clients choice of provider.
The information in the intake summary is used as the basis for the
discussion between therapist and consumer that produces the written
service plan (sometimes referred to as a treatment plan, a form with some
brief narrative sections) at the second session. The service plan includes
goals, and methods of measuring progress toward goals, that are co-created
between the therapist and the client. Because of this, writing the service
plan is a different process than writing the intake summary. This method of
writing service plans was developed several years ago, partly in response to
the consumer movements demand that clients have more voice in the
In order to study this process from a variety of viewpoints, I determined to
recruit two therapists, each of whom would engage in therapy sessions with
a client. I would conduct interviews, record therapy sessions, and run focus
groups, so that I would have two series of data sources, one series about
each therapist-client pair. This would ensure that I would record the voices
of client, therapist and peers regarding the same therapeutic session and
the same document. As I will describe more thoroughly in the Methodology
Section, that goal was harder to realize than would appear, but the results
provide interesting similarities and contrasts.
REVIEW OF THE RESEARCH: FORESHADOWING
The Purpose of Documentation
Professional organizations such as the American Counseling Association
publish standards for documentation, and resources such as Mitchells
(2001) Documentation in Counseling Records, which describes how to write
clinical documents that are clinically useful, legally defensible, and meet
requirements to bill for services. It reviews in detail each section necessary
in an intake summary document and comments on the need to be factual
and precise, but gives no advice for how to incorporate the clients voice into
the record, beyond how to document sessions with a client who uses vulgar
language (pp. 87-88). Mitchell devotes a brief chapter to a clients
perspective on documentation, which focuses on how a client might feel if
he or she were to read the notes from therapy sessions. He speculates that
if clients kept records about their service providers, I have often wondered
what they would write about us (p. 42) but does not go beyond that
statement to wonder why they dont keep such records.
Why should mental health therapy be documented? It is a method by
which a therapist can organize thoughts about a clients needs and
abilities, and it provides guideposts for the process of planning
treatment. It also provides a legal record of what occurs and why, and
the therapists understanding of the client. It provides guidance to other
therapists who may see the client on an emergency basis or when the
client returns to therapy years after the original therapist has moved on.
It verifies services provided for billing purposes, and it provides a basis
for quality assurance review (Mitchell, 2001). Viewed from an
organizational perspective, it is necessary to have a record available
which can serve as an institutional memory in case of necessary future
actions, possible challenges, changes of personnel, individual
forgetfulness, etc. And in most institutional contexts, and all
bureaucratic ones, there are strong legal requirements for what that
record must consist of and how it must be constructed (Linde, 1999, p.
Much of what is written about mental health documentation within the mental
health field focuses on how to do it better (Mitchell, 2001), with little attention
paid to the various roles played by what and how we write: the choice of
words and formats, the various uses of the written tool, the conversation
between professionals that is framed and focused by the documents used.
The spoken words used in the process of mental health therapy have been
the subjects of research from various perspectives (Labov & Fanschel,
1977), but the focus has generally been on the relationship between the
therapist and the client as expressed through their interaction during the
session, without considering how documentation of that session might
influence the therapeutic process. When written words have been
considered, there has been less written about the process of documenting
mental health therapy than about the content: what should or shouldnt be
contained in the documentary product. This results in documentation that is
created to meet the perceived needs of the moment, but may not allow the
voices of the client/consumer and the therapist to be sufficiently heard in a
manner that is useful to both.
In order to understand what and how we write, and to make informed
choices when we write, we need to understand the context of our
To be literate it is not enough to know the words; one must learn
how to participate in the discourse of some textual community. And
that implies knowing which texts are important, how they are to be
read and interpreted, and how they are to be applied in talk and
action. While any individual may have the competence required to
participate in any number of such literate or textual communities, we
must also acknowledge the fact that any society is organized around
a body of beliefs, sometimes expressed in textual form, access to
which is a source of power and prestige. In a bureaucratic society
the issues of law, religion, politics, science and literature make up
this privileged domain and access to, and participation in, those
domains defines a particular form of literacy (Olson, 1994, pp. 273-
For the purposes of this study, I am interested in three aspects of
therapists participation in the textual community of clinical
documentation: how therapists recontextualize clients spoken words
into clinical terminology; the reification of the clinical record; and how the
voices of the client and therapist are revealed in the record and what
happens when those voices are not clearly present.
Recontextualization: the Flesh Becomes Word
Everything occurs within a context; we live in environments that influence
our actions and thoughts in many ways. We choose what aspects of our
environment we want to focus on when we create our life stories, the
narratives we construct to give our lives meaning. When a client comes to a
therapy session, he or she brings an understanding about the meaning of
that context as well. When a therapist chooses what to write about the
client, he or she must focus on only portions of that story in order to write a
useful and coherent narrative. Inevitably, much of the richness of the
clients contextual language is lost in the retelling. The therapist uses some
of the clients statements and places them within a clinical framework that
serves as a new context for them, providing different information to help the
reader understand their meaning. In Ravotas and Berkenkotters (1998)
terms, the therapist recontextualizes the clients words in order to fit them
within a new, clinical story. This can be a powerful tool for shaping how the
client is understood.
In one glimpse into the textual discourse of the mental health
community, Barrett (1988) examines clinical writing as a performance
that brings about a transformation in hospital patients from a person
suffering from schizophrenia to a schizophrenic. He notes that the
research literature views seeing the patient, the talk of therapy, as the
primary reality, while the written document is a derivative record of that
live interaction (p. 265). He states that, because the psychiatrist uses
the record both to gather information before a session and to record
information that occurs during a session, the heart of psychiatric work is
an interpretive process involving a movement back and forth between
oral and written discourse (p. 266). He discusses the professional
viewpoint that a psychiatrist writes objective facts about a patient into
the record, and shows how the structure of the clinical forms lead to the
understanding that the psychiatrists written conclusions follow logically
from the data collected, as if derived from induction, instead of what
often occurs, a process of rewriting meanings in a successively more
abstract and technical idiom (p. 285). The psychiatrist reads prior
records about the patient, uses that information to structure the
questions he or she asks the patient, then formulates the response in
terms of diagnostic symptoms. The process is a circular one, where
reports of symptoms are elicited which suggest a diagnostic pattern,
leading to questions about more symptoms.
Barretts study focuses on a specialized setting, an Australian hospital
for patients with schizophrenia, and primarily looks at work done by
psychiatrists, with only brief mention of other professionals such as
social workers and nurses. As such, it cannot be simply generalized to
other settings and approaches to therapy, but there are certain concepts
from his work that can be useful when viewing other versions of
therapeutic practice. He mentions that the prevailing professional
ideology of the hospital as a place in which the patient was treated as a
whole person must be seen as partly mystificatory when viewed against
this fundamental tendency of clinical writing practices to construct the
patient as a fragmented object of work (p. 284). A holistic view of
patients (or clients, or consumers) is stated as a value in the mental
health field. Perhaps it is an unachievable goal in the setting of a
bureaucratic hospital organized around a diagnostic category
(schizophrenia), but it raises the question of how achievable the goal is
in less rigid circumstances.
Barrett also comments briefly about the characteristic lack of closure
accomplished in clinical writing (p. 292), where there was a detailed
process that was treated as crucial to establishing the patient as
mentally ill, but there was no corresponding writing process through
which the patient was transformed back into health. Hospital staff
would write a discharge summary but, unlike the admission summary
and documents written during the patients hospital stay, it was written
outside of the patients presence and after the patient had left treatment.
The discharge summary did not fill the same role in the treatment
process; it was an after-the-fact summary of what occurred in treatment,
not part of the treatment process. The writing of the admission
summary is a powerful tool, not just for recording events that lead to
therapy, but for shaping the process of the therapy itself.
Doctors in medical clinics also rely upon the record when interviewing
patients, especially children: Proper medicine could only begin when
the file as well as the patient was present, for it constituted an
alternative biography to that available from the parents, and one that
had been medically warranted (Strong, 1979, p. 133). As with the
psychiatrist, the medical doctor controls the record, even when the
patient has the legal right to view it. Strong states that none of the
parents of child patients he observed ever asked to view the chart
during the interview, despite the doctors reliance upon it. The
presence of the form and of an official pen hovering over it defined the
nature of the parental task: the production of brief answers that could be
filled in as quickly and efficiently as possible (p. 133).
The process of documenting treatment is in some ways a collaboration
between the patient and the interviewer that translates the patients
troubles into a professional problem definition (Hak and de Boer, 1996,
p. 83) and helps transform the patient into a protoprofessional, who uses
the professional words and phrasings. This transformation begins with
the words used in the initial session, in which the psychotherapist uses
specific language to elicit responses that confirm or disconfirm
professional opinions about the patient. The patient learns what
responses are valued or not valued by the therapist and can use that
understanding to become a competent patient. Hak and de Boer
describe formulation-decision pairs in the therapeutic conversation that
assist in this process.
The patient, or client or consumer, brings a different viewpoint to the
intake process. Williams (1984) shows how people try to make sense of
chronic illnesses by reconstructing the narrative of their lives. These
complex stories represent not only explanations for the onset of a given
disease, but also acts of interpretation, narrative reconstructions of
profound discontinuities in the social processes of their daily lives (p.
179). The therapist must sort through these stories to find the bits and
pieces relevant to treatment.
Brown (1993) views the psychiatric intake process as a form of negotiated
interaction: the interview is co-created by the staff and the patient as a
mystery story. After the interview is finished, however, the staff are left
alone to create the documentation of the story. How much of the patients
voice remains in the written summary? Brown quotes Kleinman (1988, p.
16): Diagnosis is a thoroughly semiotic activity: an analysis of one symbol
system followed by its translation into another, but doctors are not trained
to be self-reflective interpreters of distinctive systems of meanings. They
are turned out by medical schools as naive realists. So the doctor, or the
mental health therapist, believes he or she is being objective in the process
of translating spoken words into written text. Brown is interested in the
narrative process of the clinical assessment process. He observed
psychiatric residents in an outpatient clinic as they interviewed prospective
patients. He states that patients are interested in telling a story about
themselves, but staff view it as a mystery story, a puzzle to be solved. They
look for cues and clues, leading to a question-answer mode of discourse.
Helstone and Van Zuuren (1998) examine the process by which intake
workers at a clinic in Amsterdam assess new clients. Since their task was to
determine what variation of therapy (psychodynamic, supportive, behavioral,
group, etc.) each client was best suited for, their focus was on personal
characteristics of the client. Clients who were recommended to insight-
oriented, psychodynamic therapy (a preferred approach at this clinic) were
best liked, the quality of affective resonance was progressively positive, the
depth of verbal exchange moderately high to high-level in quality, and
prognosis for treatment was considered most promising (p. 260). Clients
found to be suited for supportive therapy (requiring little insight) were
judged to be the most difficult to treat, had the least favorable prognosis,
and effected the least satisfaction in terms of affective resonance and depth
of verbal exchange (p. 260). Helstone and Van Zuuren speculate briefly,
but do not examine, the possibility that the intake workers were attributing
characteristics to the clients that were as much (or more) aspects of the
relationship between the intake worker and client as inherent personality
traits of the clients.
The influence of managed care companies as gatekeepers for treatment can
also affect how treatment is documented. Keefe and Hall (1999) interviewed
a large group of social workers, psychologists and psychiatrists in private
practice about how they document therapy when dealing with managed care
companies. A large percentage of them admitted to altering what they wrote
in order to convince the company of the need for treatment for a client. One
concern this deceptive documentation raises is how it may affect the
therapists ability to evaluate their own practices. It may be extremely
difficult for some practitioners to advance their clinical knowledge because
of the discrepancies between what they have documented to the managed
behavioral health care organization and the documentation they keep in
their own clients files (p. 165).
Dwyer and Shih (1998) speak to a similar concern when they discuss how
psychiatrists tailor a chart. Because psychiatrists cannot include everything
they observe and everything the patient says in the medical chart, they must
select and tailor the chart to focus on what is significant for the diagnosis
and treatment of the patient (p. 1309). The psychiatrist must use his or her
professional skills to filter the raw information in order to produce a record
that is useful for treatment. Intentionally deceptive documentation, however,
done to satisfy managed care companies, to protect the psychiatrist against
malpractice claims, or to secure a placement for a patient, is considered
unethical and damages trust placed in the profession (Dwyer and Shih,
1998). Beyond the basic question of the objectivity of intake assessments,
the intentionally altered record shifts the discourse of therapy even further
from what might be considered the truth.
Mental health documentation has also been criticized for its reliance on
diagnoses codified in the Diagnostic and Statistical Manual of Mental
Disorders (DSM). Brown (1990, p. 388) states that diagnosis is a powerful
tool for psychiatrists to maintain control of the therapeutic field. Diagnosis
has been a central component of this social control. Giving the name has
been the starting point for social labelers. The power to give the name has
been a core element in the social control nature of the mental health
professionals and institutions.
Berkenkotter and Ravotas (1997) agree on the centrality of the diagnosis in
the process of writing initial assessments for therapy and in the hegemony
of the DSM. They show how a clients words can be taken from their rich
context and translated into clinical language that supports a diagnosis. One
of the translation techniques they describe is the membership categorization
device, a term invented by Sacks (1972) to show how people routinely
describe other individuals by characteristics that imply norms shared by
others in that category. When Ravotas and Berkenkotter (1998) examined
the Session Notes written by a psychotherapist during an intake session,
and the resulting Initial Assessment written from those notes, they found that
the clients voice was recontextualized within the professional perspective.
Even when the therapist used direct quotations of client speech, the quotes
were taken from the rich context provided by the client and used primarily to
support a diagnosis and demonstrate the clients suitability for treatment.
Many of the clients words were framed by the therapist-writer inside
statements that direct the readers attention to their diagnostic relevance.
Because an Initial Assessment is written to serve a specific purpose within
the institution of the mental health center, Ravotas and Berkenkotter
recognize that it may be necessary for the clients meanings to become
perspectivized by the therapist-author in such a way that only the
institutionally relevant features of that clients discourse are foregrounded (p.
232), but that may limit its usefulness as a guide to future therapy. When
the focus is placed on justification of a diagnosis, that reduces the complex,
multi-dimensional features of a clients life to a one-dimensional typification
Reification: the Word Becomes Flesh
There are a variety of definitions of the term reification. For the purpose of
this study, I am defining it as the manner in which people treat abstract
concepts as if they are real concrete items. It is the objectification of ideas
in order to think about them in easier terms. If I ask Do you grasp that
idea? I am asking if you understand the concept, but I speak about it as if
you could hold it in your hand. When a therapist writes information about a
client in a chart, that information is about a person, but the words have no
existence other than as abstract ideas. If the information in that chart is
treated as if it can stand in for the client, it becomes reified. When the
documentation is used as the basis for making decisions about the client,
we may forget that the words are one persons abstract ideas about another
person and treat them as if they are objective and have a life of their own. It
may be a subtle distinction but it can have significant effects.
The process of documenting information about a client to justify a diagnosis
leads to reification of that diagnosis and objectification of the client,
according to Berkenkotter and Ravotas (1997). They argue that the DSM is
a forceful rhetorical construction, blackboxing controversies... and
maintaining authority through institutional necessities and responsibilities
(p. 258). The initial assessment presents a clinical picture of the client for
reimbursement purposes, but, because it is often used by other audiences
(such as the court), with different defining missions or, from an activity
theory perspective, objects/outcomes, rules, tools, communities of
practitioners, and systems of distribution (p. 259), it serves many other
purposes. Because of this, what is written about the client can shape the
clients identity within the institutional system as well as their future.
Hays (1989, p. 203) discusses the controversy about how nurses should
document patient care in the home healthcare field. Once written,
documentation will take on a life and power of its own; our discourse is a
political and moral undertaking. She states that it is time for nurses to
create their own forms of documentation, different from that of doctors, in
order to more fully capture the nurses relationship with the patient and the
distinctiveness of a nurses voice in the record. Charting methods adopted
from outside sources are inadequate for clinical as well as political and
moral reasons. Mental health agencies have also adopted many of their
forms of documentation from outside the field (mostly from primary
healthcare), which probably leads to similar inadequacies. Unless we
consider this question, however, we will not know how to improve our
Voice: Bringing the Client into the Record
When a client or a therapist speaks, each has a voice, a unique expression
of personality. I might choose to express an idea in words different than the
words you would choose. That word choice is part of my voice, whether
spoken or in writing. If I speak my words, then you summarize them and
write them down, you may have captured the factual basis of what I said, but
you have stripped the message of my voice. Summarization is a useful and
necessary tool for any form of writing, but it has different implications than
direct quotes. Clinical documentation can be used to accentuate the power
of the therapist within the relationship, or it can be a means to encourage a
more collaborative process.
The implications of voice in the clinical record have been considered by
some researchers. Since clinical documentation can be a means of
maintaining power and control in the hands of professionals, the consumer
movement has encouraged a style of documentation that incorporates the
consumers voice in the record, most commonly in the development of the
treatment (or service) plan. St. George and Wulff (1998, p. 4) found that
including clients directly in composing case reports not only creates more
accurate and complete documentation, it also places the client in a role that
is more central, active, and relevant within their therapy. St. George and
Wulff list several reasons for including the clients voice in the clinical record,
including the clients increased confidence in the therapeutic process,
perception of equality between therapist and client, encouragement of the
client to take charge of the therapeutic process, and the energized
interaction that surrounds the collaborative documentary process. When a
therapist incorporates the clients voice into the record, documentation
becomes part of the therapeutic process, not just a record of what occurred.
Even with those incentives, the clients voice still finds a limited place within
most clinical records.
There are various methods for encouraging client involvement in the
process and documentation of treatment planning. Some approaches
involve checklists with problem statements for consumers to choose among,
but this constrains the consumers voice: Clients selecting anxiety may
never get to tell anyone that they dont know how to talk or that they cant
do things right. To them, these are the most succinct, personal expressions
of their needs, and call for the most immediate attention. Using the
consumers words is a more simple and direct method of helping people:
Ask them what is the matter, make a mutual plan to fix it, and then ask them
periodically if its fixed (Klein, 1993, p. 13).
Gillman, Swain and Heyman (1997) examine the use of documentation in
the treatment of people with severe learning difficulties (in DSM terms:
mental retardation). They state that the subjects of case records are not
treated as stakeholders and their voices do not appear in the record. They
discuss the difficulties of relying upon limited information and the ways that
information is used in the system of treatment in England. They suggest
incorporating client voices by encouraging them to tell their life stories,
which staff would record and incorporate into the official case
Some therapists are actively pursuing more egalitarian methods of
conceptualizing the mental health treatment process, recognizing the value
of the clients voice. In the process of informative exchange, the therapists
question invites a clients response, which is shaped in part by the question:
this takes place as a part of the therapy and within a session. The
therapists professional knowledge is further shaped or reformed by the
clients(s) responses. The therapeutic process, as well as the participants,
is being formed in a dynamic way (Roberts, 1998, pg. 20). Unfortunately,
this paper does not address how this view of the therapeutic process may
alter the nature of its record.
The focus within mental health and related fields on what factual information
should be recorded, rather than on how the process of documentation
relates to the spoken process of therapy, results in documentation that is
created to meet the perceived needs of the moment, but may not allow the
voices of the consumer or the therapist to be sufficiently heard in a manner
that is useful to both. It constrains the uses of documentation within the
system, therefore it constrains the process of therapy, as well. Once the
clients life story has been recontextualized into diagnostic and clinical
language, the documentation can take on a life of its own. If a court, a
probation officer or Social Services caseworker, depends upon this
documentation to make important decisions about the clients life, it would
be better if therapists understood the process by which spoken words are
written down in certain patterns. The burden is on the writer to make clear
his or her understanding to the potential readers.
METHODOLOGY: THE PLOT AND CHARACTERS
This study is designed as multi-level action research. It is action research
because it explicitly and purposefully becomes part of the change process
by engaging the people in the program or organization in studying their own
problems in order to solve those problems... and the research methods tend
to be less systematic, more informal, and quite specific to the problem,
people, and organization for which the research is undertaken (Patton,
1990, p. 157). The primary focus of this study is on the interaction between
therapists and clients, both spoken and written. This study is multi-level
because it also looks at the individual level of the therapist, the group level
of therapist-peer review, and the organizational level of the agency itself.
My own observations, reactions, and beliefs are considered in light of all of
these levels, as are my change efforts in response to this study. The
purpose for the study is to encourage reflection on the process and product
of documentation in order to determine the role documentation plays and to
develop better clinical writers at this agency. If the results can be
generalized to therapists in other agencies, it will be through encouragement
of reflective practice of people at those agencies.
The questions addressed by this study are: How does the spoken intake
session relate to the intake summary written by the therapist after that
session? How well does the client believe the intake summary describes
her life? How does the written intake summary influence the spoken
therapeutic relationship? How does the agency function to encourage or
constrain therapists strategies for writing intake summaries?
Because these questions involve several levels of scale, they also require a
variety of analysis methods and different theoretical frameworks, or lenses,
through which to view the data collected. Since the therapist and client do
not interact in a vacuum, the systems theory perspective is one important
lens (Bateson, 1972/2000). Actions and beliefs of individual therapists are
not the only factors that influence how documents are written and read. The
corporate culture of the agency, as expressed through policies,
procedures, supervision and peer review, as well as the formatting of the
documents themselves, provide context to the actions in which therapists
and clients engage.
And, since the process of therapy involves the telling of stories, or personal
narratives, it is important to view the narrative meaning of the documentation
that comes from it, and the organizational narratives that surround them
(Riessman, 1993; Czarniawska, 1997 & 1998, Clandinin & Connelly, 2000).
Attempts to change how therapy is documented must address the
metaphors that organize its meaning.
On a smaller scale, the therapeutic discussion can be analyzed as
conversation or discourse within a structured setting (Psathas, 1995;
Levinson, 1992; Drew & Heritage, 1992; Sarangi, S. & Roberts, C., 1999).
There are nuances in the conversational patterns of therapy that influence
its flow. These nuances must be altered to fit within the constraints of
documentation, possibly altering the meaning of the words beyond
With such a diverse toolbox, the Multi-Level Action Research framework is
necessary to capture the complexity of the data and perspectives without
oversimplification. It is important to understand what perspective, and what
level of scale, each aspect of this study requires.
This study was conducted at several offices of a community mental health
center in Colorado, which I will refer to as Prairie Mental Health Center. It
serves several rural and frontier (very low population-density) counties, with
small offices in each county. The site was selected because of accessibility:
as an employee of this agency, working with other employees, I
encountered fewer complications with confidentiality restrictions. The
management of the agency was also supportive of the research and made a
variety of staff available to participate. This helped to create a climate that
encouraged reflection on issues that were raised during the research and
supported change efforts. The dispersed nature of the offices also ensured
that focus group members were not familiar with the clients that were
recorded. The therapists who participated did know each other but, other
than within focus groups, did not work closely with each other.
In order to organize the data collection in a logical manner, the interviews,
sessions and focus groups conducted were organized into two series that
focused on different peoples viewpoints about the same session between a
therapist and client.
Selection of Participants
Prairie Mental Health Center has a system (Clinical Quality Improvement) to
compare clinical documentation to a quality standard. It is a series of 0-4
ratings on each section of the intake, service plan and progress notes.
Management staff of this agency designed the rating system. Ratings are
based on the presence or absence of observable criteria, plus the
integration of data into analyses. Two people rate each chart independently,
then compare ratings. One-point discrepancies are averaged, but greater
discrepancies must be discussed between the raters to achieve a
From the list of therapists who scored highest on the Clinical Quality
Improvement (Ql) ratings, I recruited three volunteers for this study. The
therapists were told that they were selected because of their high Ql ratings
and were asked to participate in a study about the role of documentation in
the clinical process. They were not paid specifically for participation, but
were allowed to participate during their regular work hours and the time they
spent was excused from their usual direct service requirements.
Several therapists were asked to participate, but declined. The general
reasons stated were that they were very busy, they felt uncomfortable being
videotaped during clinical sessions, or they were concerned about the
potential impact of participation on the client. Three therapists did volunteer
to participate in the study.
Of the three therapists who participated, two were female and one was
male. One was from a large office in the agency, while two were from small
offices (all were from different offices). The therapists varied considerably in
age, type of degree, years in the field and other factors, as will be described
in the analysis section of this study. All had been employed by the agency
for more than two years.
Selection of the client participants was dependent upon the therapists who
volunteered. Once each therapist was interviewed, support staff in that
office were asked to recruit a client who would be assigned to that therapist.
The only criteria for selection of clients were that they be 18 years old or
older, they could be enrolling in mental health or substance abuse therapy,
but not enrolling just for DUI treatment, and they were participating
voluntarily. At this agency, the intake process and intake summary format
are similar for mental health and substance abuse treatment. Some
potential client participants were ruled out because of the intensity of their
crises or because the research data could potentially be used in court. Two
clients, both female, volunteered to participate. Each client was told that
she would be videotaped during her first two therapy sessions, then asked
to read the intake summary the therapist wrote about her and be interviewed
about it. If the client completed these activities, she would be paid $20.00.
After the therapists and clients were selected and interviewed, and therapy
sessions were videotaped, focus groups were set up at the two largest
offices of the agency. These offices were selected because there would be
enough therapists available to participate in the groups. Neither of the
groups viewed tapes of sessions conducted by a therapist at that office.
The moderator for both group sessions was a senior member of the
management team at the agency who had experience in clinical
documentation and moderating focus groups. It did not appear that his
management status restricted comments; there was an open, friendly
discussion in both groups. His participation in the process also helped to
encourage interest in the process and results of this study.
Data Collection Steps
After I recruited three therapists to conduct the sessions, I interviewed each
therapist about how he or she decides what to document and what makes
for quality documentation. These interviews were semi-structured,
interactive and lasted approximately forty-five minutes each. This step was
audio-taped. The therapists were told that they would be participating in a
study about how therapists document the first two sessions of therapy.
Once the three participating therapists were identified, the support staff
responsible for setting intake appointments at those offices were given
instructions for identifying and recruiting clients (one per identified therapist)
who were just entering the system and were willing to be videotaped during
the first and second sessions. Two clients were recruited for this process
(one therapist was unable to recruit a client meeting the research criteria).
The clients were told that they would be participating in a study about how
therapists document the first two sessions of therapy. After the requisite
consent form was signed, the intake session was videotaped, then the
therapist was instructed to write an intake summary as usual. A second
therapy session was scheduled with each client.
The second session was videotaped for the one client who continued in
therapy. After that clients second session, I asked the client to read the
written intake summary and asked her opinion about it. I asked her whether
she thought it was an accurate summary of her life, then discussed her
answers with her. This step was audio-taped and lasted approximately
forty-five minutes. I showed the transcript of the client discussing the intake
summary to the therapist, then asked him questions about the feedback and
how it would affect how he conducts intake sessions and writes intake
summaries in the future. This step was audio-taped and the semistructured
interview lasted approximately forty-five minutes.
Since the second client did not return for a second session, I was not able to
interview her about her opinion of the intake summary. It is possible that the
process of videotaping affected her decision not to return, even though she
stated that it would not bother her and she appeared to pay little attention to
the camera during the session. She did not ask to withdraw her consent for
I then showed each written intake to a group of therapists at a large office (a
different office from where each identified therapist conducted the therapy
session). This step was structured as a focus group. The moderator was a
senior manager at this agency who has experience at clinical documentation
and running focus groups. He was familiar with all of the participants but
did not directly supervise any of them at the time of the focus groups. He
was familiar with the purpose of the study and was given a summary of the
research questions along with instructions about what questions to ask the
participants (see Instructions to Focus Group Moderator in Appendix). I
collected basic demographic data about the therapist-participants (years in
the field, years at this agency, type of degree and their rating of their own
proficiency at writing intake summaries). I provided each of them with a
blank intake form to write notes on, then after they read the intake, the
moderator asked them questions about it and had them discuss what they
thought of the intake summary, what aspects were covered well, what they
would like to see more of, what initial ideas they might have about goals for
this client, and how they thought an outside agency might view this intake
summary. This step was audio-taped and lasted approximately thirty
Immediately after the group discussion about the intake summary, I played
the videotape of the intake session and the moderator encouraged
discussion about the documenting process and how their impressions
changed (if at all). He asked questions about what they thought of the
intake summary after viewing the videotape, what aspects of the session
were present in the written summary and what were not, what they thought
the client would think about the summary, how the format might influence
the process, and how this discussion might change how they conduct intake
sessions or write intake summaries. This step was audio-taped and lasted
approximately forty-five minutes.
Since the second client did not return after the intake session, I completed
the second series by showing the transcript of the intake session to the
therapist and gave her some generalized feedback from the focus group,
then interviewed her about what happened in the intake session and what
she learned from it. This semi-structured interview was audio-taped and
lasted approximately forty-five minutes.
A total of eleven events were recorded and transcribed: six interviews, three
sessions and two focus groups. All but one transcript (the interview of the
third therapist) were organized into two series. The first series (see table)
was organized around the sessions between SG and DC and was a
complete process from first to second session with feedback from client,
therapist and focus group. The second series (see table) was organized
differently because the client chose not to return for the second session or
interview. This series focused on the intake session and reactions to it by
therapist and focus group.
Series of Events
Series 1: SG/DC Series 2: PW/CA
SG Therapist Interview PW Therapist Interview
SG/DC Intake Session PW/CA Intake Session
SG/DC Second Session 2na Focus Group
DC Client Interview PW Final Therapist Interview
SG Final Therapist Interview
1st Focus Group
Each transcript was analyzed for thematic patterns in content that emerged
from the data. A brief case description of each therapist and client was
constructed from the data in order to provide understanding of the unique
people that interacted in each session. Thematic patterns were compared
across transcripts to determine what themes might be present across the
Compared With Reason
SG/DC Intake PW/CA Intake Different styles of conducting intake sessions; different ways clients present themselves
SG initial interview PW initial interview TO initial interview How therapists view what they do in intake and service planning sessions
1st focus group 2na focus group Similarities and differences in reactions to the intakes, reflections on process
SG final interview PW final interview Reflections on the research process, what they learned
After the initial analysis of content for thematic patterns, data were
organized to show how therapists, clients and focus group members
construct meaning from the situation and what metaphors and stories they
used to describe this. I looked for phrases that not only described ideas
clearly, but also stood out as intriguing uses of words to convey meaning.
These phrases were likely to be personal beliefs of what was stated, rather
than just reiterations of standard views. I then reflected on how the various
viewpoints related to my own understanding of the use of documentation in
the therapeutic process and how my beliefs might change from that
Finally, I chose several key sections of transcripts that illustrate the
relationship between spoken and written therapeutic discourse to analyze
more closely. I examined the written intake summary for evidence of
membership categorization devices and diagnostic recontextualization
(Berkenkotter & Ravotas, 1997, Ravotas & Berkenkotter, 1998), to see how
the therapist translated the clients statements into clinical terminology. I
looked for quotations and other evidence of the clients voice within the
document and compared that to the clients spoken words. I also looked at
the pattern of the therapy sessions for formulation-decision pairs (Hak & de
Boer, 1996) that might show evidence of how the therapist might have
influenced the clients words during the session.
Description of the Intake Summary Document
The Intake Summary utilized by Prairie Mental Health Center is a
semistructured format (Beutler, 1995) that allows a therapist to organize
information about the client into clinically relevant sections. During the
course of this study, the Intake Summary format was modified somewhat,
but most of the sections remained the same or similar (see Intake Summary
forms in Appendix).
The first intake session was written in a format that started with Identifying
Information (short spaces to be filled in regarding client name, client
number, date of birth, social security number, date of intake, the therapist
who conducted and wrote the intake, age of the client, ethnicity, gender and
marital status). Following that were sections meant to be filled with more
narrative information. These sections were organized into: Referral
Information, Developmental Information, Psychosocial History, Substance
Use/Abuse, Mental Status Exam, Medical Information, Clinical Assessment,
Diagnostic Formulation, and Disposition and Initial Treatment Plan. Each of
these sections required specific subcategories of information. For example,
Referral Information asked for comments about Referral Source/Other
Agency Involvement, Relationship to Client, Current Living
Situation/Custodial or Legal Status, and Presenting Problem and Duration.
After the Intake Summary was revised, the required sections included:
Identifying Information, Chief Complaint and Referral Information,
Psychosocial History, Childhood Developmental Information, Assessment of
Aging Issues, Assessment of Special Needs, Substance Use/Abuse,
Medical Information, Mental Status Exam, Rationale for Each Axis I and Axis
II Diagnosis, Diagnoses, Factors Impacting Treatment, Consumer
Preference of Provider, and Synthesis and Initial Plan. The structure of the
Intake Summary format, as well as the reasons for modifying it, will be
discussed further in the Analysis chapter.
A second form, the Service Plan, was intended to be a major focus of this
study, but, due to unusual circumstances, no examples of its use were
recorded. One client did not return for the second session, when the
Service Plan would have been completed, and the form was not used during
the other clients second session. This form has different uses than the
Intake Summary, and the standard method of completing it is significantly
different. References to it will be made during the analysis and discussion
sections of this paper, but a full description of the relationship between what
is spoken and what is written during service planning sessions must wait for
ANALYSIS: TELLING THE STORY
Overview of the Process
This study is multi-level because it has a different focus at each step, from
the actions and reflections of individual therapists, to the interactions of
therapist and consumer that serves as the information source for
documentation, to the group process of several therapists as they review the
documenting process, to the organizational policy and procedural level of
the agency. The different focus at each level requires different methods of
inquiry and analysis of data.
At the individual level, I focused on the persons narrative of his or her views
and beliefs within the context of the therapeutic session. The intake
summary documentation itself was reviewed from various perspectives,
including how it reflects the therapist's view, brings the client into the record,
recontextualizes the clients words, and relates to the session it records.
The interpersonal level involved different perspectives of course, but also a
focus on discourse, interactions and relationship between the therapist and
client. The focus group involved an analysis of the therapist-participants
views and beliefs, as they were expressed in the group context with the
guidance of the moderator. At the organization level, I focused on how the
policies and procedures involved reflect the agencys views and beliefs
about documentation, and how information from this study might influence
The steps for analyzing the recorded and transcribed spoken data included
clarifying the narrative stories and patterns told by therapists and clients,
finding patterns in the discourse between therapist and client, and
comparing the documentation to spoken sessions and interviews. In focus
groups, I looked for evidence of reflection on practice and the patterns and
stories therapists use to conceptualize the documentation practice, as well
as the therapist-participants views about the specific intake. I also
examined their reactions to each others patterns and stories. In this
chapter, I attempt to bring the unique voices of therapists and clients into
what I write, to allow them to speak for themselves as much as possible.
Throughout the process of analysis, I reflected on how this information
relates to my own view of documentation in therapy. I also discussed
portions of the analysis with the therapists who conducted the sessions and
with the focus group moderator, in a recursive feedback loop that further
informed my analysis. When opportunities occurred to use this information
to influence changes in the process of documentation in this agency, this
also was included.
Because the people involved in this study are all unique individuals, it is
important to discuss their stories and views before combining and
contrasting them with the stories and views of others. I start with summaries
of the principal characters involved in each of these stories before tying
them together into a larger narrative.
Series One: Steven and Denise
This series consists of the initial interview with the Steven (the therapist), the
first and second therapy sessions between Steven and Denise, the interview
with Denise where she reads the intake summary Steven wrote about her,
the final interview with Steven, and the focus group.
Steven Graham, Therapist
The first therapist I interviewed was Steven Graham. If I describe him in the
language of an intake summary, he is a middle-aged, divorced, Caucasian
man who had worked for the agency sixteen years at the time of this study.
He had worked in several offices within the agency, providing both
substance abuse and mental health counseling, had supervised other
therapists and at one time had been in a management position. He has
worked with adults, couples, adolescents and children. At the time of the
study, he provided mostly adult and adolescent substance abuse
counseling, evaluations and supervision, but still did some mental health
work. He is certified by the state as a Senior Addictions Counselor, has a
masters degree in Divinity plus several classes from a doctoral program for
Professional Psychology. He found his school work and training to be
helpful in teaching him about personality dynamics and an overview of
development, but much of what he has learned about conducting intake and
service planning sessions, and documenting those sessions, he learned
from practice and supervision on the job. I have known him since I joined
the agency nine years ago, but have never worked directly with him. One
demographic detail regarding Steven that is interesting in light of the
sessions that were recorded, is that he is the father of an athletic teenaged
During both interviews, Steven generally used the term patient" and
sometimes client. He rarely used the currently preferred term consumer.
When asked about this, he appeared a little surprised.
When I began, client was definitely the term that was used, or patient.
And my thinking has changed. When I began the process, there was
very much of a theme that the therapist was the person who drove
the treatment planning, did the assessment and, if the patient would
simply follow and agree with the treatment plan, the patient would
improve. Probably true to a certain degree. But the element that
seemed to be somewhat missing was the patients motivation and the
encouragement of the patient to be responsible for their own
treatment. And I think that thats an area thats really changed for me
is that now inviting clients to begin to take responsibility in developing
the treatment plan and what they feel would be the most helpful.
Despite this discussion of change in his views, he continued to refer most
often to patients and occasionally to clients. He also frequently referred
to treatment plans rather than the currently accepted term service plan.
During the initial interview, Steven described his view of the process of an
intake session. He sees the development of a therapeutic rapport to be
I always believe that the first meeting is vitally important to the patient
and to the therapist relationship. Most of the clients that we see have
had some trauma as a result of the systems that theyve been in.
That may be from Social Services and having a lot of fear-base
around their children being removed, having extreme demands
placed on them, its sort of an authoritarian system... So, up to the
point of their seeing me, its oftentime their belief that people put
against them, that they somehow dont measure up, that what theyve
been doing has been wrongand its my hope to build a therapeutic
alliance with the patient to assist them working through whatever
issues that they have. I try to let them know that my job is not
necessarily an investigatory position, to find their faults and to report
those, but to help them look at what others are saying are problems
in their life, Im being a support to them to look out for themselves.
Steven provides information to the client as a primary method of establishing
First off I try to identify my role with the client and let them know that,
while I am a part of a larger system and certainly we would be
speaking with their referral source... I make that clear to them that Im
also a resource for them, to discuss these issues, and I attempt to
build rapport with them also by letting them know, or giving a sense
that I really want to, hear what they want to say... I attempt to be
open and honest with them if they have questions about whats
happening or why theyre here.
Information gathering is the other primary goal of an intake session. Steven
says that he values information that is gathered prior to the session from
referral sources and from the clients completion of paperwork. Clients
entering substance abuse treatment in this agency are asked to fill out a
self-report Addiction Severity Index (ASI) that covers the clients life history,
relationships, medical, legal and employment situation, substance use,
mental health issues and the clients interest in seeking treatment for any
concerns. The client is often requested to complete testing, as well, such as
a depression index and various substance abuse self-report instruments.
Steven finds these written documents to be valuable not only for the
demographic information they provide, but also because one can determine
the patients motivation, how motivated they are, a great deal of insight,
whether or not the patient has an understanding of their own dynamic and
the problems present... Substance abuse testing gives you some good
personality dynamics around the persons denial system, their willingness to
After reviewing the prior documentation, Steven gathers information directly
from the client in the intake session. He describes a methodical process,
working through each area of the clients life:
I do use Prairies Intake Form and I begin by getting just some basic
demographics from them which is fairly non-intrusive... and I try to
touch as briefly as I can on the referral source, because I know that
sometimes tends to be an issue of great anxiety for them. So Ill just
find out from them who they understand their caseworker to be or
their PO [probation officer] to be and then kind of move on from there.
I then go on to a social history with them and I just begin from the
start... the theory that were looking for there is the beginning parts of
socialization and how well they fit in... I also ask if they had any
traumatic experiences in their childhood, such as the death of a
caregiver or someone who was very close to them... I also certainly
ask if any extracurricular activities in schoolI think that thats
important, if theyve been in a team environment before, it helps them
to have, hopefully, some protective factors around having seen some
success, those kinds of things... And I certainly throughout the
process look for sort of key factors of what would be personality
development for them or what may have impacted their
Also, look for roadblocks in which the patient may sense difficulty in
gaining insight to their issues. So, those would be areas that, in the
therapy, I might go back and address and assist the patient in
removing those roadblocks so they can have a better look at whats
going on for them.
Certainly, then, we move on into the area of addictions and we cover
that, whether its mental health or substance abuse... If I can, here
were looking for insight into whether the person can determine how
its affecting them... Ultimately, at the end of the interview, if its a
substance abuse matter, Ill address, fairly matter-of-factly, whether
or not the patient feels they have the ability to discontinue the use,
and how they feel that will or will not affect their present situation...
Steven assesses the clients overall functioning during the intake session:
within that mental status exam is also some variables around their
presentation for speech, mood and affect, which are helpful because
they begin to give you the oral impression of how the person is
viewing their world... I often say that when patients come to see us, it
may be at the lowest ebb of their life, in that theyre being impacted
by other factors, their own dynamics, and, theyre often in distress.
So, I think that those are areas that we need to assess closely as
Steven also commented on the assessment of the clients strengths:
We do need to build in a strength base in our assessment about
whats going right in a clients life, what can they draw on? As well,
hopefully, give the referral source a perspective of what type of
approach would work best with this client. What type of intervention
would be most helpful? I think that clients are referred to the center
kind of in a dual perspective. One is to certainly provide treatment for
some type of malady thats been found or believed to be present. But
also to assist the referral source and others in building rapport and
how best to positively impact the clients life. So strength-based is
also vitally important. Without that, sometimes not an awful lot of
growth occurs... So, having completed an overall presenting problem,
mental status, extensive social history, reports from external folks
who have had contact with this person, the clients own view of it, you
can begin to formulate, then, a diagnosis as well as an initial
treatment in your own mind about what you believe is going to be
helpful to this patient.
Steven has a methodical approach to conducting an intake session that he
has developed during years of practice. He knows what information he
needs to gather to complete the intake summary, but also is aware of how
his own theoretical beliefs influence the process. 1 tend to be somewhat of
a psychodynamic in looking at the issues of each patient. Its certainly not in
a brief style. It encompasses more of what the patients life history has
A large proportion of the clients he works with are referred by the probation
or Social Services systems, which encourages him to consider the needs
and involvement of those agencies throughout the session, but he tries to
balance that with an understanding of the clients needs and wishes and his
own clinical judgement. He views the intake summary as an objective
document. I think that the objectivity comes in the fact that, as a substance
abuse or mental health clinician, Im not tied to investigative reporting, like
many of the other agencies are... and the other part that tends to be,
hopefully, very objective, is the assessments that the patient does, they
complete those, theyre standardized, they tend to be very objective. The
combination of standardized assessment tools with his own skills at
interviewing clients produce a document that he views as an objective
record of the client, from a therapeutic perspective.
Since Steven only mentioned diagnosis as an end result in his description of
the intake process, I asked him what the role of diagnosis is in treatment. I
dont know that, necessarily, the diagnosis is important to the client. I think it
is vitally important to the professionals because the diagnosis tends to
speak volumes in a few short words and sort of helps identify the major
issues in a persons life which gives a commonality and usually gives an
immediate impression to the professionals.
Steven concluded that: Often times, Ive found that the identification of
issues and problems, diagnoses, information gatheringthe treatment is far
more difficult at times for the client to work through than, certainly, the
identification of the issue of the problem. We can know whats wrong with
the patient. Assisting them and their making life changes is the difficult
After collecting information during the intake session, Steven proceeds to
If I feel very confident in having a treatment plan formulated, Ill then
begin to visit with the patient about what I see as the course of
treatment needing to be and will invite input from the client as well.
And, oftentimes, will invite the input from the client first before I offer
my suggestions... I really encourage patients to take responsibility for
their own treatment.
During the initial interview, Steven commented on his views about the
balance in service planning between the therapists and the clients view.
When I began doing this, certainly treatment planning was to be
objective and it was to be measurable, which often created some
difficulty but.. then we have moved into a phase in which the client,
more or less, expressed their own sense about what they felt they
needed to accomplish in more of a process-oriented perspective.
And, now, its coming somewhat full circle in that, certainly the patient
assists in driving the treatment planning, as it should be, so that the
process part is in the treatment planning. But also, now requiring
objectivity and measurement is vitally important.
Steven believes that the current paperwork requirements and process at
Prairie Mental Health Center are mostly good. As much as we kind of joke
about the paperwork, in the Springdale office, in my case, its very
streamlined and Im very grateful for that... We have a very concrete intake
assessment form that we use. Its a good form; it covers all the areas that
are necessary and provides, I think, a very excellent report... for the most
part, its a very efficient system. He generally dictates his notes for support
staff to transcribe (most therapists at this agency type their own).
After I interviewed Steven, we recruited a client for videotaping. Denise
Carter had just turned eighteen, and was referred by her probation officer for
counseling because of hot urinalyses (UAs). Three months before this
intake session, she had been enrolled in a program within this agency that
monitors UAs, but she had not been involved in treatment. Steven had
access to the information gathered by that program.
A one-page Brief Intake Summary had been filled out by the staff person
who enrolled her in the UA program (that staff person did not have a degree
and was in the process of training to become a substance abuse counselor).
That intake summary states that Denise was a seventeen year old,
Hispanic, single female. The Presenting Situation is described thus:
Denise is referred by Candy Stevens at the 19th Judicial District Probation
Department. She is on probation until August 2001 for Domestic Violence
Enhancer and trespassing. She will be doing random UAs through the
DROP program. The Brief History is: Client began drinking at least 1 X per
week at age 17 and gets it from older friends. She also began using
marijuana at age 17one time per week. Medical History and Current
Medication is: Client was diagnosed 3 months ago with cervical cancer and
is receiving treatment. No current meds. Brief Mental Status Exam:
Oriented X 3, denies suicidal/homicidal ideation. There is no entry in the
Diagnostic Summary section. Diagnosis is: 305.20 (Cannabis Abuse) on
Axis I, no diagnosis on Axis II, cervical cancer on Axis III and legal problems
on Axis IV. Axis V (a numerical impression of the clients overall level of
functioning) is 70.
At the time of her enrollment into the UA program, Denise had also
completed the Addiction Severity Index (ASI) self-report form. It is nineteen
pages long and covers many areas of a persons life. The multitude of
questions asked can often reveal interesting data, not just about
demographics, but also about a clients beliefs about herself and her
relations to others. Steven referred to this form during his intake session
with Denise, but did not ask her about information in it. There are brief
sections for the therapist to comment on the clients responses, but none of
these were filled in.
Denise answered, briefly, most of the questions asked by the ASI. There
are some answers that are interesting in relation to the intake session and
summary. She notes that she had never been treated for mental health
issues, but, in the past (more than 30 days prior) she had experienced
serious symptoms of depression, had trouble controlling violent behavior,
and had thoughts of suicide, but was not using drugs at the time. She did
not want treatment for mental health issues at that time. Her mother, father
and two younger brothers used alcohol/drugs. She writes that growing up in
her family was confussing, fsicl and I wasnt really disciplined as a child.
She endorses a history of emotional abuse by mother and others, and
sexual abuse by others, but denies physical abuse. The only drug use she
records are alcohol, starting at age 16, every weekend, ending one month
prior, and cannabis, starting at age 17, every day, ending one month prior.
Neither substance was a problem, in her opinion, and her longest period of
voluntary abstinence was seven months, ending one month prior to the date
she filled out the ASI. She marks these check boxes: arrest for assault,
history of being verbally or physically abusive (she did not describe this),
violence in her family of origin, a belief that it is sometimes necessary to use
violence to get what she wants, having used violence against a spouse or
family member, and violence against others, and feeling that she is capable
of violence when she loses her temper. Despite this, at the time she felt that
her legal problems were not at all serious and it was not at all important
to get counseling for legal problems.
The ASI includes a rating scale, from 1 to 10 of various personal
characteristics. The characteristics are paired: a positive trait (smart) on
the 10 side relates to a negative (stupid) on the 1 side. The characteristics
that Denise endorses strongly are: smart, knowledgeable, confident,
worthwhile, ambitious, attractive, faithful, happy, hardworking, normal,
honest, hopeful, and active. The only characteristic that scores below a 5 is
a 4 on bad. Her counseling goal is to be totally free from everyone,
everything. There were no issues she wanted to work on and nothing she
wanted to accomplish in treatment. She lists her ethnicity as Hispanic-
Mexican (there are various choices for Hispanic, and a Biracial/Multiracial
choice), and lists her father as Hispanic and her mother as White. She
speaks primarily English, but also Spanish.
Intake Session Between Steven and Denise
Denise was asked to participate in this study just prior to her intake session.
She answered yes without waiting for a detailed description, stating
Everyone knows everything about me anyway. Steven had been aware of
her participation in the UA program, but had only spoken to her briefly
before this session. He had access to the Brief Intake Summary and ASI
described above, and had some information about her childhood through
another family members prior treatment at the agency, but does not seem
to have reviewed these sources prior to the session.
The intake session progressed in a generally methodical fashion, with
Steven asking brief questions and Denise providing brief answers. The
conversation started with a general, open question (Hows Denise doing?)
and a request about the UA program (How has that been going?). Denise
explained that she had started, quit, went to court, then restarted. Steven
replied: Okay. Okay. What kind of happened during that period of time?
Denise responded with one of her longest statements in the session, 59
words, in an attempt to explain what happened. After that, Steven said,
Okay. Urn. Lets start, well start kind of at the beginning. Are you still at
1345 Grant? From there, his questions were primarily specific and closed,
and her answers were short, offering little beyond what was requested. He
asked a question, she answered, he gave a brief, non-committal response
(okay), then asked another question.
S: Okay. Well, lets start here. Urn. What was your original reason
for being on probation?
D: Domestic violence enhancer, second-degree assault. I got
charged with the domestic violence enhancer, though.
S: Okay. Okay. And who was that with?
D: Johnny Gonzales.
S: Do you remember when that was?
D: A year ago last Easter.
S: Okay, [pause] What kind... what kind of happened in the situation,
D: I went over to his house and I caught someone there, and so I, you
know, I started hitting him, and I broke his entertainment center and
stuff, and so and he called the cops because I broke the window.
S: [pause] Okay. And were you, were you using at that time?
S: So, no drug or alcohol use?
S: And did you do the domestic violence classes, or...?
D: Huh ah. I didnt have to. All I had to do was anger management.
S: Okay. And did you do that here?
D: I didnt do anger management classes, cause they didnt want me
to be in group or anything, and I refused to be in group. And I had
pretty much all these counselors here, so I didnt want to do
S: Okay. Okay. Where did you do the anger management at?
D: l just did an intake.
S: You just did an intake and didnt do any classes or individual?
D: Huh-uh. [pause] All that was ordered on my paper was an intake.
After a few more brief exchanges, Steven attempts to clarify what happened
regarding the anger management treatment by offering what Hak and de
Boer (1996) call a formulation, followed by her response, which they call a
S: So you go through all that and then you are on probation with
Candy, and then do you have a hot UA with her or...?
D: I had a couple.
This formulation-decision pair serves to create a shared understanding of
facts in the patients lifean understanding that can be subsequently
transformed into a professional assessment (Hak & de Boer, 1996). Denise
does not always agree with Stevens formulations:
S: So you had the positive UAs and Candy said come over here and
get in the DROP program, so you came over and saw Julie?
D: No, I didnt have any hot UAs before I got in the DROP program.
The reason I got in the DROP program was because I admitted, I
admitted to using when I went to detox, and that UA came back
S: Okay. That was before you came over and saw Julie. Okay.
D: These have just been, like, recent. Since Ive been on it.
D: Cause Ive been on probation over a year now.
S: [pause] OK. I think I understand now. You got arrested. Candy
was visiting with you. You admitted to using. Urn. You went to detox
at Valley View. Came back. Candy said you needed to do the DROP
program over here. You came over here, had some positive UAs and
then you dropped, you stopped coming, basically.
D: No, I didnt have any hot UAs before I stopped coming.
S: Oh, gotcha. Okay. So, clean UAs, and then you kind of quit
coming, and now since you came back theyve been positive.
D: Theres only been like two...one hot for THC and one hot for meth,
S: Okay. All right. About how long do you think it was that you
stopped coming in, was it a month, two months?
D: About a month.
When Denise disagrees with the summary Steven offers in his formulation,
he gathers more information, then tries another formulation. Once she has
agreed, he proceeds with the rest of the interview: Well just start at the
beginning right quick. Where were you born at, Denise? From there, they
engage in an extended series of brief questions and answers about her
childhood, parents, siblings and school history.
Most of Denises answers are expressed in less than ten words, and she
rarely initiates a conversation sequence, but there are several points at
which she chooses to explain more. After Steven asks her if she has
contact with her father, she volunteers information about her relationship
with her brother:
S: And do you have any contact with him?
D: Ah huh.
S: Um, How often would you say?
D: Um... Every once in awhile.
D: Its not like anything major, or anything, just whenever.
D: I talk to my brother, Jess more, than him.
S: Is he the oldest?
D: Huh ah. Allen is the oldest. Hes the third.
S: [pause] Is your dad still married to Stella?
Denise volunteers a piece of information that has potential emotional
significance to her, but Steven chooses to move the conversation back to
the collection of demographic data. There are several other points at which
Denise makes a statement that could be explored for its therapeutic
significance: one of her longest statements, 67 words, regards how she
moved among foster homes and a Residential Treatment Facility, including
one home that initiated but did not complete, adoption proceedings. Steven
responds: Oh, okay. Okay, [pause] Then your GED through CJC? (The
pauses before some of his statements are generally when he is writing down
During a series of brief questions and answers about her school history,
Steven asks what her grades were like in Middle School:
D: I had good grades. I was in student council in eighth grade year.
S: Good for you! [pause] Any other activities?
S: What did you do, volleyball?
D: Everything. No, I hate volleyball.
D: Softball, track, basketball, [pause] And I wrestled in eighth grade.
S: You were on the wrestling team?
D: Ah huh.
S: How did that work out?
D: I got second.
S: Did you really!? [pause] Good for you. And you went to the
S: And what weight group did you wrestle?
D: 95 for awhile and then I moved up to 98, so I wrestled 100s.
S: And you won some matches? Sounds like you won more than a
few of your matches.
Denise and Steven were both more animated in this exchange than during
most of the session. Immediately afterwards, Steven resumes questioning
her about school, eliciting brief answers about where she attended when.
Other potentially emotional topics are raised when Steven asks her an open
question about her childhood:
S: Urn...if you kind of had to describe... your childhood, what would
you say about it?
D: I never had one. I had to be an adult before I was a child, [pause]
Like, when I was around my grandparents, it was more of a
childhood. When I was around my grandfather, I had more of a
S: Grandfather on your moms side?
D: Yeah. It was her stepfather.
S: And his name?
D: Lou Jones. He passed away when I was... a couple of months
before l went to foster care.
S: [pause] And if you kind of had to describe your mom, what would
you... would you say about your mom?
D: She was worthless...! dont know...a child. Mentally and physically
[laugh]. I mean, she... no stability, thats how I would describe her.
S: How about your dad?
D: Oh, I think he has a good heart, but he grew up in a lifestyle of...
the drugs and everything, so its hard for him to...you know what I
mean, just kind of get away from it.
D: He knows right from wrong but its hard for him to choose.
When Denise touches upon such emotional topics as her closeness to her
grandfather or the instability of her mother, Steven usually chooses to
respond with closed requests for more demographic data. These data are
required for the intake summary but Steven is not constrained by the format
to request them in this manner. Immediately after the exchange above,
however, he switches to an open-ended question about her view of herself:
S: Ah huh. And if you had to describe you. If someone had never
met you before, how would you describe yourself?
D: Hmf [laugh] Kind of a nice word, really... Urn. A fronter, actually.
D: No, a fronter.
S: A fronter?
D: Well, if, for someone who had just met me, Id probably, Id
probably seem pretty nice for someone who just met me. [laugh] But
if someone has known me for a long time, then, I dont know, I get
told I minimize a lot. And I put a show on, for something that Im not.
S: [pause] What do you think? Do you think that thats the case?
D: Urn, I see it a lot, [do you?] but thats how I want my life...I feel
better feeling people perceive me in that way. I feel better about
S: Okay. So you kind of... show them what you think they want to
D: No, I show them what I want to be.
S: Okay. Thats good.
D: I show them what Id like to be and how Id like my life to be.
S: Even if it really isnt there yet?
After that exchange, Steven switches back to closed-ended questions, this
time focusing on family substance abuse and depression. He asks her
have you struggled with some depression? and she answers ah-huh.
This leads to a discussion of a time when she was evaluated for ADHD but
determined not to have it. The subject of her depression history is not
raised again, even though later questions about her medical history reveal
she had just finished treatment for cervical cancer, and had become
pregnant but miscarried.
The subject turns to her use of substances. Steven starts the questioning
about cigarettes (she does not smoke because she is allergic to cigarettes;
he responds Good! Glad to hear that) and alcohol. She states that she
used to drink a lot but not much anymore. He asks And was it a problem
for you for awhile?
D: Yeah, [pause] I dont know that it was actually a problem, but we
were going out a lot and just kind of, I dont know, it was there and we
just drank a lot. I dont know if it was actually... Its hard to actually
say if it was a problem or not, cause, you know what I mean...when
youre in high school theres a lot of parties, you know what I mean,
so it is actually hard to define if it was actually a problem or if it was
just doing it just cause it was there and you would go out and...
S: Um-hm. How much would you say that you would drink on an
D: Oh, it wasnt at night, it was just on weekends.
S: Just on weekends?
D: And wed go out a lot.
S: And how much would you say youd drink on a weekend?
D: Quite a bit. I dont know how much it would actually be, but wed
just get a lot of stuff, how much money wed have, and wed just
spend it on that and wed just drink it all.
S: Did you drink mostly wine or beer, or hard liquor, or?
S: Okay, [pause] And you said now you dont drink much. Whats
D: I get sick now.
S: Oh, you do? [yeah] Good. Thats a good protective factor.
Denise explains that she gets sick while drinking because of kidney
problems. Steven then asks her about her marijuana use, which she does
not see as a problem, and methamphetamine, which she admits to using
twice but did not enjoy. He asks her if she would continue using either
substance if she were not on probation. She would quit the
methamphetamine but not the marijuana: I like the feeling, of just not
caring, not having to worry, not worry, not care. People usually dont care.
Steven returns to the pattern of closed-ended questions leading to brief
Near the end of the session, Steven asks a question that introduces a new
pattern of responses, in which Denise speaks for longer stretches, with
some awkwardness, and more revelations about how she feels about
herself and friendships:
S: What would you say are your strengths?
D: Hm. Urn. Some people might consider it a downfall, but some
people consider it a... a strength, urn [pause] like in a way [pause]
urn... My stubbornness, kindasometimes its a strength and
sometimes its a weakness, but I... I dont know, sometimes it could
be more of a strength because I dont want people to get close, so I
dont open up, so it kind of keeps me from getting let down or getting
hurt. But then, there again its not letting people in. A chance of
getting someone too close...
S: Um-hm. And do you find that kind of a struggle in your
relationships, like with TJ?
D: Urn. Im picky and choosy about who I open up to and who I care
about, so... it, it sometimes is because like Ill feel myself getting
closer and so I push harder away. [Um-hm] And I get more hateful,
and I do things to sabotage, like in a lot of my relationships with my
family or my friends, [ok]. But Id do anything for my friends, I think
thats maybe one of my downfalls, is I... my friends, Ill do anything
for em. And thats one of my downfalls, cause I just, I help em, I help
em, I help 'em until, when I need help, they dont help me and then
Steven does not follow up on her self-disclosures, but closes the session by
addressing plans for the future:
S: OK. Ok. Well, coming back into the program, urn, Ill get ahold of
urn, Rudy Prince, your probation officer, to visit. And... what do you
think about coming back? Do you think youll be able to come back
and finish up the program, or?
D: Which program?
S: Here, at Prairie, with uh, with the stuff, do you think that youll [like
which stuff?] Like the DROP Program, [oh, Im still doing that] with
D: Oh, like if I got off probation?
S: Yeahno, while youre on probation.
D: Well, I have no choice [laugh].
S: [laugh] Well, I dont know, you had a choice last time.
D: Well, that was when I was on unsupervised probation, now Im on
The session closes with an exchange about scheduling:
S: OK. All right, well. Give me the opportunity to talk with urn Rudy,
and why dont you schedule to come see me next week.
D: I dont know what my day off is going to be, but I get off at three.
[OK] And Im always here when Golds called so...
S: OK. All right. If youd just call in up front and schedule an
appointment when you know, that would be fine.
D: Will itwill I have to wait a couple of weeks or whatever, cause it
alwaysIm confused, [ok] Cause like when you call and make an
appointment you know they never have nothing open.
S: OK. Urn, you know you probably needwell you dont know what
your day off is yet...
D: If you just schedule something after three o-clock, it can be any
S: Ok, Well when you stop in up front you can just tell them that you
need something after three.
Despite her stated reluctance to participate in therapy, Denise pursues the
appointment with more persistence than Steven does. Throughout the
interview, Steven makes no prescriptive statements other than to suggest
she schedule another appointment. He makes no evaluative statements
about the information she provides other than an occasional good. At no
point does he directly criticize her behavior or opinions, or contradict her
statements. The entire session lasted just short of one hour.
The Flesh Becomes Word: Denises Story is Written
into the Intake Summary
Within a week, Steven had dictated the intake summary and had it typed. It
is seven pages long, including the developmental section that is blank
because Denise was not under eighteen years old at the time of the intake.
The format that he used has multiple headings that section off each subject.
There are major headings, such as Substance Use/Abuse, and within that
category there are subheadings like Impact of Substance Abuse on Clients
Life. Steven had the choice of separating what he wrote into the delineated
subcategories or collapsing them into longer narratives within each major
heading. He retained the separate subheadings, but did not always
complete each subsection. For example, Patterns of Substance Abuse is
left blank, most likely because he addressed this topic within the more
general section under Substance Abuse/Use.
At the time Steven completed this intake summary, there had been a
discussion within the agency regarding the pros and cons of separating the
intake into subsections versus combining them into a longer narrative
section. Specifying subsections has the advantage of cueing the writer to
include all relevant data, while longer narrative sections encourages the
writer to bring the data into a more integrated and coherent story of the
clients life. Shortly after this intake was written, the official intake format
was changed to encourage longer narratives. Steven was a part of this
Much of the intake summary Steven wrote consists of statements attributed
to Denise within a framing clause introduced by a verb-of-saying, usually
reports (Ravotas & Berkenkotter, 1997). She reports that her grades were
good, that she was student council member in eighth grade and participated
in extra curricular activities of softball, track and basketball. In this way,
Steven is able to recontextualize Denises words into a format that lends
itself to a professional description of a client. There are no statements in
quotes, no words that are directly Denises voice. During the intake session,
she described her mother: She was worthless...! dont know...a child.
Mentally and physically [laugh]. I mean, she... no stability, thats how I
would describe her. Steven translates that into: Denise reports that her
mother is extremely immature, child-like, uses drugs and alcohol, and is
Steven writes brief sentence fragments to complete some of the
subsections, but there are longer narratives in Presenting Problem and
various subsections of Psychosocial History. He summarizes the
complexities of her entanglements with probation as her presenting problem,
accurately recounting the sequence of facts that had caused confusion
during the intake session, but adds an interpretation about causality that she
did not state: She was... requested to complete the Day Reporting System
for random urinalysis. Denise was unable to complete that and began her
use again. While the hot urinalysis for both methamphetamine and
marijuana prove that she did use drugs at that time, Denise might argue
that it was not because she was unable to complete the DROP program.
Much of the narrative within the Psychosocial section recounts the
sequences of events of her family relationships and educational history, with
little mention of emotional significance: She reported that a divorce took
place because her father had gotten another girl pregnant. The narrative
explains what happened in what order during Denises life, but provides little
insight into the reasons or consequences. He writes in the Developmental
History section that socially, she appears to be adequate, although her
choice of peers in the past has not been the most positive, an interesting
interpretation of how she recounted her life story in the intake session, but
he does not tie it in with other observations about her life.
Steven did not ask Denise directly if she had been abused. In the intake
summary, he states Having known the case and Denises situation, there
was a history of emotional abuse, physical abuse and neglect in the home.
Sexual abuse is unknown. He does not write about how that abuse might
have affected her life. Whatever emotional experiences may have
surrounded the brief pregnancy are also missing from the summary: Denise
reports that she became pregnant and TJ was the father; however, the
pregnancy was terminated as a result of physical problems that Denise
In the Client Mental Health History and Psychotropic Medications section,
he briefly reviews her statements regarding Attention Deficit Disorder, but
there is no mention of depression. Since this intake summary is for
substance abuse treatment, it would be expected that the Substance
Use/Abuse section might be more extensive than other sections, which it is.
He states that she does not smoke cigarettes, then reviews her history of
alcohol, marijuana and methamphetamine use. He begins to analyze and
interpret some of her statements:
Denise reports she began smoking marijuana at about age 16. She
reports it is not a problem for her. She indicated that, prior to her
arrest, she would use approximately one time per month. She
indicates that her use did increase quite a bit during the difficult parts
of her life, and then she would use every once in awhile after that.
She indicates that she has no desire to discontinue her marijuana
use. She does not see a problem with it. It provides her significant
mental benefits. She indicates that she does not worry or care when
she is under the influence.
Again, he recontextualizes her words about why she values marijuana: I
like the feeling, of just not caring, not having to worry, not worry, not care.
People usually dont care. From a personal, emotional statement, he
derives symptoms to indicate a diagnosis of marijuana abuse. He also
assumes that her increased marijuana use correlated with difficult times in
her life, but during the intake session she was more vague about the timing:
it went up for a little period of time, and then I just quit altogether, and
then... then every once in awhile after that.
For the Impact of Substance Abuse on Clients Life he summarizes: This
has been fairly dramatic, as she has chosen to continue to use in the face of
probation, which has led to her moving into a supervised status of probation
and requiring treatment. He also lists her Previous Treatment and
Attempts at Sobriety as none. This raises the question of what constitutes
an attempt at sobriety, since she stated during the intake session that there
have been periods of time when she has not used substances.
In the Medical Information section, he summarizes Denises statements
that she is a borderline Diabetic and had successful treatment for cervical
cancer, including three surgeries. He lists the names of her OB-Gyn and
primary care physicians. He also recaps: She indicates that she became
pregnant and TJ was the father; however the pregnancy was lost. Despite
commenting in the Substance Use/Abuse section that she suffers from
kidney failure and tying that to her increased tendency to get sick when she
drinks alcohol, this medical condition is not listed in the Medical
Information section. During the intake session, Denise does attribute her
sickness after drinking to kidney problems: I had a kidney failure. So it gets
to my kidneys right away and I just get really sick and wheezy and stuff. It
gets to me a lot faster. He later questions her about that:
S: Any other medical problems?
D: Hmmjust my kidneyI have kidney problems. I had a really bad
kidney infection and a bladder infection awhile back and itshe said
my kidneys were really bruised, and everything and sothey were
just watching it. And I have a lot of problems with my kidneys now
just the one. [um-hm] The other ones alright. So, like when I drink
or anything like that, it just gets to me.
During a discussion after he wrote the intake summary, Steven suggested
that he was suspicious of how accurate Denises account of her medical
problems might be, but the intake summary recounts her statements as if
they are fact. Kidney failure is a serious, potentially fatal, condition.
Borderline Diabetes at age eighteen can also have serious health
consequences. Drinking alcohol or using other drugs could exacerbate
either condition. Given both the potential severity of these medical
problems, and the vagueness of her reported diagnoses (kidney failure or
bruised kidneys?), it is interesting that Steven reports them as if they are
unquestionably factual and accurate.
The intake summary includes a Mental Status Exam section. This is one
place where the therapist relies more upon his own perceptions and
understanding than upon the clients statements. There is some subjectivity
involved in the process, since the semistructured interview is not well suited
to deriving reliable and valid inferences about cognitive, emotional, and
affective functioning. However, its importance for generating hypotheses
about these areas of functioning should not be discounted (Beutler, 1995).
The therapist is required to comment on the clients
presentation/appearance, mood, affect, cognitive/intellectual functioning,
speech, memory, attention/concentration, thought content and process,
delusions, hallucinations, judgement/insight, suicidal/homicidal thinking, and
orientation. Overall, the Mental Status Exam should provide a snapshot
picture of the clients current state and should support the diagnosis.
Stevens entries into some of these subsections are generally brief:
Speech: Unremarkable, Memory: Intact, Attention/Concentration; Both
appear to be appropriate. He assesses her cognitive/intellectual
functioning to be adequate. She is of average to above average
intelligence. This does not contradict his impression in the Developmental
History subsection that she is bright, witty, and able to process information
well, but it gives little information about how her intelligence relates to other
aspects of her personality or behavior.
Other subsections are addressed more thoroughly:
Presentation/Appearance: Denise was dressed appropriately and
was well groomed, however she was quite fidgety. There were times
in which her hands were fairly constant in movement and she would
rearrange herself in the chair quite often.
Mood is an internal state, for which affect provides observable clues.
Steven writes Mood: her facial expressions were matching with her mood.
Her mood was appropriately elevated and congruent, but he is describing
her affect, with no clear statement about her mood. He then describes her
affect: At times she was quite sarcastic but cooperative. She was
somewhat animated. Her affect was appropriately elevated and congruent.
She was somewhat angry and resentment [sic] at times. Sarcasm and
animation are types of affect. Anger and resentment, however, describe
mood states. This is an interpretation of what Denise was feeling at the
time, but he gives no direct evidence to support his assertion. This would be
an ideal place to bring Denises voice into the record, to have her words
describe how she feels.
Steven states in the Mental Status Exam that Denises judgement/insight is
adequate, and that she does have some insight into her difficulties, but
provides no examples of that. This would be another excellent place to bring
Denises voice into the record. In a longer narrative section, he again
Client Strengths: This patient describes herself as being quite
stubborn, which she sees as both a strength and a weakness. She
does have insight. She recognizes her closed-offness and her
inability to function and maintain close relationships. She has insight
and understanding that she often puts forth a fagade, which keeps
people at bay, and also enables her Isic] a strong defense for not
dealing with problems. The substance abuse tends to tie directly into
the facade, which strengthens her presentation and appearance to
the outside world.
For the first time in the intake summary, this section on Denises strengths
begins to create a picture of her as someone who is starting to understand
dynamics of herself and her relations to others, but whose actions are
constrained by her history of emotional pain from unreliable relationships.
Steven brings into this section his own view of this by his discussion of her
insight, and he brings Denises view by discussing her tendency to keep
people at a distance, but, again, he does not bring her voice into the record,
even when describing her internal motivation and understanding of herself.
He writes This patient describes herself as being quite stubborn, instead of
using her words: My stubbornness, kindasometimes its a strength and
sometimes its a weakness, but I... I dont know, sometimes it could be more
of a strength because I dont want people to get close, so I dont open up, so
it kind of keeps me from getting let down or getting hurt. But then, there
again its not letting people in. By recontextualizing her words into a more
professional nomenclature, he loses the emotional and situational nuances
of the original statement, its hesitations, ambivalence and motivation to
avoid being hurt.
Later in the report, while discussing Client Needs, he addresses the topic
of insight again:
Denise needs to develop a sober lifestyle. She is quite young to be
living on her own, but appears to be doing adequately in that area.
She needs to gain new insight around addiction and how is [sic]
affects individuals [sic] lives and the propensity of addiction in certain
In this case, Steven states that she needs to gain insight. He does not
address the apparent inconsistencies of his statements about insight,
although this could lead to an interesting discussion of Denise as a complex
young woman who is engaged in the difficult process of developing an
understanding of herself and her relations to others.
The intake summary has a section for recording Relevant Cultural Issues.
Steven states that there are none despite her biracial heritage and
bilingual childhood. She is clearly fluent in English, so that is not a barrier.
The agencys instructions for completing the intake summary form state that
the therapist-writer should describe cultural factors including ethnicity,
religion, sexual preference, neighborhood, peer group, etc. Steven could
have chosen to comment upon Denises peer group, at least, since he
mentions elsewhere in the intake summary that her peer group has
influenced her substance use. He also states that there are no risk factors
for abuse, suicide or homicide, and lists her Community Affiliations/Social
Supports as just County Probation and Prairie MHC.
The final section of the intake summary before the plan for treatment is the
Diagnostic Rationale, leading to the diagnosis. Steven concludes that
Denise has developed a maladaptive pattern of substance abuse, which
has led to clinically significant impairment and distress, as evidenced by her
continued use of both methamphetamine and marijuana while on probation.
This has created a far more stringent probation for her and has created legal
The conclusion is drawn from the words of the intake session, where Denise
admits that she used methamphetamine and marijuana while on probation,
resulting in two positive urinalyses. The words he uses are drawn from the
Diagnostic and Statistical Manual of Mental Disorders Fourth Revision
(DSM-IV) descriptors of Amphetamine and Cannabis Abuse. In order to
determine that a persons use of a substance is abusive, the therapist must
establish a maladaptive pattern of substance use leading to clinically
significant impairment or distress, that occurs within a twelve-month period.
One or more of four symptom categories must be present as the result of
recurrent substance use: failure to fulfill major role obligations, use of the
substance when it is physically hazardous, legal problems, or use despite
having persistent or recurrent social or interpersonal problems caused or
exacerbated by the effects of the substance such as arguments or fights
(APA, 1994, p. 182-183).
Steven uses the language of the DSM-IV to recontextualize Denises words
about her issues with probation into diagnostic symptoms. During the intake
session, Denise does not admit to distress from her use of
methamphetamine or marijuana; it is the legal consequences of her use
while on probation that establish the diagnosis of substance abuse.
Denises words about her use of substances are taken out of her life
narrative, where they can be understood in terms of her phase of life and
her relations to other people. Steven selects the points that are salient for
the diagnosis and frames them within his professional viewpoint
(Berkenkotter & Ravotas, 1997).
Steven does not offer a diagnosis of depression or ADHD, even as a rule
out. He determines that there is no Axis II diagnosis (personality disorder),
and writes deferred for Axis III (medical conditions). He lists Axis IV
(psychosocial and environmental problems) as legal problems, housing,
employment and financial problems and determines that, on Axis V, her
current Global Assessment of Functioning score is 62 (some mild symptoms
but generally functioning pretty well).
At the end of the intake summary, Steven is supposed to record Disposition
and Initial Treatment Plan but this section is blank. This may be due to his
uncertainty about what Denises probation officer wants her to accomplish in
Throughout the intake summary, Steven describes Denise as a person with
certain characteristics that she has some control over (she has chosen to
continue to use in the face of probation, which has led to her moving into a
supervised status of probation and requiring treatment) or that developed
from her past (socially, she appears to be adequate, although her choice of
peers in the past has not been the most positive). He rarely employs what
Sacks (1972) calls a Management Categorization Device, where people are
described in terms of their membership in categories (e.g.: race, age,
gender, profession), while implying that the person described would share
all of the norms attributed to that category. Berkenkotter & Ravotas (1997)
state that therapists use this technique when developing a clinical picture
of a client in order to fit him or her into a diagnostic category. Steven does
frame her statements into diagnostic terms, but he does not directly label
her as an addict or substance abuser or probationer. He does not label
her family as dysfunctional. In this way, he avoids bringing into the clinical
picture all of the related concepts those labels imply. He does label Denise
as client (or patient), but, voluntarily or not, she is a member of that
category for as long as she continues in counseling.
The Second Session of Steven and Denise
Denise returned for an individual therapy session one week later. While
there are many interesting aspects of this session, not all are directly
relevant to the subject of this study. From the first minutes, this session is
different from the first. Denise had just arrived from a meeting with her
probation officer, in which he told her that he would require her to be in
therapy. The session starts with brief questions and answers, similar to the
intake session, but the focus is no longer on gathering data regarding
S: All right. How are things, how are things going?
D: Um, all right, [all right?] I was in a bad mood right after I saw Rudy.
S: How come?
D: Because you made a lot more recommendations than were
required from the start. Its just enough thats making me mad.
S: What are the recommendations that hes making?
D: Well, just, he just changes everything every time I come in there.
Now I have to, with every recommendation you make, 1 have to
follow, and that just adds into another load of crap.
Denise speaks more quickly and with greater intensity during this exchange
than she did during the intake session. She expresses her opinions and
feelings. Steven asks another question, and she begins a rapid, intense
replay of her conversation with Rudy:
S: Well, youve been, kind of, working through a lot of this stuff. What
do you think would be most helpful?
D: Nothing, right now, actually. [Do they...] Cause Ive been up, like,
you know what I mean, like, I just tried to explain to him right now,
you know, because, he was listening to me. Because I, you know,
um, he said that I have to follow whatever recommendations you
guys made. And then I said, well, what about me? I said, Do I have
an opinion? He said, Yeah. You have an opinion but you still have
to follow it. I said, So, you guys are telling me whats right for me, I
said, when its not you the one that has to do it. I said, right, I said,
you know nothing about me, I said, you know nothing about me
personally, but you want to make the recommendation. I said, then,
Im supposed to follow whatever you guys tell me to do. I said, but if
you guys are trying to help me, why should-- you know what I mean?
And Ive been to so many counseling that, why? You know what I
mean? Im pretty sure now its not going to help bringing up my past,
it's not going to help me at all anyways, now. Im at the point in my life
where, the past is past. Its not affecting me now because I dont even
care anymore, but whats facing me now is what Im doing now.
Steven asks one question before Denise continues with her rapid, intense
exposition about the roles of drugs and counseling in her life:
D: Just living life, day by day. Trying to--1 mean, thats about it. And
thats another question about the drugs, too, because he wanted me
to be in drug counseling, stuff like that, [urn hm] But I have a question
about that, too. So, if you go home tonight and you say you, you drink
one drink, [urn hm] Does that make you an alcoholic and should you
go to AA? [well] I understand that you could, if you admit its a
problem, or if its daily use or daily, you know what I mean, that its an
every day thing, that, of course, you have a problem. But if it happens
a couple times and thats that, what, urn, thats what I dont
D: And I, I definitely dont want to be in a group for drug use or
whatever, but-- Im pretty sure I dont want to know much about
drugs, [laughs] so-- you know what I mean? Thats why I got angry
S: So, you got angry with him, uh, today, and, and what kind of
D: I just started yelling. Hes used to it, though. He understands that I
get angry. When I get mad I refuse to do anything.
S: So you just kind of shut down?
D: Yeah. I refused to comply.
S: Ok, so stay with me, when you do that, then, how does that affect
your life, or does it?
D: No. It doesnt, really. Its my choice, so, do you know what I mean?
Everything in life is my choice. Thats how I want my life. If I want my
life to be lived in jail, then thats my choice. Do you know what I
mean? Like, this is why Ive never, OK, this is why Ive never liked
counselors or anything, not that I dont like you or anything, but, but
con-, counselors in general. Its because, like, say the first counselor
you see theyre gonna to tell you, Well, I, I suggest that you... You
know what I mean? And in all reality, you cant really suggest that
anybody do anything, if you havent lived it yourself, or been there
yourself. And, you can suggest, make all the suggestions in the
world, if you make suggestions for me to go rehab, you know, to be in
group, to be in class, you know what I mean? Classes. But theyre not
going to change me. I could go to them but the choices I make are
still the choices Im going to make. Not from what I hear, from what
Ive seen but from what I make, its still my choice, [urn hm] no matter
what. And, um, so I was just trying to tell Randy, I said, youd better
go ahead and put me wherever you want to, I said, but Im still going
to choose to do whatever I want to do. He said, well, he goes, if you
go to- cause I told him, I said, I, cause 1 dont want to do counseling.
I hate counseling. Obviously I do. You know, I dont like counselors.
Because, Ive never tookenyou know, I mean, no one really takes
the time enough to get to know you to help with your problems
anyways. You sit here and you listen to my problems, right, and you
give me advice to try to help me with my problems, but its still my
problem, you know what I mean? [laugh] [um hm] And its still going
to be my problem for the rest of my life and I, I, I, personally am a
person that does not get close enough to open up enough to let my
problems out and there aint nobody in the world that has enough
time to open up to my problems, so- thats my opinion.
S: Well, well, my purpose, and I hear what youre saying, what my
purpose is though, is to help you avoid consequences and to get
what you want.
D: Well see- you can help me as much as you want to but Im still
going to make my choices.
S: Exactly, you are.
D: So, whats, um, like- [laugh, pause]
S: The point of counseling is that hopefully, your counselors
somebody who you can trust to talk about your
D: Thats not true. Because counselors are in it for their jobs and they
listen to you and they help you. But theyre in it for their jobs. I mean,
they dont have to go home with you and deal with your problems
when you go home. They dont have to, do you know what I mean,
the next day, they dont have to see you if they dont want to, do you
know what I mean? They wake up with their own problems, do you
know what I mean? And, I dont know. Thats just how Ive always
thought. Its just, I dont know. Every person that I have actually
opened up to and taken time [um hm] to work out my problems with
has left. So, thats why I gave up all of that. And when I started, when
I first got on probation with my with my ankle monitor, I had with
Diana George. And we started, she was going to do my counseling
for me and my anger management, [um hm] And, when we started
getting close and everything, and she quit. So, you know what I
mean, its hard enough to get, I dont know and so I just, I dont worry
about my problems too much. They dont affect me today because
the choices I make today have nothing to do with my past. Its just,
right now, the choices I make right now. You can grow up with the
worst life in the world, you can grow up and be the richest in the world
because you want your life to be that way, right? You can grow up in
poverty and grow up and be the smartest, most intelligent person in
the world because you want it that way. I can grow up in a world of
drugs and grow up to be the healthiest person in the world cause you
want it that way. Or you can choose to do it the way they do it. Right?
S: Thats all true. It could happen. [D laughs] But what we know is
that most people live their life a lot in the past. In other words, the
mistakes that they made back here, if they dont really look at them
and do some work on them, theyll come back again. They find
themselves in the same situation.
Steven allows Denise to speak with few interruptions, encouraging her
occasionally with urn hm or other statements that do not try to redirect the
flow of her conversation. When she pauses, he responds with statements
designed to encourage her to rethink her understanding of the purpose and
practice of the therapeutic process. Throughout this session, many of
Denises statements are significantly longer than the longest statement she
made during the intake session (113 words). Within the first few minutes,
she speaks for 230,109, 291, and 331 word passages. The length of her
statements decreases somewhat after her initial burst, and the pace is a
little slower, but she continues to speak with some detail about her feelings
and opinions throughout the session.
Most of Stevens statements are shorter, generally fewer than twenty words.
There is a distinct therapeutic quality to much of what he says: he asks her
more pointed questions, often with qualifiers that soften the impact (So you
kind of, you say, took advantage of Candy?), brings the discussion back to
certain points after allowing her to express her feelings, and offers her
reformulations of her statements (Hak & de Boer, 1996) designed to get her
to think about her situation:
D: ...and it has nothing to do with counseling or talking or about it or
anything. Its how I feel, my personal feelings.
S: It is about how you feel, and it is about you. And really, if you view
it as a help to you to make these choices that are going to get you
where you want to be.
D: But what if I dont want the help?...
At one point in their discussion of probationary constraints, Steven brings up
the documentation of Denises case:
S: Right. But I was looking over your file ...
D: Yeah you see, thats my file. Thats not me.
S: Oh, Im sorry. But I was looking over your probationary thing and I
think it said that you needed to follow whatever rules...
Denise is very clear that she is not the sum of what is written about her.
The second session is generally when goals are set for therapy, and
documented on the Service Plan. Steven never brings up the subject of
goals or planning for therapy. The only time goals are mentioned, near the
end of the session, occurs during a discussion of Denises tendency to push
people away from her, and she brings them up:
D: And sometimes, if I get too close to people, I push them away.
Because Im afraid to get hurt. [Urn hm] I get to that certain extent
and when I get there, I push. [Yeah] But Ill, Ill keep working up to
that point. And when I work up to that point, thats done. Theyre
S: And then you get disappointed again.
D: And I disappoint myself.
S: You recognize that.
D: Yeah. I set myself up for failure every time.
S: You see that. All right, wellits a huge area.
D: Thats when Im, set myself-- goals? I set them higher than I could
accomplish so that at least I accomplish my regular goal. But I would-
S: But youd be disappointed that you didnt--
D: Not, not really. Cause, like, if I want to jump ten feet, or no say I
wanted to jump five feet. I set my goal for ten and at least I get seven.
And then I still get my five. Do you know what I mean? I go over my
original goal but I still get my regular goal. I go over because, 1,1 dont
S: You push those people away-- this is what [Im alone again] so
youre alone again. [Urn hm. I end up blowing it every time] Right.
Rudy is trying to hold onto you.
D: Uh-huh, so Im going to push him harder away.
S: And you try to let Rudy go.
Steven could use this as an opportunity to set goals for therapy, but he does
not. He never mentions the word, and pursues the therapeutic thread of the
conversation. Near the end of the session, he mentions, in an off-handed
manner: So, its not me going to be telling you what you can do. [ok] Its
going to be a lot of you telling me this is what I want for my life. And well
talk about, OK. How can we get that for your life. That make sense? You
covered tons of ground today. I just got to have you sign this little baby. Its
a treatment plan. Ill fill it out and what Ill fill it out for is that we will do
individual counseling, ok, until a time in which you and I and Rudy agree that
you dont need it. Does that make sense? [she nods her head] Alrighty.
Denise signs the blank Service Plan form, but, after several months it still
has not appeared in her chart.
Despite the assumption by the agency that Steven will co-create the Service
Plan with Denise, he marginalizes the document by leaving any mention of it
to the very end of the session, presenting it in an off-hand manner, and
asking her to sign a blank form with vague spoken explanation of what it will
contain. After that, he does not complete it and include it in her chart, even
though that is a deficiency in documentation that could reflect negatively on
Interview with Denise
Immediately after the second session, I showed Denise the intake summary
Steven had written about her and asked her what she thought of it. At that
time I was unaware of what they had discussed in the second session. She
laughed a little while reading and asked for explanation of a phrase, but
seemed most interested in what Steven had to say about her drug use.
J: If you dont mind, why dont you tell me what you think about, just
in general, after having read the intake?
D: I dont know. Somewhat true.
D: Uh huh. Not all.
D: Its not all. Its not. I dont know. Its, its me but its not me. Know
what I mean? Its not the real me. So its me but its not. Its hard to
explain, [yeah] Just, like, if someone who uses drugs once it doesnt
mean they have, urn, problems the rest of their life. Its not like theyre
headed onto addiction or anything cause you can do drugs as many
times as you want and still not be addicted.
J: OK. So, do you think theres things in there that, that are not you,
that shouldnt be in there or just...
D: Theres a lot more to my life.
J: OK. Theres more of you than whats in there.
D: Theres a lot to my life that half of those, youd realize that werent,
that couldnt happen or anything, you know what I mean?
D: Or, I dont know. Its a little hard to explain...
J: If you can give an example, that might help.
D: Urn. Like, theres, theres like that one right there, you know, I
mean, the one about that I need to be around it and see what people
lives and stuff and I grew up with it and Ive seen my mom and
everything so its not like I havent been exposed to seeing people
being addicted, [yeah] because Ive lived with it, so its not like Im
being exposed to it, seeing whats done to it. [OK] Like that.
J: OK. Yeah. If you were, say, you were going to put something else
into that, what would you put in?
D: Theres a lot thats not in there. Theres a lot about me and stuff.
J: Well, like what?
D: I dont know. I dont know. Theres a lot. [laugh] Theres a lot to my
life that that nobody knows.
J: OK. You dont have to tell me, either.
D: I know. I just dont want to talk about it, thats why.
J: OK. Thats fine. But it sounds like those are things that are
important to you.
D: Yeah. [OK] That explain a lot.
J: A lot about how you are and who you are? [yeah] OK. So those are
things you, you just dont really want to share with somebody just,
without getting to know them and all?
D: Yeah. [OK] Things that I dont share with anybody, [yeah] Its just,
J: OK. Then, it would be kinda hard for Steven to put those in a
report, wouldnt it?
D: Yeah, well. But sometimes reports make you sound different than
what you really are. [yeah] And, ah, I dont know, describe you
J: Yeah. Thats part of why Im asking you now because were looking
at this and yeah, I can look at it and say that looks like a well written
report but if I dont know you ..
D: If you read it, and didnt meet me first, theres a lot you could get
from it and a lot you could expect from it, youd think that I use drugs
and that I, you know what I mean, I wouldnt be able to be stable if I,
you know what I mean, that I was starting to fall for drugs, that I
wouldnt be able to pick myself up but [ok, pause] you know and now
its not who I really am.
J: OK. So, it sounds like you, from reading it, you feel it gives a
picture of a young woman thats started going down the track of~
[yeah] getting into drugs and wont be able to get yourself out. [yeah]
OK. It sounds like you also say that, thats not you. [yeah] OK.
D: Just because I tried em doesnt mean Im going to fall for them.
We discussed the restrictions placed on her by her probation officer and
recommendations made by Steven for individual therapy.
J:... is it important to you to have all these people to have a good idea
of who you are?
D: No. I dont really care. [OK] Honestly, I dont, like, if, like if you read
these reports and just based an idea about me in these reports [yeah]
and didnt want to, like if you didnt sit down right now and talk to me,
you know, and you just went off of these reports [yeah] that doesnt
bother me because thats your opinion about me. [OK] If someone
isnt going to take time to get to know me for me, then they aint worth
it to begin with... I like the part where he said Im intelligent, [both
laugh] [thats good] I like that part. I dont know. I just dont like to
hear about the drugs and stuff cause I know its a part of my life
where I messed up [urn hm] and I realize that.
Denise shows a clear distinction between who she is as a person and how
she is portrayed in the documentation. She is willing to endorse parts that
she likes, such as intelligence, and reject what she doesnt agree with, such
as current problems from her drug use. She also distinguishes among
aspects of what Steven wrote about her drug use, acknowledging that she
messed up in the past, but rejecting his opinion that it remains a problem in
the present. Overall, Denise expressed the belief that Steven had written an
accurate summary of the information she had given him, except that he
over-emphasized the importance of her drug use and there is important
information about her that he missed because she did not share it with him.
I also asked her about goal setting that I expected would have occurred in
the second session.
J: OK. Did you guys set some goals today?
D: No. I dont like goals. [OK] I dont like goals. Ive never set goals. I
used to set goals. [Yeah] But I set myself up for failure so I dont set
goals anymore. I tell myself Im gonna do it but I dont set goals. [OK]
J: Did you, did Steven talk with you about, about goals today? OK.
D: We talked a little bit about goals and I told him, cause I told him
how I am with goals and I dont, I dont do good with goals.
Her statements to me contradict what was said in her second session with
Steven. He did not ask her to set goals. She brought up the subject and
stated I set them higher than I could accomplish so that at least I
accomplish my regular goal. Despite that inconsistency, it seems that
neither Steven nor Denise felt it was important to structure goals on paper
during that session.
The Final Interview with Steven
After Steven read the transcript of my interview with Denise, I asked him
what comes to mind first? He believed Denise was pretty honest and
not rehearsed. He thought that it may have been kind of shocking to her
to read the words on the paper about herself, especially when some of those
words had some critical nature to it around the drugs and the alcohol.
J: So the words on the paper are different in some ways than the
S: Oh, yeah, without any question. Often times with the written word,
theres no context. It is what it is. And sometimes in communication,
your voice can portray a context that either creates a more serious or
less serious situation. And I think when its read, the context, to a
degree, is lost. And so I think that part may have been kind of difficult
J: OK. Are there advantages to being able to read it in writing as
opposed to just hearing it?
S: For the client?
J: Yeah. Looking at it from her perspective.
S: I, you know, I think it really draws out how really strong context,
that therapists, ah, clients dont generally read their stuff. Its really
rare that a client will read their intake, or their material. But I think it
lends us to really being more strength-based in our approach with
clients in the written word, which would carry over into the verbal
word and the relationship. I think we tend to be really problem-
focused most of the time, with clients. We tend to focus in on what
the problem is and talk about, discuss the problem as opposed to
bring out what the strengths of a client are... I think that much of the
focus, often times, of the treatment tends to get lost in the problem.
And we tend to be problem-focused. I think that we need to, probably,
draw more on the strengths. But we have to identify, as part of the
record, why were seeing them, what the problems are and where
their past failures have been. And those are hard to read no matter
who you are, to look back and say, failed here. Failed here. Lost,
broken relationships, those kinds of things. Those are hard to digest
and yet, for other professionals, they are critical if you are going to
transfer the chart or someone else is going to see this person. They
need a full picture of whats going on there.
J: OK. But, presumably, it would be good for the professional, also, to
see the strengths.
S: Oh, no question, no question. And, because otherwise it just
becomes, sort of this diatribe of issues in the persons life that either
havent been resolved or theres been failures and sometimes theres
not a focusing on whats real positive, what could be helpful.
For Steven, much of the distinction between what is spoken and what is
written in the therapeutic relationship relates to context: the spoken word
conveys contextual information that is lost in writing. Those contextual clues
can give the listener a better understanding of the seriousness of a problem.
Steven did not discuss how a therapist-writer might bring more of the
contextual information into the documentation in order to provide the reader
with similar tools for assessing the situation.
Steven thinks that asking the client to read her intake would cause the
therapist to focus more on strengths, to conceptualize the situation in terms
of client strengths, which would be helpful for therapeutic change. He
believes that strengths alone are not sufficient, however; the therapist must
state the problem as well, to create a full picture of the client.
I asked Steven what changes he might make, if any, in light of his
experience with this study.
I think that, probably, one of the changes that Ill really look at making
is developing more of a rapport--1 know that may sound odd. But
often times, theres a real, I dont know if fears the right word,
apprehension on the part of clients to be real communicative about
their lives and whats going on. And, certainly in this case, Denise has
been through the ringer of social services, foster care, judicial. And I
think that my taking a fairly neutral to positive approach toward her
has been beneficial for us to get this far. Any negativity that she
would sense would throw up red flags and shed probably bolt from
the office, so I think that part has been good. And I think, throughout
the course of this is a matter of continuing to have time with her so
that she feels comfortable in expressing, as she says, what the rest of
her is that she doesnt let anybody know.
Steven believes that developing more of a therapeutic rapport with the client
will foster a sense of trust that will lead to greater comfort in sharing
personal information. Without that, much of the important information about
the client will remain a mystery to the therapist.
In Stevens therapeutic style, context is important as a tool for examining
patterns in the clients life. He addresses the dynamic tension between
information gathering and developing a therapeutic relationship.
S: I tend to run intake sessions an hour, do the opening paperwork,
dictate the report and done in two. The reality is, probably would be a
lot more helpful to do an hour and a half intake and be able at those
points, to really move, step into that therapeutic relationship. The
difficulty is, you really have to strike the balance, as you know,
because you can fall off the end of the world and be in this
therapeutic relationship and have gathered zero information. And
youre going to go write your intake and youve got nothing to do it
with. So, you really have to strike a balance and let them know this is
going to be an overview session... It probably wouldnt be a bad idea
to say, you know, This is going to be an overall session about what
your life has been. And our sessions after this will be more specific.
And I think, just strategically, for many of these folks who come here,
they have family histories that fill a file cabinet and Im not sure that
theyre real conscious of how their interactions have impacted their
relationships. And, so, they sort of just lump it all together and move
on without giving it any focus or any kind of-- looking back and trying
to say, yeah, I could have done some things differently in that area.
J: OK. So, the intake process of gathering information could be a way
of gathering information also for them? [sure] And structuring it?
[Absolutely, absolutely] OK. [It very much could be]
One purpose of the intake process can be to gather information, then help
structure it for the client in a manner that shows the patterns from the past
as they impact the clients current life.
Steven addressed the concept of rapport and trust again when discussing
the lack of goals set during his second session with Denise.
S: I think that one of the big things that I picked up is, sort of between
the lines with what she said and knowing the case is that, she doesnt
trust people or situations much at all, mostly because of the damage
that shes had in the past. And, so, itll be a slow go for her to begin to
trust people, to set goals, and to be able to carry those out. But I think
that we need to start in a smaller scale of goal setting, even if its,
primary goals that you will attend the session next week. And when
she does, do a lot of praise for that... I think that any time human
beings arent given choice or given input into the process, we tend to
get hostile, passive-aggressive about it.
Goal setting in this agency is intended to be a collaborative process, with the
client making choices regarding goals and the therapist helping to shape
them into therapeutic tools. While working with Denise, however, Steven
asserts that he chose to delay the use of the Service Plan form in order to
foster her sense of control within the therapeutic relationship.
At one point in the interview, Steven addresses the issue of motivation.