I spent almost 10 years as a lecturer at the FBI National Academy in Quantico, Virginia. The very best of the best from every possible area of forensic science were clustered together in the behavioral science unit deep underground on sublevel two.
I learned a lot from my colleagues in those years, but the most memorable thing I heard while I was there was this: “Agents will get themselves in far more trouble with their pens than they will with their guns.”
Written documentation lasts forever, and poorly written documentation can cost you your job. Most agents never have to take their guns out of their holsters through most of their careers, but every one of them will write hundreds of pages of reports over the course of 25 or 30 years. That is a very long paper trail, and it provides plenty of opportunities to do it wrong.
The counseling profession is much the same. I like to believe that most of us will never get in trouble for egregious ethical violations — the equivalent of an unauthorized shooting in law enforcement. But all of us will, like my FBI friends, write hundreds of pages of reports over the course of our careers.
We will file insurance documentation, create case notes, develop treatment plans, and perhaps write excuse notes to employers, teachers, colleges and other important people in the lives of our clients. Some of us will provide written statements to the court, child protective services, and other government agencies.
Most of our documents will never be seen by anyone other than us, our staffs, and perhaps insurance company employees. But sometimes, others will see our written work.
Once when I was consulting with a business, the company employee assistance program representative had required an employee to seek a mental health evaluation to ensure the employee was not a risk to self or others at the worksite. The written report from the psychologist was more than two pages long and full of opinion and subjective commentary about the client. But the worst part was the first sentence: “I declare that the employee is sane.”
Sanity is a legal term, not a mental health term. If the case involving this employee had gone to court and the psychologist had been questioned on the stand, the first thing a lawyer would have done would be to drop the Diagnostic and Statistical Manual of Mental Disorders on the bench and ask the psychologist to flip to the page where “sane” shows up. It isn’t there. The psychologist would have, at the very least, looked incompetent.
Likewise, to declare someone “sane,” ethically one must have training and expertise in competency evaluations. Because this psychologist apparently didn’t know the meaning of the word, I suspect she did not possess the requisite training. A single word on a more than two-page letter could have created major troubles for this psychologist with the ethics committee of her licensing board.
It’s likely this psychologist had never written such a letter before and didn’t think to run it by a colleague before sending it. That was risky. An otherwise (what I can assume to be) stellar career could have been derailed by the pen.
With this in mind, I propose five simple rules for counseling professionals:
Rule 1: If you don’t have to write it down, don’t. The letter from the psychologist could easily have been limited to one sentence: “I do not find this client to be a risk to self or others.” That was the mandate and all that the company wanted to know.
Rule 2: Be objective. What do you see or hear that is clear, pertinent to the case, and that another therapist sitting in the room would also see? Avoid adjectives and modifiers. The psychologist wanted to help her client, but her personal feelings about the client were irrelevant in that situation. Another therapist in the room might have had different feelings.
Rule 3: Use professional and clinical language carefully. “Sane”? Really? If you haven’t diagnosed depression, for example, don’t say that a client is “depressed.”
Rule 4: Assume someone else — a judge, a jury, a licensure board member, an attorney — might someday see what you have written. Don’t write anything that you would be ashamed or embarrassed for someone else to see.
Rule 5: If you don’t have one already, find a mentor who can help you polish the writing part of your career.
I was trained as a person-centered counselor and, consequently, kept very few case notes. Looking back, I’m embarrassed at what I produced in those days when I was beginning to learn the art of writings things like progress notes. Today things are much different, and I’m hopeful this word of caution will help you get there quicker than I did.