Yes, therapists often make detailed and objective notes during therapy sessions to document the client's progress, behaviors, emotions, and other relevant information. These notes are an essential part of the therapeutic process and are typically kept confidential and securely stored.
If a client exhibits certain behaviors during a session, such as rubbing their arm a lot while discussing a traumatic story, it is common for therapists to make note of such observations. These notes serve several purposes:
Objective documentation: By recording the client's behaviors, the therapist ensures that they have an accurate account of what occurred during the session. This information can be useful when assessing progress over time or when considering potential treatment interventions.
Tracking patterns: Noting specific behaviors or body language can help therapists identify patterns or triggers that the client may not be explicitly verbalizing. For example, consistent arm-rubbing during discussions of trauma may indicate discomfort or distress related to that particular topic.
Informing treatment planning: Therapists use these observations to tailor their approach to meet the client's needs effectively. If a certain behavior indicates distress or a need for additional support, the therapist may explore coping strategies or adjust the therapeutic techniques used.
Providing evidence-based care: Detailed notes can be essential for demonstrating that the therapist is providing evidence-based and client-centered care. It can also be valuable if a therapist needs to consult with colleagues or supervisors about the treatment.
Legal and ethical purposes: Thorough documentation is essential for maintaining ethical standards and may also be necessary in legal or insurance-related situations.
It is important to note that therapists are trained to maintain a non-judgmental and empathetic stance towards their clients. The purpose of documenting observations like arm-rubbing is not to label or judge the client but to better understand their experience and provide appropriate support.
Additionally, therapists are bound by confidentiality and privacy laws, and their notes are typically kept secure and shared only when necessary for the client's care or as required by law. Clients have the right to access their therapy records in many jurisdictions, but this can vary depending on local laws and regulations.