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veggybutcher

Psychotherapy case - How to write it up

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Hi,

Does anyone know how to write up their psychotherapy cases? Is there a well known format to accomplish this? If not can some genius suggest one? I need to write up long cases, short cases and couple therapy.

Thanks in advance

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Are you referring to the notes to be written directly after each session, or on completion of all sessions?

I have only done one case, but my understanding is that after each session it's pretty much the content of that session, which may include your counter-transference feelings.

On completion of all sessions for my psychotherapy case, what I did was write up a psychodynamic formulation, with the presenting problems, the predisposing, precipitating and perpetuating factors, a summary of the themes explored during the sessions, what the patient felt they had achieved from the sessions and my objective assessment. +/- further recommendations.

Justme    

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I was asking about writing up on completion of a case. ie for a long case of 35 sessions.

thanks to anyone offering more on this topic.

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from my experience what i did was to write a summary after each session and attach the clients homework, and after the sessions had ended , i wrote a summary of d progress attained and also included the views of the benefit the client said got from the therapy sessions

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I guess it mainly depends on local practise. Its worth getting hold of a few from your predecessors or colleagues -i'm sure your supervisor may be able to help.

Aside from that then then a general summary of the case/therapy is the most important thing. Usually the leter to the GP is quite cursory; 1-3 paras on what happend, learnt, attendance, ending, brief formulation and recommendations for the future. The longer one (if necessary) is more for the notes/departmental record and usually depends upon the modality. e.g. CBT record of sessions (how many, general theme to them, eg of successful homework or something they couldnt do/found difficult), disease status at the start and end of therapy and further recommendation for therapy, etc.

so about wot justme says!! ;)

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