the therapist’s notepad

Every therapist has a notepad within reach, just in case. The very first session, when someone is emptying out the whole giant suitcase of their life, tons of stuff tumbles out. You have to write a lot of notes that session because otherwise it’s a huge pile of underwear, torn sweaters, and unpaired socks, and nothing in the pile is familiar to you yet. If you don’t write it all down that first session, you run the risk of having to ask the next time they come in, “Sorry – which parent did you say died last year?” That’s just terrible form.

Before you see the person a second time, you carefully study the notes you took, like a new song that you’re going to be expected to sing from memory, a cappella, at 10:00 that morning. Usually I do this over breakfast: “Okay, she has a new puppy, regrets it. Her husband is away a lot, and what was she thinking getting a puppy. Oh, right — she’s the one whose sister is being a jerk. Dad not well. Mom died last year.” It takes me a couple of sessions to completely separate out this new person from that new person, too. If you have a few brand new clients, you quiz yourself a little bit as you heat the water for tea: Is Michelle the one with the passel of little kids, or is she the one with twin teenaged boys?

As soon as possible after that first session, you write down all the details you can remember, filling in the gaps from your scrawled notes. Otherwise, I’m sorry to say, a lot of it evaporates. You may be able to have lunch before doing “intake” notes, but whatever you do, don’t go to bed for the night before you’ve done them. By the morning, you will just have remembered that you saw a new person and they seemed to be nice, but a little sad. Or was it anxious? You remember they talked about…something, and it was a really poignant and meaningful conversation, but everything else is lost.

After the first session or two, though, you don’t use the notepad much at all, unless you’re That Kind of Therapist. Once you know the client, their narrative has a place of its own, and you recognize the items in the pile as belonging to Michelle or Luana or Bob, so you can put it all in their respective newly-built cubbies. The notes you keep help put each cubby together, but the notes are a tool, not the cubby itself. The cubby is in your mind. Are you building one now for all this?

I do reach for the notepad when a client tells me they’ve changed their medication, because I’m pretty sure that’s what you’re supposed to do. In case all heck somehow breaks loose, I am supposed to have known about their medication. While I’m writing I have a thoughtful expression on my face that says, “Ah. Yes. 25 magillagrams of PerqMeUp®. That’s a sensible amount.” Some of the drugs I’ve never heard of – they continually come out with new models of various meds, and they all have model-ly names, like Lexus and Impreza. That night you have to google these things to figure out if the new model is known for its turbo drive, as you’d find in most anti-depressants, or emphasizes its brake system, as with anti-anxiety meds and, er, related car models. Maybe I am getting too technical here.

I also keep the notepad close by so I can draw some of my favorite diagrams when the moment is right. It’s more compelling to draw it fresh for each client, so you do. You want to give the client a feeling of “this only applies to you in your special circumstances at this special junction in your life, so I have drawn it for you because it just leapt to my mind while I was listening deeply to you.” It would be easier to say, “Turn to page 2” in my 5-page book called Diagrams That I Tend to Refer to. But it’s so much more real when we take a moment to watch the therapist try to write legibly around a circle with arrows showing continuous motion.

The client file, where you keep all your notes as time goes by, is supposed to be so you can track “client progress,” but the main function for me is to keep track of what we’ve talked about, largely so I don’t ask any of the same questions or use the same clever analogies again. I have a couple of client files where I have made a note to myself: “Do not use the kite analogy again! You’ve used it twice!” Also, with good notes I can remember to say, “How did your son’s science fair project come out?” and seem like I have both a mind like a steel trap and a heart like a loving parent.

When I hear something that I want to write down for other reasons, I need to wait until they’ve said something for which I can legitimately pick up the notepad. The client says: “We were watching Curb Your Enthusiasm – oh, my god, that show is so funny – and my mom called to say my dad had collapsed.” I am concerned, of course, and listen carefully for what came next — how her dad is, how distressed she or anyone in her life might have been. But I’m also holding in my mind the name Curb Your Enthusiasm. want to get it out of my mind, but I have to put it someplace first. Laura and I are in the market for a good comedy, and maybe this would fit the bill. When the client says, “So I guess as heart attacks go, it was fairly mild, but it was really scary,” I say with sincerity, “It must have been,” and I reach for the notebook and write “Dad  ❤ .” Next to it I write “Crb Enth.”

Then there are things that clients say that just must be recorded. You can’t widen your eyes too visibly – they teach you how to control this reflex in grad school, but it takes practice. The notepad is useful here—it provides kind of a written widening of the eyes or raising of the eyebrows. When a client recently said, “Last week, my sister literally threw me under a bus,” for example, I was able to maintain my composure and say, with warmth and concern, “How so? What happened?” But I was distracted until I could finally get the notepad — I had to wait until she said something that seemed worthy of the notepad — and jotted down “literal bus.”

The same goes for the person who said, “Some ice creams are 100% air.” This side comment was wedged, like a poppy seed between two molars, into a story about her son’s struggles and a spreading depression in the family. The notebook says “Son ADHD — fam sad — ice crm 100% air.”

You can see and, I hope, empathize with the fact that concentrating on the client’s narrative takes some extra energy when you are stopped short both by, say, an image of her being thrown under a bus, as well as the burning desire to tell someone, probably your stickler-for-correct-language daughter, about this gem. Here, if I could, I would draw a diagram of how this works psychologically, this visibly patting your head while surreptitiously rubbing your stomach. It’s not easy, and I wouldn’t suggest trying it at home. You need a license to do this work.

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