Mental health conversation record sheet

The "Mental Health Conversation Record Form" is essentially a personalized practical tool in psychological counseling scenarios, rather than a standardized assessment ledger. There is no optimal template that is common to the entire industry. Its core function is to anchor emotional clues, retain traces of intervention, and support subsequent program adjustments. The use logic needs to be flexibly adjusted to the service scenario, consultation genre, and case characteristics.

I felt particularly deeply about this when I helped organize and archive case data at a university psychological counseling center two years ago. At that time, there was a full-time counselor who had just joined the job. At first, he used the standard form issued by the school. Each column was filled in neatly: self-evaluation of mood was 3 points, poor sleep quality, and social avoidance. It seemed that there was no mistake. Until a sophomore girl came to consult for the second time. After sitting for a long time, she finally said: "Last time when you lowered your head to write something, I always felt that you were labeling me, and I didn't dare to say a lot of things. ”Later, the consultant secretly added a half-page blank column to his record sheet, titled "Unspoken Details." During that consultation, he wrote half a line in this column: "I tightened my sweatshirt 12 times, dug my nails into my palms when I mentioned the rumors about the campus wall, and said 'I didn't do it.' When I said 'I didn't do it,' my voice shook so much that I could barely hear it. ”Don't tell me, with such a small change, the subsequent consultation progressed extremely smoothly.

Speaking of differences in templates, the difference between the record sheets of consultants from different schools may be greater than the final exam papers for liberal arts and science. If you look at the record sheet of a psychoanalytic counselor, you will most likely see a bunch of fragmentary records without beginning or end: "When the class teacher was mentioned, there was a sudden silence for 17 seconds, and the fingers were wrapped around the ends of the hair three times." "The conversation about final exams suddenly jumped to say that the stray cat downstairs was hit by a car last week." There is not even a place to score. But if you are a CBT (Cognitive Behavioral Therapy)-oriented counselor, there must be fixed sections on the chart to record automatic thinking, distorted cognitive types, homework completion, and the emotional score of each consultation is clearly listed. There are also counselors who do family therapy. They will even draw a relationship map of family members on the record sheet. Whoever sits far away from whom or who is always interrupted by another person when talking will be marked on it.

As for whether records should be detailed or coarse, the industry has been arguing for many years and there is no conclusion. Some people think that the simpler the record, the better. During the consultation, you can only write three keywords at most, and add the rest after you finish. Otherwise, if you lower your head and write, the visitor will not dare to say the private things he originally planned to talk about when he sees your pen tip moving. Some people firmly objected, saying that it is easy for novice consultants to miss information. If you didn't take down a few more things at the time, and then turned around and forgot the core clues mentioned by the visitor, you would be blinded by the review later? I once heard an example from a supervisor that left a deep impression on me: a counselor gave a client 8 consultations. Each time, he felt that the conversation was not on point, and his mood improved very slowly. I looked through the first consultation record and saw that I casually wrote "My mother remarried and had a younger brother when I was in elementary school." However, I didn't follow up on this clue at all the next 7 times. If I had marked more stars when recording, I wouldn't have taken such a long detour.

In addition to genres, the record sheets for different scenes also vary greatly. The school's psychological consultation record form must include a risk assessment linkage item. If the visitor mentions a tendency to self-harm, it must be immediately marked whether to contact counselors and parents to go through the crisis intervention process. However, the corporate EAP record sheet must not contain identifiable information such as department or workstation, and even the visitor's position must be blurred. After all, everyone is afraid that their colleagues and leaders will know that they are seeking psychological counseling. I previously adjusted the record sheet for a friend's EAP project, and deliberately changed "work-related worries" to "recent worries" because I was afraid that people would be wary when they saw the word "work."

While talking about this, I have to mention the pitfall that many novices often fall into: don’t forget to consult yourself just to fill in the form. Don't laugh. In order to fill out the form beautifully, some counselors actually guide the client to say what they have preset, completely forgetting that the consultation is following the client. I have seen a particularly "perfect" record form before. Every item meets the assessment requirements, and even the words spoken by the visitor are written like a sample essay. But if you look through the entire form, you can't see the living person at all, and you can't even find any trace of emotional fluctuations. No matter how standardized this form is, it's useless.

Let me talk about two small details that I have summarized after going through pitfalls. They are all practical experiences that can be exchanged for real money. The first is to avoid using silly terminology when writing. Your writing of "picking the strap of your schoolbag three times" is 10 times more useful than "having non-verbal expressions of anxiety". After all, the recording sheet is for you to read, not for reviewers. The second is that risk-related content must be marked separately and not buried in a pile of text. For example, if a visitor says, "I saved half a bottle of sleeping pills last week," you can just circle it with a red pen. You can see it when you turn it over next time and there will be no leakage. Also, don’t be too troublesome. Records must be kept in accordance with ethical requirements, locked in special filing cabinets, and electronic files are encrypted. They should be kept for at least 5 years after the case is completed and destroyed upon expiration. Don’t keep them and post them around as some “successful cases.” Secrecy is the bottom line, right?

In the final analysis, no matter how you modify the recording form, the core purpose is to help you see the real person sitting across from you. If you forget this original intention, it will be useless no matter how perfect the form is.