Brown, H., 2010. Confidentiality and Good Record Keeping in CAT Therapy - A Discussion Paper. Reformulation, Summer, pp.10-12.
This short discussion paper has been drawn up to inform debate amongst ACAT members about current practice in recording. CAT is currently practised in a wide range of settings within and outwith the NHS. Recording and storage of information varies significantly across these settings and is subject to specific policies in NHS trusts and voluntary organisations.
Therapy is usually understood to be a confidential process, and confidentiality is an important part of the contract between therapist and patient. There are exceptions already written in to professional and agency policies, including the over-riding obligation to report concerns about the abuse of children or vulnerable adults, but outside of these circumstances the person would normally expect details of their life and inner world to be protected and not be subject to discussion with other professionals or agencies.
This is the case in relation to all treatment modalities, but CAT raises particular issues that may need to be negotiated separately within these broad policy statements because of the range of material co-produced between the therapist and the patient as the therapy proceeds. This will include a reformulation letter written by the therapist to the person between sessions 4-6 and an SDR that draws out the person’s reciprocal roles and the main procedures that flow from them that is usually constructed jointly with the patient during the sessions. The collaborative nature of this material means that much of the record of a CAT therapy would consist of documents written to, rather than about, the client and that subsidiary material is often written by the client as homework, or in the form of creative work, no-send letters, drawings, diaries or representations of their inner dialogue. The patient may also use rating sheets, or design their own ways of monitoring changes in their patterns of thinking, feeling or acting as they come to recognise and revise these patterns.
Hence material that could potentially be placed on the patient’s confidential file may include:
Most Trusts require that all written information pertaining to a patient is placed on the person’s record,- with some variation as to whether this is kept in an electronic or paper format. There are good reasons for this sharing and storing of information in that it facilitates the support that is often provided to our patients by other professionals, and provides useful background information for any future interventions. Why then is this a problem for CAT therapists in particular?
It can be seen that these documents do not fit neatly into the terms of most Trust’s policies and procedures, creating a need for specific addendums to Trust policy in relation to the material generated during a CAT therapy. Unless there are compelling reasons to the contrary, ACAT proposes that material should be treated differently depending on its authorship and addressees.
Base line and outcome measures should be kept on the record and the patient should be asked to give their informed consent for this as a part of their induction process before attending therapy. Where additional measures or documentation, including video or audio tapes, are produced as part of a clinical trial or research programme, written permission is needed in advance of the therapy. The patient’s inclusion in any research cohort should be made explicit and subject to their informed consent in writing as set out by the ethics committee overseeing the research project. If, during the therapy, the research goals seem to clash with the therapeutic goals, the latter should take precedence.
Safety over-rides confidentiality in forensic settings and CAT practitioners in secure services should proceed on the basis that all records are kept on the file in these settings. The patient should be informed of this at the outset.
The reformulation letter belongs to the patient and this should normally take precedence over any other considerations. Therefore if they do not wish it to go on the file they should be allowed to retain it.
However if they have objections they could, if the therapist thinks there are good reasons, be asked if there are parts of the letter that can be put on the file and advise the therapist as to which sections of the letter they would want to see removed. A revised, abbreviated version of the letter could then be agreed with the patient. The therapist can note on this letter that the patient was given a fuller version but declined for it to become part of the file. This discussion may take place alongside a broader discussion about the boundaries of the therapy: it is not unusual for patients to discuss whether they should share their reformulation letter, or aspects of it, with partners, parents, friends or other professionals and to take this decision for themselves as part of their responsibility within the therapy.
If they are not willing for the letter (which is their property) to go on file, the therapist should inform them that a brief statement of the TPP’s will be put on file in its place.
The SDR should also become part of the file unless the patient objects in which case a written note about the diagram, the principle reciprocal roles and procedures should be added to the clinical notes.
Although this process of checking out and negotiating may seem cumbersome, it underscores the collaborative nature of the therapeutic process within CAT and should only be over-ridden in exceptional circumstances, ie in forensic settings and/or when a person lacks capacity (see below) to make the decision on their own behalf in which case the therapist should make the decision in the patient’s best interests and record this on their file. The form of words should be something like this:
The patient did not give their permission for this document to be included as part of the record of the therapy but since they were deemed to lack capacity to make this decision at the time, it is the view of the therapist that it was in the best interests of the patient for it to be included on the file. The document has therefore been added to the record by the therapist acting in the patient’s best interests as stated in the Mental Capacity Act 2005.
This statement should be signed and dated by the therapist
Patients with learning disabilities, acquired brain injury, significant mental health problems or dementias, should usually be treated in the same way as other patients unless there are grounds to believe that they lack capacity to make the decision about what records should go on file, in which case the practitioner should make a “best-interests” decision on their behalf. The therapist should weigh up the benefit of including all material on the file, against any disadvantages that this might incur. The therapist should then manage any potential for distrust within the therapeutic alliance that might occur as a result of over-ruling the patient’s wishes. The therapist should make every effort to make it possible for the person to make the decision with assistance, by providing information in an accessible format and manner. A person lacks capacity if it is the view of the decision-maker that they are unable to understand, retain and use the relevant information to make the decision, including weighing up the advantages and disadvantages of each course of action, or of taking no action. Usually in cases where a person lacks capacity to make such a decision for themselves, it will be in their best interests for the details of the therapy to be included on their file so that others can assist them in managing their lives in full knowledge of the facts and of their ways of managing their feelings and relationships.
People with serious mental health issues, whether of an acute, cyclical or enduring, nature, may also lack capacity to make decisions about putting confidential material on their records, by or for themselves. They are also subject to the best interests decision-making process set out in the Mental Capacity Act 2005 but in the event that their condition improves to the point where they later have capacity they may choose to review the documents on record with the therapist and /or to make changes to the documents held on their file.
Patients with learning disabilities, are often deprived of opportunities to create boundaries around their personal space or emotional experiences because information is routinely shared with other professionals and with their informal carers without their permission. They may benefit from producing an account of the therapy, perhaps in the form of an alternative “goodbye letter” produced jointly with the therapist, for their carers or care staff. This should set out the facts that they want to share, while keeping those that they prefer to keep private to themselves. This models good boundary setting for them and for care staff who interact with them on a daily basis. However if they lack capacity to manage this process, the therapist should make a best interests decision on their behalf about what it is helpful to share from the therapy.
Practitioners working in private practice should adhere to the same principles but should also produce a short statement they give to their patients as part of their initial consultation and induction prior to starting therapy setting out briefly what their arrangements are for
Hilary Brown is Professor of Social Care at Canterbury Christ Church University where she specializes in safeguarding vulnerable adults. She also works as a CAT therapist and supervisor one day a week at the Sussex Partnership NHS Trust where she is helping to set up a psychotherapy service for people with learning disabilities and she has a small private practice.
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