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Confidentiality and Good Record Keeping in CAT Therapy - A Discussion Paper

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:

A clinical assessment
Results of various diagnostic, screening and assessment measures
A reformulation letter, written to the patient that may include powerfully personal material about the person’s life and issues, or include their amendments and additions, together with Target Problem Procedures
An SDR (Sequential Diagramatic Reformulation) that may have been drawn by the therapist, the patient or both during the course of the therapy
“No send” letters written by the patient, designed to make explicit the internal dialogue between the patient and key figures in their past or current life
Further diagrams or pictorial representations of traps, dilemmas and snags as these recur in the person’s current relationships and circumstances
Rating sheets to show the extent to which the person can now recognise and revise their identified Target Problem Procedures
Outcome measures using independent scales or instruments
Good-bye letters written to the patient from the therapist and vice versa.

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?

CAT is a collaborative therapy, breaches in this confidentiality, without the person’s explicit consent would seem to undermine the equality which is the basis of the therapeutic relationship.
The reformulation letter is not an “official” letter or diagnostic statement. It will be framed in language that echoes that used by the patient to tell their own story, and /or expressed in terms that are accessible to them.
The reformulation letter will often include specific, but often unverifiable material about third parties: and, since it is written to reflect the patient’s own story, it may include inaccuracies, exaggerations or blind spots, breaks in the narrative or contested facts and feelings that are not usually part of an objective clinical record.
The reformulation letter is written by the therapist to the patient and is strictly speaking therefore their letter and not part of the Trust’s official paperwork.
No send letters are written by the patient as part of the imaginal work that patients do to make explicit the internal dialogue that dominates their thinking: refuting this dialogue may involve verbally violent, angry or even abusive comments made possible by the “no-send” stipulation that creates a boundary. These letters may be censored if the patient is aware that they will become part of his or her record.

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.

Material that is written by the therapist about the patient should be placed on file routinely
All clinical material including letters or reports, such as assessment, referral information or recommendations for further treatment during or subsequent to the therapy, that are written by the therapist for others in the professional network, and visa versa should be placed on the person’s file
Material that is written by the therapist but addressed to the patient as part of the therapy, this would include the reformulation and goodbye letters and the diagram, could be placed on the file subject to the patient’s consent and right of amendment (see below): if the patient objects their decision must stand unless they lack capacity to make this decision, and/or are being cared for within a secure or forensic setting (see below)
Material that is written by the patient as part of the therapy, could be placed on the file but only if it is addressed to the therapist
Material that is written by the patient as part of the therapy, but addressed to a person or persons who are not part of the professional network, (this would include no-send letters, drawings, diaries and so on), should remain their personal property. This supplementary material may be held by the therapist for the duration of the therapy but should be returned to the patient at the end of the sessions and/or shredded within an agreed timescale
Process notes are written by the therapist, for their own use, they act as an aide-memoire for the therapist and inform their interventions as they proceed with the therapy, and evidence their own professional practice: these should not go on the file. The patient should not have a right to see the therapist’s process notes.
Supervision notes do not identify clients and these are also process notes that should not become part of the record
Details of the patient’s attendance should be recorded by the therapist as part of the electronic record of the Trust
During the therapy the therapist may exceptionally write to other professionals or agencies as a result of concerns about risk to the patient or to others, including safeguarding issues regarding children or vulnerable adults. These letters will usually be written with, but exceptionally without, the patient’s knowledge and consent. These documents are the property of the therapist and the agency and should be appended to the file.

Additional Considerations and Special Cases

Research

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.

Forensic and Other Secure Settings

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.

Negotiating Whether the Reformulation Letter Goes on the File

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

Best Interests Decision-Making

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.

Making a Best Interests Decision to Share Information with Others

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.

Working in Private Practice

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

Keeping patients’ contact details and personal information securely and separately from notes and documents generated during the therapy
Managing issues of confidentiality within their own networks
Keeping process notes for a given length of time after the therapy concludes
Shredding all notes and personal information within one year of the end of a therapy
Filing computer generated documents in a format that is not identifiable to the individual patient
Exceptional circumstances in which the therapist would refer to the person’s GP or other health and social services professional namely when the therapist is concerned about risk to the patient or to others and/or needs to report concerns about safeguarding children or vulnerable adults.

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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Full Reference

Brown, H., 2010. Confidentiality and Good Record Keeping in CAT Therapy - A Discussion Paper. Reformulation, Summer, pp.10-12.

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