Monday, July 7, 2014

Therapist Notes Disclosure Online

There is a well-known, unbroken rule in psychotherapy which mandates that therapy notes are never shared with the patient if there is any indication they may cause harm or if, for whatever reason, it would be counterproductive. Understandably, if notes were going to undermine the therapeutic relationship, the therapist would not want to share them, but things aren't always what they seem, even in therapy notes.

For one thing, assuming that therapy notes are somehow truly revealing of the patient may not be a good hunch. Not everyone tells the truth in therapy because they may have been forced into therapy, they really don't want to reveal much of their turmoil and, let's not forget this one, the therapist may be limited in their ability to zero in on what's truly going on. Then, of course, there's always the matter of disclosure relative to legal issues, will the notes be brought into a court action, how would they be misread, etc. In fact, it's not unusual for therapists to keep two sets of notes. Yes, two sets of notes. One set is for the insurance company and one for the therapist's own use.

A brave new experiment is now taking place in a Boston hospital's group therapy sessions. Seven hundred patients, not an insignificant number mind you, will now have access via either computer or smartphone to their therapist's notes on their sessions. Is this a good thing? I wonder. If a therapist knows the patients will be able to read the notes, might they not be skewed in some way?

Guidelines issued for psychologists provide information about notes, where they must be kept, to whom they may be released and how to best guard the privacy of the patient. The guidelines cover a lot of territory, but the bottom line is attention to protection of clients and psychologist as well. Yes, notes may be released under appropriate circumstances or a summary of notes may be given to them.

Undoubtedly, this is an interesting step relative to therapy and how patients being informed might have some effect on the entire process. Of course I am concerned about the entire thing; the oversight, what IRB (institutional review board) permitted it, what questions they hope to answer with the data they will develop, how will they develop the data and how will they know that all-important answer to the question of whether patients will tell the truth about how they felt it affected them.

The initial idea for more disclosure of therapist notes came from a variety of sources, but one doc noted that the current experiment in Boston grew out of interest and value found in another program for physicians.  Literally thousands of medical patients now have access to their records and other groups are earnestly investigating the costs and benefits. Of course, one of the "costs" may be that notes regarding how protected the notes on a computer may be. We have seen too many instances of where hackers can get into almost any database. There seems to be no guarantee that they are truly safe and, if they aren't, who might use them in ways detrimental to the patient?

A note in an article in The New York Times indicates: "But even those institutions (that made medical notes available) have hesitated to share mental health notes. Critics have raised concerns about whether reading notes could prompt anxiety and even rejection of treatment. What will happen if the patient posts the notes on Facebook, inviting comment?"

Institutions that have used the open-note premise have indicated that their patients have, in an almost overwhelmingly positive basis, indicated it was helpful. But psychologists know that self-report is notoriously riddled with all manner of social forces pushing in a positive direction. The more fruitful approach may be to plan a true division of the samples where patients are appropriately placed into groups that have access and those who don't. A number of factors would then need to be investigated to see if the data does agree with the patients in terms of its usefulness and success in making therapy even more effective. So, it's not just giving patients access, but being more rigorous in how you plan the approach in order to answer the questions you pose. What questions have been posed besides patient satisfaction? Doesn't it seem reasonable that with this much patient access you would want to make the data as useful as possible? Questions, guys, questions.

There are never easy approaches to research that is striking out in uncharted territory, especially in the mental health field. Certainly, we need to continue to do everything to improve results from any therapy and this is one attempt toward that end.