Take Note of These 4 Perennial Factors of Your Clients

I’m amazed it has taken me about 2 decades of writing case-notes to finally come up with this system for myself. I’ve been using this particular format to capture what I call “evergreen” information, that is, information that are not time-bound and salient.

In the First Kiss, I wrote a chapter called “The 4Ps versus the One P” (This chapter is made available in Frontiers). I wanted to emphasis the importance of not just capturing the the 4 P’s: Predisposing, Precipitating, Perpetuating, and Protective factors about our clients, but figuring out what is the single Prior our clients has of themselves. That is, “what is one thing that my client needs help from me right now and is willing to work on in the first session?“

While I found this way of thinking and facilitating the conversation to hone in on what’s most essential helpful, I also needed a more robust scaffold––one that would not only help me in the initial session––so that I can develop keep my compass as I work with each person.

As it’s evident in the central thesis of The First Kiss, I found the Intake Model approach of obtaining a thorough clinical assessment at the get-go to be over-emphasising on what we as practitioners were getting, and less on what the client was receiving.

Further, the traditional note-taking system was designed around a session-by-session basis. Why not a separate note-taking system that is designed to be less time-bound, more of the time-less matters that practitioners would value to be primed immediately with, before they meet the client for a subsequent session? Previous session’s case notes provide information that are relevant to that engagement, but most therapists would attest, there are perennial information to note of the client that may or may not be elicited in the first session, and would be highly valuable to return to and/or add on to as therapy progresses.

Even though I have been using this format in less than a year, I’ve found this to be indispensable. Let’s get straight to what I’m referring to in this Evergreen casenote.

The 4 S’s

Whether you are documenting your notes digitally on e-health platforms or on paper, this Evergreen 4Ss approach can be applied nonetheless. The 4Ss are

1. Sense of Self
2. Sparks
3. Significant Events, and
4. Systemic

1. Sense of Self

In this first section of Sense of Self, you’d fill in information about the client’s

• Beliefs
• Personality
• What the person identifies with
• Different parts of self
  

Beliefs can relate to spiritual/religious affiliations that inform their sense of being in this world and in relations to others.
Personality can include what we sometimes refer to the Big 5 Personality Factors, and “pre-morbid personality” (PMP).
What they identify with can be related to cultural (i.e., Asian minority), political (i.e., liberal), or even in terms of interest groups (i.e., a running group, dungeons and dragons, a music scene).
The last point about different parts of self is worth clarifying. Therapists who are trained in Internal Family Systems or the Voice Dialogue approaches might be familiar with this languaging. All of us have different “sides” of ourselves. Someone might have a highly anxious side on one hand, but on the other hand, may also have a highly caring and empathic side to their personality.

2. Sparks

In the second section called Sparks, you will attend to

• What makes them come alive?
• What does this person care about?

Sparks are not just about trying to be “strengths-based.” Sparks tap into the life-force within each and everyone of us. On the empirical front, it is found that client factors account for 80-87% of the outcomes in therapy. [1] More specifically, an intriguing study conducted in the University of Bern found that “Unsuccessful therapists focussed more on the patient’s problems and tended to overlook the patient’s resources.” Instead, the degree of resource activation distinguished successful sessions from the unsuccessful sessions. Resource activation, as the researchers noted, focuses on the vibrant and healthy parts of a person’s lives.

What a person truly cares about sheds light on their sense of self. For example, I had a client who was truly engrossed in things film related. Those some might see it as simply a pet hobby, he went on to tell me how movies saved his live, gave him a sense of wonderment and possible, as well as life-lessons from powerful stories made in the visual art form of filmmaking.

3. Significant Events

In the third section called Signifiant Events, you will take note of

• Adverse events, and
• Life-changing events.

Not surprisingly, adverse events experienced across the lifespan are worth noting, as they point to potential emotional wounds and/or further exacerbations of the hurts to the psyche. Making space to take about this traumatic events can be a therapeutic experience. One time, when I asked a client about a significant event, she was quick to assure me that she had a “normal” childhood, much like another one else growing up in a well-to-do family. But as soon as we made room to explore further, she shared about the loss of her nanny when she was 6-7 years old. It was sudden. Out of the blue, her father asked her to leave and said that the nannie’s services was no longer needed, because the girl’s mother is sufficiently equipped to take care of her. Her nanny was her mother. As she was telling me this, she was trying to normalise this event, but her tears were said quite another thing. Her tears were coming from a well of sudden loss at a young age, that was not given room to grief.

Though significant events often relate to traumatic incidences, significant events also entail threshold moments––a sort of bridge-crossing from one place to another––when a change so drastic alters the course of one’s life. This could be a move to another country, falling in love, a surprising life-affirming feedback from a teacher, or any other happenstance that wouldn’t have ordinarily lead to transformation of the self.

Sometimes, when appropriate and relevant, as a therapy homework, I would ask client’s to draw up a timeline take time to reflect on what were the significant moments in their lives and why.

4. Systemic

Finally, in the fourth section called Systemic, you’d take note of

• key relationships in the family, and
• key relationships outside of the family (e.g., friends, colleagues, mentors)

This is where genogram and sociogram are really helpful to sketch out. I encourage you to draw them out (and if you need your notes to be digital, scan them in. Alternatively, use a digital drawing tool like Concept or Thoughts, and then export the image file).
The reason for sketching them out is that images of related nodes (to represent people in the client’s lives) taps into the “dual coding theory” where the brain processes verbal and visual information in two different channels. As such, this enhances your awareness of “who’s who” in a the client’s lives. I make an effort to even know the names of significant people, alive or have passed away. Even when clients are referring to their grandparents, I ask them what do you call your grandmother (Nona, Grannie, or other idiosyncratic names unique to the family’s traditional). I’ve found this to be helpful in deepening the process of therapy, making the conversation less generic and more personal.

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It’s a Timeless Case-Note, Not Session-Notes.

Reassure that you needn’t fill out this 4 domains in one session. In fact, even if you did, you might find yourself adding and amending some of the information in this Evergreen casenote. My aim for sharing this not to impress to you that this is ” the four most important things to ask in therapy.” Rather, what I’ve found is that these 4Ss: Sense of Self, Sparks, Significant Events, and Systemic has helpful me organised and updated my thoughts about a client, above and beyond session notes.

If you’d like a copy of The Evergreen Casenote template, click on the link below. I would love to hear if you’ve found this 4S’s helpful or not.

Footnotes:
[1] Wampold, B. E., & Imel, Z. E. (2015). The great psychotherapy debate: The evidence for what makes psychotherapy work (2nd ed.). Routledge/Taylor & Francis Group; US.
[2] Gassmann, D., & Grawe, K. (2006). General Change Mechanisms: The Relation Between Problem Activation and Resource Activation in Successful and Unsuccessful Therapeutic Interactions. Clinical Psychology & Psychotherapy, 13(1), 1–11. http://dx.doi.org/10.1002/cpp.442