How to fill in the psychological consultation record

Record objective facts first, then add professional judgment, strictly adhere to ethical boundaries throughout the process, and don’t pile up unsubstantiated subjective speculations.

Let’s take the case of the sophomore boy I received last week. He had his head drooped when he entered the door. He rubbed the cuffs of his school uniform repeatedly with his fingertips while talking. He said that he had been lying in bed for two hours recently and couldn’t fall asleep, and his chest felt tight when he thought about the mock exam next week. A few days ago, his mother came into his room casually to look through review materials, and the two of them quarreled so much that he tore up the exercise booklet. When I started to pick up the pen, I almost wrote "The visitor has moderate test anxiety and parent-child communication difficulties". Fortunately, I paused and wrote down the objective content such as his status and original words at the beginning. Later, when supplementing the assessment, I mentioned "the possibility of test anxiety cannot be ruled out for the time being. It needs to be further confirmed with the follow-up scale". After all, what if the person just stayed up late this week to review? Making casual judgments is not only irresponsible to the visitor, but also easy to set up a trap for yourself.

However, when it comes to the specific scale of recording, there are actually different voices in the industry. Take the angry words spoken by the visitor as an example. If the visitor says "I really want to smash my dad's car" in front of you, many consultants feel that they must write it down unchanged. If there is any subsequent conflict, this will be evidence that you have fulfilled your obligation to disclose risks. ； However, many counselors feel that as long as the client has no clear action plan and no history of violence, there is no need to record the emotional and angry words in detail. If one day this record is obtained by the visiting family, it will become a trigger for intensifying family conflicts and defeat the original intention of helping others. My current habit is that if I encounter this kind of situation, I will only vaguely remember that "I was very emotional and expressed anger when I came to the interview about the conflict with my father." I will not write down specific extreme expressions. This can be considered as finding a balance between risk and ethics.

Speaking of which, when I first entered the industry, I suffered a loss from this. I picked up a girl who had just resigned. She cried three times in a row and said that she didn't want to live. I didn't think much about it at the time and wrote on the record, "The visitor has suicidal tendencies and the risk level is high." As a result, when she wanted to join a new unit, she needed a certificate not related to mental illness. I was found This record took nearly a month to come out. I called me specifically to tell her about it. I felt guilty for a long time - I later found out that she was under PUA by the company during that time, and after two weeks of adjustment, she was almost fine. I made a casual judgment without doing detailed risk investigation, which caused a lot of trouble for others.

There is also content related to the privacy of the visitor, such as sexual assault and domestic violence. When recording, it must be blurred. Don’t write down the specific time and information about the person involved in too much detail. I heard from seniors in the industry that a consultant recorded the visitor’s records. The specific time, place, and details of sexual harassment at the company were all written down in the record. Later, the agency’s filing cabinet was pried open, and this record was leaked to their company’s group. I immediately resigned and moved, and the consultant’s license was also revoked. This lesson is really serious.

Of course, you don’t have to be too constrained. For example, you smelled the smell of alcohol on his person as soon as he walked in, or he sat for ten minutes without raising his head. You can write down the details you observed. These seemingly inconspicuous little information may be the key breakthrough when sorting out the case later.