ACC E-Accord Summer 2022

Keeping counselling records and disclosure requests
by Kathy Spooner, on behalf of the ACC Team
We are noticing that many
more counsellors are coming
to us with questions regarding
requests for access to, or
disclosure of, counselling notes.
The experience is often stressful
and sometimes highlights issues
with the whole process of notetaking
in counselling practice.
We therefore thought it might be
helpful to revisit the practice of
record keeping and share some
observations about the challenges
highlighted by such requests.
WHAT ARE COUNSELLING
RECORDS?
For the purposes of this article,
counselling records are identified
as notes taken of a counselling
session with a client/couple or
family. There are other records
relating to the working with clients
which include, for example, the
signed contract, client referral
information and notes taken in
any assessment session. There
is also correspondence, emails,
text messages and notes taken
of between-session phone calls.
Everything held by a counsellor
and/or counselling agency that
includes a personal identifier
(initials, code etc) may be
requested by a subject access
and/or a disclosure request, but
in the majority of cases it is the
sessional notes only that are
requested by clients or their legal
representatives.
WHY KEEP COUNSELLING
RECORDS?
There is a broad consensus
in the relevant literature that
keeping records demonstrates
professional rigour, care and
accountability. Although not a legal
requirement, the judiciary have
an expectation that counsellors
and psychotherapists will keep
appropriate notes of therapy.
Additionally, keeping records helps
organise thoughts, acts as an aide
memoire, facilitates the tracking of
changes in the client process, and
in these and other ways supports
a counsellor. Most accredited
registers, including ACC, have,
as an ethics and practice
requirement, the obligation to
keep counselling records unless
there is a documented and
compelling reason not to do so.
WHAT CONSTITUTES GOOD
PRACTICE IN RECORD KEEPING?
Ethical codes often refer to the
keeping of appropriate notes.
However, ideas about what
is appropriate vary according
to macro factors, for example:
setting (employment, agency,
private practice); client groups
(family, couples, children) and
counselling approaches. They are
also influenced by what is taught
in differing training organisations,
favoured by colleagues and what
factors represent a good fit with
personal style and preference.
Most authorities agree that records
should be factual, adequate
and relevant and must also
comply with data protection
legislation. What we have noticed
is that members’ practice varies
widely. For some, the preference
is to record very brief notes of
sessions. For others, there may be
more detailed structured notes
following a template model (see
box), while some prefer sessional
notes in a more lengthy, free form
including anything produced in
(or brought into) a session by the
client, such as drawings or photos
of sand trays etc. Records can
be kept only by consent, so it is
imperative that clients are fully
informed about your intention
to retain information relevant to
their therapy, together with your
commitment to data security and
confidentiality, how long you are
going to keep the records for and
why, and their right to access the
information held.
Key points when keeping
counselling records (This list is
not exhaustive, but it represents
the major issues that have arisen
at ACC and elsewhere relating to
record keeping):
• When there is more than one
client, make sure that all parties
sign an agreement that the
records you keep are accessible
to both or either, gaining a
commitment that if either party
requests a copy of the record
they should respect the privacy
of the other and not share the
notes more widely than with
another therapist and/or their
legal representative.
• Write everything knowing that
your client, their representatives
and/or legal teams could read
the notes. Except in very rare
and special circumstances, you
are obliged to give clients their
counselling records as they
have been written.
• Develop proficient record
keeping, so that notes are
accurate, timely and sufficient.
• Ensure that you record
significant factors that
could help the client in any
subsequent court proceedings.
For example, note down
anything that a client tells
you (alleges) about adverse
events involving a third party
e.g. an industrial accident, a
sexual assault or an incident of
domestic abuse.
• Ensure that you record
significant factors that would
help to protect you, were you
subject to professional scrutiny.
Note down any discussions
where there is some concern
for a client, for example about
significant risk to wellbeing
(self-harm/suicidal ideation).
Note down the rationale for
16 accord Summer 2022 www.acc-uk.org • www.pastoralcareuk.org