Discourse Community Ananlysis

Clinical Counseling Writing

Information for this project was obtained in a phone interview with Mrs. Mary Boyce,

Mrs. Boyce has been a practicing Clinical Psychologist for 25 years specializing in Marriage, Family, and Child Psychology. Her experience includes families, couples, children, adolescents, small ones, and a variety of disorders. The interview focused on the amount and types of writing involved in the Clinical Counseling profession, specifically Childhood Counseling. Mrs. Boyce runs her own private clinical practice.

Child Counselors work alone in a private practice setting, however may from time to time consult with other professionals for assistance in a particular case. Their records must be readily available for board review at any time. Keeping accurate records in this setting is extremely important to protect against litigation. Mrs. Boyce also added that Child Counselors who practice in a setting such as Children's Services or a Group Practice would have their case records reviewed by their superiors on a regular basis. Mrs. Boyce stated, "Record Keeping is the most tedious and most important task for the Clinical Psychologist in any setting."(Boyce, interview, 2002).

Clinical psychologists keep many standard forms in their practice. The types and information contained on the forms is standardized throughout the industry. The most common forms in this industry are Record keeping, Scheduling, Initial Intake and Screening, Progress Reports, Case Notes, Termination Summaries, Informed Consent and Client Information Forms, Release of Information, and Policy Guides. If you are a one-person practice you must also do billing, insurance forms, and tax records in addition to the other clinical paperwork

The majority of writing is clinical forms. However, there may be occasions where professional guides and reference manuals may be consulted for portions of the forms. The majority of information comes from counseling sessions with the patient. When asked if professionals refer to libraries or electronic sources for information, Mrs. Boyce responded that there are certain professional reference books, which are accepted as standard in the field. Library or electronic sources may be helpful, but there is a concern over the source of the material. Mrs. Boyce added, "There are many well intentioned people on the Internet, and a lot of mis-information also."(Boyce, Interview, 2002).

Professional writing for the Clinical Psychologist is different from academic writing. Accuracy and detail are the most important features of the paperwork required in this field. When a patient leaves the office, the clinical notes are the only tools that the clinical psychologist has to work with and it is important in the ability to recall specific details, which may be important to the case.

Writing tasks do not change for the clinical psychologist who runs their own private practice. However, for a person working in a position for an institution or Family Services setting, the paperwork does change as the person advances in their career. At an entry level, one usually starts out as an "Assessor." At this phase the person primarily fills out intake forms and performs a preliminary investigation. As "Case Manager" one reviews the assessors notes and makes a diagnosis, writes a treatment plan, keeps case notes, and finally a termination report. Management above this level reviews the paperwork submitted on cases, writes policies and procedures, and assures that the practice is in compliance with Federal Guidelines. In a Group setting the paperwork required for each position changes as a person advances. This contrasts with the private practice, where one must do all of the required paperwork themselves.

In order to become a licensed Counselor, one must complete an internship in a setting closely resembling their chosen career path. This internship usually lasts two years. During this time, the intern watches and works with seasoned professionals. They then move into performing some of the tasks themselves. This is where they learn to do the required paperwork and keep accurate records of each case. This is all done under the strict supervision of a seasoned professional.

It is extremely important to record accurately all events of a case. However, many practicing clinical psychologists find that the paperwork is overwhelming and they often must work late hours to get it completed. The law requires most of the paperwork and to fall behind could mean the loss of a license to practice or perhaps disciplinary action by the reviewing board. In addition, insurance companies require extensive paperwork on each case. All paperwork must be completed at the end of each day. Several software packages have been specifically designed to aid practicing clinicians in this task. These software packages contain standard scripts and assure that all of the necessary information, required by law, is included. This software can help to reduce or eliminate omissions or errors and can be a powerful asset to the practicing clinician.