3rd Edition
Record Keeping in Psychotherapy and Counseling Ethics, Practice and Supervision
Record Keeping in Psychotherapy and Counseling: Ethics, Practice and Supervision, grounded in contemporary challenges, emphasizes protecting the therapeutic and supervisory relationship through offering an essential framework for thoughtful record keeping within legal, ethical, supervisory, and clinical contexts.
A reader-friendly conversational style plus compelling case examples from a variety of settings—clinic to courtroom—bring dilemmas and strategies to life. New case studies invite readers to examine principles of ethical decision-making in order to reach sound decisions, meeting a critical need in training and continuing education. New material on telehealth and electronic records, the impact of digital communications on the therapeutic relationship, and experience implementing the Health Insurance Portability and Accountability Act (HIPAA) bring this book up to date. Sample forms for readers’ use and modification are available on the publisher's website.
Practitioners in all mental health disciplines, from students to seasoned clinicians, the supervisors, and teachers will continue to rely on this book for protecting themselves, their patients, and their trainees.
1. A Decade in the Making: Ethical Decision-Making, Record Keeping, and the Therapeutic Relationship in Extraordinary Times 2. Purposes of Clinical Records 3. Documenting Informed Consent 4. Characteristics and Contents of Good Records 5. Confidentiality 6. Exceptions to Confidentiality 7. Developing Policies and Procedures for Protecting Confidentiality and Managing Its Exceptions 8. Boundary Challenges: Impact of Digital Communication on the Therapeutic Relationship 9. Inactive Records: Access, Retention and Destruction 10. Using Patients’ Records as Therapeutic Tools 11. Clinical Supervision Records 12. Teaching Record Keeping 13. Sailing in Choppy Waters: Therapists Navigating in the Legal System 14. Planning for Interruptions or Closures of Psychotherapy Practices 15. Using Principles of Ethical Decision-Making: Case Studies
Biography
Ellen T. Luepker, MSW, BCD, is a licensed psychologist and clinical social worker in private practice and Psychiatry Instructor in the University of Minnesota Medical School. She was honored by the National Academy of Practice as a Distinguished Practitioner and by the National Association of Social Workers as a Social Work Pioneer, and received Smith College’s Day Garrett Award for her contributions to professional standards in mental health.
"Ellen Luepker enables you to view your records as an evolving, collaborative narrative of your understanding of your patient and your relationship; you will come to regard your records as integral to effective treatment rather than a mere professional obligation. Required reading, I’d say."
Jon G. Allen, Ph.D., Clinical Professor of Psychiatry at the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas, USA (retired) and author of Trusting in Psychotherapy.
"My graduate students, along with experienced clinicians, have consistently ranked Ellen Luepker’s previous editions as one of the most influential and clinically relevant text material they’ve read. Her chapters pertain to the ethical issues we are required to consider for each client. This 3rd edition addresses the ever-changing dynamics which therapists are forced to address and highlights significant issues with impeccable detail. Each chapter includes examples which challenge us to protect confidentiality, while maintaining the therapeutic alliance."
Janice R. Gagerman, Ph.D, LCSW, BCD, Professor Emerita of Social Work, California State University, Sacramento, USA
Praise for Previous Editions
"This book is a lively, reader-friendly compendium of essential knowledge for every clinician that provides specific advice and examples of clinical records while illuminating a wide spectrum of legal, ethical and complex clinical issues."
Judith Wallerstein, PhD, author, The Unexpected Legacy of Divorce, Second Chances, and What about the Kids?
"Ellen Luepker gives her readers the best of both worlds – a masterful synthesis of contemporary regulatory requirements grounded in clinical sensitivity and wisdom."
Jon G. Allen, PhD, senior staff psychologist, The Menninger Clinic; professor, Baylor College of Medicine, Texas, USA
"I have used the first edition for years to teach therapists and case managers the basics of good record keeping, and this new edition updates and adds depth…The chapter on ‘Teaching Record Keeping’ should be required reading for every social work and counseling school in the country. This is must reading for anyone who is called to court to testify or who wishes to become an expert witness or develop a forensic practice."
R. Keith Myers, LICSW, vice president, Clinical and Training Services, Wellspring Family Services; affiliate faculty, University of Washington School of Social Work, USA
"Ellen Luepker’s work provides a remarkably complete and readable volume on the current processes concerned with clinical record-keeping and confidentiality. Whether a student, teacher or clinician, this book is a must-have resource for practice information."
Barbara Berger, PhD, Institute for Clinical Social Work, Illinois, USA
"Rooted in 30 years of experience with patients, Ellen Luepker provides detailed practical guidelines and especially wonderful examples of how to keep written records that actually improve therapy and meet the requirements of the legal system. Practicing therapists will find [this] detailed guide to be one of the most useful books they read all year."
Thomas T. Frantz, PhD, Professor of Counseling Psychology, University at Buffalo, USA
"Ellen Luepker has finally made practical common sense out of the thicket of clinical, ethical, and legal requirements for record-keeping. For HIPAA implementation, this should be on the ‘must read’ list of every practitioner!"
Hubert H. Humphrey III, JD, former Minnesota Attorney General
"Record Keeping in Psychotherapy and Counseling was an invaluable resource to me as I launched a private practice. The success of this book is due to Ellen Luepker's dedication to ethical standards in patient care, coupled with her devotion to providing the highest level of clinical care. Ellen's book provides an opportunity for new and seasoned therapists to learn how to address challenging situations."
Kate Cosgriff, LCSW, PLLC, Durham, NC, USA
"This book deserves a place next to the DSM on every therapist’s reference shelf, the shelves of therapists of other treatment professions as well as those of social work clinicians. There are interesting case examples, and much of the text is written in easy-to-read conversational language. [It is] a tightly packaged reference tome. The information is detailed and covers every area for which appropriate and adequate record-keeping is essential. Always with record keeping as context, this work offers a richness of guidance and information in every area of treatment ... a fascinating and credible resource for currently practicing psychotherapists. Using the typical online protocol for scoring the value of an item – one to five stars - I give this book a resounding ***** assessment."
Inge Oppenheimer, LCSW, BCD, American Association of Psychoanalysis in Clinical Social Work Newsletter
