A Therapists Guide to Writing in Psychotherapy Assessment,

Documentation, and Intervention 1st Edition

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Library of Congress Cataloging-in- Publication Data
Names: Reiter, Michael D., author.
Title: A therapist’s guide to writing in psychotherapy :
assessment, documentation, and intervention / Michael D.
Reiter.
Description: New York, NY: Routledge, 2023. | Includes
bibliographical references. | Identifiers: LCCN 2022060763
(print) | LCCN 2022060764 (ebook) | ISBN 9781032279336
(hardback) | ISBN 9781032279343 (paperback) | ISBN
9781003294702 (ebook)
Subjects: LCSH: Psychotherapy—Authorship. |
Communication in psychiatry. | Medical writing.
Classification: LCC RC437.2 .R45 2023 (print) | LCC
RC437.2 (ebook) | DDC 616.89/14 — dc23/eng/20230406
LC record available at https://lccn.loc.gov/2022060763
LC ebook record available at https://lccn.loc.
gov/2022060764

ISBN: 978 -1- 032-27933- 6 (hbk)

ISBN: 978 -1- 032-27934 -3 (pbk)
ISBN: 978 -1- 003-29470 -2 (ebk)

DOI: 10.4324/9781003294702
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This book is dedicated to Thursday, Mika, Mr. Friendly,
Sushi, Emi, Piper, and Buddy. Thank you for being a
companion on the journey.
Contents

List of Figures viii

List of Tables xi
Preface xii
Acknowledgments xiii
About the Editor xiv
List of Contributors xv

1 Writing in Psychotherapy 1
2 Writing Progress Notes 18
3 Assessment Writing 42
4 Forms and Pragmatic Letters 72
5 Therapeutic Letters to Clients 96
6 Temporal Therapeutic Letters 119
7 Client-Written Letters 135
8 Client Writing Therapy 157
9 Documents and Counter-Documents 179
10 Writing in Psychotherapy via Technology 202
11 Writing for the Legal and Medical Contexts 228
12 Article and Grant Writing in Psychotherapy 252

Index 275
Figures

2.1 The APA Guidelines for Record-Keeping 19

2.2 Example of a SOAP Note 28
2.3 Example of a DAP Note 31
2.4 Example of a STIPS Note 33
2.5 Example of a BIRP Note 34
3.1 Sample of the Presenting Problem Section of a
Biopsychosocial Report 45
3.2 Sample of the History of Presenting Problem Section
of a ­Biopsychosocial Report 46
3.3 Sample of the Background Information Section of a
­Biopsychosocial Report 47
3.4 Sample of the Developmental History Section of a
Biopsychosocial Report 47
3.5 Sample of the Social History Section of a
Biopsychosocial Report 48
3.6 Sample of the Educational History Section of a
Biopsychosocial Report 49
3.7 Sample of the Occupational History Section of a
Biopsychosocial Report 49
3.8 Sample of the Medical History Section of a
Biopsychosocial Report 50
3.9 Sample of the Psychiatric History Section of a
Biopsychosocial Report 51
3.10 Sample of the Substance Use History Section of a
Biopsychosocial Report 52
3.11 Sample of the Abuse/Trauma History Section of a
Biopsychosocial Report 53
3.12 Sample of the Diversity Considerations Section of a
Biopsychosocial Report 54
3.13 Sample of the Patient Strengths Section of a
Biopsychosocial Report 54
 Figures ix

3.14 Sample of the Mental Status Exam Section of a

Biopsychosocial Report 57
3.15 Sample of the Clinical Summary Section of a
Biopsychosocial Report 58
3.16 Sample of the Treatment Goals and Strategies Section
of a Biopsychosocial Report 59
3.17 Sample of a Risk Assessment Note 61
3.18 Sample of the Triggers and Warning Signs Section of a
Safety Plan 63
3.19 Sample of the Internal Coping Strategies Section of a
Safety Plan 64
3.20 Sample of the External Coping Strategies Section of a
Safety Plan 65
3.21 Sample of the Emergency Services Section of a Safety Plan 65
3.22 Sample of the Restriction to Means Section of a Safety Plan 66
3.23 Sample of the Reasons for Living Section of a Safety Plan 66
3.24 Sample of a Treatment Plan 68
3.25 Sample of a Treatment Summary 70
4.1 Sample of Informed Consent Form 78
4.2 Sample of Release of Information Form 81
4.3 Sample of Permission to Record the Session Form 83
4.4 Sample of Welcome Letter 84
4.5 Sample of Letter to Maintain Engagement 85
4.6 Sample of Letter of Recruitment 87
4.7 Sample of Coordination of Care Letter 90
4.8 Sample of No Contact Letter 91
4.9 Sample of Termination Letter 92
5.1 Sample Brief Therapeutic Letter 102
5.2 Sample of Three-Paragraph Brief Therapeutic Letter 104
5.3 Sample of Narrative Therapeutic Letter Focusing on a
Star Resource 108
5.4 Sample of a Solution-Focused Supplementary Letter 111
5.5 Sample of Letter from a Reflecting Team 112
8.1 Sample of a Self-Esteem Journal Template 162
8.2 Sample of an Autobiography Worksheet 168
9.1 Document of Knowledge (Adapted from Fox, 2003) 181
9.2 Document of Knowledge for Skills (Adapted from Fox, 2003) 181
9.3 Sample of a Document of Circulation (Adapted from
Fox, 2003) 182
9.4 Award for Small Achievements 183
9.5 Award for a Rite of Passage 183
9.6 Certificate of Completion 185
9.7 Bon Voyage Card 187
9.8 Anniversary Card 188
x Figures

9.9 Coping Card 189

9.10 List of Accomplishments 190
9.11 Side-by-Side List 191
9.12 Sample gratitude list sheet (Adapted from Dankoski, 1998.) 192
9.13 Genogram of Billy 197
10.1 Sample of Email Correspondence between Therapist
and Client Engaging in Online Therapy 213
10.2 Sample of Chat Exchange between Therapist and Client 215
10.3 Sample of Text Message Exchange between Therapist
and Client 218
10.4 Sample of Homepage for a Fictional Private Practice 221
10.5 Sample of Webpage Explaining the Therapist’s
General Therapeutic Philosophy 222
10.6 Sample of Webpage Describing the Therapist’s
Theoretical Orientation, Method and Location of
Therapy, Rates, and Insurance Possibilities 222
10.7 Sample of About Me Page on a Group Practice’s Website 223
10.8 Sample of Website Displaying Past Client Testimonials 223
11.1 Clinical Summary Sample 232
11.2 Clinical Letter Summary Sample 234
11.3 Sample of Treatment Recommendation Letter 244
11.4 Some Useful Medical Shorthand 247
Table

10.1 Sample Emoticons and Emoji Chart 219

Preface

I have been a psychotherapist for more than 30 years now. For more than
20 of them I have been a full-time faculty member, training students on
the philosophy and practice of psychotherapy. I have also engaged in a
lot of writing about therapy. In 2020, I began writing an article about a
specific type of therapeutic letter that I had found myself constructing
and giving to my clients. I was also training/supervising students in a
university-based therapy clinic and would train the therapists to write
a therapy letter in the format I had developed. I brought on board my
graduate assistant, April Brown, to help write the article, Temporal Ther-
apeutic Letters: Utilizing Time as a Structural Guide, which was published
in the Journal of Systemic Therapies (Reiter & Brown, 2020). Afterward, I
realized there hadn’t been, to my knowledge, a book on writing therapeu-
tic letters. I began to consider doing so. However, a bigger understanding
came to me; psychotherapists use writing in many more ways than just
therapeutic letters. They do so when they write progress notes, construct
their contractual forms, contact other service providers, and get clients
to write for their own benefit. Further, I realized that there hadn’t been a
book that had explored the variety of writing psychotherapists engage in.
Thus, the impetus for this book was born. In thinking about this, I also
realized that much of the writing that occurs in therapy doesn’t happen
alone. Thus, I asked some of my friends and colleagues to join me for
certain chapters, which is why you’ll see different co-authors (Chapter 3
was written completely by Sara Ferguson, who has much more expertise
than me in psychological assessment writing). I’m very glad I was able to
collaborate with each of them. It is very nice when you get to work with
people you enjoy. My hope is that there will be much in this book that
you will find useful for your work with your clients. Some information
may be old hat, while other information is new. We tried to provide many
examples of writing so that you can have a more in-depth understanding
of their possibilities. Please feel free to use, adapt, or ignore whatever you
find that will be most useful for you—and most importantly useful for
your clients—in your psychotherapy practice.
Acknowledgments

I want to thank all of my co-authors: Myron Burns, April Brown, ­Pei-Fen

Li, Sara Ferguson, Lori Pantaleao, Jessica Popham, Kelsey Railsback,
Natalie Rothman, Kayleigh Sabo, and Shaelise Tor. Thanks also to my
editor at Routledge, Heather Evans, who has been supportive of this and
my other projects with Routledge. To all of the Routledge support staff,
especially Upasruti Biswas, my utmost appreciation. And to my students
whom I learned with about writing in psychotherapy along the way….
About the Editor

Dr. Michael D. Reiter, PhD, LMFT, has been a practicing family ther-
apist for more than 30 years. Michael is a licensed marriage and fam-
ily therapist in the state of Florida and an approved supervisor through
the American Association of Marriage and Family Therapy. From
1999–2022, he was a faculty member at Nova Southeastern University,
teaching in the Division of Social and Behavioral Sciences, Clinical
Psychology, Mental Health Counseling, and most recently in the De-
partment of Family Therapy. Michael has been heavily engaged in schol-
arship, having written 11 books, including Therapeutic Interviewing (2nd
ed. Routledge, 2022), Systems Theories for Psychotherapists (Routledge,
2019), Family Therapy: An Introduction to Process, Practice and Theory
(Routledge, 2018), Case Conceptualization in Family Therapy (Pearson,
2014), and The Craft of Family Therapy (Routledge, 2nd ed., 2021), which
was co-written with Dr. Salvador Minuchin, founder of Structural Fam-
ily Therapy. Michael’s books have been translated into Spanish, Polish,
Chinese, Italian, and Korean. He has also co-edited two books with
Dr. Ron Chenail: Behavioral, Humanistic-Experiential and Psychody-
namic Approaches to Couples Counseling and Constructivist, Critical, and
Integrative Approaches to Couples Counseling. Both books were published
in 2017 by Routledge. Michael has also published more than 20 journal
articles and presented at state, national, and international conferences
regarding a variety of therapeutic interventions and models.
Contributors

April Brown, MS, is a licensed marriage and family therapist residing in

Miami, FL. She is a doctoral candidate in Family Therapy at Nova
Southeastern University. April is the owner of a group private practice
for couples and mothers postpartum; her clinical work centers on a
systemic and narrative approach. Writing, specifically letter writing,
is an integral part of the therapy process with her clients.
Myron J. Burns, PhD, is currently an associate professor in the Depart-
ment of Psychology and Neuroscience at Nova Southeastern Univer-
sity College of Psychology. He has instructed a variety of courses in
psychology, counseling, and substance abuse. Dr. Burns has worked
with individuals, families, first responders, and military personnel on
stress management, depression, and drug use.
Sara Ferguson, PsyD, is a licensed clinical psychologist with specialty
training in forensic psychology. She provides psychotherapy and psy-
chological assessment services to individuals across the lifespan in
a south Florida private practice. Dr. Ferguson’s research and publi-
cation interests emphasize at-risk youth needs, including adolescent
suicide and violence prevention, juvenile offending, school shootings,
and forensic psychological assessment.
Pei-Fen Li, PhD, is an associate professor in the Department of Couple
and Family Therapy at the Dr. Kiran C. Patel College of Osteopathic
Medicine, Nova Southeastern University. She is a licensed marriage
and family therapist and AAMFT-approved supervisor. Her research
interests include dyadic analyses of couples’ relational characteristics
on their well-being, application of MFT models in Eastern cultures,
acculturation of immigrant families, reentry experiences of interna-
tional students, and solution-focused brief therapy intervention with
parents of children with Autism.
xvi Contributors

Lori Pantaleao, PhD, is an assistant professor of Family Therapy in the

Department of Couple and Family Therapy of the Dr. Kiran C. P ­ atel
College of Osteopathic Medicine at Nova Southeastern University
and serves as the assistant program director for the MS students. Lori
is a dually licensed clinician in mental health counseling and marriage
and family therapy; she is a certified addiction professional and a certi-
fied telehealth practitioner. Lori has presented solutions-focused brief
therapy training concepts at national and international conferences.
In addition, Dr. Pantaleao is an editor for The Qualitative R ­ eport and
holds a Certificate in Qualitative Research.
Jessica Popham, PhD, is an assistant professor of psychology and practi-
cum coordinator at Albizu University. She is a licensed marriage and
family therapist and approved supervisor of the American Association
of Marriage and Family Therapy. She has presented nationally and
internationally at conferences on family therapy, qualitative ­research,
adoption, and clinical application.
Kelsey Railsback, PhD, is a licensed marriage and family therapist. In ad-
dition to instructing family therapy courses and practicums at Touro
University Worldwide, she has an international life coaching practice
and works as a guest editor for The Qualitative Report. She is pas-
sionate about growing an ethical qualitative research community. Her
clinical interests include a focus on social justice and working with
marginalized populations, and she has presented nationally on her
­research and clinical work with sexual survivors and sexual offenders.
Natalie Rothman, PhD, is an assistant professor of Family Therapy in
the Department of Couple and Family Therapy of the Dr. Kiran C.
Patel College of Osteopathic Medicine at Nova Southeastern Univer-
sity. Natalie also serves as the interim clinical director of the Brief
Therapy Institute for NSUHealth. She is a dually licensed clinician in
mental health counseling and marriage and family therapy, a certified
addiction professional, and a certified telehealth practitioner. Natalie
has assisted in managing a thriving practice in Royal Palm Beach,
Florida, and has presented at national and international conferences.
Kayleigh Sabo, MS, has a master’s degree in Marriage and Family Ther-
apy from Nova Southeastern University (NSU) and is currently pur-
suing her PhD in Couple and Family Therapy at NSU as well. She is a
registered marriage and family intern in Florida, working toward full
licensure. Kayleigh is a certified yoga instructor (RYT-200) and incor-
porates yoga practices into her therapeutic work. She has worked as a
therapist in university and community mental health centers as well as
in private practice.
 Contributors xvii

Shaelise Tor, PhD, is an assistant professor at Nova Southeastern

­University. She holds an MS in MFT from the University of ­Rochester
and a PhD in MFT from Syracuse University. Her research focuses on
understanding cultural differences in expressions of attachment to cre-
ate more culturally responsive clinical interventions. She is also clini-
cally a­ ctive and trained in Medical Family Therapy, Narrative Exposure
Therapy (NET), and Assessments for Medical Gender Affirmation
Procedures.