How to Write a Verbatim Psychotherapy Process Note

Today, most therapists learn how to write only one kind of therapy note: a progress note. Progress notes primarily function as a legal document, a record of basic facts required by law and available for inspection by authorized third parties (e.g., insurance companies, parents, the government). Because others (including the patient) may end up viewing them, they should be brief, clinical, and with little detail about what was said to preserve as much of the patient’s privacy as possible. As a result, the document says very little about the actual therapy session.

Psychotherapy process notes serve two purposes:

1. Record what actually occurred in session. A process note describes the actual session in some amount of detail, including what was said, changes in behavior and feelings (affect) in the room, and the therapist’s thoughts, feelings, and fantasies. Such a record helps facilitate a deeper, more enriching supervision experience by presenting more meaningful process data to explore. If you are regularly creating process notes, you'll also be able to better track the patient's development as well as your own.

2. Tool for thinking about the patient and the therapy process. Writing and reviewing process notes facilitates self-reflection and developing/organizing one's thinking about clinical challenges. While by reflecting on our patients in an unstructured way is also helpful, writing brings a clarity and organization that is often lost with less structured thinking.

A process note can vary in detail and length. Many therapists write short process notes summarizing the main themes and progression of the session as part of their daily practice after each session. These notes usually take 5-10 minutes to write and are useful records to help track what is happening in broad strokes from session to session.

It is also common practice to write a verbatim transcript of a session especially when preparing to present a case to a supervisor or consultant. Given the time intensive nature of this endeavor, it is typically not something done for most sessions. Many therapists (particularly psychoanalytic therapists) continue to write these more detailed process notes throughout their career as a tool to improve their work with particular patients and develop their skills more generally.

An increasingly common aid for writing verbatim process notes is digitally recording sessions with the patient’s consent. While this makes for a more accurate transcription of the session, it comes with the considerable drawback of introducing a potential threat to privacy that can negatively impact the patient and the process. For some, this intrusion into the process is tolerable, but for many, it hampers the safety and trust needed to do the vulnerable work of therapy.

In cases where recording a session could cause more harm than benefit, a detailed process note can be written by memory. For much of the history of psychotherapy, process notes were written by memory almost exclusively, even in the past 75 years in which audio recording devices have been widely available. While labor intensive, the process of remembering the session by memory has added value lost when simply making an audio transcription. Of course, it’s very difficult to remember word for word what was said in a 45-60 minute session, but with practice and intention, it is possible to become skilled at creating a close-to-verbatim process note.

Instructions for Writing a Process Note

The first step to writing a good, detailed process note to share with a supervisor is preparing for it:

1. Choose one session per week. Before a session, make a plan to write out the process. If you know you’re going to need to remember it, you’re more likely to listen more closely and hold onto more words and turns of phrase. While there's nothing wrong with doing more than one detailed process note per week, its better to dedicate your time and energy to doing one process note well given how much work is required.

2. Reserve at least 1 hour immediately following the session to write the process note. The sooner you get to writing, the more you’ll be likely to remember, and the more enjoyable the process will be. Writing a process note from memory days, or even hours, after a session makes the process much more painstaking, cumbersome, and less useful than if written immediately following the session.

3. While in session, listen closely, making mental links between what is happening now and what came before. A benefit of doing process notes is that it encourages you to work on developing your ability to listen very closely to the patient’s words and the flow of their words. Beyond helping you remember more when writing, it will also help you develop a clinical skill you use in all sessions regardless of whether you're writing a process note.

Immediately after the session ends and the patient has left, begin writing. I recommend typing rather than handwriting as most people are faster typers, but of course do what works best for you. Here’s a process for writing I’ve found useful:

1. Create a broad session outline. Review the session from beginning to end in broad strokes and break the session into meaningful segments. There are lots of ways to do this, and you shouldn’t overthink it. Think of it as making a brief outline of the session with enough words to help remind you of what happened when. As an example of a brief outline with broad indicators only meaningful to the therapist:

   1. Anxious start, comments on waiting room, weather

   2. Typical acting out, deli, speaks with manager

   3. Back and forth exploring how he thinks others view him and why, patient gives multiple non-answers

   4. Pointing out session process, patient says understands, doesn’t know how to answer

2. Fill in the details starting at the beginning. Once you have this brief outline, go to the first section and begin to write down what was said verbatim as best you can remember.

   1. Try to replay the session in your mind and type out whatever you hear being said. Try not to censor yourself, trust that what comes to mind is close enough, and keep moving forward. You can always return to edit and refine after you've gotten a basic transcript written.

   2. Try to be as close to the actual words as possible while accepting that you’ll inevitably be unable to exactly reproduce what was said.

   3. If after several minutes you’re unable to recall what was said in a section, write down whatever you can remember in a more summary manner. As an example: “The patient kept returning to the idea that everyone hates him. I tried to get him to consider why he thinks that through asking questions like, ‘What do you notice in the other person that makes you think that?’ He mostly ignored my questions and continue to emphasize how he is sure that others hate him.” It’s much better to have some account of what occurred than none at all. If you have time later, you can return and try to add more verbatim details.

   4. Repeat this process for the entire session.

3. Once the verbatim is complete, add nonverbals, feelings, and therapist’s thoughts/feelings. Re-read the transcript of the session and add in these details. 

   1. Nonverbal details include silences, body movements of the patient (e.g., “patient starts fidgeting”), changes in affect (e.g., “sad, tears welling”), and the therapist’s private thoughts, feelings, or ideas at that moment (e.g., “I thought of how similar the dynamic with his friend is to the dynamic with me” or "I felt annoyed here").

   2. This part can be done at a later time with much more ease. Once you have what was said written down as a reminder, it’s much easier to recall these details later.

With practice, it’s possible to write a process note from memory in 60-90 minutes. When you're new to writing these, however, it will likely take 2-3 hours to complete. 

Writing process notes can often feel like a frustratingly tedious task to do, especially when starting out. The time-consuming process is, however, part of what makes it useful. Writing is a tool to think about our patients and what is happening in the session. It is only by taking time to think about our work and organize our thoughts that we become more effective therapists. As much as you can, try to embrace the seeming tedium by remembering you are building a skill that will serve you well throughout your career.