Effective note-taking is a key tool for any therapist, particularly when dealing with group therapy. These notes can help you view the session and group as a whole, and respond to the needs of individual clients. They might also be necessary for billing insurance providers.
Group notes and individual notes work together to create an accurate portrait of a group session. For a substance abuse group, these notes can track the progress of a client, and their interactions within the group.
To help you get started, we’ve put together this guide to writing effective substance abuse group notes.
Writing Substance Abuse Group Notes
When dealing with substance abuse, group therapy can be an effective way of encouraging clients to open up, share their experiences, and feel encouraged to make changes.
As a therapist, when you’re leading a substance abuse group therapy session, you will be required to take notes.
These notes serve two purposes:
- First, they allow you to better monitor these sessions, plan future meetings, and build better treatment plans.
- Second, your notes might be needed to bill an insurance provider.
As you observe group therapy, you’ll need to take notes on both the group itself, and the individuals within the group.
Individual notes help you engage with all members of the group, and prevent anyone from becoming overlooked. They also help you to see the interpersonal interactions occurring within the group.
Substance Abuse Group Notes
Group notes offer a general overview of the group itself. This will mark the progress of the group, how the group is interacting with one another, and the topics discussed.
The summary will act as an introduction to the group session, and the information contained in this will be copied into every individual note. Because these notes are relatively generic (and avoid referencing specific individuals), they might not be accepted by insurance providers.
Substance Abuse Group Note Example
Session Remarks: Substance Abuse Group Therapy
Group Type:
A support group for managing and maintaining sobriety, with discussions of strategies. Group members are encouraged to interact, and these interactions form part of the clinical focus.
Members Present At The Session:
Five members were present in today’s session.
Topic(s) covered in today’s session:
- Identifying topics and behaviors that can trigger substance abuse.
- Past responses to triggering events.
- Recognizing patterns of behavior surrounding triggers.
- Coping strategies in triggering situations.
- Developing new strategies for identifying triggers.
- Developing new strategies for responding to triggers.
Interventions implemented:
- Therapist facilitated discussion of recognizing triggers.
- Therapist facilitated discussion of responding to triggers.
- Therapist provided techniques for identifying triggers.
- Involved all members of the group in the discussion.
- Kept group members focused on the topic.
- Assisted group members with setting boundaries.
- Therapist provided techniques for responding to triggers.
- Created the structure of the discussion.
Schedule:
- Session start time: 9:00 AM
- Session end time: 9:55 AM
- Introductions: 9:00 AM
- Establish goals of discussion: 9:10 AM
- Discussion of identifying triggers: 9:20 AM
- Discussion of responding to triggers: 9:30 AM
- Evaluate session: 9:45 AM
- Prepare For Next Week: 9:50 AM
Substance Abuse Group Notes For Individual Clients
Individual notes for group therapy discuss how a client interacted with the group, and how the group interacted with the client.
The notes for every individual within the group should follow a set structure. If you work for an agency or a group practice, you may be provided a template that you’re required to follow. Otherwise, you can develop a template that works for you.
It’s important when writing these notes to stay objective, and to view all clients through an equal lens. In group therapy, strong personalities can color your judgements, but it’s crucial to move beyond those initial responses.
Finally, when you’re creating individualized notes for group therapy, other members of the group should not be identified.
Substance Abuse Group Notes For Individual Clients Example
Patient Name: Doe, John.
Patient Number: 100056242
Individual behaviors observed in today’s session:
John appeared alert and cheerful in today’s session. He responded to direct questioning, and took responsibility in leading discussions. Other group members responded well to his leadership. John showed a higher level of physical engagement today. He spoke about previous triggers that have led to relapse, and behaviors he engages in to avoid these triggers. John spoke about avoiding cravings, and distraction techniques when cravings occur.
Mental status:
John’s mood appeared slightly elevated, and he was more alert than in previous sessions, and willing to engage with members of the group.
Recommendations and instructions:
John will create a plan for assessing and responding to triggers, unique to his own needs.
Writing Effective Notes In Substance Abuse Group Therapy
Accurate and effective notes will make it easier for you to track client progress, and to bill insurance providers. In substance abuse therapy, accurate notes can also help you identify when an individual is at risk of relapse, or might have been using.
Effective substance abuse group therapy notes should contain: a general outline of the session, how a client behaved in the session, how the group reacted to the client, and the methods used by the therapist.
Try and include details that might be necessary for a third party, such as the background of the group, and the topics discussed. This can help to form the historical record of the client, and ease discussions with insurance providers.
Once you’ve established a method for writing notes, it will be easier moving forward. Set a system that works for you, and enables clear communication without unnecessary details. When you have your system, it can be used to create accurate notes for everyone in the group session.
Final Thoughts
Group therapy can be a useful tool for helping those with substance abuse issues navigate their behaviors. These sessions can also be emotionally fraught, and navigating group dynamics can be tough.
Accurate notes for both the group as a whole and individual clients within the group help determine the structure of the session, individual treatments, and responses moving forward.