Requested records for lengthy treatment, received less than 2 pages

[Justmehere]

I sent a letter to request records from a therapist I saw several years ago. I requested everything, including psychotherapy notes, copies of communications with victims comp, etc. I saw this therapist at least once a week for 18 months.

I thought I’d get back things like copies of the intake paperwork I signed, copies of forms she completed, a copy of the termination letter, something indicating she would or wouldn’t provide psychotherapy notes, etc.

Instead, what I got was less than 1 1/2 pages, widely spaced. No cover letter. It starts off with “Treatment/Progress Summary” ... lists my name, date of birth and with lots of spaces between sentences, lists dates of service, and a very brief summary for 18 months of treatment. The treatment plan summary was less than 10 words, only indicating number of sessions.

I didn’t request a summary. I wanted the actual records... or at least a denial indicating why she wouldn’t provide them. This therapist terminated care very suddenly, saying her own issues were triggered. But it’s been a few years. I paid a lot for this treatment. She took notes in session. I thought therapists in the US had to keep records for 7 years.

Does this seem right? I mean, less than 1.5 pages is all she has? I asked for everything, all records.

I’m thinking of mailing another letter to request the rest, or for an explaination why a treatment summary was sent instead of the requested records.

 

[Teamwork]

No idea, other than when I asked for records once got the same thing, but I’m in canada. the word redacted comes to mind, but it’s probably the wrong word.

 

[joeylittle]

I thought therapists in the US had to keep records for 7 years.

You should check the laws for your state. In many states, notes and other details may be withheld from the client if the practitioner deems them to be potentially harmful to the client's well-being.

7 years is the APA standard, and I think there's a national law about that as well, but state laws can supersede any national laws around mental health disclosure.

 

[mamachick]

I am a therapist and in my state, therapist can only have one set of records/progress notes. If records are supenode , they have to turn them over, which at times can be harmful to the client. My daughter is now an attorney for a hospital and she told me the law changed recently and notes can be summarized to prevent harm to the client. This is a bit different than your situation but the same rules may apply.

 

[Justmehere]

Thanks all. This is helpful.

In many states, notes and other details may be withheld from the client if the practitioner deems them to be potentially harmful to the client's well-being.

True. And they also can withhold notes they take in session and keep separate from the medical record. s for the records, if they do decide to withhold them, HIPAA requires they state they are withholding them, and indicate this as the reason. There was no such indication or explanation, and I have a hard time seeing why my intake forms I signed or the termination letter she sent would be of great harm to me.

I've asked for records from every mental health care provider I have seen. Once records were withheld stating they were concerned about harm, another time they said they would review them with me, and another, they said they would send them to someone else who could share them with me. Generally, records have been sent, no big deal.

I didn't expect this short treatment summary that was created last week (according to the record itself). That's sort of a creation of a new record, not provision of access to what was already in the record. I expected either a denial or the records. Not a treatment summary.

My daughter is now an attorney for a hospital and she told me the law changed recently and notes can be summarized to prevent harm to the client.

I can understand this regarding the notes on each session if it's provided with an explanation that this is what is being provided and why. I also would think that 70+ sessions would be summarized more fully. In fact, she lists session dates, but I paid for considerably more sessions than what she lists. I also don't understand why I am harmed if she provides another copy of her letter to terminate care and the other letters she wrote during the treatment to others.

Thousands of dollars spent and it's summed up in a vague useless document. It frankly leads me to be less inclined to continue to purchase future mental health care... but that's a whole other thing.

I need to do more work looking into what my rights are and what I should and shouldn't expect if I request mental health records.

 

[grit]

I had a thought one time to ask for my notes of a bad therapist and then I thought hmmm if she was that bad what could I possibly gain from her opinion of me?

I think maybe let this go. I only say that because revenge, vindictiveness, trying to find something to gain against her are not really healing path and is taking energy away from your healing path. I know this is not what your post is about but I hope you understand my intention for you.

She was as bad as you remember nothing she says will mean anything or will make you feel better. If anything I think the reason she was bad is that what she wrote about you in her notes were harmful and she acted on it. and now she will not give you unless court ordered and (my trauma side speaking) I would not trust she kept good professional notes or would not temper with in the first place.

You are giving her a lot of credence she does not deserve.

 

[Justmehere]

I appreciate the input @grit. I should clarify that it's been several years since I have seen this therapist and I didn't think she was a bad therapist.

 

[grit]

I appreciate the input @grit. I should clarify that it's been several years since I have seen this therapist and I didn't think she was a bad therapist.

Then why are you questioning her professionalism and her response to you. Maybe (just maybe) this is how she does her business or it has been so long and she did not keep good record and had to summarise your old file.

 

[Abstract]

It does sound a little as if she is avoiding. That is of course not acceptable. If that is the case. If she said treatment had set off her own stuff its possible she is self protecting rather than protecting you. Is it possible she was not able to manage her records and that this is the result? Or there could be another innocent explanation.

It frankly leads me to be less inclined to continue to purchase future mental health care... but that's a whole other thing.

Be careful of generalising. What she does makes no comment on others. It also doesn't change any good work the 2 of you did. Sounds like the end wasn't great.

It sounds as if it may be a good idea to find out the specifics of what she is required to do and then write a letter back to her pointing out the errors in dates, and the lack of other documents.

 

[Justmehere]

@grit - I don't think my options are 2.) just write it off as bad therapy and not get the records 1.) or trust that whatever she gave me is everything she has, summarized, and to not exercise my rights to request and obtain records.

I think it's possible she is a good therapist who has made a mistake. Therapists are human. It's also really helpful for me to learn about my rights as I sort out my future decisions about mental health care.

Mental health care patients do have a right to request and obtain at least some records. It is very rare that a therapist (or any human) is all horrible in all things or all trustworthy in all things. Most therapists (and humans) are a mix of strengths and weaknesses.

 

[grit]

@grit - I don't think my options are 2.) just write it off as bad therapy and not get the records 1.) or trust that whatever she gave me is everything she has, summarized, and to not exercise my rights to request and obtain records.

I think it's possible she is a good therapist who has made a mistake. Therapists are human. It's also really helpful for me to learn about my rights as I sort out my future decisions about mental health care.

Mental health care patients do have a right to request and obtain at least some records. It is very rare that a therapist (or any human) is all horrible in all things or all trustworthy in all things. Most therapists (and humans) are a mix of strengths and weaknesses.

Now you are just repeating words.

a long time ago therapist send you information you requested and you are still adding a lot of feelings so unnecessarily. I wish you the best. This to me sounds wagging the dog sort of situation.

If she is a human and you are giving a chance for any human to make a mistake, then give the chance that you asked for an old record, and she sent you document...not to your liking but that is your liking. She probably has one way of sharing documents and is not going to change because you send another email challenging her about her ways.

if you are being reasonable, why not take this as a face value?

I want to add it is my feeling (mine...) that you have suspicious about something and rather than directly ask her about that particular thing you want to see how she worded such. therapists do not need to keep as much detail as psychiatrist and if she is a doctor then just file at court to have access to your health record and still you may not find what you think she wrote.

 

[Justmehere]

It does sound a little as if she is avoiding. That is of course not acceptable. If she said treatment had set off her own stuff its possible she is self protecting rather than protecting you. Is it possible she was not able to manage her records and that this is the result?

This possibility has lurked in my mind. It actually stirs up a ton of shame. She was clear when we ended that the therapist in her wanted to continue, but the rest of her was dealing with her own stuff badly triggered, and she unable to continue. She actually had kind been falling apart for two weeks prior to the sudden end... I won't go into it, as it's her personal stuff that was leaking into sessions. It ended. She said she was very surprised by her own response and didn't think the matters that came up would bother her. But it did. And she backed up and ran so fast...

From me.

Now facing that she could be avoiding again.... honestly, it triggered some suicidal thoughts for me when I first got the envelope Friday night. Ya know, really distorted thoughts like, "my existence is so intolerable even she would be better off with me dead several years later..." Blah. Took a moment to back wayyyy up from that dark spiral.

Reminding myself she is a professional, still works as a trauma therapist, is able to obtain her own support, it's been years, I do have some rights... has helped me chill the weird shame I have about the possibility she was triggered.

What she did send was very incomplete and vague, but she did describe me quite respectfully and responded super quickly. I actually expected her to make me out to be a horrible person or something, or to refuse to send anything to me but to offer to send it to someone else to go over with me.

Be careful of generalising. What she does makes no comment on others. It also doesn't change any good work the 2 of you did. Sounds like the end wasn't great.

Fair point. I guess I'm really struggling with the profession as a whole in several ways, that this become very quickly another way someone else screwed up.

It sounds as if it may be a good idea to find out the specifics of what she is required to do and then write a letter back to her pointing out the errors in dates, and the lack of other documents.

Yeah, this is what I'm going to do. Figure out what should happen, how far off this is from it, and then send a letter addressing it.