Lately in my clinical psychology work I have been writing an increased number of therapeutic letters to my clients (“therapeutic letters” are not in a report format but more like a personal letter, and part of the process of therapy, such as a description of a case formulation or a summary of the work we have been doing).
I think the main reason for this change in my behaviour is that a number of the clients I work with experience problems with memory and attention during recovery from psychotic episodes and so report having trouble remembering what we discuss in the sessions. From my end I have thought that it has been useful to provide a summary, with more detail than the couple of bullet-points that we usually come up with at the end of the session.
Writing a therapeutic letter has got me thinking about the style of letter writing, and how to convey a compassionate, validating stance while also describing my conceptualisation of what is going on for the client, and what I think might help. It provides a challenge to convey psychological concepts in manner that makes sense, is caring, and may move things forward for the client. Letter writing also feels a more linear activity than a conversation in a session, which allows for dialogue, questions and clarification. It is harder to judge how the message is coming across, compared to meeting the client and observing body language. Letter writing has a delayed feedback quality while also having more of a permanence than conversation in the therapy room. It can invite perfectionism, as I try to find the right words and think about how this letter may be something more lasting that the client may refer to. I occasionally have an image of the client reading the letter years later, and that sense of posterity can be a bit intimidating as a writer (for me at least).
I know my colleagues who use a cognitive analytic therapy approach put a lot of stock into letter writing as one of the central interventions. Also Paul Chadwick has recently described the use of letter writing in working with psychosis in his excellent book, “Person Based CognitiveTherapy for Distressing Psychosis“.
There have been broader changes within the NHS in policies concerning copying letters to patients, so that there is greater transparency in what health professionals communicate about a patient’s healthcare. I think it could mean that professionals write letters about the details of patients lives in a more compassionate way and the idea of a dialogue between patient and professional is built-in.
The act of writing can, of course, clarify things in my own mind about the approach we are taking. I have also found my own sense of compassion for clients increases by writing; it is helped at times when I have felt “cut-off” or blaisé about my client’s problems. Like good journaling, the meditation of writing a therapeutic letter allows for sustained exposure to my own thoughts and feelings about what it is happening in the therapy room.
And it isn’t one way traffic either: the other day I received a reply letter from a client about her view of the unusual experiences she has been having and what she thought was important to focus on in therapy. This was really valuable to me as this client has tended not to assert herself in the session and it has been hard to judge my efforts so far. The letter both reassured and challenged me: the benefits of a good dialogue.