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Canadian Psychology / Psychologie canadienne
2015, Vol. 56, No. 1, 118 –122

© 2014 Canadian Psychological Association
0708-5591/15/$12.00 http://dx.doi.org/10.1037/a0037860

Record-Informing and Note-Taking: A Continuation of the Debate About
Their Impact on Client Perceptions
Chelsea D. Christie, Taryn B. Bemister, and Keith S. Dobson
University of Calgary
This article was written as a continuation of the debate between Mills (2012) and Bemister and Dobson
(2011, 2012) on record-keeping practices, specifically informing clients of their right to access their
records and taking notes during sessions. Prior research has found that clients react positively to being
shown their records, but no studies have examined the impact of informing clients of their right to access
their records. Research on note-taking has been mixed, showing either a negative impact or no impact.
This study investigated how perceptions of a therapist are altered by the following: (a) note-taking during
a session, (b) informing clients of their rights to access their records, and (c) the combination of
note-taking and record-informing. A total of 110 undergraduate students watched 1 of 4 videos designed
to credibly simulate a clinical intake session, and then rated the therapist’s competency and professionalism. No differences were found on perceptions of competence or professionalism scores across the
groups, suggesting that informing clients of their right to access their records and note-taking during
sessions do not have a significant influence of perceptions of a therapist. The clinical implications of
these findings are discussed.
Keywords: record keeping, note-taking, client files, record-informing

their right to access their records. In addition, although previous
research found detrimental effects of note-taking during therapy
sessions, these studies were largely outdated (e.g., Hickling,
Hickling, Sison, & Radetsky, 1984; Miller, 1992). Another author
added to this academic debate (Furlong, 2013) by arguing that
psychologists should use their own judgment around record keeping as part of a larger movement to strengthen psychologists’
professional autonomy. Consistent with the perspective of the
psychoanalytic community, Furlong asserts that professional autonomy necessitates an “optimal distance from the law” (p. 81).
Hence, she argued that Bemister and Dobson’s recommendations
serve to weaken psychologists’ ethical integrity and autonomy by
focusing on laws and risk management.
In the most recent article on this debate, Castonguay (2013)
disagreed with Furlong’s concerns about psychologists losing autonomy. She suggested that following record-keeping regulations
does not result in an unfair loss of professional autonomy for
psychologists, because they choose to adhere to the requirements
of the regulatory body when they join that organization. She
argued that professionals can still exercise their judgment autonomously as long as that behavior is within the ethical guidelines
put forth by the regulatory body. Castonguay argued that it is in the
public’s best interest for all mental health professionals to adhere
to the same norms after they are evaluated and adopted by a
regulatory body.
Despite the lack of research to date that has directly examined
the effect of informing clients of their right to access their records
on perceptions of a therapist, multiple studies have found that
clients respond positively to reviewing their records with their
psychologist (Jha, Bernadt, Brown, Sawicka, & Stein, 1998;
Laugharne & Stafford, 1996; Roth, Wolford, & Meisel, 1980).
Client access to their records has been shown to give clients
greater understanding and autonomy (Laugharne & Stafford,

A topic of recent debate in the field of psychology concerns how
therapist behaviors, such as informing clients of their right to
access their records and taking notes during session, may impact
the client’s perceptions of the therapist. Bemister and Dobson
(2011) published an article on the ethical and legal considerations
of record keeping, which unintentionally elicited this debate. The
authors made several recommendations consistent with the current
legislation and ethical guidelines (Canadian Psychological Association, 2000), including the suggestion that psychologists should
inform clients of their legal right to access their records as a
demonstration of general respect. A commentary on their article
disagreed with the recommendation and argued that following this
recommendation would tarnish the reputation of psychologists
(Mills, 2012), because it could engender distrust, damage the
therapeutic alliance, and potentially end treatment (pp. 141–142).
Furthermore, in response to Bemister and Dobson’s recommendations regarding the content and handling of case notes, Mills
argued against taking notes altogether during sessions because it
may focus too much of the therapist’s attention onto recording and
may become a barrier between the client and therapist (p. 141).
Bemister and Dobson (2012) published a reply to Mills’ commentary, which restated the legal and ethical premises for their
recommendations and stressed the speculative nature of Mills’
assertions. As Bemister and Dobson highlighted, no known study
had empirically investigated the impact of informing clients of

This article was published Online First October 13, 2014.
Chelsea D. Christie, Taryn B. Bemister, and Keith S. Dobson, Department of Psychology, University of Calgary.
Correspondence concerning this article should be addressed to Keith S.
Dobson, Department of Psychology, 539 Campus Place NW, University of
Calgary, Calgary AB T2N 1N4, Canada. E-mail: ksdobson@ucalgary.ca
118

EFFECTS OF RECORD-INFORMING AND NOTE-TAKING

1996). Kosky and Burns (1995) also found that open access to
records promotes more collaborative relationships between therapists and clients. Another result of informing clients of their right
to access their records is extending the conversation on confidentiality. An article that reviewed the literature on medical confidentiality found that patients are often confused about the limits on
confidentiality and sometimes refuse to seek treatment because of
concerns over confidentiality (Sankar, Moran, Merz, & Jones,
2003). Patients with concerns about confidentiality would likely
benefit from additional discussion about who has access to their
records. These studies suggest that confidentiality is an important
issue and that clients would appreciate being given the opportunity
to see their records and potentially think well of the therapist who
made them aware of their right to access their records.
Research on note-taking has found that the cognitive effort
expended while listening and taking notes is substantial (Piolat,
Olive, & Kellogg, 2005). This result suggests that note-taking may
have a negative impact on the ability of psychologists to provide
quality therapy. On the other hand, it has been argued that notetaking improves the therapist’s memory and reduces the effects of
the therapist’s biases (Hartley, 2002), thereby improving the therapist’s ability to deliver quality therapy. Furthermore, research
suggests that modern note-taking methods (e.g., iPad and computer) do not detrimentally affect the therapeutic relationship compared with traditional paper-pencil methods (Wiarda, McMinn,
Peterson, & Gregor, 2013). As such, there may be both beneficial
and detrimental effects of taking notes during psychotherapy sessions.
Two previous studies have examined the effect of note-taking
on ratings of a therapist, albeit they are largely outdated. Hickling
et al. (1984) had social work graduate students watch one of two
videotaped dramatizations of a therapy session. The participants
rated the therapist as significantly more favorable in the video
where he did not take notes compared with the video where he did
take notes. The ratings were higher for perceived therapist effectiveness, client reaction to the session, and total therapeutic impact.
Hickling and colleagues concluded that note-taking was viewed by
the training clinicians as distracting and detrimental to the clinical
interview. A similar study (Miller, 1992) examined the effects of
note-taking on ratings of a career counselor. The results revealed
that there was no difference in ratings between the two videos
(with and without the therapist taking notes) for perceived counselor expertness, attractiveness, or trustworthiness. There was,
however, a significantly greater willingness to see the counselor
again who did not take notes during the session. The results of
these studies indicate that note-taking may be detrimental or nonsignificant for client perceptions of a therapist.
In the absence of recent evidence on note-taking and no evidence on the effect of informing clients of their right to access their
records (record-informing), the debate on their impact has thus far
been mostly one of professional opinion. In light of this issue, a
study was conducted to directly examine the effects of note-taking
and record-informing on client perceptions of a therapist. Based on
prior research demonstrating clients reacting positively to being
shown their records, it was predicted that participants in the
record-informing conditions would rate the therapist as more favorable. Note-taking was also expected to have an effect on
perceptions of the therapist, but the direction was uncertain be-

119

cause of the outdated research and inconsistent findings on the
topic.

Method
Participants
A total of 110 undergraduate students from the University of
Calgary participated in this study. According to a power analysis,
to determine a large effect size with power equal to .80 and a
critical value of .05, a minimum of 18 participants per group was
needed (Cohen, 1992; Thalheimer & Cook, 2002). More participants per group were allocated to try to ensure that the study was
not underpowered to find a statistical effect. To partake in the
study, participants were required to be at least 18 years of age and
able to fluently read and speak English.

Materials
Four videos were created to credibly simulate an intake therapy
session. The videos were each about 9 min in length, and the script
for each was identical except for the independent variables of
note-taking and record-informing. The videos depicted a client and
a therapist’s first session together where the client presented with
excessive anxiety that emerged during her first year of university.
Both actors were female to reduce potential sources of variance
because of gender. To simulate a realistic therapy session, the
actor-therapist was a formally dressed doctoral-level clinical psychologist with considerable experience in practice settings,
whereas the actor-client was a young adult (early 20s) and informally dressed.1 The videos were recorded with high definition
cameras. Two camera angles were used for filming: one showing
both the therapist and the client and one showing only the therapist. Both angles were shown for equal amounts of time and during
the same points of the interview across the four videos. The videos
were edited using iMovie software and were carefully scrutinized
for consistency in dialogue, camera angle changes, and body
language of the actors. Two registered psychologists and a clinical
psychology doctoral student reviewed the videos to ensure they
were credible (comparing them with their own experiences as
clinicians) and consistent across the four conditions, except for the
critical differences described later.
The videos differed only in the manipulation of the two independent variables—note-taking and record-informing—to create a
total of four conditions. The four conditions were as follows: (1)
note-taking, (2) record-informing, (3) note-taking ⫹ recordinforming, and (4) control (neither note-taking nor recordinforming). In the note-taking conditions, the therapist jotted down
notes eight times throughout the interview, and the therapist introduced note-taking near the beginning of the interview by stating
that she would occasionally take notes to remember what was
discussed. In the record-informing conditions, the therapist told the
client at the beginning of the session that a record would be
created, that the client had a right to access her records, and the
steps she could take to access her records.
1
We thank Dr. Deborah Dobson and Jennifer Panek-Christie, who
served as the therapist and client actresses for the current study, respectively.

CHRISTIE, BEMISTER, AND DOBSON

120
Perceived Therapist Effectiveness
Questionnaire (PTEQ)

The PTEQ is a 22-item Likert scale that was developed for this
study to assess perceptions of a therapist. The questionnaire items
were generated according to previous literature (in particular,
Miller, 1992 and Strong, 1968) and were assessed for face validity
by the third author (KSD). The items aimed to assess characteristics that are essential for an effective therapist according to the
previous literature. The questionnaire includes five theoretical
subscales, four of which represent components of therapist professionalism and effectiveness (i.e., therapist effectiveness, attentiveness, trustworthiness/sincerity, and therapeutic value). The fifth
subscale consists of two questions assessing willingness to see the
therapist again. Examples of questionnaire items include the following: “the session appeared valuable to the client” (therapeutic
value) and “the therapist appeared distracted” (reverse-scored for
attentiveness). Scores on the PTEQ range from 22 to 110 with
lower scores indicating higher approval of the therapist.

watched and listened to the corresponding video to their condition.
Next, participants independently filled out demographic questions
and the PTEQ, using the online survey software, Qualtrics, and
laboratory computers. Participants were debriefed at the end of the
study. The data was anonymous, and the consent forms were
stored in a locked cabinet at the University of Calgary. This study
was approved by the University of Calgary Conjoint Faculties
Research Ethics Board.

Statistical Analyses
Chi-square tests and an analysis of variance (ANOVA) were
used to determine whether the groups differed on any of the
demographic variables. Because the PTEQ is a new measure,
we assessed its internal consistency using Cronbach’s alpha.
Last, we tested the effects of record-informing, note-taking, and
their interaction on perceptions of a therapist by using ANOVAs with Bonferroni corrections.

Results

Procedure
Participants signed up for the study online using the University
of Calgary’s Research Participation System and were randomly
assigned to one of four conditions: (a) note-Taking; (b) recordinforming; (c) note-taking ⫹ record-informing, and (d) control.
Conditions were randomized to different time slots. The participants signed up for time slots without any knowledge of which
condition might occur and gathered in a computer lab in groups of
approximately 15 people. They filled out consent forms and

Sample
The participants consisted of 110 undergraduate students who
were predominately female (82%) and Caucasian (49%). The age
of participants varied from 18 to 49 years (M ⫽ 20.90, SD ⫽ 3.56).
The demographic variables are shown in Table 1. Chi-square tests
and an ANOVA revealed that the four groups did not significantly
differ on any of the measured demographic variables (i.e., age,

Table 1
Summary of Sample Demographics
Condition
Characteristic
Gender
Male
Female
Ethnicity
Hispanic
Pacific Islander
Caucasian
Black
Southeast Asian
East Indian
Middle Eastern
Mean age in years (SD)
Seen a therapist previously
Yes
No
Willingness to see a therapist
Yes
No
Currently seeing a therapist
Yes
No
Majoring in psychology
Yes
No

1 (n ⫽ 26)

2 (n ⫽ 29)

3 (n ⫽ 29)

4 (n ⫽ 26)

Total (N ⫽ 110)

5 (19%)
21 (81%)

6 (21%)
23 (79%)

4 (14%)
25 (86%)

5 (19%)
21 (81%)

20 (18%)
90 (82%)

1 (3.8%)
0 (0%)
12 (46.2%)
0 (0%)
8 (30.8%)
5 (19.2%)
0 (0%)
21.1 (2.62)

0 (0%)
0 (0%)
14 (48.4%)
1 (3.4%)
4 (13.8%)
9 (31.0%)
1 (3.4%)
21.3 (2.64)

0 (0%)
0 (0%)
16 (55.2%)
0 (0%)
9 (31.0%)
4 (13.8%)
0 (0%)
20.8 (5.84)

1 (3.8%)
1 (3.8%)
12 (46.2%)
0 (0%)
8 (30.8%)
3 (11.6%)
1 (3.8%)
20.4 (2.27)

2 (1.8%)
1 (0.9%)
54 (49.1%)
1 (0.9%)
29 (26.4%)
21 (19.1%)
2 (1.8%)
20.9 (3.56)

7 (27%)
19 (73%)

9 (31%)
20 (69%)

10 (34%)
19 (66%)

5 (19%)
21 (81%)

31 (28%)
79 (72%)

20 (77%)
6 (23%)

28 (97%)
1 (3%)

25 (86%)
4 (14%)

23 (88%)
3 (12%)

96 (87%)
14 (13%)

0
26 (100%)

2 (7%)
27 (93%)

3 (10%)
26 (90%)

1 (4%)
25 (96%)

6 (5%)
104 (95%)

14 (54%)
12 (46%)

10 (34%)
19 (66%)

17 (59%)
12 (41%)

9 (35%)
17 (65%)

50 (45%)
60 (55%)

Note. Values indicate number of participants in each category and percentages indicate the percentage of each group that have that characteristic.
Condition 1 ⫽ note-taking. Condition 2 ⫽ record-informing. Condition 3 ⫽ note-taking ⫹ record-informing. Condition 4 ⫽ control.

EFFECTS OF RECORD-INFORMING AND NOTE-TAKING

gender, ethnicity, having seen a therapist previously, willingness to
see a therapist, currently seeing a therapist, and psychology major
status; data not shown), which suggests that random assignment to
condition was successfully attained.

Internal Consistency of PTEQ
The PTEQ total scale and most of the subscales exceeded the
minimum reliability standard for Cronbach’s alpha (0.70). Specifically, the PTEQ has excellent overall internal consistency
(Cronbach’s alpha ⫽ .91), whereas the subscales had acceptable to
good internal consistency (Cronbach’s alpha ranges from 0.71 to
0.81), with the exception of the Trustworthiness/Sincerity subscale,
which had only moderate reliability (Cronbach’s alpha ⫽ .56).

Effects of Record-Informing and Note-Taking
The results of the overall PTEQ scores indicated that recordinforming and note-taking did not significantly affect ratings of the
therapist, record informing: F(1, 106) ⫽ 1.13, p ⫽ .29; notetaking: F(1, 106) ⫽ 0.06, p ⫽ .81 (Table 2). Similarly, there was
no significant interaction between note-taking and informing clients of their right to access their records, F(1, 106) ⫽ 0.15, p ⫽
.70. The results on the PTEQ subscale differences were also not
significant, because none of the components of the PTEQ were
significantly affected by record-informing, note-taking, or their
interaction. The only result that approached significance was the
effect of record-informing on the Attentiveness subscale, F(1,
106) ⫽ 3.43, p ⫽ .067. This trend suggested that the therapist was
perceived as more attentive in the conditions in which the client
was informed of her right to access her records.

Discussion
The purpose of this study was to investigate the effect of
note-taking and informing clients of their right to access their
records on perceived therapist professionalism and effectiveness.
Both note-taking and record-informing were expected to have
significant effects, although only the latter effect was hypothesized
to be in the positive direction. These hypotheses were not supported. The only result that approached statistical significance
indicated that record-informing may have a favorable effect on
perceptions of therapist attentiveness. This trend is generally consistent with previous findings that clients respond favorably to

121

being able to access their records (Jha et al., 1998; Laugharne &
Stafford, 1996; Roth et al., 1980).
This study failed to replicate previous research studies that
found that note-taking during sessions has detrimental effects on
perceptions of therapists (Hickling et al., 1984; Miller, 1992). The
differing results may be partially because of the sample selection,
type of session, and frequency of note-taking. For instance,
Hickling and colleagues’ sample consisted of social work graduate
students who may have had preexisting expectations about
whether note-taking is appropriate given their clinical training. In
addition, the current study focused on note-taking during an intake
session, which may be perceived more positively than in a typical
therapy session because the therapist may be expected to write a
report or provide the client with a diagnosis afterward. Last,
Hickling and colleagues did not report how frequently their actortherapist took notes, so it is possible that the actor-therapist in their
study took copious amounts of notes and appeared distracted to
participants.
One possible explanation for this study’s null findings is that the
manipulations of note-taking and record-informing were too subtle to
significantly alter perceptions of the therapist. For example, only two
comments in the dialogue were devoted to the therapist informing the
client of her right to access her records. In contrast, note-taking
occurred throughout the session and may have been more apparent.
The therapist took notes eight times (almost three times the frequency
of Miller’s, 1992, study) and had a notepad on her lap. It is important
to highlight that these manipulations, although arguably subtle, resemble that of clinical practice. This study was particularly designed
to be high in external validity (see Method), and the therapist was
instructed to take notes at natural places in the session. It is also
noteworthy that the overall ratings of professionalism and effectiveness were high, because they averaged about 5.5 on a 7-point scale. It
is possible that variables, such as informing client about access to
records or note-taking, may affect the perceptions of therapists with
lower values of professionalism and effectiveness more than in the
current circumstance.
Notwithstanding the care that was taken in the design and methodology of the study to carefully control the variables of interest, there
are limitations to the current study. An undergraduate student sample
was employed. Their perceptions may not generalize to the general
population, so future research could utilize community or clinical
samples to increase its generalizability. Another limitation of this
study is that we cannot eliminate the possibility that the failure to find

Table 2
Mean Scores on the Perceived Therapist Effectiveness Questionnaire (PTEQ)
Condition, M (SD)
Subscale

1 (n ⫽ 26)

2 (n ⫽ 29)

3 (n ⫽ 29)

4 (n ⫽ 26)

Total (N ⫽ 110)

F

p

␩2p

Trustworthiness/sincerity
Effectiveness
Attentiveness
Therapeutic value
Willingness to see therapist again
Total

15.42 (4.56)
7.69 (3.12)
12.38 (4.44)
7.38 (3.31)
5.42 (2.44)
42.88 (13.71)

15.03 (3.00)
7.62 (2.80)
11.41 (4.05)
7.07 (2.74)
5.41 (2.31)
41.14 (9.80)

15.21 (2.92)
6.55 (2.63)
10.86 (3.82)
7.21 (2.96)
5.21 (2.60)
39.3 (10.09)

14.5 (3.00)
7.62 (2.76)
12.77 (4.00)
7.69 (2.48)
5.65 (2.38)
42.58 (9.80)

15.05 (3.38)
7.35 (2.83)
11.82 (4.09)
7.73 (2.86)
5.42 (2.41)
41.55 (11.00)

0.35
1.07
1.27
0.24
0.15
0.45

.79
.37
.29
.87
.93
.72

.01
.03
.04
.01
.004
.01

Note. Condition 1 ⫽ note-taking. Condition 2 ⫽ record-informing. Condition 3 ⫽ note-taking ⫹ record-informing. Condition 4 ⫽ control. Lower scores
indicate higher approval of the therapist.

122

CHRISTIE, BEMISTER, AND DOBSON

between-condition results is because of type II error. According to a
power analysis calculation, the study had enough power to detect a
medium to large effect (Cohen, 1992), which is what was expected
based on previous research (i.e., Miller, 1992). However, the effect
sizes in the current study were small; sample size calculations based
on the current results indicated that a sample size upward of 1,000
participants would be needed to elucidate differences between the
groups (Cohen, 1992). It is noteworthy that the effects support the
positive impact of record-informing and note-taking on perceptions of
the therapist, although the clinical significance of these effects remains dubious given their small size. Nonetheless, the results provide
strong evidence against Mills’ (2012) claims that note-taking and
record-informing negatively affect perceptions of the therapist.
The results of this study have important implications for clinical
practice, because they suggest that the therapist behaviors of
note-taking and record-informing do not significantly alter perceptions of the therapist. Therapists may therefore choose to take
notes to enhance their memory of sessions. Similarly, therapists
can inform clients of their rights to access their records because it
does not negatively affect the relationship, and, as Bemister and
Dobson argue (2011), it demonstrates general respect for clients
(Principles 1-I.4 of CPA’s Code of Ethics, 2000). On the other
hand, informing clients about their rights and note-taking do not
appear to enhance perceptions of the therapist, so therapists are
still able to use their own clinical judgment, in conjunction with
their knowledge of relevant research, when they decide to engage
in note-taking and record-informing. This study serves to add
empirical evidence to the debate on the impact of record-informing
and note-taking, which has largely been based on professional
opinion up to this date (e.g., Bemister & Dobson, 2011, 2012;
Mills, 2012). Thus, this study adds a valuable contribution to the
literature, as well as helps inform therapists and clinical practice.

Résumé
Cet article a été écrit pour faire suite au débat entre Mills (2012)
et Bemister et Dobson (2011, 2012) au sujet des pratiques relatives
a` la tenue de dossiers, en particulier celle d’informer les clients de
leur droit de consulter leur dossier et de prendre des notes pendant
les rencontres. Les recherches antérieures ont montré que les
clients réagissent positivement a` la lecture de leur dossier, mais
aucune n’a examiné les répercussions d’informer les gens de leur
droit d’accès a` ces dossiers. Les résultats des recherches sur la
prise de notes sont mitigés, certains révélant un effet négatif,
d’autres, aucun effet. La présente étude s’est penchée sur la façon
dont les perceptions qu’on se fait d’un thérapeute sont influencées
par les éléments suivants : a) la prise de notes pendant une
rencontre; b) le fait d’informer les clients de leur droit d’accès a`
leur dossier; c) la combinaison de la prise de notes et de
l’information sur le dossier. Cent dix étudiants inscrits a` un programme de premier cycle ont regardé un de quatre vidéos illustrant
de façon crédible une séance clinique, puis ils ont évalué la
compétence et le professionnalisme du thérapeute. Aucune différence n’a été trouvée quant aux scores attribués a` la perception
de la compétence ou du professionnalisme parmi les groupes, ce
qui suggère que le fait d’informer les clients de leur droit d’accès
a` leur dossier et la prise de notes durant les rencontres n’ont pas
une influence notable sur les perceptions qu’on se fait d’un

thérapeute. Les répercussions cliniques de ces résultats font l’objet
d’une analyse.
Mots-clés : tenue de dossiers, prise de notes, dossier des clients,
informer du droit a` la consultation des dossiers.

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Received March 5, 2014
Revision received June 16, 2014
Accepted July 22, 2014 䡲

Reproduced with permission of the copyright owner. Further reproduction prohibited without
permission.


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