Insights into using AI from a Mental Health Therapist and Documentation Expert
In an era where technology permeates every aspect of our lives, it’s no surprise that artificial intelligence (AI) is finding a home in mental health care. One area where AI is gaining greater use is in the creation of progress notes for therapy sessions. AI platforms tout the convenience and efficiency of AI-generated notes, but as a practicing therapist and documentation expert, I have reservations about their impact on client confidentiality and privacy, their efficacy, and their effect on clinical work. Though AI is a very useful time saver for some things, like developing worksheets and homework for clients, letter writing and other administrative tasks, I am not a fan of using AI for clinical documentation.
Are AI-Generated Notes HIPAA Compliant?
Every AI company I’ve looked at that specializes in mental health documentation, promises they are HIPAA compliant and as secure as secure gets. However, given the recent cyberattack on Health Change, the largest clearinghouse for insurance billing and payments, my trust in the security of client information is not high. You probably already know this, but it bears repeating; if you use AI, omit all identifying information. It’s one way to help keep private information private, at least sort of.
Confidentiality and Privacy
Another significant misgiving I have with AI-generated progress notes is the reliance on session recordings and transcriptions. Even though the information you fed into AI is deidentified, the more often one uploads information about the same client with recurring details and themes, the greater the chance someone intent on finding the information could piece it together and identify the client. It would take considerable work from a bad actor to hack a program for this information, but companies that collect client information are data rich and therefore an alluring target.
Given how a big company like Change Health was hacked, I’m concerned that sophisticated cyber criminals will develop more ways to mine the data of smaller companies. Having my life turned upside down by the Health Change breach and figuring out how I’m going to get paid for my sessions reminds me that anything can be hacked if someone wants the information bad enough.
Does AI Really Help With Time Management?
While some therapists love AI-generated notes, insisting they save valuable time and effort, I am not convinced. AI platforms don’t accurately capture the nuances of therapeutic sessions. Often, these algorithms produce overly detailed notes, incorporating interventions that were not used and details that were not present or relevant. This means that therapists need to review every AI-generated note, clean up the mistakes and then copy and paste the information into their template. It could take more time reviewing and uploading the AI note than writing one’s own.
My opinion is controversial and I’m sure AI lovers will disagree with me. I’m OK with that. Though I’ve looked at several AI platforms for mental health progress notes, I’m not an expert in this subject. Perhaps, once you fine tune the template you use and know exactly what information to feed the program, AI can do a good job and do it quickly. But there is one last important reason why I’m not a fan of AI note writing.
AI-Generated Notes Don’t Contribute to Clinical Thinking
Therapists weren’t taught clinical documentation in graduate school and most likely did not learn it on the job. Many therapists find AI for note writing attractive because they are intimidated by the documentation process.
Plus, no one likes spending unpaid time writing their notes. But if you know the requirements and how to implement them, documentation can be quick. It also provides valuable time for what I call “self-supervision.” Self-supervision gives us the opportunity to reflect on what happened in session; what worked, what didn’t work, why, and the direction for the next session. Writing notes is not just about documentation; it’s a form of reflection and self-supervision essential for professional growth and competence.
Outsourcing this aspect of clinical practice to algorithms perpetuates the lack of training and knowledge. It undermines confidence and competence. Therapists risk diminishing their ability to think critically about their sessions and articulate their clinical insights effectively. Writing is thinking. If therapists can’t think about what they’re doing, and articulate it, how is anyone going to take our profession seriously?
While AI undoubtedly has its merits in certain areas, such as generating homework assignments and assisting with administrative tasks, its role in clinical note-writing is contentious. There are those that swear by it and those, like me, who think it’s not the ideal solution for mental health professionals.
The risks to client confidentiality, the erosion of therapeutic skills, and the potential for legal or ethical complications outweigh any perceived benefits. As therapists, it’s our responsibility to prioritize the integrity of our practice, our competence and confidence, and the well-being of our clients above perceived convenience or technological advancements.
What we really need is not someone or something to write our notes for us but to know what the requirements are and how to implement them in a systematic and efficient way so it contributes to high quality clinical care.
How to Write Notes Quickly Without Using AI
You may never love writing your notes, but if you choose to learn good mental health documentation skills, you can learn to write notes that are clinically useful and reduce the time you spend on paperwork. Learn the skills you need to be a documentation wizard in my upcoming LIVE webinar, Misery or Mastery: Documenting Medical Necessity for Psychotherapists on Friday, May 3, 2024 from 10am – 6pm EDT.
You’ll learn how to:
- Fulfill all documentation requirements.
- Reduce the time you spend on paperwork.
- Write clinically useful notes.
- Preserve client confidentiality.
- Maintain your professional standard of care.
- Reduce your anxiety.
Choose mastery over misery. Allow good clinical documentation to be a contribution to high quality care and protect your practice at the same time.
Beth Rontal, LICSW, a private practice therapist and the Documentation Wizard® is a nationally recognized consultant on mental health documentation. Her Misery and Mastery® trainings and accompanying forms are developed to meet strict Medicare requirements. Beth’s Documentation Wizard® training program helps clinicians turn their clinical skill and intuition into a systematic review of treatment that helps to pass audits, protect income, maintain professional standards of care, reduce documentation anxiety and increase self-confidence. Beth’s forms have been approved by 3 attorneys and a bioethicist and have been used all over the world. She mastered her teaching skills with thousands of hours supervising and training both seasoned professionals and interns when supervising at an agency for 11 years.