In their own words: note-taking and legal considerations in gender-based violence cases

November is a time of family and cultural celebrations. However, it also marks the International Day for the Elimination of Violence against Women, followed by 16 days of activism. As a former frontline worker in emergency shelters for women escaping violence and abuse, this month holds deep significance for me.

Even after transitioning from a decade of work in women's emergency shelters and a nearly 20-year career advocating for women and children, the impact of those experiences remains. For many women and girls, this time of year can mean increased emotional and psychological stress.

Rather shockingly, nearly 1 in 3 women globally experience physical or sexual violence from an intimate partner, in addition to emotional, financial, and other forms of abuse (United Nations, 2023).

The importance of note-taking in GBV cases

Gender-based violence, particularly intimate partner violence, presents unique challenges for mental health professionals. As healthcare professionals, we are often the first point of contact for victims, and how we respond when someone discloses abuse can have a profound impact.

In my experience, clients experiencing abuse may be hypervigilant due to the constant need to assess unpredictable and volatile moods in their partners. Being able to document sessions without triggering a hyperarousal state is crucial. Using AI note-taking allows for better listening while still capturing necessary data, fostering a strong therapeutic relationship and supporting the victim's sense of safety and healing.

Many survivors struggle to find their voice, especially at critical junctures in their journey to safety. Providing a compassionate, safe space for expression is vital for healing, regardless of whether that space is provided by doctors, nurses, therapists, or social workers.

One way I've been able to improve my support for both myself and my clients is by utilizing AI note-taking tools. These tools are particularly valuable in helping clients find their voice. While accurate documentation and attention to detail are essential note-taking skills in therapy, GBV cases require additional considerations. 

Accurate documentation can also play a crucial role in ensuring ongoing safety. However, balancing the need for detailed records with the importance of capturing the survivor's experiences in their own words can be challenging.

The importance of documentation for GBV clients

Early in my career, I learned that support for GBV survivors can quickly become a matter of life and death. Research into femicide shows that the risk of serious harm, including domestic homicide, increases significantly when a victim tries to leave an abusive relationship. This risk can remain high for up to two years after an abusive relationship has ended. 

Detailed and accurate documentation not only supports treatment but can also provide evidence useful in obtaining restraining orders, and empowering survivors to advocate for themselves. These are some of the key reasons I've chosen to use Upheal.

9 ways Upheal supports note-taking in GBV cases

Here are eight key points I've learned about maintaining presence for my clients while ensuring proper documentation, and how Upheal facilitates this process:

1. Prioritizing client safety

Upheal allows me to organize my documentation more than traditional note-taking methods. By reviewing and refining notes after sessions, I can ensure accuracy and identify areas for further exploration. Additionally, the tool facilitates the collection of crucial information, such as client allies' contacts and other service contacts for safekeeping should a client need to leave their home quickly.

Confidentiality risks

‍It's crucial to be mindful of how documentation could put a client at further risk. Having information that may be accessible to their abuser like phone, or text messages, emails or mail correspondence will increase the risk of harm if a client needs to leave.

Safety planning

‍Documentation should avoid details that could compromise a client's safety. Exploring safe friends and family members or offering to keep a copy of important documentation or a safety plan outside of their home can prevent it from falling into the wrong hands.

2. Asking for consent

In my experience, obtaining informed consent helps my clients to feel in control of their information. Upheal, explains in great detail how information is captured, transcribed and stored, who has access to it, and that the audio file is deleted after transcription. 

If a client prefers I not record a session, I ask to dictate my notes into Upheal afterward. 

This transparency helps to build trust and ensures clients feel comfortable and empowered in their therapeutic journey. GBV clients have a say in how I write my treatment plans and my notes. I also tell them about the risks of sharing their files during criminal or family court cases. 

3. Building Risk assessments and Safety plans

Having access to Upheal's AI transcripts, allows me to use these as a tool in the collaborative creation of risk assessments and safety plans. Reviewing post session notes can help clients recognize the extent of the abuse they've experienced and develop strategies for safety. Being able to have someone be with them while they reflect back and acknowledge abuse may be truly eye-opening and important to the healing process, since it may not be obvious to a victim at the time that the situation is truly serious. 

Conducting a lethality-risk assessment

A risk assessment should be more comprehensive than a safety plan. I would argue that of the two documents, a Risk Assessment Tool is the more important. It uses past behaviors to identify future risks. 

I recommend you use a structured document like the Danger assessment, or SARA with specific questions to gauge the risk of serious harm associated with leaving an abusive relationship. When I audiorecord a risk assessment, I can interview a client and stay focused on getting as much information as I can. Without having to stop to write or asking them to repeat themselves helps save valuable time in completing the assessment too.

Completing a Safety plan

‍A safety plan should be regularly updated to accurately reflect the client's current circumstances. Whether the client's IPV safety plan is comprehensive or straightforward, secure storage of this document is essential. The plan should also consider and incorporate demographic factors unique to the client, including aspects of marginalization such as First Nations identity, LGBTQIA+ status, mental health needs, immigrant experiences, and BIPOC identities, to ensure it effectively addresses their specific needs and vulnerabilities.

4. Ensuring understanding of consent and disclosure

Upheal helps me to ensure that I have reviewed important information and risks to safety with my clients – both for themselves and their children (see more on this important topic lower down in “Following legal and ethical guidelines”).

Informed consent

‍It's crucial that clients understand the limits of confidentiality. This includes mandatory reporting requirements related to child abuse or potential harm to themselves or others. Additionally, clients need to be aware of the possibility of subpoenas in legal proceedings. Always consult with your regulatory body and adhere to provincial or state laws regarding disclosures of abuse, neglect, or imminent risk of harm. And you can read this to understand more about which information may be subpoenaed on Upheal.

Documenting threats

‍Any threats or acts of coercion must be accurately documented, especially those involving potential harm to children. During moments of crisis, it is easy to miss asking key questions or reviewing important information. We may have to go beyond confidentiality when a child or the client themselves are in a place of imminent risk of harm. After a session, when I review the session transcript I can ensure information is accurately documented.   

If you are ever unsure if something that has been disclosed to you by a client should be reported, check with your regulatory body and your state or provincial laws.  

5. Maintaining objectivity and professionalism 

Upheal allows me to record my observations in the moment, ensuring a more accurate and objective record. In the past, I didn’t feel like I was capturing all the relevant information, and I worried that my own biases overshadowed clients' lived experience. I feel that being able to ask for clarification or more information, knowing that it is accurately captured in real-time while using Upheal’s transcription software helps to ensure that I am not misinterpreting my clients.      

Objective note-taking

‍I focus on factual statements directly from my clients, rather than personal interpretations as much as possible. 

Direct quotes

‍I use the client’s exact words whenever possible to ensure clarity and accuracy.  I can also support them in finding their voice by reflecting back using their own words, knowledge, and understanding of what has happened to them.   

6. Using neutral language

In the past, I found it challenging to capture the intensity of a session while maintaining a neutral tone. It’s always been best practice to review notes to ensure they accurately reflect the session, including all essential details. I can modify Upheal’s generated notes or adjust the style and emphasize the most relevant details. While it’s still essential to review AI transcriptions for accuracy, my notes are clearer, more consistent and it takes me less time to review. 

Non-judgmental terminology

‍Avoid emotionally charged or judgmental language. I also try to use more neutral terms and I try to verify with clients what they said, and what I am seeing by asking for clarification: “Can you tell me more about what you're feeling right now?”

7. Capturing relevant details

It is easy to miss key details when trying to document injuries, threats, or controlling tactics that a client describes. Using Upheal helps to review previous sessions, reported injuries, and pertinent details. This is particularly important if a client may be seeking a restraining order from an abuser. 

Concrete descriptions

‍I provide detailed, factual descriptions of injuries, threats, or incidents in the client's own words. I include specific dates, times, and locations whenever possible. This makes the documentation reliable for both therapy follow-up and potential legal purposes. In addition, I can create a Client note for the client that summarizes the session, helps to simplify, and outline the next steps and plans for future appointments.  

8. Following legal and ethical guidelines

I believe it’s important to be prepared for the possibility of records being subpoenaed.  Upheal helps me keep my documentation organized with professional language, treatment plans, defining goals, and key information relevant for the client and their case. 

Upheal further supports my work by providing tools to edit and anonymize information directly within my notes. This includes concealing personal details, locations, individuals’ identities, and any sensitive information that could increase risk for my client, such as critical elements of their safety plan or details that are irrelevant to the specific request.

Legal obligations

‍During instances when it’s been necessary to provide notes to clients, or a third party, like insurance providers or court orders for legal reasons, I can save time by utilizing edit features for redacting non-essential information. 

Please note you can find many answers to regarding privacy, security, and legal requests on the Upheal Support center including:

• ‍Can the documentation stored on Upheal be subpoenaed?‍
• What documentation stored on Upheal may be subpoenaed?

9. Build hope on the road to reclaiming their lives

Lastly, our records can serve as a reminder of a survivor's progress. The analytics drawn from session notes allow us to track that progress easily and highlight the contrast between the initial trauma and the client's resilience as they heal and reclaim their lives. Many of my clients are surprised by the positive changes they make as they move further away from their abusers.

Going forward

I feel that as advocates, proper documentation is one of our most powerful tools when working with survivors of GBV. It's not just about ensuring a safe therapeutic space; our documentation can also ensure ongoing physical and emotional safety. While November is the month we hold the International Day for the Elimination of Violence against Women, GBV happens daily. I hope these points are useful to other practitioners because I believe by incorporating these key points into our practice, can help us to effectively advocate for clients' safety and well-being both inside and outside of therapy.