Turns Out Sam Faked Her Notes

Ending my time with Sam was the beginning of another journey. Whether I wanted it to our not, my mind wanted answers. What had happened, how had it happened, what was Sam’s perception throughout it all that allowed her to mess with me the way she had? Was it all, in some way, my fault?

During the whole ordeal, Sam was scrupulous about taking notes. When we were meeting in her office and I was about to tell her about a dream I’d had, she would grab a pad and write very fast to capture what I’d said, often asking me to repeat something so she’d get it right. When we went to video sessions at the start of Covid, I noticed that she was taking copious notes by hand and she told me she had decided to use this time to work on her note taking. So all of our conversations had been captured, in at least some detail, in handwritten notes. And by both law and insurance requirements, each of our sessions was required to have a “Progress Note” typed into her practice management software and locked from further edits when finished.

Notes were important to Sam. A couple of sessions after my breakdown, I asked her why she had chosen to write down a certain phrase of mine. She responded:

Because I want help keeping my thoughts organized. Because this is this is a very emotionally laden conversation that we’re having. It’s very charged. There’s a lot at stake. And I’m wanting to do everything I can to think clearly and writing things down helps me do that. And you’re laying out a conflict and conflicts beg to be written out.

My attorney requested her notes. I had done so twice while still seeing her (see my post “Letter to Sam” for one of them), but she had ignored both requests, even while overtly agreeing to one of them. At first she sent a small number of notes, then, when my attorney pointed out that she had missed a lot and we would know it because I had recordings, she provided more, along with a notarized certification that she had sent us everything she had.

Dear reader, she did not. And many that she did were riddled with ass-covering false statements that my recordings could refute.

I recalled talking to her about her notes and her telling me about them.

[T]here needs to be a diagnosis and there needs to be a treatment plan with objectives and identifiable interventions. And that’s all you know, a lot of bullshit. I mean, not with everyone, but with us.

Upon reviewing the Progress Notes I discovered that they contained material misrepresentations and falsehoods. Following are a few examples (there are more) of these apparent falsifications. I can’t publish images of these, as they have real names on them.

• Most egregiously, in her Progress Note of our June 15 session, in which I told her that I thought I was having a heart attack during the previous 10 days and wanted it to end my life, Sam recorded “Px denies SI” (patient denies suicidal ideation).” I had expressed a desire to die or, at least, not save myself from doing so. Further, I have the entire session recorded and she never asked about suicidal thoughts. What was she doing writing this, both here and in later notes? Well, my guess would be that she actually thought I was at risk of hurting myself and wanted a record that she’d asked me and I’d said not to worry so that she wouldn’t get in trouble if I was found at the business end of a noose.
• In her Progress Note of July 20,2021, Sam wrote: “Pt reports ongoing difficulties with sleep, focus, self-doubt, ‘skepticism’ of thx and ongoing relational disconnection. Mood predominantly sad, irritable. Addressed persecutory anxiety, Focused exploration on thx’s use of therapeutic phrase pt reported as ‘triggering’, provided psychoeducation re: same. Discussed pros and cons of medication consultation, pt continues to decline, feels can manage on his own. Reports no SI.” I recorded the entire July 20 session. At no time did I mention sleep or focus difficulties. Further, there was no discussion of medical consultation or whether or not I claimed to be able to manage on my own. (In fact, at no time since my breakdown began did she ever raise the idea that I consider medication; much less that I “continued to decline it.”) There was no discussion of suicidal thinking or intention, then or ever.
• Her Progress Note for July 22,2021 reads: “Pt reports continued difficulty managing sadness, mistrust and frustration in his significant relationships, and increased anxious sx and sleeplessness additionally associated with current work challenges… Significantly elevated levels of depressive and anxious sx and increased life stressors now including financial. Pt reports feeling slightly less intensively sad as a result of exploration in sessions over past several weeks which has allayed some mistrust, but continues to feel victimized in multiple domains. Focused on reviewing strategies for compartmentalization of tasks, perspective taking and emotional expression, also sleep hygiene.” I recorded this entire session. In no instance did I mention increased anxiousness, sleeplessness, work or work challenges or the subject of finances. And in no instance did Sam speak about compartmentalization of tasks or perspective taking or emotional expression or sleep hygiene.
• As mentioned earlier, in her Progress Note of January 18, 2021, she recorded “Pt expressed wish to increase session frequency due to current life stressors, discussed same in context of clinical guidelines, advised against.” However, after that session, I wrote her an email in which I thanked her for offering to lower her rate so we could have the second weekly sessions, which began approximately two weeks later. So she must have been writing that to cover her ass.

Not only did she falsify records, it appears that she also either withheld or destroyed “Progress Notes” for sessions that bore directly on the events surrounding my breakdown. For example, she billed insurance for the May 28, 2021 session in which she told me that she loved me, however she did not provide a Progress Note for that session. Similarly, she did not provide a Progress Note for the June 3, 2021 session when she took back her “I love you,” nor did she provide one for the emergency June 4, 2021 session she insisted on having when I told her I was having a breakdown. No Progress Note was provided for the session in her office or one a week later.

Sam kept detailed handwritten notes and I watched her writing during almost every session. She often asked me to stop and repeat something he had said in order to record it accurately. However, despite attesting that she had turned over to my attorney all of her records, no handwritten notes for any session (but one, see below) that involved discussion of our “relationship” were produced. That she took notes that were not turned over is proven by several recorded instances in which she and we discussed specific notes she was taking or had taken. That quote about conflicts begging to be written down? No handwritten note from that session. There are more examples.

Sam did provide one complete page of notes from our next to last session on September 9, 2021.

While she presumably included this note because she thought it was exculpatory, in it, she records that she had said “I love you” as the basis for my subsequent breakdown. But, more importantly, this note is an example of the detail with which she took notes in general. Because a significant number of similarly detailed notes relevant to our relationship and what we said about it are missing, she has made it impossible to reconstruct a record of what transpired in my “treatment”.