- For the most part, 700% of all diagnoses should be made with
a very thorough history. I usually tell patients in the first
session that it may take 2-3 sessions before you feel like you
are getting anything out of therapy. There has to be a get to
know each other period. In this period of time, we need to pursue
many avenues in terms of questions and past history.
- What is a thorough history? A thorough history should take
a minimum of one hour. It usually encompasses the second session.
Information continues to be pulled out in the 4th, 5th and 6th
session, even a month later. The diagnostic history clearly begins
with the patient’s presenting illness, which would be the
presenting symptoms and whey they are here, followed by past medical
history, past psych history, social history, past family history
(going back 2 generations on both the maternal and paternal sides),
school/academic history inclusive of grade school, high school
and further degrees, marital history/relationship history, dating
(how frequently, how infrequently, how long do the relationships
last).
- Have there been blood workups? Have we ruled out any physiological
cause or etiology of a disease process?
- Recreational drug use, alcohol use*.
- Criminal history, arrests, misdemeanors, felonies, DUI’s,
etc.
- Suicidal, homicidal ideation and intent, past, present or future.
- Short term and long term goals. What do they see themselves
doing 6 months or one year down the road? Do they have any at
all?
- Family or social support network? How close is the family and
their support network? Is it close by or 2-3 states away? Is it
within driving distance.
- Religion. Are they religious? Are they spiritual? (Two different
questions.) If they are involved in an organized religion, what
religion is it?
- Cultural background is very important. As discussed in earlier
areas, certain cultures practice certain rites and rituals. These
can be misinterpreted as obsessive-compulsive or psychotic behavior,
when in actually they are a part of the norm.
- Hobbies and interests, often overlooked, very important. What
are their passions in life? What do they like to do?
- Attributes, assets, what does the patient perceive, what do
family members perceive as this person’s assets and attributes?
What do they tout? In supervising many psychology students, as
well as physician assistant students, and in working with many
residents, this often goes unasked, and is not even addressed
in the psych field. This is extremely important because as clinicians,
we are taught and trained to look for illness and diagnoses. We
are not trained or focused to look at positive attributes and
assets of the patient. These are key in terms of self-esteem and
building on a foundation later in sessions.
- Openness vs. closed-minded. Are they open? Are they open to
alternative treatments? Are they closed-minded and very rigid.
Do they want specific types of treatment?
- Last but not least, always take the person as a whole, and
that is what the history is about, not only trying to ascertain
a diagnosis, but looking at this human being that has walked into
your office as a whole person, spiritually, mentally and emotionally.
You will gain the individual’s trust much more quickly,
and find there fore find a quicker path to resolution.
*People who use recreational drugs always minimize, they do not
disclose everything, ever, in the first session.
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