Dr Saida looked through the previous week’s notes about Shida. She remembered the girl as she had been so distraught and wanting to run away before the session. She was looking forward to hearing more about her. Her diary was full today and she hoped that all the clients would keep time so that she could get to choir practice on time this evening.
Shida presented an all too common scenario. Relationship issues were common in her age group, the young-adult stage of life. This was the age to identify a man or woman to share life with, in a significant way. Shida’s relationship had all the red flags, but something in her family background was making her blind to them! The doctor suspected an anomaly in her early childhood that may be causing her some emotional trouble to-date. “This is why it is very important to take a full and detailed history of the client,” she thought to herself. As it is, the context of the client is cardinal in understanding the client’s current situation and issues.
Dr. Saidia planned to take Shida’s full history in today’s session. This would involve her sharing a lot of details about her life that would make Dr. Saidia be able to help her. Her family background would be the place to start. In this part, she would learn about Shida’s nucleus family and the relationship dynamics in it. In addition, she would also learn about any history of mental illness in the family, both the immediate and extended. This would be important in identifying any patterns of mental illness in Shida’s family.
Clinicians are interested in the totality of the client, therefore, the doctor will ask Shida about the situation of her own mother’s pregnancy with her. In addition to her mother’s pregnancy, the doctor will also assess Shida’s developmental milestones from birth until adulthood. Information on Shida’s beliefs about herself will be necessary to help the therapist understand her (Shida’s) view of self. For a lot of people, the problems they experience have been maintained by a negative or wrong perception of themselves. Knowing this will help the clinician to identify the areas that need working on.
Another important aspect of history taking is identifying a client’s social circle and significant others. One of the reasons why this is important is that it helps the therapist assess the client’s support system. In some cases, however, some of the client’s problems may be due to some of the relationships in their lives. All this needs to come to the fore so that the therapist takes note of what needs to be explored and clarified.
In history taking the therapist will also want to know about the client’s school, career and marriage history where applicable.
This initial history taking session may take one and a half hours. This is more than the regular one- hour sessions that are the norm with the therapy of individuals. Most clients are usually surprised whenever the hour ends, thinking it is very short. However, it is a researched fact that it is sufficient for both the therapist and client to deal with the issue at hand for that session. What remains is addressed in subsequent sessions. It becomes counterproductive to make it longer and sometimes this may make it end up being just a friendly chat.
All this information will help Dr. Saidia diagnose Shida’s problems which will, in turn help her devise and recommend a treatment plan to Shida. Together they will clarify the goals for therapy and then therapy can begin.
Presently, Dr Saidia is pleased to hear Shida, her first client of the day arriving 15 minutes earlier than the scheduled time. She smiles to herself and is grateful about Shida’s punctuality. She actually is waiting to hear Shida’s story and help the lady to straighten her life. This case promises to be quite challenging since Shida had indicated that she was her father’s third wife’s firstborn daughter, had been molested by her father. This resulted in her getting a baby. She isn’t sure if this baby is her half-brother or son! She could not bear the idea of having the child and thus procured an abortion. This was one of the reasons her boyfriend had broken up with her.
Photo Credits: Pinterest.
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