2024 Author: Harry Day | [email protected]. Last modified: 2023-12-17 15:43
Demographic data
Name, age, gender, ethnicity, race, religious orientation, relationship status, parents, educational level, job, previous psychotherapy experience, who referred to therapy this time, other (besides the client) sources of information.
Name - specify whether the client wanted to change the IFO earlier or now, if so, what is it connected with.
Age - specify how he relates to his age, feels his age, whether aging and death worries.
Ethnicity and race - clarify his attitude towards representatives of a different racial and ethnicity, whether he feels proud of belonging to a particular race, ethnic group.
Religious orientation - ask the client whether it is possible to freely discuss religious views within the framework of the analytical position, if the atheist is due to what is the reason, if the believer is how dogmatic he is to a certain religious group, his main views (idealized images of father and mother, oedipal problems, the nature of Oedipus)
The state of the relationship - the nature and duration of the relationship, how the client characterizes them (can he see problems in his relationship)
Level of education - specify whether he himself chose his education, whether he strove to be the best, the nature of relations in the group, the nature of conflicts and their frequency.
Current problems and their status
The main difficulties and the patient's understanding of their causes, the history of these problems, the treatment undertaken, why he came to therapy right now.
The nature of the client's request, namely its compliance with the professional opinion of the therapist, will reflect the observing ability of the ego, which in turn is an important diagnostic indicator. At this point, confrontation to analyze the characteristic defenses of the client is very appropriate.
Personal history
Where was born, grew up, the number of children in the family and the place of the patient among them, the main moving. Parents and siblings: get objective data (whether they are alive, causes and time of death, if they died; age, health, profession) and subjective data (personality, nature of the relationship with the client). Psychological problems in the family (diagnosed psychopathology and other conditions, such as alcoholism).
In this place, we can get exactly the material that will allow us to further identify inconsistencies with other parts of the client's diagnostics and this, as a result, can demonstrate how the client is able to test reality
Infancy and childhood
Did the patient's parents want a baby, family conditions after birth, something unusual during critical periods of development, some early problems (food, toilet, speech, physical activity, nocturia, nightmares, falling asleep, biting or not nails, etc.).), early memories, family stories or jokes about the client.
Latency period
Separation problems, social problems, academic problems, behavioral problems, cruelty to animals, illness, moving or family stress during this time, sexual or physical abuse.
It is always worth remembering here that information about violence against a client can be provided by the client's perception and not be related to real actions, however, confrontation in this place can cause regression and traumatic actions for the psyche as a disabled child's environment.
Adolescent period
Age of puberty, physical problems associated with puberty, family preparation for sexuality, first sexual experience, masturbatory fantasy, school experience, academic performance and socialization, self-destructive patterns (eating disorders, drug use, doubts about sexuality, risky excesses, suicidal impulses, antisocial patterns); illness, loss, relocation or family stress during this time.
Adulthood
Work history; relationships; the adequacy of the current intimate relationship; attitude towards children; hobbies, talents, pride, or satisfaction.
Current views (mental status)
General idea, state of affects, mood, speech quality, presence of reality testing, intelligence level, memory adequacy, assessment of information reliability. Explore the possibilities of further development of areas of perceived problems, for example, in depression - the possibility of suicide.
Dreams: Are They Memorable? Some are repetitive, some are recent.
The substances used - described and others - as well as alcohol.
the adequacy of the current intimate relationship - ask for a detailed emotional portrait of the significant person. If the client describes it superficially, laconically, this may be one of the signs of ego weakness.
Finally
Ask the patient if there is any other important information that they have that they have not been asked about.
Ask if he was comfortable and if he has anything to say.
conclusions
Major current topics, areas of fixation and conflict, basic defenses, unconscious fantasies, desires and fears; central identifications, counter-identifications; unmourned loss; connectedness of one's own “I” and self-esteem.
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