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Therapy History

  1. Within this section, you will describe the patient’s therapy history to inform your diagnostic impression. Analyze the patient’s therapy history to identify the effectiveness of previous treatment(s). Analyze previous treatment interventions based on information and knowledge of the patient’s cultural background.

    Typically, this section within a psychological report seeks to answer the following questions (further elaboration within this section is encouraged where possible):

    • Who was the previous therapist (if applicable)?
    • How long did the previous therapy/therapies last?
    • What was the patient’s diagnosis?
    • What interventions did the therapist(s) use?
    • Were those interventions appropriate for the patient’s culture?
    • Was treatment successful?
  2. Medical Conditions
    Within this section, you will analyze the patient’s medical history and comment on any possible medical conditions that could influence your diagnostic impression. Interpret specific behavioral issues as they relate to salient medical conditions. If the person has any medical conditions, indicate that in this section. Integrate information and knowledge about the patient’s cultural background as it affects treatment options for medical conditions.
  3. Substance Use
    Within this section, you will analyze and comment on the patient’s substance use to identify any potential issues that could influence your diagnostic impression. Interpret specific behavioral issues as they relate to substance use. If the person misuses specific substances, indicate that in this section. Integrate information and knowledge about the patient’s cultural background to inform your interpretation of substance misuse in this patient’s case.

    Typically, this section within a psychological report seeks to answer the following questions (further elaboration within this section is encouraged where possible):

    • Which substances does the patient use? (Include any over-the-counter, herbal, and/or prescription medications.)
    • For how long has the patient used the substance?
    • What is the patient’s quantity and frequency of use?
  4. Collateral
    Within this section, you will interpret specific collateral information as it relates to your patient’s abnormal behavior and behavior patterns. You will also integrate information and knowledge regarding the patient’s culture in your evaluation of the maladaptive behavior as reported by the collateral sources.

    Typically, this section within a psychological report seeks to answer the following questions (further elaboration within this section is encouraged where possible):

    • What do other people have to say about the patient’s behavior?
    • Are there any commonalities between the collateral sources’ reports?
    • Do the collateral sources have any psychological issues that might exacerbate the patient’s problems?
    • Are there any police reports?
    • Are there any personality testing or intelligence testing reports available?