Taking A Patient History In A Hypnotherapy Session

 

Patient History – Identifying The Problems & The Underlying Causes

Your patient will tell you what they think is the problem and probably offer as number of explanations for the cause.

Milton Erickson always said that the patient will unconsciously tell you what the real problem is within the first few minutes even if they do not consciously know themselves. You have to be highly receptive to what they tell you.

For each of their reported symptoms, you need to establish a complete patient history of a problem

  1. When a symptom first appeared and what else was happening in their life at this time
  2. When it was at its worst and how frequently it occurred then
  3. How often it occurs now
  4. Under what circumstances it occurs: with a particular person, in a particular place or at a certain time.
  5. Is there a common trigger that sets off the problem.
  6. When it doesn’t happen
  7. How the symptom happens – the exact sequence of events
  8. How long does it last
  9. What else is happening at the same time
  10. What is happening in their family and relationship life currently and historically – any patterns?
  11. The occurrence of any traumas in their life
  12. If they have had medical or psychiatric treatment.
  13. Are they currently taking any medication or receiving any other treatment (you should check this befor they see you – but always recheck in the session)
  14. What do they think about their problem and what do they think has caused it

Once you have the complete patient history then you will want to summarise this information for them and ask them if there is anything they might want to add or correct.

While you are taking the patient history then you will trying to identify the following:

  1. What is the real problem (or problems)
  2. Is there a deep underlying problem that needs to be identified. Do they need to know about it or can you work on it without their conscious knowledge.
  3. Secondary gain – Does the problem actually have an advantage for them so that they are hanging on to a particular behaviour? They may or may not be aware of this if asked.
  4. Are they unconsciously supressing a problem or a possible cause because they find it difficult to consciously deal with it?
  5. Ecology – Are they best left with the problem if you suspect that dealing with it could be more problematic and possibly traumatic?
  6. Look for mismatches between verbal and non-verbal behaviour
  7. Establish what is their normal body language – how do they show signs of tension, stress, dishonesty, deflection or emotion
  8. If it is safe to do so then you should have them demonstrate or elicit from them the problem behaviour. It is very useful to know exactly what happens. Have them describe the problem in detail and relive an event if it is not traumatic.

You should also be careful about how you ask questions

  1. Do not use the word ‘problem’ if you can help it
  2. Do not give any opinions, advice or judgements of any kind
  3. Do not interpret anything for them – discovering things themselves, even if lead by you is much more powerful and effective

You will then need to establish exactly what the patient would like to happen. What they hope to achieve from the specific session and overall from treatment. You may want to give them feedback on what you think is realistic or if you think that the problem is not exactly how they perceive it. You can offer them an initial assessment if you believe that this will help or that their expectations are unrealistic or misguided.