Working as a psychologist requires the presence of a consistent body of knowledge , both regarding the usual functioning of the human mind and non-typical or even pathological processes.

It also requires knowledge and understanding of how and in what cases to apply the various techniques and procedures available. However, the presence of knowledge is not the only indispensable thing to exercise as a good professional, requiring observation skills, empathy and initiative, among other characteristics. All this is necessary to be able to offer a good service to the client or patient, being the improvement of this one and the problems and demands that can present the main objective of the professional. Knowing why you have decided to come to a consultation, the story behind the problem you may have and what you expect from the interaction with the psychologist is fundamental.

To this end the psychologist must be able to collect all the data he or she may need to start working on the case , i.e. to carry out the anamnesis.

Defining anamnesis

Anamnesis is the process by which the professional obtains information from the patient through a dialogue in which the professional has to obtain basic information about the patient’s disorder or problem, his or her life habits and the presence of family history in order to establish a diagnosis of the problem to be treated or worked on.

This is the first stage of the diagnostic process, essential for the psychologist to be able to understand the individual’s life situation, his or her problem and the way in which it affects or is affected by events and personal history.

The subsequent development of the anamnesis allows the professional to detect symptoms and signs , observing not only what is said but also what is avoided, the reticence or facility to express oneself and elaborate on certain subjects. It is not only a matter of observing what is said, but also how it is expressed and the non-verbal communication that is carried out.

In general, the anamnesis is made to the subject to treat or final user, but sometimes it is advisable to make it also to relatives, friends or even teachers, as in the case of various child diseases.

The anamnesis is not only limited to the field of clinical psychology, but is also used for the diagnosis of problems both in other branches of psychology (it is extrapolated to the level of educational psychology, for example) and in other disciplines such as medicine. However, the use of this term is usually applied especially in the clinical field.

Main elements to take into account in an anamnesis

The dialogue established during the anamnesis has to gather diverse information , being fundamental that certain fundamental aspects appear in it, specifically the following.

1. Identification

This is the basic data of the person, such as name, sex, age or address . It is also essential to establish a communication mechanism, such as a contact number.

Reason for consultation

Although it may be obvious , the reason why the subject comes to the consultation , which causes him/her a problem or the demand he/she wants to make, is one of the main information to be obtained in the anamnesis.

3. History of current problems

The reason for consultation is a fundamental knowledge , but to fully understand the situation, the psychologist or professional who carries out the anamnesis needs to know how and when it has appeared in the patient’s life, in what situation or situations it appears, what causes the subject considers that it has been provoked, what symptoms he or she suffers from and which ones seem most relevant.

4. Affect on normal life

The problems presented by the subjects have an effect on their daily life , generally producing a decrease in their quality of life in areas such as social, labour or family relations. Knowing this information may help to direct the type of strategies to be employed, directing the therapeutic objectives both to the resolution of the problem itself and to the effects of these on daily life.

5. Psychosocial history

The life history of the individual who comes for consultation is usually closely linked to the appearance of certain phenomena and problems. The type of education received, the process of socialisation of the subject, the events that have marked or configured his personality and the elements that the individual himself associates with the initiation or maintenance of a problem can be very useful.

6. Personal history

Sometimes people who come for consultation do so for problems derived from phenomena , previous events or illnesses or whose effects have produced a change in their own lives. In this sense, it is useful to know the existence of previous problems.

7. Family history and family situation

Knowing the presence or absence of a family history of a problem or how the family is structured can allow us to refine the diagnosis and focus on some intervention strategies or others. It may be relevant in order to observe risk factors, effects or causes of certain problems.

8. Expectations regarding the results of the intervention

This section is relevant in the sense of explaining what the patient expects to happen , the presence of motivation to follow a treatment and what he considers he can or cannot achieve with professional help. Apart from knowing their expectations with respect to the functioning of the therapy and its results, it also allows us to see the user’s vision with respect to their own future and the existence of cognitive biases that underestimate or overestimate what the treatment can achieve (they may have unrealistic expectations or provoke a self-fulfilling prophecy), with the possibility of working on these issues in the therapy itself.

Considerations

The completion of the anamnesis is, as we have mentioned, of great importance for the exercise of the profession. However, this cannot be done without taking into account a series of considerations .

Assessment of the extent and completeness of the anamnesis

It may be tempting to consider the idea of getting as much information from the patient as possible from the beginning in order to establish a firm strategy to follow from it. However, although it is clear that the acquisition of information regarding the case is essential.

A too exhaustive anamnesis can be extremely aversive for the patient , and he may feel uncomfortable and reduce the emission of information and even abandon the search for help. We must not forget that this is a first step in the diagnostic process, and a good therapeutic relationship must be established in order to maximize the acquisition of information. The data collected in the anamnesis should be sufficient to get an idea of the patient’s situation, his problem and his vital state, but this collection should not be carried out as an interrogation.

In certain cases, it may also be necessary to shorten or even delay its realization, as in the case of patients with suicidal ideation.

Immodifiability of the information received

It should also be considered that the information obtained during the anamnesis does not have to be immutable . The patient may not know exactly what is wrong, may need more time to reflect on how it affects their life or even need to feel more comfortable with the therapist in order to trust him/her with certain information.

Respecting ethical limits

The collection of data and information by the professional is a fundamental and essential point in the therapeutic process. However, the anamnesis or collection of information cannot be done indiscriminately .

It must be taken into account that the patient must have the right to maintain privacy, trying to limit himself or herself to the phenomenon causing the discomfort or the reason for the consultation or, in its absence, to aspects of the patient’s life that are considered to affect him or her and the compliance with the therapy.

Bibliographic references:

  • Borreli, C.F. & Boschi, F.J.M. (1994). Clinical interview. In: Martín ZA, Cano JF, eds. Primary care: concepts, organization and clinical practice. 3 ed. Barcelona: Doyma:158-69.
  • Rodríguez, G.P.L.; Rodríguez, P.L.R. and Puente, M.J.A. (1998). Practical method for the preparation of the clinical history. Rev Electrón Innov Tecnol, Las Tunas;4(2). 6 .
  • Rodríguez, P.L. and Rodríguez, L.R. (1999). Technical principles to perform the anamnesis in the adult patient. Cuban review. Gen. Med. 15(4); 409-14