Assignment 2: Patient History

Patient: Mom from the movie Mommy Dearest.

One of the first steps in any clinical assessment is to gather a thorough history from the patient. This history includes, at minimum, the patient’s identifying information, presenting problem, and relevant personal history relating to their presenting problem.

Identifying Information
Within this section, you will describe basic information on your patient, including the person’s name, sex, gender, sexual orientation, age, race, occupation, and location of residence (country, state, and region).

1. Chief Complaint/Presenting Problem
   Within this section, you will include the patient’s primary complaint verbatim to identify and describe the main source of his or her distress and/or concerns. If there is no verbatim complaint, include observable information to create an overall picture of the presenting problem.
   Typically, this section within a psychological report seeks to answer the following question (further elaboration within this section is encouraged where possible):
• What are the patient’s complaints? (e.g., the patient might complain about “feeling on edge” or experiencing stress)
2. You will not be completing section III of the Final Paper for this week’s assignment.

1. Personal History
   Within this section, you will describe your patient’s personal background and history of abnormal behavior(s) that inform your diagnostic impression. You will also gather information about the patient’s cultural background and cultural norms.

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

• Where did the patient grow up?
• What cultures did the patient experience throughout life?
• What was the patient’s school life like?
• What were his or her grades? What is his or her highest level of education?
• What is the patient’s interpersonal relationship history?
• What was/is the patient’s romantic relationship history?
• What was/is the patient’s friendship history?
2. Family History
   Within this section, you will describe the patient’s familial relationship(s) and identify any abnormalities that might affect future treatment. You will also integrate information about the patient’s family and cultural background to identify any maladaptive behaviors and relational patterns.

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

• How old were the patient’s parents when the patient was born?
• Who were the patient’s primary caregivers?
• What was/is family life like? (Include any information relevant to your diagnostic impression.)
• Did the family move often?
• What was/is the patient’s relationship with their siblings (if applicable)?
• What culture did/does the family come from?
• What belief systems are attached to that culture?
3. Therapy History
   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). Evaluate 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 any)?
• 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?

Assignment should include both a title page and reference page, and be of sufficient depth and detail to support and inform your diagnostic impression, with an absolute minimum of four pages (not including the title and reference pages). A cursory or surface level review of the patient’s presenting problem and history will unlikely provide enough information for your diagnostic impression.

Q1: Ethical Relationships between Humans and their Environment – Consider the way in which Dr. Lindholdt’s book brings political or environmental issues to light. Choose one of the three essays we read—“Black Bear on Gold Hill,” “Three Coyotes,” or “On Attention”—and discuss the following:

• How are humans and culture linked to the environment in this text?

• Does this text suggest a certain attitude or action regarding the environment and/or the relationship humans have with that environment?

• Does it have an ethical motivation?  If so, what is it? If not, why not?

Q2: Attention to Detail & Introspective Memoir – Dr. Lindholdt has said that “if we intentionally pay attention to our surroundings we can shape our consciousness and personal character.” Annie Dillard uses the moment of a moth dying in her candle to reflect on her own place in nature and her responsibility for stewardship towards the earth. Both she and Dr. Lindholdt use attention to their surroundings to think introspectively and learn about themselves in their essays.  Choose a moment in one of the three essays we read from Dr. Lindholdt’s In Earshot of Water where an observation of the external world—a detail about nature or an event he witnessed—offered the opportunity for the author to learn and explain a truth about himself. Compare and contrast how Dr. Lindholdt does this with how Annie Dillard does. How does each use observation to reflect on their personal thoughts and beliefs? Do you find this effective? Why or why not?

Q3: Using Environment and History to Tell Personal Stories – Consider how Dr. Lindholdt uses his physical environments and the history attached to these environments in his essays. Choose one or more of Dr. Lindholdt’s three essays that we read and think about and answer the following:

• How does the author use his observations and descriptions of his environments to make his personal stories relatable to his readers?

• What history does he explicate in the essay and how does he weave the history into the essay to make his personal story more effective?

• If the story were told outside of the environment in which it is set or without the historical context given, could it have the same impact on us as readers? Why or why not?