I’m a big fan of thorough biopsychosocial assessments, including gathering a detailed history. There is a lot that can be learned from your client’s life story as it unfolds in their reporting of their own and family history.
Over the years, as an auditor and leader of auditors, as well as a documentation consultant, I have gotten a number of questions regarding history related to its overall value in treatment. One of those is related to Family Medical History. I’m surprised how often this information is skipped and excluded in the assessment process.
Why do we need to gather this information when we’re not treating them medically?
It’s a great question.
There is, of course, the direct “is this a mental health condition or a physical issue?” There are situations where a client can come to you with all of the symptoms of an anxiety disorder, but in reality, it is something like hyperthyroidism. Or depression when it’s really anemia, a sleep disturbance, or diabetes. Knowing your client’s medical history as well as the medical history of family members can often lead to a simple question of whether they have discussed the symptoms with their primary care physician or not? Some of these medical conditions run in a family and ensuring your client has addressed the issue medically helps in getting to the bottom of things.
Then there is the social dynamics element of significant family health issues. Cancer, heart attacks, or significant injury of a parent or sibling can create tremendous turmoil and trauma in a child’s life. While some individuals may have a clear understanding of how that experience has influenced their current life experience, many others have not quite tied those things together quite yet. Having that information at the outset, or even the conscious decision on the part of your client not to disclose it initially, but bringing it into the room later on, can be a helpful insight into your work with them.
Either way, asking the question about Family Medical History, especially in a client intake form, is easy to gather and might just open a door into the work ahead with your clients.