Why I Don’t Start Therapy with a “History”

Even some sophisticated psychoanalytic therapists start therapy by taking a “history,” by which they mean a psychiatric interview about family, work, love, and so on. Many cognitive-behavioral therapists also follow this practice, as do those with other theoretical allegiances. Some therapists start with paperwork, which I think is also a mistake, but that’s a subject for a different post. I begin therapy by asking, “What can I help you with?” This post will focus on four of my reasons for not “taking a history.”

One way therapy works is that it changes patients’ master narratives. All of us have some grand scheme into which we integrate our life events. Sometimes that narrative is unsustainable. It might exclude aspects of ourselves that are intrinsic to our humanity, such as our sexuality or aggression, or it may be too inflexible to allow for mutuality and collaboration with others. It might cast others in undesirable roles, such as sidekicks, which interferes with successful friendship. It might contain generalizations about men or women or power or children that interfere with flexible functioning. It might be a story of doom or retribution or injustice that has outlasted its utility. The master narrative might be as simple as a self-image that does not conform to current life demands. This is in part what is meant by the psychoanalytic koan, “Identity is defense.” We have to have a sense of who we are to function, but that same sense limits us.

In this context, psychotherapy reworks the master narrative. This reworking might entail the review of evidence in support of or against the narrative in cognitive-behavior therapy, the discovery of confirming or disconfirming aspects of the self in a relational therapy, or an exploration of the fit between the narrative and the reality of the therapy space or the person’s life. Given the utility of reworking the person’s master narrative to include more of the actual self and to provide more flexibility under current circumstances, the last thing I’d want to do would be to nail down the current version of the master narrative or sense of identity. “Taking a history” ties the patient to his or her current view, when I want to change that view.

A second major problem with taking a history is that it brings up troubling moments from the past out of context. This can make these moments feel as if they are defining and trapping the patient. An example might be a woman who was sexually abused as child and reports the event in the “history.” The therapist is likely to think this is a big deal, as it is likely to be, and uses this fact to understand the presenting problem. Suppose, for example, that the patient sought help to deal with intimacy problems with her husband. The narrative arc from sexual abuse to intimacy problems is the definition of tragedy: the patient is hindered by a long-ago event which will have its due. Getting the facts about childhood abuse before exploring the problem sends the wrong message. Instead, if the therapy starts with a discussion of the presenting intimacy problems, part of the discussion can include an invitation for the patient to report what if anything her intimacy problems remind her of. At this point, when she says she was sexually abused as a child, it comes up to illuminate the intimacy problem. The message is not that she is tragically doomed to be constrained by her past; the problem is that intimacy reminds her of abuse. Good therapy sends the message that Jonathan Shedler calls, “That was then; this is now.” Taking a history sends the message, “What has been is what will be.”

Third, history doesn’t matter in the sense of what actually happened; it matters in its lingering effects on organizing principles, core beliefs, and personality patterns. And even if what actually happened did matter, you certainly can’t discover what actually happened, especially in early childhood, by asking the patient. Instead, listen to what James Baldwin said on the topic: “History … is not merely something to be read.  And it does not refer merely, or even principally, to the past. On the contrary, the great force of history comes from the fact that we carry it within us, are unconsciously controlled by it in many ways, and history is literally present in all that we do. It could scarcely be otherwise, since it is to history that we owe our frames of reference, our identities, and our aspirations.” The point for therapists is that everything salient about the patient’s history is operating in the patient’s approach to the therapy, the way the relationship is framed, the identities revealed, and the patient’s initial goals. Careful attention to the way the patient approaches the therapy will reveal much more of the salient “history” than bad journalism about what the patient thinks happened a long time ago.

Finally, even though therapy does indeed start out as a professional consultation and then morphs into a therapy relationship once a treatment contract is agreed on, I want to make the initial professional consultation as much like therapy as possible to smooth that transition. For example, in a purely professional relationship, I would decorate my office with family photos and a personal taste in art. Professional clients who might then have to suppress parts of themselves or certain reactions to the environment would not be all that ill-served, because in a professional key, clients are not asked to produce their innermost selves as they are in therapy. Therapy patients need a décor that does not make them (as much as is reasonable) bite their tongues about their reactions. So I decorate my office in preparation for therapy, even though the first session is a professional consultation about whether therapy can help. To me, taking a history lays down professional features that run counter to a therapeutic process of revealing oneself collaboratively rather than being an object of inquiry. Following specific examples and exploring them through associations works just as well if not better, and it looks a lot more like therapy will look (if the therapy is done well).



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