The information collected from visitors can be sorted out from three angles:
( 1)
1, demographic data of visitors (name, gender, age, birthplace, occupation, income, religion, nationality, etc. );
2. Living conditions of visitors (living conditions, daily activities, lifestyle and habits, lifestyle changes, etc.). );
3. Marriage and family (general marital status, major marital events, evaluation among family members, important family events);
4. Work record (attitude, interest, satisfaction, career change, etc. );
5. Socialization (social network, friends, interest in participating in group activities, etc. );
6. Entertainment activities (activities that make you feel happy, and whether the description of the happy experience is accurate);
7. Self-description (strengths, weaknesses and words used in the description);
8, the characteristics of the visitor's inner world (imagination, creativity, values, etc. );
9. Other information.
(2)
1, infancy (birth situation, natural delivery, etc. );
2. Childhood life (walking, talking, whether you have been seriously ill, family life, parents' emotions, parenting styles, etc.). );
3. Youth life (family, school education, social education, important events, interests, etc.). );
4. Adolescence (love, study, employment, marital status, etc. );
5. Important changes in personal growth and current evaluation of it.
(3)
1, mental state (cognition, emotion, will, behavior);
2. Physical state;
3. State of social activities (work, social interaction and family life).
In addition, we have to judge the reliability of these materials and explain them in the report. The possible factors that affect the reliability of data are hints (hints in conversation, hints in clinic, etc.). ) and early impressions (caused by the early impressions of visitors to the consulting room). The reliability of data can be verified by supplementary questions, psychological tests, questionnaires and comparing data from different sources.
When interpreting these clinical data, we should pay attention to the relationship between phenomena and possible causes, find out where they deviate from the normal standards, and grasp the "conspicuous" and "prominent" events to explain. After that, these clinical data were given meaning: you can talk about it (you can't reveal the full meaning of the event); Correlation analysis can be carried out to analyze the factors related to the problem (but always speculative); You can also analyze psychological traces and take facts as the result to further find out the reasons.
If the visitor has a past history, we can also get some information from it: understand the diagnosis made by the doctor at that time, what the treatment was, and how effective it was; Analyze the reasons for seeing a doctor from the beginning; To understand the effect of previous psychological counseling for help seekers.