How to Take a Psychotherapy History (And Why It Reveals Personality)
This is Part 6 in our series on Past Psychiatric History.
Read Part 5: Understanding Support Systems for the previous component.
Psychotherapy history reveals something distinct from medication or hospitalization history. It captures how a person has engaged in the work of psychological change, their ability to build trust, reflect on experience, and tolerate discomfort in relationships. Each therapy experience leaves a trace, whether it strengthened insight, ended abruptly, or failed to take hold at all.
Your goal in this part of the evaluation is to reconstruct those experiences in a structured way, identifying what types of therapy were attempted, how the patient participated, what helped or hindered progress, and what patterns emerge across time. Understanding those patterns does more than clarify treatment history; it provides a window into relational style, personality organization, and readiness for future therapy.
Learning Objectives
After reading this section, you should be able to:
- Identify relevant chart sources for previous psychotherapy records
- Gather structured information about prior therapy experiences
- Recognize engagement patterns that reflect personality and relational capacity
- Document psychotherapy history clearly and interpret it for treatment planning
Start With Chart Review
Before interviewing the patient, review available documentation for clues about previous therapy experiences:
Past mental health notes – Look for therapy types, frequency, duration, and clinician names. Previous psychiatric evaluations often summarize therapy history.
Discharge summaries – Inpatient notes sometimes document scheduled/previous outpatient psychotherapy or therapy engagement during hospitalization.
Prior psychological evaluations – Often list therapist names, describe therapy response, and note engagement quality.
Collateral information – Family members, case managers, or primary care providers may document therapy attendance and engagement patterns.
💡 Clinical Pearl: Therapy notes often reveal how patients interacted with providers. If multiple therapists document “limited engagement,” “frequent no-shows,” or “therapy discontinued after conflict,” this pattern may be diagnostically meaningful even before your interview.
Interview the Patient
After chart review, explore psychotherapy experiences directly with the patient. A psychotherapy history reveals something distinct from other interventions – it illuminates relational capacity, insight, and the patient’s ability to engage in psychological healing.
Opening Questions
Begin broadly to establish the overall therapy experience:
- “Have you ever been in therapy or counseling?”
- “Can you tell me about your experiences with therapy?”
- “What kinds of therapy have you tried?”
Information to Gather
For each significant therapy experience, explore the following dimensions:
Type and Duration
- “What kind of therapy was it?” (Individual, group, family, couples)
- “How long did you see this therapist?”
- “How often did you meet?” (Weekly, biweekly, monthly)
Content and Focus
- “What did you work on in therapy?”
- “What was the therapist’s approach or style?”
- “Did the therapist give you homework or specific exercises?”
Outcome and Experience
- “What was helpful about that therapy?”
- “What wasn’t helpful?”
- “Why did therapy end?” (Completed goals, moved, insurance issues, therapeutic rupture)
💡 Clinical Pearl: How therapy ended matters enormously. Planned endings suggest capacity for healthy separation and goal completion. Abrupt terminations, especially after conflict with the therapist, may suggest personality dynamics that will affect future therapeutic relationships.
Common Therapy Modalities
Patients rarely know technical terms. Help them identify therapy types by describing approaches. Clarifying the therapy type helps interpret what skills or insights a patient may have already developed and what gaps remain.
Cognitive Behavioral Therapy (CBT):
“Did your therapist focus on changing your thoughts and behaviors? Did you work on identifying negative thought patterns?”
Dialectical Behavior Therapy (DBT):
“Were you in therapy that taught skills like distress tolerance, emotion regulation, or mindfulness? Did you attend both individual and group sessions?”
Psychodynamic/Insight-Oriented Therapy:
“Did you explore your past and how childhood experiences affect your present? Did you talk about patterns in your relationships?”
Supportive Therapy:
“Was it more about having someone to talk to and get support from, rather than learning specific skills or techniques?”
Trauma-Focused Therapy (EMDR, Prolonged Exposure, CPT):
“Did you specifically work on traumatic memories? Did therapy involve revisiting difficult experiences in a structured way?”
Red Flags and Patterns
Patterns in therapy engagement often reveal more about personality structure and relational capacity than the therapy content itself. Watch for:
Multiple brief therapies: May indicate difficulty engaging, personality dynamics interfering with therapeutic relationships, practical barriers (transportation, finances), or repeated mismatches between patient needs and therapeutic approach.
Repeated therapeutic ruptures: A pattern of therapy ending after conflict with the therapist suggests potential for splitting, idealization/devaluation cycles, or difficulty tolerating the discomfort inherent in therapeutic work.
Long-term therapy with limited progress: May indicate that therapy provides support but not change, wrong modality for the condition, treatment-resistant pathology, or that the patient values the relationship over behavioral change.
Never engaged despite recommendations: Assess for practical barriers, beliefs about therapy effectiveness, cultural factors that stigmatize mental health treatment, or ambivalence about change.
Special Considerations
Therapy During Childhood/Adolescence
Therapy experienced in childhood often shapes later attitudes toward mental health treatment – either as a trusted refuge or as an imposed burden. These early experiences often color how adults later perceive therapists and therapy itself.
When patients report therapy as children, explore:
- Was it voluntary or mandated? (School-based, court-ordered, parent-initiated)
- What was the focus? (Behavior problems, trauma, family conflict)
- Did the patient understand why they were there?
- How did it end?
Mandated childhood therapy often leaves negative associations that affect adult treatment engagement and willingness to participate.
Family or Couples Therapy
These modalities add relational complexity. Explore:
- Who initiated the therapy?
- Who participated consistently? Who dropped out?
- What was the stated goal?
- Did it help or harm relationships?
- Is the patient still in contact with other participants?
🎯 When to Go Deeper: Therapy Ruptures
If a patient describes multiple therapies ending in conflict or dissatisfaction, this pattern becomes diagnostically important and should be explored thoughtfully.
Consider asking:
“I’m noticing you’ve mentioned that several therapy relationships ended after disagreements or feeling misunderstood. What tends to happen in your relationships with therapists over time?”
Naming the pattern collaboratively can itself be therapeutic and helps plan for similar dynamics in future treatment. This exploration provides critical information about:
- Transference patterns likely to emerge
- Countertransference risks for future therapists
- Need for specific therapeutic approaches (e.g., mentalization-based therapy for personality pathology)
- Realistic expectations for treatment duration and outcomes
What to Document
Your documentation should capture not just what therapy occurred, but the quality of engagement and meaningful patterns.
| Documentation Level | What to Include | Example | When to Use This Level |
|---|---|---|---|
| Minimal | Basic therapy history (types, reason for ending) | “Patient reports two prior therapy episodes, both ended due to insurance loss. Open to resuming.” | Uncomplicated history with no concerning patterns; therapy ended for practical reasons; patient engaged appropriately |
| Standard | Minimal + Specific outcomes, duration/frequency, patient’s subjective experience, current status | “Patient engaged in CBT for anxiety (6 months, weekly) with significant symptom improvement. Therapy ended when patient relocated. Also tried supportive therapy in college (1 year) but found it less helpful. Currently not in therapy. Expresses willingness to resume structured, goal-oriented approach.” | History includes multiple therapy types or clear preferences; need to guide future treatment recommendations; mixed outcomes warrant explanation |
| Detailed | Standard + Patterns of engagement/termination, personality dynamics, therapeutic alliance quality, formulation implications, specific recommendations | “Patient has extensive psychotherapy history spanning 15 years. Multiple episodes of individual therapy (CBT, psychodynamic, supportive) with varied outcomes. Reports CBT most helpful for managing anxiety symptoms. Pattern of premature termination noted across several therapy relationships, typically following perceived criticism from therapist. Patient demonstrates insight into this pattern and acknowledges difficulty tolerating negative feedback in close relationships. Currently engaged in DBT skills group with regular attendance. No current individual therapy.” | Repeated therapeutic ruptures present; complex personality dynamics affecting treatment; history reveals diagnostically significant patterns; future therapist needs specific preparation; formulation requires detailed relational information |
Why This Information Matters
A patient’s psychotherapy history reveals their capacity for introspection, relational stability, and treatment engagement. This information is essential for several clinical reasons:
Predicting Therapeutic Alliance: Patterns of therapy rupture, idealization, or premature termination often mirror broader personality organization and predict challenges in forming new therapeutic relationships.
Tailoring Treatment Recommendations: Understanding what has helped (or failed) before allows you to recommend therapy types aligned with the patient’s psychological readiness and learning style. A patient who thrived in structured CBT but struggled with open-ended psychodynamic therapy needs different recommendations than the reverse.
Anticipating Countertransference: When a patient has repeatedly experienced conflict with therapists, future clinicians need this information to recognize their own emotional reactions and maintain appropriate boundaries.
Formulating Personality Structure: The quality of therapy engagement – capacity to reflect, tolerate discomfort, maintain consistency, manage endings – provides rich information about personality organization that supplements formal diagnostic criteria.
Setting Realistic Expectations: A history of treatment resistance or dependency helps frame realistic timelines and goals for future interventions, preventing both patient and clinician frustration.
Psychotherapy history is not just a list of past treatments – it’s a window into how patients form relationships, manage vulnerability, and approach psychological change. This understanding directly shapes your formulation and guides future treatment planning.
Next in this series: Part 7 – Medication History: How to Identify Treatment Resistance and Avoid Repeating Failed Trials
Previous post: Part 5 – Understanding Support Systems
