MCC – 670 Defining The Problem

“​The development of a list of problem titles involves two separate processes…”(Ingram, 2012, p41).  Ingram, (2012), defines a problem as “difficulties, dysfunctions, complaints, and impairments that are identified by the client” (p. 41).

FIRST, by gathering data and developing a preliminary list of problems. NEXT, by conceptualizing and giving titles to the problems we can better understand our treatment targets.  If they are defined by the client we refer to them as complaints.  Problems defined by significant others are relationship problems. Problems defined the professionals who counseling are called diagnoses.  Helping the client understand and gain some awareness regarding the nature of this problem is essential.

Step #1: Understanding the Goal

“When the goal is to arrive at a diagnosis, we check the list of criteria to see if there are enough to warrant the diagnosis, as if the criteria are a means to an end. When we think in terms of problem lists, the criteria are the end – they give us names of problems” (Ingram, 2012, p. 42)

The Presenting Problem

The presenting problem consists of the client’s stated reasons for seeking therapy in his/her own words.  It is not uncommon for the client’s presenting complaint to undergo a transformation as they develop a greater understanding of their problems.  For this reason, it is useful to record how it changes over time.

“SHOULD I JUST ACCEPT THE CLIENT’S STATED PROBLEMS OR AM I SUPPOSED TO GO FURTHER AND FIND OTHER PROBLEMS?”

In response to this question, Ingram (2012), describes three different attitudinal perspectives. However, at the end of this discussion, Ingram, (2012), stay

Narrow Position

According to this position, the therapist should simply accept the client’s complaints without attempting to create awareness of needs the client hasn’t mentioned.

Intermediate Position

Here, the therapist focused on the client’s request but if other problems become obvious, they will invite client to consider them.

A Comprehensive List

According to this perspective, the therapist should be concerned about the whole person, and examine all aspects of function in terms of a holistic assessment of the individual.  Just because the client is able to identify some problems, that doesn’t mean they are accepted as critical for treatment. The approach this book upholds is to utilize a comprehensive problem list. It is better to be too inclusive than to miss something important.  Finally, it is important to note that “the therapist’ values inevitably enter the problem-identification process” (Ingram, 2012).

Step #2: Developing A Comprehensive Problem List.

With the attitude of someone who is brainstorming, write down every problem (Ingram, 2012, p43). Complete the following assessments.

THE BASIC SID

  1. BEHAVIOR – What is the person doing, and not doing; what can others observe; the quality of skills?
  2. AFFECT: Internal emotional experience and overt verbal and nonverbal expression of feeling.
  3. SENSATION: Awareness of the body; use of senses; what is seen and heard with minimal filtering through cognition.
  4. IMAGERY: Mental imagery about past, present, or future; fantasies and dreams
  5. COGNITIVE: Constructed meaning; self-talk, beliefs, and schemas; cognitive skills; mental abilities
  6. INTERPERSONAL, SOCIAL, & CULTURAL: Relationships with others; family context; membership in social groups; cultural issues; and issues of social injustice.
  7. DRUG AND BIOLOGICAL: Physiology; biology; genetics; medical issues; use of illegal drugs, including alcohol.

DOMAINS OF FUNCTIONING (WHODAS)

Ingram, (2012) lists several domains of function that can be found in the DSM-IV manual.  “Therapists need to balance a psychiatrists emphasis on pathology with a counselor’s concern for growth and development” (Ingram, 2012, p. 44).
These domains are listed below, (Ingram,2012, p. 44-45).

a. Health and safety
b. Home Management
c. Financial status
d. Life planning
e. Academic
f. Employment
g. Legal status
h. Leisure and Recreation
i. Communication
j. Friendship
k. Family
l. Emotional Intimacy
m. Sexuality
n. Parenting
o. Religion & Spiritual
p. Cultural

Also contained in the DSM-IV is the Global Assessment of Functioning. While it is currently an out-of-date assessment, I’m including a link of it here for the sake of thoroughness. It is important also to note that the new DSM-5 manual focuses instead on the WHODAS-2. I’m also including a link for this instrument, since it is utilized at my current place of employment.

Step #3 Creating The Preliminary Problem List

“The quantity of problems on the preliminary list might make you feel hopeless. Remember you can combine and condense the list until it is manageable”. (Ingram, 2012, p46).

Overall goal

When defining problems it is useful to think about they can describe the target of your future therapeutic efforts. Ingram, (2012) suggests that “the problem title is a brief specific phrase…[and] stay focused on the client’s reason for being in therapy, not yet moving to your conceptualization of the problem” (p 45). Additionally, “avoid using language that reveals our explanations that attribute a cause for their problem” (Ingram, 2012, p 45).  Finally, check to make sure you Problem List is comprehensive.  While it is vital that we address the client’s pain, we must not automatically accept the client’s understanding of the problem without critical examination.

Standards for Problem Definition

  1. Problems should be defined as a “solvable target” (Ingram, 2012, p.45) for therapy. In other words, what is the desired outcome.
  2. Problems must reflect the client’s current level of functioning and capture their real-life problems.
  3. Problems are specific and designed with an individual client in mind based on data gathered.  This will aid in the development of your treatment plan.
  4. Do not include technical jargon, or theoretical concepts.  These things reflect a clinical hypothesis.  Your goal is to summarize findings from your data gathering.  This can allow for a therapist to utilize whatever theory might best apply at a later point.  Ask yourself if what you’re writing down is s hypothesis or a problem definition.
  5. Be cautious of how your values and biases might color your understanding of the client’s problems.  “Does the problem title reflect the client’s values?” (Ingram, 2012,)</h6<
  6. “How do you handle a list of 20 or more problems? The solution is lumping and splitting.  Lumping involves combining separate problems into a single problem” (Ingram, 2011, p. 55).  This is useful if signs and symptoms overlap and stem from common cause.  Occasionally, this might involve the utilization of an umbrella title.  With outcome goals for each sub-Problem.  Splitting involves “dividing one problem into separate problems…” (Ingram, 2912, pp. 56) Instances in which splitting might be useful include those cases in which separate treatments are needed or if this aids in clarity,
  7. Finally, be sure your problem list is complete and comprehensive.  “The omission of problems is a much more serious error than inclusion of too many problems” (Ingram, 2012, p. 60).

Reference

Ingram, B.L. (2012). Clinical Case Formulations: Matching the Integrative Treatment
​Plan to the Client. (2nd ed.). Hoboken, NJ: Wiley.

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