The development of a list of problem titles involves two separate processes: (1) identifying problems by gathering data and making a preliminary problem list, and (2) defining problems by conceptualizing and giving titles to the problems that will be treatment targets.
The term problem refers to difficulties, dysfunctions, complaints, and impairments that are identified by the client, by others with whom the client interacts (e.g., family members, courts, or school systems), or by professionals who evaluate the client’s functioning.
When a problem is identified, it means that there is a discrepancy between the current state of reality and a desirable, achievable future state. Problems are reasonable targets for change. It is useful to remember that there are unpleasant experiences in life—pain, defeat, disappointment—that can be called normal life difficulties instead of problems because it is utopian to hope to eliminate them (Watzlawick, Weakland, & Fisch, 1974).
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 the names of the problems. We cannot treat the abstraction “paranoid personality disorder”; but we can target the symptoms and impairments that lead us to use that diagnosis, such as: Persistently bears grudges or Unjustified suspicions regarding spouse’s fidelity.
The client’s presenting problem—the reason for seeking therapy—should never be ignored. However, the problem title may undergo change from how the client first worded it. The first problem that the client presents is often not the main issue but rather a secondary concern that is used as a “ticket of admission” while the client evaluates you, develops trust, and works up her courage. It is also possible that the client might change her perception of her problems during the first few sessions. For instance, Frustration over husband’s lack of interest in social activities can become Difficulty accepting unchangeable aspects of husband’s personality or Difficulty engaging in social activities on her own.
A common question from students and trainees is: Should I just accept the client’s stated problems or am I supposed to go further and find other problems? There are three positions that a therapist can take in response to that question, illustrating a continuum from a narrow to a broad approach to problem identification:
The therapist’s values inevitably enter the problem-identification process. The following questions may help clarify your own position:
The approach in this book is that you should create a comprehensive problem list. It is better to start by being too inclusive than to miss something important or to deprive the client of unnoticed opportunities.
How can you tell if your list is comprehensive? Physicians know that they are doing a thorough examination, one that will effectively identify medical problems, by routinely examining all of the systems of the human body (e.g., circulatory, digestive, nervous). We need frameworks that cover every aspect of psychological and social functioning. There are many sources of possible problem lists: Bjorck, Brown, and Goodman (2000) developed a patient impairment lexicon; Jongsma and colleagues have published a large set of treatment planning manuals that list numerous problem categories for various populations (e.g., Jongsma, Peterson, & Bruce, 2006); there are lists of emotional and social competencies (Bar-On, 1997; Goleman, 1995) and inventories of human needs (e.g., Maslow, 1999). I believe that two frameworks, the BASIC SID and Domains of Functioning, embrace the ideas from these sources and provide additional categories.
The BASIC SID: This acronym was presented in Chapter 2 as a data-gathering tool; here it is presented as a means to organize your preliminary list of problems.
My use of the acronym differs from that of its creator, Arnold Lazarus (1981), who developed the BASIC ID for his Multimodal Psychotherapy, an approach categorized as technical eclecticism. In his method, each problem leads directly to a therapeutic procedure: there is no intervening conceptualization process with integration of ideas from various theoretical models. I recommend the use of the BASIC SID as a tool for (a) gathering a thorough database for a specific problem, and (b) generating a comprehensive problem list that will subsequently be synthesized into a compact list of treatment targets. A blank BASIC SID form in Appendix II (Form II.A) can be copied for use in practice activities and with your own clients.
Domains of Functioning: Freud was satisfied with “work and love” as the only domains of interest. Fortunately, we started to realize that “play” is also important for a satisfying life. Table 3.1 provides a list of many domains, incorporating the topics that psychiatric diagnosis addresses in “V-codes” and Axis IV. Therapists need to balance the psychiatrist’s emphasis on pathology and remediation with the counselor’s concern for competence, growth, and development of potential. In the spirit of positive psychology (Seligman, 2002), therapists need to help their clients build a large variety of strengths rather than just deliver specific damage-healing techniques. Table 3.1 provides samples of strengths as well as problems. The items in the strengths column can provide ideas for outcome goals, the topic addressed in Chapter 4. A blank Domains of Functioning form is available in Appendix II (Form II.B).
Table 3.1 Strengths and Weaknesses in Domains of Functioning
| Domains | Strengths: Skills, Resources, and Assets | Examples of Problems, Weaknesses, and Deficiencies |
| Health and Safety | Maintains healthy lifestyle. Exercises regularly. Knowledge about AIDS and safe sex practices. Good compliance with medical instructions. |
Inadequate health-care skills (e.g., poor nutrition; diabetic fails to measure blood sugar). Excessive drinking. Drug addiction. Smokes cigarettes. Lives with violent spouse. |
| Home Management | Creates comfortable home environment. Invests appropriately in house repairs. |
Excessive clutter and disorder. Starts home improvement projects and leaves them incomplete. Lives in overcrowded apartment without room of his own. |
| Financial Status | Pays bills on time. Effective investment strategy. Employed at well-paying job. |
Homeless/lacks money for basic needs. Excessive credit card debt. Submits to spouse’s restrictions on use of money. |
| Life Planning | Effectively managing midlife career change. Maintains adequate insurance and savings. |
No long-term goals. Fails to save for retirement. Poor time-management skills. |
| Academic | Chose academic major that is consistent with interests. Good study skills. |
Learning disability. Lack of study skills. School avoidance/truancy. |
| Employment | Stable employment. Feels challenged at work. Able to set limits on inappropriate behavior. |
Conflict with supervisors. Difficulty maintaining job. Restricted view of possible career goals. |
| Legal Status | No criminal record. Satisfied with attorney representing her in divorce proceedings. |
AWOL Delinquent in alimony/child support payments. |
| Leisure and Recreation | Pursues creative hobby. Ability to plan a vacation. |
Dangerous, thrill-seeking activities. Feels guilty about relaxing and taking time off from duties. |
| Communication | Expresses anger appropriately. Good listening skills. Able to express needs and grievances in close relationships. |
Bullies when partner disagrees. Expects partner to read mind. Poor conflict resolution with spouse. |
| Friendship | Makes new friends easily. Good skills for handling conflict. Able to politely refuse invitations when she prefers to do something else. |
Superficial friendships, lacks a confidante. Loneliness. No social support in time of crisis. Social withdrawal/isolation. |
| Family | Supportive extended family. Able to balances needs of different people. |
Excessive dependence on parental approval. Emotional/physical abuse (perpetrator or victim). |
| Emotional Intimacy | Shares private feelings with significant other. Able to provide comfort and support when partner needs it. |
Unable to develop trusting relationship. Lacks dating skills. Fails to take point of view of other people (egocentricity). |
| Sexuality | Satisfying sexual relationship. Practices safe sex. Comfortable with sexual identity. |
Gender dysphoria. Excessive casual sex that goes counter to values and goals. Fears of revealing sexual orientation to family. |
| Parenting | Shows empathy and respect toward child. Able to set age-appropriate limits. |
Overreacts to normal adolescent steps toward independence. Neglectful of child’s emotional needs. |
| Religion and Spiritual | Satisfied with religious/spiritual life. Enjoys activities with religious community. |
Damaging experiences in religion of childhood. Frustrated and disappointed with spiritual quest. |
| Cultural | Relates well with members of different cultures. Sense of community with members of culture. |
Difficulties working with members of minority groups. Uses racist speech. |
If you write down every single problem that you identify in your first few sessions with a client, a huge list often results. The quantity of problems on the preliminary list might make you feel as hopeless as the client does. Remember that through the problem-definition process, you are going to combine and condense that list until it becomes a manageable size. The best way to develop problem-identification skills is to have real case material with which to work. If you are already seeing clients, you have the data from your first few interviews. You can also use a friend, relative, or classmate to provide the thorough database needed for developing an initial list of preliminary problems. Activity 3.1 provides a useful practice experience.
Problem definition is an extremely important part of the case formulation process. The way the problem is defined will determine the goals of therapy and shape the entire therapeutic journey. Different problem definitions based on the same data can lead to solutions that differ enormously.
When you define a problem, you write a title that describes the target of your future therapeutic efforts. A problem title is a brief, specific phrase—neither a full sentence nor, except in rare cases, a single word. It often begins with words such as difficulty, lack of, or excessive, or uses terms that we recognize as problem states, such as stress, depression, conflict, or anxiety. To make the title specific, you add details—a sentence or two that are free of explanations or treatment ideas. Here are examples.
Problem Title: Difficulty adjusting to pregnancy
Descriptive details: A 32-year-old White woman, married 6 years, is 6 months pregnant, and is feeling resentful, angry, and trapped by being in a situation that will “disrupt my life.”
Problem Title: Difficulty managing feelings of guilt, frustration, and anger while caring for elderly mother
Descriptive details: A 58-year-old married Latina mother of three grown children lives with her husband and her 90-year-old mother who suffers from chronic obstructive pulmonary disease (COPD) and is showing early signs of dementia.
You must stay focused on the client’s reason for being in therapy, not yet moving to your conceptualization of the problem. We need to be vigilant to avoid using language that reveals our explanations, such as because of, due to, and stemming from. Here are examples of appropriate problem titles: Stress following geographic relocation and a new job and Depression accompanied by social withdrawal and impaired work performance. (Notice that the words following and accompanying are descriptive, not explanatory.)
Problem definition is a creative and sometimes frustrating activity. At times, good titles for problems may jump to mind very early in the first interview. At other times, the therapist has collected a hodgepodge of seemingly unrelated problems that are later bundled together under a single title.
The development of the formal problem list is a collaborative process between the therapist and the client. The therapist may have the skills to put problems into words, but it is the client who must determine the purpose of therapy. A discussion of alternate ways of defining problems is part of achieving informed consent. A highly valuable resource for building problem-definition skills is Change by Watzlawick, Weakland, and Fisch (1974), which has recently been rereleased. These authors explain that poor problem definitions can prevent the achievement of satisfactory outcomes. Problems are frequently defined in ways that make them unsolvable. An example adapted from their book will demonstrate the importance of good problem definitions:
Clients often come to therapy because their problem definitions are deficient. Watzlawick and his coauthors (1974) explained that clients often bring in their attempted solutions as the problem to be solved. The client’s form of problem definition has not worked, and he or she is “doing more of the same” rather than going back to the data and creating a new problem definition. Here is an example of faulty problem definition, where the problem definition was really a proposed solution.
Sometimes, all the client needs is help in defining the problem. When a brief therapy encounter gives a client a good problem definition, he or she may no longer need the therapist because the resources for the solution are already available.
There is an important lesson for problem definition:
Skills for problem definition can be developed by studying seven standards.
The wording of the title must be closely scrutinized to be sure that you are really defining a target of treatment, rather than a normal life difficulty. Grief over death of beloved pet is an example of distress that is not a problem, but rather a normal human reaction. Here are acceptable problem titles: Prolonged and excessive grief over death of pet or Feels ashamed over normal reactions to death of pet.
When you read your problem title, you should ask yourself: Is there something that can be done about this? Is this something that a therapist would work to change? Can I imagine a realistic, attainable outcome? If your answer is no, perhaps you have identified a life difficulty. Try rewording the title so that it truly expresses a target of treatment. Instead of Irreversible memory impairment, try Difficulty coping with irreversible memory impairment.
A common erroneous problem definition occurs when the solution is under the control of someone other than the client. If the solution of the problem requires another person to change his behavior or make desired choices, then the problem definition fails to meet the “solvable” criterion. So instead of Overly controlling husband, make it Dissatisfaction with overly controlling husband or Difficulty asserting her freedom for fear of negative reactions from husband.
The skill of defining problems involves asking yourself: Is this a solvable problem? Could I specify a desired outcome? Therefore, problem definition must be integrated with setting outcome goals, which is addressed in Chapter 4.
As stated in Chapter 1, case formulation is not a linear process; instead there will be many iterations of the steps. To check the quality of your problem definition, review it after you have completed writing your treatment plan. You need to ask yourself, What problem is this plan intended to resolve? What looks like an excellent title might not really be correct if your treatment plan is not addressing it. When there is a discrepancy between problem titles and treatment plans, the first few sentences in the plan will often reveal an implicit problem title. If this is a better title than what you originally wrote, you need to change the title. However, if the original problem title is appropriate, the plan needs to be rewritten. Here is an example of a mismatch between problem title and plan and what to do about it.
We must be open to the possibility that there will be no definable problem. All people who show up in the office of a psychotherapist are not in need of therapy. There is a natural bias in mental health settings to find mental health problems in people who show up at their doors. It is simply assumed that every person who makes an initial appointment is a client-to-be. This important point is illustrated by a supposedly true story from the psychiatric emergency room where I did an internship rotation. When asked the classic opening question by the therapist, What brings you here today? a patient answered, My feet are hurting. The inappropriateness of this statement created the expectation of severely disturbed thought processes. The end of the story is that the patient had been directed to the wrong room and was looking for podiatry instead of psychiatry.
A couple may come to therapy and label their problem as excessive conflict; however, after listening to their story and watching them engage in what they call a typical fight, we may need to educate them that their level of conflict is not only normal but also healthy, as relationships without conflict often lack emotional honesty and connection. After that discussion, they may smile and hug and decide that therapy is not necessary; or they may benefit from the problem title, Difficulty tolerating normal amount of conflict in marriage.
There are two key points in this standard: (1) the problem is described in terms of functioning, not vague abstractions; and (2) the problem is in the present, not the past. Often when the client tells a story of a difficult life, you will be tempted to select experiences from the past and use them as problem titles. Here are faulty titles that reflect that error: Abandoned by father and History of drug abuse. These phrases do not belong in problem titles for the obvious reason that they cannot be changed. You can use them for the “conceptualization title” explained under Standard 4.
When you recognize that your initial attempt at a problem title contains a problem from the past, ask this question: How does this impact functioning now, in the present?
Abandoned by father: What is the problem today that this has caused?
Difficulty trusting men or Selects romantic partners who refuse to make a commitment
History of drug abuse: What is the problem today that this has caused?
Actually, it does not cause a current problem. In fact, it demonstrates his strengths: He overcame a destructive habit and avoided a downward spiral into addiction.
Titles must be descriptive and should not contain technical jargon. The title needs to be clear and specific enough to maintain a focus as you proceed with the complete case formulation and write the treatment plan. If you rely on lists of impairments in treatment planning manuals or the instructions for Axis IV of DSM, you will get into the habit of writing problem titles that are appropriate for groups of people but not individualized to fit a specific client. It is not sufficient to use a category name (e.g., interpersonal problems, vocational problems); you must tailor the wording so that it describes your client’s specific problem.
If your problem title is too broad or contains a vague abstraction, try to define it in terms of functioning that can be observed, measured, or evaluated. For example:
Faulty Problem Title: Excessive dependency
Correction: Excessively demanding and clingy in close relationships with women friends or Difficulty moving out of parents’ home and becoming self-supporting
The following examples show a continuum in problem titles from very broad and general to more specific and detailed
Marital problems—Poor marital communication—Difficulties resolving disagreements without verbal abuse
Chronic pain—Chronic pain from arthritis—Chronic pain from arthritis preventing involvement in hobbies involving physical activity
In defining problems, it is essential to remember the distinction between data and formulation. The problem title, based on data about the client’s current situation, must be acceptable to therapists of all theoretical orientations. Here are examples of faulty problem titles, which inappropriately reveal the therapist’s preferred clinical hypothesis, and corrections, which are free of explanatory concepts.
Behavioral
Psychodynamic
Family Systems
Humanistic-Existential
The phrases that are incorrect for the problem title provide words for good topic sentences for the hypotheses section of the case formulation report and, therefore, can be considered “conceptualization titles.”
When you realize that the problem title you wrote is really the title for your conceptualization, you should move it to the hypotheses section and come up with a new problem title. You need to ask yourself questions such as: What is the problem that is explained by this hypothesis? What problem would be solved by resolving this issue? For instance, “unresolved anger toward father” could explain the following problems:
Sometimes the difference between problem title and conceptualization title is subtle. For instance, “lack of assertive skills” is a conceptualization; the problem it explains might be worded Frustration with lack of advancement at work or Difficulty asserting her needs with her husband.
It is important not to let conceptualization ideas creep into the sentences following the problem title, as occurs in this example:
Ideas of “unhealthy,” “dysfunctional,” “maladaptive,” and “abnormal” imply values that could be universal, cultural, or personal. Values inevitably enter into problem titles; therefore, it is essential to be aware of them. This standard requires high levels of personal awareness, tolerance for other value systems, and vigilance for subtle ways in which you can impose your biases on your clients.
As part of increased emphasis on cultural diversity and cultural sensitivity, students are taught to understand the client’s culture and to design treatment plans that take cultural values into account. This poses an interesting challenge at the problem identification stage. Do you just accept the values of the client’s culture and agree immediately to promote conformity? Or do you identify the values involved and help the client explore them, deal with internal conflict as well as interpersonal conflict with parents, and then make mature choices about the value system he or she wants to create, as an adult? (I am aware that my own biases and values are evident in the way I worded that choice.)
Especially when working with young adults, you need to be aware of how the client’s developmental stage of “leaving home” is enormously influenced by the culture’s views on independence, individuality, community, the correct ways of showing respect for parents and grandparents, and so on.
Cultures have different answers to the question: Whose needs are more important—the individual’s or the family’s? This question is very important when a client brings problems related to choice of career, spouse, or sexual orientation.
It could be easy to slip into using a problem title that shows some kind of bias. Just as I might be tempted to write, Difficulty choosing own life path and tolerating disapproval of parents, someone else might prefer, Difficulty making choices that serve the needs of the family and honor the authority of parents.
In the field of money management, the concept of fiduciary responsibility makes clear that the counselor must act for the sole benefit and interests of the client, with loyalty to those interests. The same ethical duty is even more important in the mental health arena. The problem title must be worded in a way that allows the client’s best interest to be discovered. We need to avoid a priori assumptions of how the client will choose to balance self and family. In these examples, the client’s specific outcome is left open:
Sometimes the best problem title would be Lack of clarity about personal values. Even when it seems that the client is clear about his values, you should ask metamodel questions (see Table 2.3 in Chapter 2) to see if the client has internalized, without conscious examination, the culture’s messages. Therapists must be cautious about defining problems in a way that imposes the values of the majority culture. For instance, Difficulty establishing marital commitment or Lack of readiness for parent role are titles that imply that one should get married and be a parent. If the client holds those values and expresses the wish to use therapy to smooth the path to marriage and parenthood, then the problem titles are appropriate. But if, without further exploration, the therapist assumes that without marriage and children the client cannot have a satisfying life, the therapist is inappropriately limiting the client’s freedom of choice. Furthermore, we need to be aware of how easily we impose values of our own professions. In his book Solitude, Anthony Storr (1989) noted a huge bias among most psychotherapists, claiming that they seem to believe “that health and happiness entirely depend upon the maintenance of intimate personal relationships . . . [and that] love is being idealized as the only path to salvation” (p. 8).
Sometimes clients assume that they must make changes because they have internalized society’s standards and perhaps have received pressure from their family and judgment from peers. Corey (1966), in a classic article about reverse format, suggests that in such instances, the problem is not that the client needs to change, but that he cannot accept himself the way he is. The therapist must avoid buying into the client’s belief that something is bad, deviant, deficient, and objectionable. Instead, you offer the client the possibility that everything is perfectly all right exactly the way it is. If the therapist does not challenge the need to change, the client will receive the message that he is not good enough the way he is. Reverse format questions take these forms when the client speaks negatively about himself and his lifestyle: “What would be so bad about that?” “Why is that a problem?” “Who says that you need to change?” “What are some good reasons for staying the same?” “Is it possible that things are going exactly the way you want them, but you need to placate your wife by coming here?” You might guess that sometimes these questions serve to increase the client’s motivation to change, and this approach is consistent with Motivational Interviewing (see www.motivationalinterview.org). At other times, these questions can help reduce motivation to change by increasing self-acceptance.
Remind yourself that in order to define a weakness or shortcoming as a problem (i.e., target for therapy), we need to be able to point to desired future goals, descriptions of impairments in functioning, or actual real-world negative consequences. For instance, if a college student’s problem is poor grades in chemistry, it may indeed be a problem if his ambition is to go to a medical school but it may not be a problem if he is just in college to humor his parents and intends to be an artist. In these cases there may be no problem to define, or the problem would be worded Difficulty choosing a lifestyle that is negatively judged by parents/peers/dominant culture.
There are times when we are obligated to impose society’s values, as when the client is at risk of causing harm to self or others, including the harm of being incarcerated, losing custody of children, or destroying options for a positive future (e.g., Perpetrator of child [spousal, elder] abuse or Vandalism leading to incarceration in youth facility). At these times, the client may not be seeing you on a voluntary basis but rather is attending sessions of mandated therapy to meet the legal system’s requirements. In these situations, the “reluctant client,” as he is known, might benefit from therapy if the therapist can help define additional problems that fit his values and needs. For instance, the perpetrator of child abuse might want to find solutions for Frustration over inability to get compliance and cooperation from child; the person who is abusing illegal substances might agree that she wants help in reducing Painful emotions of worthlessness and abandonment; and the juvenile who is incarcerated in a youth facility might want to overcome Limitations in access to well-paying occupations.
After the first session, you start writing down your preliminary list of problems—and this list can easily contain more than 20 problems. What do you do with them? How can you possibly formulate a case with so many problems? You are faced with the task of organizing these preliminary problems in a coherent way; you are ready for the tasks of lumping and splitting.
The theoretical orientation in which you have received the most training will influence your leanings toward lumping or splitting. The skills of behavioral analysis teach clinicians to be very specific and concrete, leading to splitting. The use of personality theories, such as those of Freud, Jung, and Rogers, which use abstract constructs such as character, individuation, or the self, encourages lumping. Furthermore, decisions to lump or split will depend on individual differences in the therapist’s cognitive style. Some of us think in global, abstract terms and are always looking for the big picture. Others of us just naturally break things down into components and like to deal with a piece at a time.
Here is an example of two approaches to problem definition with the same client.
A client who is employed in the family business is extremely unhappy at work, but says he is obligated to stay there because his father counts on him. Whenever he talks about pursuing a career in graphic arts, his mother scolds him and accuses him of being a bad son.
One therapist used a single problem title:
Dilemma of pursuing own career interests versus yielding to parental demands
Another therapist defined three separate problems:
Sometimes when you lump problems together, you create a single problem title, and treat the original problems as part of the database. Other times, you want to keep the original titles for subproblems. When you create a broader title that encompasses several subproblems, you can call it the umbrella title. With this approach, you only need to write one SOHP; however, you need to develop outcome goals for each of the subproblems.
The process of lumping and splitting is the most creative part of problem definition. The “how to” of creating the problem list is learned through practice with case studies and clinical experience. You cannot learn it from reading; you need to experience a learning process that sometimes feels like trial and error. There is no “right” way of defining problems; the best we can do is evaluate how well the problem list is supported by the database, and then wait to gather evidence of the effectiveness (or ineffectiveness) of the implementation of the treatment plan. What matters most is whether the problem definition leads to successful therapeutic outcome. You may discover new and better ways to lump and split your original problems only after monitoring therapy process and progress. A benefit of discussing cases in groups is that the exchange of different ideas about the same client can improve decisions about problem definition by forcing you to explain your decisions about lumping and splitting.
The diagnostic labels from DSM represent the lumping of specific problems (the criteria); the needs of your client are often best served if you go back to the items on the list of criteria that led you to choose the diagnosis.
To assure that the problem list is complete, you need to gather a thorough and comprehensive database. Once you have a database, the best way to evaluate the completeness of the list is through supervision, consultation, and group discussions of the clinical case.
The omission of problems is a much more serious error than the inclusion of too many problems. Often the therapist and the client define a single problem and appear to have blinders to many other problems that would be obvious to an outside consultant.
The number of problems on the formal problem list must be appropriate to the client’s resources and motivation. Not every problem will be included: The client may have problems that could be targets for therapy, but that will not be addressed at the present time.