This category of articles is mainly geared toward therapists, clinicians, and people with an interest in the mental health field, but they can also be used to help a variety of people to understand mental health, mental disorders, and even their own symptoms. Just ALWAYS keep in mind that this blog is NOT a substitute for a mental health or medical provider and should not be used as such. If you are experiencing symptoms please contact a therapist, psychiatrist, or your Primary Care Doctor as soon as you can!
Primary Problem
When a client comes into therapy, they typically have a main complaint that brought them in. This is referred to by therapists as the "chief complaint" or the "primary problem". Once the primary problem is identified, diagnosis and treatment becomes a lot easier. So how do you identify the main problem, especially if there are a long list of issues? Listen, reflect, and clarify.
Listen
When a therapist asks "What brings you in today?" or "What seems to be going on?" This is an invitation for the client to express their chief complaint. Let's use a hypothetical case to try and discern what the "primary problem" is:
A female client comes in to therapy for the first time. When asked "what brings you in today?", she looks tearful and avoids eye contact.
"I just don't feel like me anymore.. I don't feel like doing anything. I used to get up early and now I'm lazing around. I just feel so stuck."
What stands out about this response? This client is explaining a few different symptoms: lack of motivation, trouble waking up, fatigue, and frustration.
Most of what the client focuses on is a decline in functioning based on lack of motivation/decrease in activity. Although she says both "I don't feel like me anymore" and "I don't feel like doing anything", it seems as though not feeling like herself is BASED on not wanting to do anything. I would most likely believe this client is experiencing some type of depressive symptoms (without more information).
Reflect
After hearing what the client has said and creating a hypothesis (the symptoms are depressive), it's always important to reflect what you're understanding to the client. In this case, the therapist might say something like "I hear you saying that you're not as active as you used to be and you're not feeling motivated."
"I hear you saying that you're not as active as you used to be and you're not feeling motivated."
This lets the client know what you're hearing and gives her a chance to correct anything that you may have misunderstood. The client may just agree, they may correct you, or they may add some more information. For the sake of this case, we will assume that the client says "Yeah, that's exactly it, I'm not motivated anymore."
Clarify
The last interaction of reflection did clarify the client's main complaint, but it didn't clarify the nature of the symptom. Lack of motivation could be caused by quite a few things so clarification will be the last step to attempting to get as much of an accurate understanding of the primary problem as we can. To clarify, the therapist may say something like
"What do you think caused this change?" "Have been feeling down or depressed?"
The reaction could go one of a few ways. The client could say something like "No! I'm not sad, I'm just tired all the time" or "No I'm constantly on edge, that's why I can't sleep!". OR they might say "I've been down for about a week. I feel sad."
Their response will determine what direction you go with your assessment and will help you to eventual come to a reliable diagnosis that will make their treatment more effective!
Because of these variations, the decision charts included in these articles are in no way hard and fast rules. These are simply suggestions that can be used with the help of client report and sound clinical judgment.
-Faith
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