Clinical Presenting Issues

The clinical presenting issue is the brief description clients use to describe their reasons for seeking help when seeking psychological services. It is the initial clue encountered by psychologists in their efforts to help clients solve the problems that have brought them to therapy. The presenting issue may be complete and focused on the primary issue of concern to the client, vague and largely unrelated to the most pressing concerns of the client, or somewhere in between those extremes. This imperfect relation between the presenting issue and the focal issues upon which the client and psychologist will eventually work is reflected in the common clinical adage: “The career counseling referral is always a psychotherapy referral, and a psychotherapy referral is always a career counseling referral.” Therefore, the presenting issue is best regarded as the opening statement in a dialogue between the psychologist and the person seeking help rather than as a statement of fact. As such, psychologists must give it their close attention and treat it with the respect it deserves while understanding that it does not necessarily tell the entire story. Presenting issues tend to vary as a function of the helping professional being addressed (e.g., psychologist, counselor, psychiatrist, clinical social worker, or vocational counselor), the setting in which services are sought (e.g., college counseling center, community mental health center, or hospital), and the client’s characteristics (e.g., mandated client or child, teen, or adult voluntarily seeking services). This entry reviews the presenting issues prominent in each of these.

Helping Professional

The theoretical and empirical contributions of Stanley Strong, Charlie Gelso, and Howard E. A. Tinsley have been instrumental in demonstrating the influence of the helping professional on the presenting problem. The name by which the “helper” is known influences the likelihood an individual will seek assistance from that person. The typical individual is more likely to seek help for personal problems involving a spouse, family member, or member of the opposite sex from a counseling psychologist. Psychiatrists, clinical psychologists, and peer counselors are less likely to be seen by persons with those presenting problems. Psychiatrists and counseling psychologists are most likely to be seen by individuals who are troubled by thoughts of suicide or concern about their emotional stability. People who desire help with career plans, problems on the job, or developing a life plan are most likely to seek the assistance of a career counselor, a college counselor, a close friend, or a relative. In general, therefore, people tend to have a general idea of the relative areas of expertise offered by the different potential helpers and to base their help-seeking decisions on those beliefs.

Although this is a sound, common-sense approach, people seeking help do not always understand (or may not be ready to admit) the true nature of their concerns. For this reason, helping professionals must be broadly trained and stand ready to refer clients when they conclude that another helper is better prepared to help the client.

Clients are in a state of vulnerability or even crisis at the time they are stating their presenting problem. For this reason, Randolph Pipes and Donna Davenport have underscored the importance of therapist sensitivity and competence in crisis management. Skilled therapists understand that in addition to the pain caused by their personal situation, clients typically experience some trepidation about disclosing the relevant personal information to a therapist (and many clients are troubled by the nagging doubt that no one—and especially not the therapist they do not yet know—could understand what they are experiencing.

A substantial number of clients do not return after their first interview with a therapist. For this reason, experiencing and communicating respect for clients and their experiences is a key therapeutic factor when considering the referral problem. Although that may sound like a fundamental social skill, skilled psychologists understand that respect is deeply embedded in a cultural context. Multicultural competency is critical clinical skill expected of therapists, and psychologists are called upon to exercise this competency from the clinician’s first reading of a phone message to their more formal assessment of the reason for referral.

Setting

The most systematic body of research on presenting issues has been conducted in university counseling centers. The evidence, of course, tends to yield answers that are somewhat typical of individuals at that developmental stage. Concerns about personal values, academic and emotional stress, body image, alcohol use, and adjustment to college life tend to be salient presenting issues on college campuses. For female students the 10 most distressing concerns, ranked in terms of their severity, are anxiety and worry, academic concerns, depression, stress management, concern about the future, self-esteem and self-confidence, procrastination and motivation, career and college major selection, finances, and concentration. In contrast to popular stereotypes of the college years, loss of relationships and dating concerns ranked relatively low. For males the same 10 problems were ranked as their most severe presenting concerns, but the order was slightly different. The men ranked concentration, procrastination, and motivation as more troublesome than the women did, and stress management, self-esteem, and self-confidence as less troublesome.

A different picture emerges from clients seeking services from the department of psychiatry in a university medical center. Their most frequent presenting issues involved mood disorders, substance abuse, anxiety disorders, psychotic disorders, and eating disorders.

Community mental health centers often see the broadest range of presenting problems, since these centers tend to be both the initial point of contact for the community, particularly those with few resources, and the safety net or service provider of last resort. As a result, community mental health centers deal with mental health matters ranging from the crises of suicidal behavior to the chronic problems of schizophrenia and bipolar disorder.

Help Seekers

Children and Adolescents

In general, parents initiate mental health services for their children. However, the agreement between parent and child identifications of the presenting problem is quite low. In one recent study more than 60% of the parent-child pairs failed to agree on a single problem for which the child needed help. Even when the presenting issues were grouped into broad categories, more than a third of the parent-child pairs failed to agree on even one general area in which the child needed help. It appears that parents and children see the presenting problems quite differently.

Parents and children are in better agreement regarding the child’s need for help with externalizing behaviors than their need for help with internalizing behaviors. Externalizing behaviors such as fighting, arguing, and disruptive behaviors are readily observable, so it is not surprising that parents are more aware of the child’s needs in this regard. In contrast, internalizing behaviors such as anxiety, depression, and low self-esteem are more subjective. It is more difficult for parents to become aware of the child’s need for help with these issues, and their awareness of the child’s needs is dependent in large part on the child’s willingness to express these needs to his or her parents. It is also true that parents and children are in better agreement regarding the problems that bother the child than they are the problems that bother the parents. This is most likely due to the parents’ decision to avoid burdening the child with knowledge of the stress and anxiety the child’s problems are causing the parents.

A recent Surgeon General’s Report on Mental Health stated that during the course of a year, one in five children and adolescents manifest the signs and symptoms of a disorder found in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV), and about 5% of all children experience an “extreme functional impairment.” This estimate is consistent with the 2001 finding of the Policy Leadership Cadre for Mental Health in Schools that more than 20% of the primary healthcare visits of children are prompted by mental health concerns.

A different perspective emerges from a large survey of regular and special education teachers, school counselors, and school psychologists who were asked to rate the severity of 10 presenting emotional/behavioral problems in their school. Impaired self-esteem was rated as the most serious problem. Suicidal thoughts or behaviors and inappropriate sexual behavior were generally rated as being of least concern. However, these findings may speak more to the prevalence and amenability to observation of adolescents’ problems than to their severity. School personnel may be quite aware of the troublesome nature of common and observable problems. More severe problems may be more rare and not as readily observable (internalized). For example, even highly trained specialists are not able to predict with any degree of accuracy which child will commit suicide or bring a gun to school with the intent of harming others.

Young Adults

Young adults form the predominant clientele of university counseling centers, so information on the presenting complaints that are most prominent in this age range is largely overlapping with that for university counseling centers presented earlier. One recent study compared the prevalence of presenting issues gathered from 50 university counseling centers on two occasions across a 6-year interval. The five main presenting problems were academic concerns, relationship/adjustment issues, depression/romantic relationships, sexual issues, and eating concerns. Comparison of the earlier and more recent years revealed that the presenting complaints of students had increased in severity and chronicity. For example, longstanding, persistent depression, bipolar disorder, and schizophrenia have become more common.

Even within a somewhat homogeneous group such as university students, subgroups of students can experience quite different concerns. For example, the major presenting issues of concern to gay, lesbian, bisexual, transgender, and questioning (GLBTQ) clients are development of their social identity, isolation, educational issues, family issues, and health risks.

Adults

The clinical presenting issues of adults are as broad as the DSM-IV. Depression (e.g., suicidal ideation) and anxiety (e.g., panic attacks) are often identified by screening instruments, but other presenting issues are more difficult to diagnose. Approximately 10% of the general population experiences a personality disorder (i.e., a chronic and frequently severe condition associated with high levels of impairment and suffering in social, occupational, and other important areas of life due to an enduring, inflexible personality pattern). Roughly half of the patients seeking services from a community-based clinical setting meet the diagnostic criteria for a personality disorder.

Mandated Clients

Clients who are ordered to receive psychological services by the courts or some other authority pose particular challenges because they did not freely choose to seek the services of the mental health professional. However, therapists cannot assume that mandated clients are unwilling clients, or that their motivation to seek therapy is different from that of nonmandated clients. Some mandated clients are willing if not eager to see the mental health professional. It is also true that many nonmandated clients seek the services of a psychologist because someone else brought them or urged them to do it. For example, children and adolescents often seek the services of a therapist at the urging or direction of their parents, and oftentimes one of the persons in a marital dyad is an unwilling participant.

Many court-ordered mandated clients are more willing to participate in therapy than might be expected. While the presence of legal charges provides some information, this information cannot be taken at face value. For example, the juvenile who took the family car and is referred to therapy because of the stated offense of auto theft is different from the youth who stole a car from the streets. Nevertheless, many mandated clients are resistant to the notion of counseling. Given this, the main tasks of the mental health professional are to elucidate the choices the client has, explain how cooperation in the client’s best interest, and treat the client with dignity. Mandated clients, like nonmandated clients, need to tell their story because the presenting problem makes little sense without context.

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