Assessment of Client Core Issues

CONTENTS

Cover

Title Page

Copyright

Dedication

Preface

Acknowledgments

About the Author

Chapter 1: An Introduction to Client Core Issues

Chapter 2: Conceptual Foundations for Understanding Client Core Issues

Chapter 3: Assessment of Core Issues and the Nature of the Client's Living Story

Chapter 4: Designing the Counseling Intervention: Framing the Client’s Living Story

Chapter 5: The Case of Sue

Chapter 6: Incorporating the Core Issues Framework in Counseling Practice

References

Index

Technical Support

End User License Agreement

Assessment of Client Core Issues

Richard W. Halstead

American Counseling Association

5999 Stevenson Avenue

Alexandria, VA 22304

www.counseling.org

Copyright © 2007 by the American Counseling Association. All rights reserved. Printed in the United States of America. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher.

10 9 8 7 6 5 4 3 2 1

American Counseling Association

5999 Stevenson Avenue

Alexandria, VA 22304

Director of Publications

Carolyn C. Baker

Production Manager

Bonny E. Gaston

Copy editor

Kay Mikel

Editorial Assistant

Catherine A. Brumley

Text and cover design by Bonny E. Gaston.

Library of Congress Cataloging-in-Publication Data

Halstead, Richard W.

Assessment of client core issues / Richard W. Halstead.

p. cm.

Includes bibliographical references.

ISBN-13: 978-1-55620-235-3 (alk. paper)

ISBN-10: 1-55620-235-0 (alk. paper)

1. Counseling. I. Title.

BF637.C6H295 2006

158’.3—dc22

2006009720

Dedication

This book is dedicated to my first and always family with whom I shared my formative years: my mom, June; dad, Donald; and sisters, Cherie and Marylou. Together they provided a wonderful foundation upon which to build a life of meaning and purpose. This work is also dedicated to my family of choice, Linda, Ben, Lisa, Mia, and Bluza, with whom I share the present. My families have provided amazing opportunities for living a full life of learning, and I truly cherish the time I have shared with them.

Preface

Living a life that results in finding personal satisfaction can be a challenging endeavor. Even under the best of circumstances, an individual is bound to struggle to some degree with the stresses, strains, and pressures that arise as a result of everyday living. Under less favorable conditions, individuals can become overwhelmed by stressful challenges and begin to lose a grasp on life's more enjoyable aspects. It is the counselor's role to assist those who may be experiencing a whole host of difficulties that might arise from such circumstances. Among the many complex factors involved in the counseling process is accurately conceptualizing the underlying nature of the client's problem and designing an appropriate counseling plan to address the client's overall struggle.

Early in my counseling career I came to what I thought was an important realization. It had occurred to me that clients' problems could be roughly grouped into two categories. In the first category were clients who presented with problems resulting from some unexpected event or isolated situation. In these cases, the client usually presented with no remarkable problematic history. In the second category were clients who presented with problems that were more complex in nature and that reflected a larger set of significant patterns of problematic issues that reoccurred over time. A client in this second category would present problems that often had a historical context and could be traced to earlier points of that client's life.

Having these categories helped me establish a framework for understanding the nature of a client's presenting problem, but it did little to help me design effective interventions. I struggled to provide effective interventions for clients in either category. I would create counseling plans that included an array of traditional counseling interventions with mixed results. I spent most counseling sessions actively listening to clients telling me in great detail about how, at certain points in their lives, they felt sad, anxious, confused, helpless, hopeless, unloved, abused, or angry. Despite all of this information, I rarely felt able to more fully understand the central issue or issues that continually generated discomforts or problematic response behaviors. With no framework for understanding the deeper nature of a client's problems—what I refer to in this book as the client's core issues—I often missed the bigger picture of each client's struggle. Without a broad frame of reference to work from, I found myself initiating a counseling process that would falter and eventually stall. The important outcome goal of either consistently helping the client adjust to a crisis event (category 1) or change repetitive problematic life patterns (category 2) was rarely achieved. As a result, I often felt frustrated and unable to provide the best possible counseling services to clients. More important, the larger core issues with which clients struggled often remained unaddressed and, as a result, unresolved.

When providing clinical supervision to counseling interns later in my career, I would often ask, So what do you think is really going on at the core of this client's struggle? My question was, in part, aimed at getting counseling interns to think past the more situational surface aspects of a client's presenting problem and the observable symptoms associated with that presenting problem so that they might focus on deeper aspects of the whole person. The other reason for posing this question was an attempt to get a bit closer to what I felt was missing in my own work as a counselor, understanding the client's core issues. Although the interns' responses to my question varied, it was clear that these well-schooled and talented novice counselors did not have a framework for understanding their clients' core issues any more than I did.

The problem of identifying and working effectively with core issues is not limited to those who lack experience. I have come to believe that the problem is more systemic in nature. During my tenure as a college mental health counselor and later as a counseling center director, I had access to information on clients who had been hospitalized for inpatient treatment. In hospital settings, symptom classification via the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision, or DSM-IV-TR (American Psychiatric Association, 2000), was where client assessment and treatment planning started and, all too often, seemed to end. It was after one such hospital case conference that I began to wonder about the power of models used for conceptualizing how a client presents. It occurred to me that conceptual models strongly influence what clinicians look for and, as a result, see in a client's presentation. What if the counseling profession had developed a complete companion manual to the DSM-IV-TR that focused on something other than sets of psychiatric symptoms as a means for conceptualizing client problems?

Counselors should not ignore the fact that some individuals benefit greatly from interventions based on the medical model. We must respect the fact that symptoms associated with current classifications of psychiatric disorders are synonymous with human suffering and, as such, counselors need to attend to intervention strategies that enhance the likelihood of symptom reduction. I am not suggesting, therefore, that there is no place for medically based assessment and treatment as a primary or ancillary intervention in one's overall clinical practice. What I am suggesting is that conceptualizing client problems based on the DSM-IV-TR has limitations. Counselors can move beyond those limitations by employing alternative models for conceptualizing client problems, such as the client core issues model presented here.

A major contribution of the multicultural counseling movement has been to advance the notion that a wide variety of valid perspectives exist for constructing a view of the world. Each perspective includes a contextual basis for understanding the nature of self, the social and relational roles of others, and the world's natural order. Through exposure to these ideas, members of the counseling profession have learned that holding a singularly absolute view of the world limits and marginalizes the validity of others. With more than one model for understanding the nature of the world, counselors can begin to see and understand aspects of life that previously were invisible or incomprehensible. I contend that the very same principles apply to the diagnostic conceptualization and understanding of client problems. Having only one formalized framework for diagnosing the nature of client problems is tantamount to imposing a culture of pathology on every client who seeks counseling services. This form of clinical encapsulation serves neither the client nor the counseling profession well.

As I continued to work with clients and developed as a counseling supervisor, it became clear that my work would be enhanced if I could more adequately conceptualize a client's reported problem on a deeper and more personally meaningful level. My goal was to find a problem classification framework that would allow me to better understand the core elements of a client's struggle as opposed to limiting my assessment to sets of observable symptoms. The underlying question associated with this goal was, What are the core issue factors responsible for establishing and maintaining problematic thoughts, feelings, behavior, and associated meanings in the client's life? If I could assist clients in articulating their concerns, I believed I could help them form a deeper understanding of their own struggles through the discovery of the thematic threads that ran through various problematic situations. If these thematic threads of a client's core issues could be identified, they would serve as working reference points from which new and perhaps more adaptive personal perspectives could be generated. The motivation for developing such an approach rested fully on the desire to bring resolution to the client's presenting concern and at the same time offer a means for helping the client create lasting change.

Using a client core issues framework has four advantages. First, such a framework allows the counselor to conduct an accurate assessment of the client's stated concern and draw some preliminary hypotheses about the core elements that may underlie the client's struggle. Second, once identified, the client's core issue becomes a focal point for designing an effective counseling plan and choosing appropriate interventions. Third, the counselor is better able to systematically monitor the client's progress in making transformational change over the course of the counseling process. Fourth, by committing a portion of the counselor's clinical focus to the client's core issue, the counselor helps facilitate the type of change that decreases the likelihood of relapse (Young, Beck, ' Weinberger, 1994).

I believe that relational themes at the center of the client's problem are clinically richer and provide a more useful nomenclature than the classification of symptoms associated with psychiatric disorders. It is my contention that a different problem nomenclature provides a basis for forming a clearer understanding of the core nature or essence of a client's problem-based struggles as well as the accompanying symptoms. Using this different, and more expansive, understanding of diagnostic assessment, counseling intervention strategies can be designed to assist the client in making core changes that are more adaptive over the longer term. Put simply, this book has been written to help the counselor formulate an understanding of the client that is qualitatively different from the traditional psychiatric diagnosis. My hope is that the client core issues model will help counselors understand the core elements of the client's presenting problem and design appropriate interventions to help the client create lasting change.

Overview of the Book

In writing this book, I have drawn heavily on the creative ingenuity of others who have advanced theoretical perspectives in cognitive and narrative therapies. My contribution is in offering a unique integration and synthesis of these theoretical perspectives that can enhance a counselor's work with clients. As such, I have made every effort to present the ideas and concepts in a concise manner that lends itself well to clear clinical application for the practicing counselor or counseling student.

Chapter 1 sets the stage for considering alternatives to assessing a client's presenting problem and the client's responses to the stated struggles. Chapter 2 offers a theoretical overview of the proposed diagnostic framework, tracing the conceptual framework of the core issues model and the validity of the construct and describing the 18 core issues and their specific origins. Chapter 3 focuses on client core issues and the nature of the client's living story. Chapter 4 frames the thematic nature of core issues and how they are expressed as a living story detailed in a client's relational history and current life. Chapter 5 is a case study that illustrates how core issues are assessed, how the client's living story can be deconstructed to reduce the hold it has on the client's relational worldview, and how to help the client find specific themes around which a new, more adaptive living story can be created. A video of this case study is available through ACA Online Courses (www.counseling.org). Chapter 6 explains how counselors can begin to incorporate the proposed framework in their practice and assist their clients' in developing greater resourcefulness in coping with their difficult personal struggles as well as creating positive and lasting change in their lives.

Acknowledgments

I have drawn on the creative works of many scholars, past and present, who have developed better methods for helping others and published their theoretical perspectives and research findings. Most notably I have drawn on the work of Jeffery Young, PhD, who built on earlier theoretical concepts to propose a cognitively oriented and relationally based diagnostic framework.

More personally, a number of friends and colleagues have provided valuable suggestions, ideas, and encouragement. Special thanks are extended to Alan D. Goldberg, Syracuse University; John Derbort, COB Fellow; Marta Carlson, Assumption College; Pam Lizdas, Jody Farmer, Cindy Trifone, Judi Durham, Saint Joseph College; Amanda Costin,