This Month’s Expert: Practical Issues in Using Transcranial Magnetic Stimulation John O’Reardon, M.D.When a family comes in for their initial session, one of the first questions a therapist asks is something like, “What brings you here today?”

Someone in the family usually takes the lead and describes what he or she thinks is “the problem.” Others nod in agreement – or don’t. Therapy starts with how the therapist responds to that statement. Is the problem or even the argument about the problem really the problem?

Part of the art of therapy is not taking things literally, but instead investigating what people aren’t saying or even, at times, what people aren’t even aware might be going on.

Defining the problem is the important starting point for treatment.


I wish I could remember who first told me about these three possibilities so I could give credit where it is due. Early in my career, I learned that it is extremely helpful to give consideration to each one as I work with a family to define their problem and determine our goals.

3 Ways to Look at a Presenting Problem

The Problem Is the Problem: Sometimes family members are absolutely correct. The only problem they are having is the problem they come in with. For example: A couple comes in with their 13-year-old son. He says he is too tired to go to school. The mother says she can’t get him up in the mornings. The dad is equally concerned. They want him to go to school. They are sick of the regular morning drama around getting him up. They worry that he might be depressed.

It could be that the stated problem really is the problem. The boy is too tired. Yes, maybe the boy is depressed. But the first recommendation a therapist should make is that he see his pediatrician. The boy may be suffering from an undiagnosed medical problem, not a mental disorder.

Another possibility is that his parents don’t know how late he is up at night playing video games. Or just maybe this young man is over-scheduled with school, sports, and other activities and is exhausted. The problem of “being too tired” may simply be a consequence of too much activity or too little sleep.

The Problem is Communication of Another Problem: Let’s take a look at the same case. The parents present the problem that their son won’t get up in the morning. They’ve taken him to the doctor and he is medically fine. He does not have a computer in his bedroom and phones are put on the kitchen counter at bedtime. He has a reasonable schedule. So what’s the problem?

The therapist is aware that there is a problem with bullying at the teen’s school so she asks him directly about it. He shyly admits that it is a problem for him. He doesn’t want to deal with the bullying he gets at school so he doesn’t want to go. When asked why he didn’t tell his folks about it, he gives the usual answers: He didn’t want to worry them. He thinks it would make things worse. He thinks he’s a “wuss” for not being able to deal with it.

Years ago, we therapists learned that if we didn’t ask about domestic violence, we often didn’t learn of it until much later in our treatment of an individual. Similarly, we now know how important it is to ask school-age kids about whether bullying is an issue for them. In this case, the teen’s tiredness was a way to communicate to his parents that there is something going on at school that he can’t bring himself to tell them about directly.

The Problem is a “Solution”: Related to communication is an even more sophisticated use of a problem. In the case above, not going to school can also be seen as the teen’s solution to his dilemma about whether to tell his parents about the bullying. If he doesn’t go, he doesn’t get bullied and he doesn’t have to confide in his parents. That’s pretty straight-forward. But sometimes it’s more complicated than that.

A young teen says he’s “too tired” to go to school. Careful questioning of the family surfaces that the parents have been fighting a great deal lately. The boy is worried about them both. He has discovered (maybe not even consciously) that if he balks about getting up in the morning, his parents focus on him instead of each other. They drop their fight and spend the time before they go to work cajoling, bribing, and threatening him with consequences if he doesn’t get up and go to school.

They eventually give up in exasperation and leave for work. The boy then gets up and gets himself to school, tardy but there. He’s willing to serve detentions for tardiness in order to get his folks to stop fighting every morning. His “tiredness” is a solution. It gets his parents to stop fighting.

The strength in this situation is that the parents’ love and concern for their son is bigger than their conflict with each other. They do stop their fight to try to help him. That’s a place to start.

Clearly, these possibilities overlap. A problem can even be a consequence of all three. Perhaps the boy in this case has a vitamin deficiency, is staying up every night to play video games, is trying to alert his folks to a bullying problem at school and is worried about the fighting between his parents.

Nonetheless, I’ve found it a useful exercise to think about each category as I begin working with a case.