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Article Excerpt
The K-State Problem Identification Rating Scales, a new screening instrument for college counseling centers, gathers information about clients' presenting symptoms, functioning levels, and readiness to change. Three studies revealed 7 scales: Mood Difficulties, Learning Problems, Food Concerns, Interpersonal Conflicts, Career Uncertainties, Self-Harm Indicators, and Substance/Addiction Issues.
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Effective treatment planning for psychotherapy requires a reliable and valid assessment of the problems that need to be addressed. For more than 90% of medium to large university counseling centers, this diagnostic process is set in motion when the client is given a brief checklist of symptoms (Zalaquett, 1996). Often completed in the waiting room, these intake checklists provide counselors with an initial screening of common problem areas that might need a more detailed assessment by the clinician. This practice is not novel to counseling centers; many physicians also ask their patients to endorse various problem areas on a checklist before beginning the clinical interview in the examining room.
Checklists function to identify symptoms that need to be explored further, either during the clinical interview itself or through the judicious use of standardized diagnostic instruments. These three resources--an intake checklist, the clinical interview, and selected standardized assessment instruments--enable the counselor to develop a diagnostic impression that leads to appropriate treatment plans and strategies.
Two factors in the current university climate underline the importance of using an intake screening instrument that is both reliable and valid. First, college counseling centers are reporting an increase in the demand for services from students with more complex and serious problems (Benton, Robertson, Tseng, Newton, & Benton, 2003; Gallagher, Gill, & Sysco, 2000; O'Malley, Wheeler, Murphey, O'Connell, & Waldo, 1990; Robbins, May, & Corazzini, 1985). At the same time, counseling center psychologists are experiencing higher demands from university administrators for evidence of the efficacy and efficiency of psychotherapy services (Hiebert, 1997; Stewart & Cairn, 2002). Psychologists and other mental health specialists working in counseling centers must therefore respond to two pressure points: students who are struggling with severe difficulties and administrators who are making decisions about university budget cuts and belt-tightening measures. In this context, it makes both therapeutic and economic sense to begin the assessment process with a psychometrically sound screening instrument that identifies problems needing a more thorough assessment.
INTAKE MEASURES
The checklists currently used in college counseling centers vary widely in length, quality, and evidence of psychometric examination (Zalaquett, 1996). Several checklists have been subjected to factor analysis, including the Mooney Problem Checklist (Mooney & Gordon, 1950), the Symptom Checklist-90-Revised (Derogatis, 1993), and the Brief Symptom Inventory (Derogatis & Melisaratos, 1983). In addition, several other authors have reported results of factor analyses on unpublished problem checklists used in university counseling centers (e.g., Bauman & Lenox, 2000; Miller & Rice, 1993; Zalaquett & McManus, 1996).
These problem checklists have several advantages. They are easy for clients to complete. They take little client time, and they enable psychologists to effectively scan a wide variety of client concerns. Furthermore, checklists allow clients to endorse sensitive items that they might not readily report in an interview, and they also may prepare clients for the intake interview by focusing attention on specific symptoms.
However, the checklist format does have some important disadvantages. For example, the yes/no format used by most checklists is less sensitive than a rating scale approach to gauging the severity of a symptom. Furthermore, checklists tend to list only client problems and do not address other important client dimensions, such as problem-solving styles, readiness for change, or level of interference with overall functioning.
Other screening instruments use rating scales. The College Adjustment Scales (CAS; Anton & Reed, 1991) provide broad topic coverage of student anxiety, depression, suicidal ideation, substance abuse, self-esteem, interpersonal problems, family problems, academic problems, and career problems. The response format is a 4-point Likert scale used to assess how true each item is for the client that ranges from 1 = false, not at all true to 4 = very true. Clients are not asked about the degree to which various problems are interfering with their academic or social functioning. With 108 items, this instrument is relatively long compared with other screening measures, making it less appealing and relatively expensive for routine use at intake. Nafziger, Couillard, Smith, and Wiswell (1998) reported that the CAS holds some promise as an evaluation and outcome measure but recommended more research to support the instrument's efficacy and value.
Heppner et al. (1994) developed the Computer Assessment System for Psychotherapy Evaluation and Research (CASPER) for the purpose of measuring client presenting symptoms. The CASPER evaluates seven problem areas (use of chemicals, suicide, thought problems, physical problems, interpersonal problems, mood problems, and leisure activities) and provides a global rating of distress. It does not include measures of academic and career concerns or of learning disabilities.
Another commonly used instrument in college counseling centers is the Outcome Questionnaire-45 (OQ-45; Lambert et al., 1996). The OQ-45 is inexpensive and brief and has been used to measure changes in client distress levels across psychotherapy sessions (Lambert, Okiishi, Finch, & Johnson, 1998; Vermeersch, Lambert, & Burlingame, 2000). The OQ-45 was developed with three factors in mind: Symptom Distress, Interpersonal Problems, and Social Role Dysfunction. However, confirmatory factor analysis (CFA) failed to support a three-factor structure and instead revealed a single global factor that might be described as client distress (Mueller, Lambert, & Burlingame, 1998). The OQ-45 has less utility in specific client problem identification and associated treatment planning.
Heppner, Cooper, Mulholland, and Wei (2001) developed an instrument with a more focused purpose--to examine client adaptive coping strategies in problem resolution. Factor analysis identified four underlying factors: Problem-Solving Strategies, Problem-Solving Self-Efficacy, Problem Impact on Daily Functioning, and General Satisfaction With Therapy. Although this instrument has the advantage of being multidimensional in its assessment, it is not symptom based and so does not assess specific presenting problems.
THEORETICAL CONSIDERATIONS
Counselors also have available several theoretical taxonomies of student problems to aid in identifying possible client problems. For example, Grayson and Cauley (1989) classified eight potential problem areas of college students: suicidal ideation, family problems, relationships, depression and anxiety, academic difficulties, substance abuse, sexual problems, and eating disorders. Archer and Cooper (1998) identified 15 problems among students and presented examples of actual interventions for such issues as eating disorders, autonomy training, career assistance, chemical awareness, date rape, stress, and learning disabilities.
In sum, screening instruments are a valuable source of information to counselors. They minimize assessment time by targeting problems that need further attention and should perhaps be measured by standardized testing. To form a reliable and valid assessment without using any screening device would require that clients be given an extensive battery of standardized tests, a process that would take several hours and be neither convenient nor appropriate.
On the basis of an analysis of the instruments cited previously as well as our own experiences in university counseling centers (more than 200 years, cumulatively), it was our view that university counseling centers need a new standardized screening tool. Such an instrument would have the following characteristics: it would provide information on both academic and clinical problems faced by college students; it would examine a list of symptom clusters not currently available in any single checklist; it would use a rating scale rather than a dichotomous checklist in order to increase sensitivity; it would give counselors an estimate of the degree of severity with which the symptoms are interfering with a student's academic and social life; it would supply counselors with an early look at a client's readiness to engage in therapy; and it would be completed in a relatively brief amount of time. The use of such an instrument, therefore, would allow counselors to gather leads in developing a more refined diagnostic assessment and to make better decisions regarding case disposition and treatment planning. This article reports on a series of studies undertaken to meet these needs in a single screening tool.
METHOD
Participants
Samples of university students were used in three separate studies: (a) a derivation sample of active clients for an exploratory factor analysis (EFA), (b) a replication sample of active clients for a CFA, and (c) a nonclinical sample for a cross-validation study.
Derivation sample. Participants for the EFA were university students (N = 872) who sought counseling or psychological services during the 2000-2001 academic year at a university counseling center in a large public university (enrollment greater than 20,000 students) in the Midwest. The center employs 16 mental health professionals, 4 support staff, and 3 student assistants who serve an average of approximately 1,000 clinical clients each year. All clients were asked to complete the K-State Problem Identification Rating Scales (K-PIRS) at the time of their intake. Nearly two thirds of the students in the derivation sample were women (n = 560, 64.2%). Clients' ages ranged from 16 to 64 years (M = 22.90, SD = 5.78). Graduate students made up 12.3% of the total sample. Undergraduates included seniors (29.3% of the total sample), juniors (21.8%), sophomores (20.6%), 1st-year students (15.1%), and special students (0.9%). Slightly more than half the participants (52.5%) had a grade point average (GPA) of 3.0 or higher. Most participants described their ethnicity as White, non-Hispanic (82.9%); other ethnicities represented included African American (3.3%), Hispanic American (3.1%), Asian or Pacific Islander (2.5%), multiracial (2.4%), Native American (1.2%), and other ethnic heritages (1.7%). Some students (2.9%) did not answer the question about ethnicity.
Replication sample. Participants for the CFA were university students (N = 879) who sought clinical services at the same midwestern university as that for the derivation sample during the 2002-2003 academic year. In this sample, 65.1% of the students were women (n = 572). Client ages ranged from 17 to 57 years (M = 22.93, SD = 5.59). Graduate students made up 13.7% of the total sample. Undergraduates included seniors (28.3%), juniors (24.2%), sophomores (18.6%), and 1st-year students (15.2%). A little more than half the participants (55.6%) reported GPAs of 3.0 or higher. Regarding ethnicity, 85.3% reported that they were White, non-Hispanic. Other ethnicities included African American (3.0%), Hispanic American (2.2%), Asian or Pacific Islander (2.2%), multiracial (2.0%), Native American (0.8%), and other heritages (1.2%); 3.4% chose not to respond. (Percentages were rounded.)
Group comparisons were made between the derivation and the replication samples. In addition to gender, age, class standing, GPA, and ethnicity, we compared the two groups using a variety of descriptors: marital status, campus or community housing, approximate hometown size, referral source, and academic major grouped by college. We also asked whether or not the participant was employed, a transfer student, a full-time student,...
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