Problemsolving Therapy Rationale

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Problem-solving therapy is a time-limited, structured intervention, which helps patients use their own skills and resources to cope with specific current problems and which is in keeping with cognitive- behavioural approaches. The connection between psychological symptoms and impaired capacity to resolve psychosocial problems is a basic assumption of this approach and the primary aim is to develop more effective problem-solving skills leading to symptom improvement. Problem solving capacity is conceptualised as a moderator in the problem-distress interaction such that improved capacity should ameliorate symptomatic distress. The causal factors leading to symptomatic distress are argued to be multiple and variable, interacting directly and distally (Nezu et al., 1997). Problem-solving aims to adapt beliefs that inhibit problem solving, to promote functional attention to emotions as a signal of a problem and reduce the tendency to reactive responses rather than systematic problem solving. Training assists in identification and clarification of problems, prioritisation of areas to be addressed, breaking the problems down into manageable tasks with achievable goals, generating a range of alternative solutions, selecting and implementing preferred solutions and evaluation of outcome.

Empirical Evidence

Research evaluations of problem-solving therapy have been exclusively conducted in primary care and community samples, with patients with mild depressive symptoms. Dowrick et al. (2000), Nezu et al. (1986), and Nezu, Nezu & Perri (1989) have shown problemsolving therapy to achieve greater symptom reduction than no-treatment control conditions for depressed patients at the end of treatment. Nezu's studies reported better outcome for full problem-solving therapy over components of the therapy and this was maintained over a six-month follow up. Dowrick's community sample did not maintain the initial gains over a naturalistic 12-month follow up.

Mynors-Wallis et al. (2000) conducted a randomised controlled trial of PST, anti-depressant medication and combined treatment in depressed primary care patients and found no difference between individual and combined treatment.

Clinical Practice

Problem-solving treatment has three main steps: patients' symptoms are linked with their problems, problems are defined and clarified, and an attempt is made to solve the problems in a structured way. The treatment involves approximately six to 10 individual sessions.

The first treatment session lasts one hour, with subsequent sessions lasting 30 minutes and emphasis placed on between-session activity to implement the solutions generated. Problems are selected to be highly relevant to the patient's life situation rather than teaching abstract skills. Each stage of the problem-solving process is distilled to a series of steps to assist patients in acquiring a reasoned and deliberate approach to problem resolution.

The first three sessions provide an introduction to the approach and primarily address problem-orientation - addressing interfering beliefs and promoting a constructive problemsolving approach. The experience of difficulties is normalised and the potential to aggravate symptoms is made clear. An active coping stance is encouraged to empower the depressed individual to achieve change and symptom relief. The extent to which cognitive strategies are employed varies between individuals from minimal to the primary techniques. Subsequent sessions revolve around ongoing training and practice of rational problem-solving skills. Progress with problem definition, generating solutions, evaluating potential consequences to aid selection and monitoring outcomes is repeatedly revisited and solutions refined in the light of each attempt.

Problem definition is collaboratively encouraged to help individuals to develop a measure of what troubles them and to determine the direction in which to target their energies. If this is not already loosely defined in the patient's mind a period of self-monitoring may help to specify the difficulty. Problems are listed rather than narrowed down to a single example, and efforts to resolve are prioritised, based on the relative contribution to the depression. It is important to try to generate an optimally comprehensive list of difficulties to prevent misdirecting the process or failing to uncover the connection between problems. Assessment should cover the individual and the environment, examining cognitive, affective, behavioural and biological components of the individual's experience and the physical and social environment (Nezu et al., 1997). Current and past experience may inform problem definition - significant changes in perspective may clarify deficits or excesses. The extent of the symptomatic problem is also clarified with use of standardized measures in conjunction with clinical assessment, both to give an indication of the work likely to be involved and as a means of monitoring progress. The sequence and reciprocity of interactions - triggers and consequences - is made clear rather than a generic statement of association between the identified components.

Creativity is encouraged in generating possible solutions, looking both internally and externally for exits. The expansive nature of brainstorming helps to combat the filtering and self-criticism, which can undermine and halt problem solving and loop back into depression. As problem solving focuses on the skill of the patient to bring about change, this stage also involves an assessment of patients' resources, actively directing attention to what they have and can do rather than what they cannot. Action is encouraged and supported in choosing a potential solution and testing out its effect. Targets are selected based on their potential to achieve the ultimate goal of treatment or to an intermediary step towards this. The basic assumption that more than one solution might be implemented and run through the same process to test the limits and responsiveness of the problem can also help to counteract the disappointment and frustration that can arise if success is not immediately forthcoming. Whenever possible the goals identified in relation to the target problem should be described in behavioural terms, offering a clear and realistic guide for the patient. Regularly monitoring progress helps to ensure that energy is not unduly wasted on ineffective strategies and supports a self-correcting approach. Progress is reviewed both through repeated administration of standardized measures and through the session-by-session review of the patient's diary of activities. Obstacles that emerge through this process, such as negative expectations, can be worked on more directly to increase the chances of subsequent success. As with all time-limited therapies patients should be prepared for the ending from the outset, with a clear expectation of treatment duration. Care should be taken not to extend therapy unnecessarily to work through all the identified problems once the patient has demonstrated an independent capacity to use problem-solving skills.

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