Problem Solving Flashcards
Problem solving in depression:
Depression: The symptoms hinder an active approach in dealing with difficulties
- > problems accumulate
- > they feel overwhelmed and less able to manage
A deficit in problem solving skills is not needed!
Problem solving Generalized Anxiety disorder:
Avoidance of problems, but worry to anticipate all possible negative outcomes associated with uncertainty
- > chain of worries unrelated to the problem but catastrophic in nature
- > higher anxiety and less ability to tackle problems
A deficit in problem solving skills is not needed!
What is problem solving therapy?
- Brief structured psychological intervention to teach clients problem solving skills
- Based on principles of cognitive behavioural therapy (3rd generation) with a clear focus on the here and now
. • Requires an active role of the client in planning of the treatment and implementation of activities.
Theoretical framework for Problem Solving Therapy:
Stress-vulnerability:
Stress-vulnerability:
Theoretical models assume that biological, psychological, and/or social factors make people vulnerable for the development of psychological disorders like generalised anxiety and depression
In addition there are protective factors that make you less likely to develop psychological disorders such as good interpersonal relations, social support, self-esteem, locus of control, self-efficacy, and a good health. (Problem solving is about the locus of control)
Theoretical framework for Problem Solving Therapy:
Problem solving and feelings of control:
Problem solving and feelings of control
Psychological disorders, like generalised anxiety and depression, are caused by problems that people experience in their daily life.
When people learn in a structured way and step-by-step (1) to deal with their problems and (2) relate to them to what they find important in their life the internal locus of control will increase.
This protects against the development of generalised anxiety and depression and decreases symptoms in people with generalized anxiety and depression.
Aims of problem-solving treatment (a-d)
(a) The client gains insight in the relation between symptoms and problems
(b) The client defines current problems that they experience
(c) The client learns problem-solving skills to solve problems in a structured way.
(d) The client will have a positive experience re problem solving
What makes the intervention attractive?
- Generic and applicable to a lot of disorders (transdiagnostic)
- The intervention has a clear structure
- Clients often recognise the relation between problems and the development of symptoms
- De therapy is not psychologizing
These characteristics make the treatment applicable to a broad population including people with low socio-economic status
Different approaches (1) SPST
Social problem solving therapy (SPST; D’Zurilla & Nezu, 1982)
- 10-12 sessions
- Format: group
Next to learning problem solving skills attention to attitudes and beliefs that may interfere with problem solving tasks.
Different approaches (2) PST-PC
Problem solving therapy for primary care (PST-PC; Mynors-Wallis, 1995)
- 6-9 sessions
- Format: individual (nurses)
Aimed at the key elements of problem-solving
Different approaches (3) SET
Self-examination therapie (SET; Bowman, 1995)
- 4-6 sessions
- Format: Guided self-help (can be individually or in groups)
Next to problem solving skills also focused on the goals in life
PST: Six steps (Mynors-Wallis) long
(1) Orientation about the approach: rationale of PST
(2) Identify problem (Identify immediate and real problems and start with easier problems
- Losing my job
- Gettng into debts
- Health of parents and children
- Boiler broken down
- People at work don’t like me)
(3) Generate as many solutions as possible (Boiler broken down
- Get in contact with plumber
- Ignore the problem
- Try to fix it myself
- Move house)
(4) Choose a solution
(5) Make a plan to implement the solution (Set manageable goals: when will you do what
Contact a plumber:
- Get recommendations from friends
- Ring recommended plumbers
- Get quotations (a new problem may arise when quotations are extremely high and a new boiler is needed, how to pay for the boiler)
(6) Review the outcome, if unsuccessful go back to step 3
PST: Six steps (Mynors-Wallis) short
Challenges in treatment
- Convince clients that talking about the past is not necessary
- Motivate clients to make an action plan
- Clients deny that they have a problem
- Clients do not take responsibility for problem-solving (but want others to solve the problem)
Good explanation about the treatment and its rationale is very important!
Effectiveness of PST
- Firm evidence for depression
- PST is included in the guidelines for the treatment of mild to moderate depression (i.e. NICE: NHG)
- Evidence for anxiety, emotional disorders, physical health problems and self-mutilation
- Effects are relatively small (but comparable to other treatments)
Results for depression Meta-analysis
(Cuijpers et al., 2018 European Psychiatry, 22, 9-15)
- Average effect size g=0.79: but g=0.34 in studies of high quality (moderate effect)
- A lot of heterogeneity between studies
- Larger effects in studies from :
- the general population,
- group sessions,
- North America,
- waiting list control groups, \
- studies with a large risk of bias
- Target group or type of PST was no predictor (although SPST did slightly better)
- PST was slightly more effective than IPT and CBT
Cocnlusion Meta-analysis by Malouff et al.
(Malouff, J. M., Thorsteinsson, E. B., & Schutte, N. S. (2007). The efficacy of problem solving therapy in reducing mental and physical health problems: a meta-analysis. Clinical psychology review, 27(1), 46-57.)
PST is more effective than no treatment, usual care, or placebo
Effects are larger when:
(1) There is attention for problems orientation
(2) Homework is provided
(3) The developer of the intervention is involved (researcher allegiance)
Study suggests effectiveness broader than depression
‘Alles onder controle’ (SET)
- (Guided) online self-help course or self-help book
- Based on ‘self-examination’ therapy
- 5 Lessons: Explanation, Examples, Assignments
In 5 weeks, clients learn to formulate what is important in their life, they define problems and think of possible solutions and make a plan to reach goals
Aim of the course (‘Alles onder controle’ (SET))
Target group:
People with stress, anxiety and low mood.
Contra-indication:
Serious cognitive limitations, crisis sensitive
Aim:
Decrease symptoms and prevent and reduce the risk of developing (more serious) anxiety or depression
Idea behind the course is that symptoms will decrease when clients work on their problems independently and they will gain control over their life and their problems..
Course structure (‘Alles onder controle’ (SET))
(1) What is important?
(2) Make a list of problems
(3) Categorise problems
- Important and solvable
- Unimportant
- Important and not solvable
Content of the lessons (‘Alles onder controle’ (SET))
Lesson 1: List important things and problems: categorize problems
Lesson 2: Use a 6-step plan to deal with solvable problems
Lesson 3: Worry less about unimportant problems
Lesson 4: Cope with problems that cannot be solved
Lesson 5: Make a plan for the future
Task of the coach (‘Alles onder controle’ (SET))
Provide weekly feedback after each lesson
- Motivate the client to follow the course
- Discuss progress, questions and bottlenecks
- Provide feedback on the assignments
So no therapeutic techniques!
Lesson 1: List important things and problems (‘Alles onder controle’ (SET))
Important things
- My study and my work
- Find the love of my life
- Go out travelling
- Enjoy life
Problems
- Did I make the right decision regarding my job? (I had to choose between 2 jobs). Important and solvable
- What I want from my relationship important and solvable
- The death of my father not solvable
- Ongoing feeling of emptiness and loneliness important and solvable
- Fear that I make the wrong decision important and solvable
- My drinking habits and diet are not good important and solvable
Lesson 2: 6-Steps plan (‘Alles onder controle’ (SET))
Step 1: Define the problem
Step 2: Think of as many solutions as possible
Step 3: Choose a solution
Step 4: Make a plan
Step 5: Implement the plan
Step 6: Review the outcome
Lesson 3: Stop worrying (‘Alles onder controle’ (SET))
3 strategies
- Worry time
- Thinking stop
- Keeping a log of positive thoughts
Lesson 4 Problems that cannot be solved (‘Alles onder controle’ (SET))
Phases of loss: denial, bargain, depression, acceptance no rules!
- Accept feelings
- Also accept negative feelings
- Talk to other people
- Contact fellow sufferers
Make a decision and a plan!
Lesson 5 Plan for the future (‘Alles onder controle’ (SET))
Feedback to the important things in life (lesson 1)
- What can I do to focus more on the important things in life
- Plan: when can I do what?
- Are there things I no longer want to do?
Effectveness of online guided SET
Three studies in the general popula1on show posi1ve effects
Average effect size:
- Depression 0.50, 0.43, and 0.38
- Anxiety 0.33 and 0.30
Adjusted versions of ‘Alles onder Controle’ SET (work environment)
(Geraedts AS et al. (2014). Journal of Medical Internet Research, 16;5: e121.)
Happy@work for employees with depressive symptoms
Happy@work was not more effective than psychoeducation only
Adjusted versions of ‘Alles onder Controle’ SET II (For Turkish Migrants)
(ÜnlüInce, B., (2013). Journal of medical Internet research, 15(10).)
AOC for Turkish migrants with depression
AOC was slightly more effective than waiting list control
Adjusted versions of ‘Alles onder Controle’ SET (specialised mental health care)
(Kenter RMF (2016). J Med Internet Res;18(3):e80.)
AOC for people on a waitlist for specialised mental health care
AOC not more effective than doing nothing
Conclusion (Alles oder Controle)
‘Alles onder Controle’ SET can be effective but not under all circumstances
Smart Oncology: Collaborative care
(Walker J., General Hospital Psychiatry 31 (2009) 436–441)
Series of three studies on the effectiveness of Collaborative Care for oncology patients with major depression
SMART Oncologie-1: people with a good prognosis
SMART Oncologie-2: people with a good prognosis
SMART Oncologie-3: people with a bad prognosis
PST is the core of treatment
Depression and cancer
About 10% of the people with cancer meets criteria for a major depression
Depression makes it harder to deal with the disease and lowers the adherence to the cancer treatment
Integrated treatment for depression and medical care involves medical specialist, GPs and other health care professionals in the treatment for depression
Intervention (Depression and Cancer)
Case manager:
Nurse specialist provides psycho-education about depression and medication and a maximum of 10 sessions PST according to the Mynor-Wallis protocol.
Supervision was provided by the psychiatrist; GPs and oncologists were informed about the diagnosis. GPs were advised to provide anti-depressants.
Nurses were often specialised in oncology, which is less stigmatising and this facilitates the contact with the medical specialist and the GP
Results SMART Oncology
All trials showed more significant effects for Collaborative Care compared to enhanced Usual Care
SMART Oncology-1: people with a good prognosis (g=0.37)
SMART Oncologie-2: people with a good prognosis (d=0.78)
SMART Oncologie-3: people with a bad prognosis (d=0.62)
But ~ 80% were taking anti-depressants
What problems do clients have? Cancer patients with major depression
(Kleiboer, A., Bennett, F., Hodges, L., Walker, J., Thekkumpurath, P., & Sharpe, M. (2011). The problems reported by cancer patients with major depression. Psycho‐Oncology, 20(1), 62-68.)
“The most common problem categories were ‘concerns about other people’s well‐being’ (65%), ‘problems in interpersonal relations’ (61%), ‘loss of interest’ (56%), ‘low mood’ (55%), and ‘cancer recurrence or relapse’ (54%).”
main treatment options
PST: Six steps (Mynors-Wallis)
step four:
Smart Oncology: Collaborative care