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Problem Solving Treatment
WorkshopMarch 20, 2013
Patricia A. Areán, PhD
Alinne Barrera, PhD
Presenters
Patricia A. Areán, PhD.Professor in Psychiatry at University of California, San Francisco; Consultant and Senior Trainer to AIMS Center, University of Washington.
Alinne Barrera, PhDAssistant Professor, Palo Alto University; Consultant and Trainer to AIMS Center, University of Washington.
Overview
By the end of this session, you willo Become more familiar with current thinking in PSTo Be able to apply PST to adults with disabilities, co-
occurring anxiety, and people from different cultural groups;
o Make this model flexible to patients and your therapeutic style.
Problem-Solving TreatmentWorkshop
Morning
08:30 What is PST?
08:45 PST Components
09:00 Using PST with your clients
09:30: Small Group Role Play
10:30: Break
10:45: The initial PST session
11:30 Small Group Role Play
12:30 Lunch
Afternoon
1:30 Follow Up Session
2:15 Small Group Role Play
3:15 Managing Affect/Crisis
4:00 Small Group Debrief
4:20 Where to go from here
4:30 Adjourn
Small Group Role Plays
You will be divided up into your focus groups of interest (13 in each group).
You will role play with the leader to practice different skills throughout the day;
In role play #1, you will each have up to 10 minutes to explain how you will work with your client.
In role play #2, you will have up to 10 minutes to explain PST;
In role play #3, you will have up to 20 minutes to solve a problem.
Mr. T
2
What is Problem-Solving Treatment
(PST):An Introduction
What it is…
Brief treatment Patient centered treatment Goal focused Effective for:
o All adults, 18-100o Children with oppositional defiant disordero Self Harmo GADo PTSD
Available in Spanish, Chinese, Hebrew, Dutch, French, Vietnamese, Japanese.
What it is not…
Long term psychotherapy A panacea Clinical Case Management Something you do once in a while
Seven Steps of PST‐PC
Orient, Clarify and Define the Problem
Set Realistic Goal
Generate Multiple Solutions
Evaluate and Compare Solutions
Select a Feasible Solution
Implement the Solution
Evaluate the Outcome
How is PST Different from What I Already Do?
Like MI, BUT: picks up where MI ends
Like BA, BUT: focuses on life problems
Like Case or Self Management BUT: Patient has to eventually do the plans on their own –personalized plans
Like CBT BUT: emphasis is on patient creating their OWN strategies, not learning fix strategies (personalized strategies)
PST Components
3
What you need to do
Educate and socialize the patient to the treatment Create a problem list Teach the patient the 7-step process Use the worksheet as a guide to PST Create an action plan Schedule in pleasant/valued activities
Therapeutic Frame
6-10 sessions at place they feel most comfortable
You work on problems EVERY SESSION
They need to solve problems between sessions
Eventually the patient should be able to problem solve on their own
Educate Patient About PST Process
What PST is or is not: o not life review therapy
o not psychodynamic analysis
o Not *just* supportive therapy/case management
o action focused on immediate issues causing depression
Process Continued…
Meet first for one hour to get familiar with model and learn PST process
Meet for 30 minute sessions afterwards, for up to 10 sessions
Can meet in person or by phone Will work on one problem at a time Will create action plans the patient can implement
between sessions
Problem ListIf you’re not having a problem, you’re missing a chance to grow. – anon.
Domainso Financialo Housingo Medicalo Socialo Family
Organize in a hierarchy
Start with easiest problem
Problem DefinitionA problem well‐stated is a problem half solved. – Kettering
Concrete and specific terms
Assumptions versus facts
Details
Breaking down problems
4
Goal SettingGoals are dreams we convert to plans and take action to fulfill. – Zig Ziglar
Specific Attainable Realistic Measureable
BrainstormingDon’t put all your eggs in one basket – anon.
All ideas that come to mind
Withhold judgment Be detailed Generate five
Decision Making
Weighing the pros and cons
Does it meet immediate goal?
Does it meet long term goal?
Does it create other problems?
Is it feasible?
Again and again, the impossible problem is solved when we see that the problem is only a tough decision waiting to be made. – Robert H. Schuller
Selecting the SolutionYou are the sum total of all your choices up to now. – Dr. Wayne Dyer
One with the most pros and least cons
Most feasible
Less amount of effort
Solution Implementation
Steps to implementation
Specify when will do (earlier the better)
Delegate
When to check in
Do you need other people to help?
Even if you are on the right track, you’ll get run over if you just sit there. – Will Rogers
Solution EvaluationWhen you lose, do not lose the lesson. – The 14th Dalai Lama
Did it work?o If so, why?
• Would you do anything differently?
• Will you use this solution again?
If not why?o What did you learn?
• Does the problem need to be redefined?
5
Rewards and ActivitiesOne joy scatters a hundred griefs. – Chinese proverb
Make sure includes pleasant activities
Include a reward for hard work
Reinforce patient efforts at change
Name:
Review of progress:
1. Problem:
2. Goal(s)
3. Solutions 4. Pros Cons
Date:
PROBLEM-SOLVING WORKSHEET
Visit:
a) a) + a) -
b) b) + b) -
c) c) + c) -
d) d) + d) -
e) e) + e) -
( + ) ( - )
5. Choice
6. Steps
a)
b)
c)
d)
Pleasant Activities
Day 1:
Day 2:
Day 3:
Day 4:
Day 5:
Day 6:
Day 7:Next Appointment:
Using PST with your clients Intake session versus 1st session
Get to know your patient first Collect your own problem list as they talk Listen for:
o Financialo Housingo Interpersonalo Disabilityo Medicalo Legalo Functional
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Explain the process
Brief treatment Goal focused Meetings are to discuss problems and come up
with a plan Client must try solving problems on their own Importance of facing problems head on
Leader Demonstration:Explaining the Process
Small Group Role Play #1
You will each have up to 10 minutes to explain how you will work with your client
This is a new patient, you have never seen her before
Your task: Explain the PST process:o How often you will meeto Will be working on problems togethero Client works on problems during weeko Will make a list of problems nowo Will start next week
Break
Initial PST Session What a Session Should Look Like
Brief check in (2 minutes)
SET AN AGENDA! STICK WITH IT!
Review of between session PST (3 minutes)
Solve another problem (20 minutes)
Review the skills while going over PST
Review the session, be CLEAR about who is doing what during the week
Help the patient with environmental prompts
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What Makes PST* Effective?
Use of compassionate time management
Patient understands how PST works and the action oriented framework
Patient engages in action planning
*or any brief treatment
Compassionate Time Management
Always set an agenda;
Set aside time to get to know patient in context of why they are seeking help;
Always schedule in time to talk about other issues;
Use of gentle redirection.
PST Session
1. Clarifying and Defining the Problem
2. Establishing a Realistic Goal
3. Generating Multiple Solutions
4. Evaluate Pros and Cons
5. Choosing the Preferred Solution(s)
6. Implementing the Preferred Solution(s)
7. Evaluating the Outcome
If it’s Problem Solving, Why does the Structured Process Matter?
It’s a cognitive training technique (plasticity intervention) – you are conditioning cognitive and emotional control networks in the brain
Personalized action plans – you cannot tell them what to do, they learn to come up with their own, unique strategies
The patients need to know the process first before RE-incorporating it into their way of being
Leader Demonstration:Explaining the PST Steps
Small Group Role Play #2
You will each have up to 10 minutes to explain PST to your client
This is the same client as before Your task: Explain the PST steps:
o Use the worksheeto Go through the steps by solving one of the problems
with hero Do not be afraid to redirect
8
LUNCH!
BE BACK AT 1:30 SHARP!!!!
The Follow Up Session
Components
Similar to first session but patient has to solve the problem (you help)
Your tasks:o Set an agenda (this takes seconds to do)o Review Symptom Checklisto Review action plano Pick a problemo Solve ito Create action plan
Leader Demonstration #3:Follow up session
Small Group Role Play #3
You will each have up to 30 minutes do a full PST session.
This is the same patient you were working with last time.
Your task: Do a follow up session:o Set an agenda (this takes seconds to do);o Review Symptom Checklist;o Review action plan;o Pick a problem;o Solve it;o Create action plan.
Managing Affect, Anxiety and Crises
9
Problem Orientation
Pre-step to problem solving process
Helps patients who are either very negative, distressed or emotional to identify mood that prevents them from focusing on the problem
Teach patient to first identify the most troubling thoughts or feelings
Explain that feelings, even negative ones, are just a signal from the brain (or heart, depending on what resonates with the patient) that a problem has to be solved
How to Choose the Best Problem Orientation Option
Is it Learned Helplessness/Hopelessness (doubting that their situation can change)
Is it Negativity Bias (focusing only on the negative, extreme pessimism)
Is it Affect Regulation (strong emotions override the ability to focus on here and now)
Is it Attention Deficit (difficulty focusing on one issue at a time)
LearnedHelplessness / Hopelessness
Problems are normal part of living
Negative mood may indicate a problem
Some degree of control can often be achieved
Effective solutions exist at least in part, if not in total
Taking action alone will improve mood
Devil’s advocate exercise
Visualization
Negativity Bias
Education about the role of negativity bias in survival
The need to strengthen positivity bias
Columbo approach
Readiness to change rulero On a scale of 0 -10, how ready are you to change xyz/meet your
goal, etc
Evoking change languageo What would you like to see different?o What will happen if you don’t meet this goal?o What will happen if you do meet this goal?
Affect Regulation
Education about importance and role of emotion Importance of learning to regulate feelings so you
still have them but they do not take control Mindfulness strategies The 4 survival skills for distress tolerance (DBT):
o distracting oneself,o self-soothingo improving the moment, and o thinking of pros and cons
Prayer
Attention Deficit
Physical focus work (squeezing a squishy ball, “the yellow balloon”)
Setting reminders and timers to refocus attention (zen bell app)
Use of tools such as calendars and lists
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What if There’s a Crisis?
By all means, address it
Add it to the agenda
Use PST and orientation techniques while you have them tell you what is going on with the crisis
Emphasize profusely but not exclusively
Show them HOW PST can be helpful in a crisis
What if they Confess to a Horrible Thing from their Past?
Again, add it to the agenda
Listen to them
Ask them what their goal is in sharing the information with you: to get it off their chest? To work on the problem? To help you understand their plight?
Use that information for problem solving.
If it comes up in a middle of a session, ask them “Do you want to shift gears and work on that problem or do you want to finish this one and then get to that one?”
What if they have 100’s of Awful Things that all seem Important?
Take a deep breath
Help them focus
Emphasize that by focusing on one problem, others often fall into place
Have them prioritize
Look for opportunities where case management would be appropriate
If All ElseFails…
Clinician Concerns when Working with Latino/Spanish‐speaking Clients
1. PST structure does not allow culturally-sensitive engagement and rapport buildingo How can I be genuinely warm and empathic within
such a structured model?
o My client just wants to “desahogarse” (to unburden woes, to vent painful thoughts / feelings / experiences, short-term cathartic experience)
o How can I involve my client’s family?
Clinician Concerns when Working with Latino/Spanish‐speaking Clients
2. Limited literacy not conducive to PST structureo How do I use the worksheet when my client lacks
formal education?
o Should I always fill out the worksheet for them?
3. Clinical presentation too vague, complex and multifaceted for PST
o My client has a history of trauma
o Problems externally focused (e.g., my husband drinks too much)
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Tips
1. PST structure and culturally-sensitive engagement and rapport buildingo Always be your authentic self as a clinician. Practice,
practice, practice. The more familiar you are with the model, the more it will become “yours.” The more comfortable you are with the model, the more flexible you can be in adapting it to your client
o Align the client with the expectations of PST (e.g. psychoed, rationale behind structure, set agenda, etc.); this will give them room to desahogarse with guidance and focus while addressing PST steps
o Involve family where appropriate i.e. when client needs help implementing action plan (needs reminders, a ride, accompaniment, emotional/physical support)
Tips Continued
2. Limited literacy not conducive to PST structureo Be creative!o Assess what works best for the client and adapt PST to fit
their unique needso It is not always necessary to use the worksheet if it’s not
working for your client. The worksheet is only there to reinforce the problem solving steps and help guide the session
o Consider using the worksheet as a conversational guideo Use images to convey steps if that’s helpful to the cliento Involve the family if appropriateo Empower the client to design their own form or way to
remind themselves of the PST process so they can problem solve in between sessions
Tips Continued
3. Clinical presentation too vague, complex and multifaceted for PSTo It is therapeutic to provide structure to reduce
“spilling” especially around clinical material related to trauma. Remember to implement clinical skills (e.g. containment, redirection). Remind client that the action plans will empower them to change their relationship to the problem
o Bring it back to the client – what does the client want to change about themselves? True change starts with the self
o For e.g., How does husband’s drinking affect the client? Define problem from that vantage point. This is your agent of change
Leader Demonstration #4:Demonstrating Problem Orientation
When to end PST• Patient understands PST and utilizes it well on
their own
• Patient expresses desire to do BA only
• Patient not doing PST in sessions
• Patient needs specialty mental health care
• Patient isn’t coming in or available by phone for three sessions in a row
• Treatment is not effective
• Patient no longer meets medical necessity
Break(you’re in the home stretch).