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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

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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

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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

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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?

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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

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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

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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).

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Small Group Wrap Up and Q&A