Problem-Solving Therapy (PST) for Late-Life Depression

Rebecca Crabb, Ph.D.

Overview: Session 1Friday, January 23

• Rationale and overview of PST• PST: Step-by-step clinical process• VideoBREAK• Modifications• Trouble-shooting and questions• Role play

Overview – Session 2 Friday, January 30

• PST: Step-by-step clinical process• Modifications (Group, Chinese,

and PST with psychosis)BREAK• Role play

Three Goals of PST

• Improve problem orientation

• Teach systematic problem-solving strategy

• Support behavioral activation

Problem Orientation

• Increase understanding of link between symptoms and problems in living

• See problems as solvable and self as capable of solving them

Today I say to you that the challenges we face are real, they are serious and they are many. They will not be met easily or in a short span of time. But know this America: They will be met. –Barack Obama, January 20, 2009

Rationale for Problem Solving

Depression

Weak problem-

solving skills

Unresolved problems

Seven Steps of Problem-Solving

• Problem orientation• Problem definition• Goal-setting• Solution-generation• Decision-making• Implementation• Solution verification

Rationale for Activity Scheduling

Feel Bad

Do Less

•Social and physical activities tend to be the most potent mood boosters.

PST + Case management

• Making problem list in first session includes full needs assessment

• Distinguish between case management problems and client problems

• Case manager models PST strategy in solving problems involving linkage or advocacy

PST: Clinical Process

Frame

• Six 50-minute sessions (or more)

• Each session, work together through one full problem plus activity scheduling

• Between-session problem solving

Overview – Session 2 Friday, January 30

• Questions/thoughts from last week?• PST: Step-by-step clinical process• Modifications (Group, Chinese, and PST with

psychosis)BREAK• Role play

Introducing PST

• Explain the link between problems and depression: unresolved problems cause and worsen depression, and depression interferes with problem-solving

• PST strengthens problem-solving skills, which in turn lifts mood

• Improvement follows action

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:

Making the Problem ListIf you’re not having a problem, you’re missing a chance to grow.

–anon.

• Domains– Financial– Housing– Medical– Social– Family

• Organize in a hierarchy (1,2,3)

Modification for Case Management

• Most urgent, pressing case management problems are addressed first

• Clients should work on less complex problems first

Problem OrientationNothing is either good or bad, but thinking makes it so. -Hamlet

• Cognitive component• Emotions as red flags• Challenging distortions

Problem Orientation questions

What kinds of feelings do you have about the problem?

What kinds of thoughts?

Can you play devil’s advocate with your negative thoughts?

Problem DefinitionA problem well-stated is a problem half solved. -Kettering

• Concrete and specific terms

• Assumptions versus facts

• Details• Breaking down

problems

Problem Definition questionsWith this problem, what happens to make you

feel badly?Is another person part of the problem?When does the problem occur?Where does the problem happen?What do you do when this problem occurs?What makes it better/worse?Write out/state the problem in specific terms:

Goal Setting"Goals are dreams we convert to plans and take action to fulfill. -Zig Ziglar

• Specific• Attainable• Realistic• Measurable

Goal Setting questions

What would you like to see change?

What’s your goal?

Does your goal need to be broken down into smaller pieces?

Solution Generation (Brainstorming)

don’t put all your eggs in one basket – anon.

• All ideas that come to mind – generate at least five

• Withhold judgment• Be detailed

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) -

( + ) ( - )

Decision-Making 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

• Weighing the pros and cons

• Effort, time, money, effect on others, short- and long-term effects

• Choose solution with the most pros and least cons

Decision-Making questionsFor each solution, think about:

PROS

CONS

Short-term effects

Long-term effects

Effects on you

Effects on others

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) -

( + ) ( - )

Selecting the solution"You are the sum total of all of your choices up to now. -Dr. Wayne Dyer

• One with the most pros and least cons

• Most feasible• Less amount of effort

Solution ImplementationEven if you are on the right track, you'll get run over if you just sit there.

- Will Rogers

• Step-by-step plan• Specify when will do

(earlier the better)• Potential barriers?• Reward for trying?

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:

Solution VerificationWhen you lose, do not lose the lesson – Dali Lama

• Did it work?– If so, why?

• Would you do anything differently?

• Will you use this solution again?

– If not why?• What did you learn?• Does the problem need

to be redefined?

All sessions: 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.

Common issues in PSTDifficulty keeping on Track

• Use agenda setting. • Instead of: “Hi, how are you?”• Try: "It's nice to see you again, I'm looking

forward to hearing your progress on your homework and how your walking has been going after I check in with you about your symptoms, so let's start with that. How many days in the past two weeks….”

Common issues in PSTDifficulty keeping on Track

• Gently interrupt and redirect • Establish internal timelines for reaching

certain points in the session – e.g., symptoms and homework review for the

first 5 minutes; action plan review and activity scheduling the last 5 minutes; 20 or so minutes to do the core problem-solving.

Common Issues in PSTWhere to start?

• Allow client to decide importance of problems (1,2,3, etc.)

• Suggest easier, more concrete problems to start

• Save unwieldy, abstract problems for later• Expect to spend time breaking down large

problems

Video Presentation

PST Modifications

• Groups

• PST + Case management

• PST-Chinese

Group PST

• Choose common/shared problems to work on at first

• Each session begins with brief check-in on each member’s “success experience”

• Try to let each person solve their own problem

PST-ChinesePST-ChineseAdaptationsAdaptations

Stigma regarding the word “depression”Stigma regarding the word “depression”– ““It’s pretty common for my Chinese patients to come in It’s pretty common for my Chinese patients to come in

complaining of liver problems or sleep problems in place complaining of liver problems or sleep problems in place of depression. They don’t know they’re depressed, or at of depression. They don’t know they’re depressed, or at least don’t want to say.”least don’t want to say.”

– Recommendations:Recommendations:• Do not utilize the Do not utilize the disease model of depressiondisease model of depression as the as the

diagnosis/illnessdiagnosis/illness• Making the Making the connection between problems and depressionconnection between problems and depression may may

not be necessarynot be necessary• Tailor the psycho educationTailor the psycho education component – piecemeal rather than component – piecemeal rather than

all at onceall at once• Do not call it a treatment for depression – Do not call it a treatment for depression – “stress management” “stress management”

or “healthy living”or “healthy living” instead instead

Hierarchy, authority, and respectHierarchy, authority, and respect– ““My Chinese patients look to me for guidance. I My Chinese patients look to me for guidance. I

am their doctor. I’m not sure they’ll like having to am their doctor. I’m not sure they’ll like having to generate all their own solutions without my help. generate all their own solutions without my help. If I don’t suggest anything, they may think that’s If I don’t suggest anything, they may think that’s strange.”strange.”

– RecommendationsRecommendations• The need toThe need to establish authority and credibilityestablish authority and credibility – Have – Have

the therapist do one problem for them firstthe therapist do one problem for them first• Sensitivity to the hierarchical nature of the Sensitivity to the hierarchical nature of the

doctor/patient relationshipdoctor/patient relationship -- The therapist may have -- The therapist may have to give “permission” for the patient to generate their to give “permission” for the patient to generate their own solutions (rather than looking to the therapist for own solutions (rather than looking to the therapist for instruction)instruction)

Acculturative processesAcculturative processes– ““Some Chinese patients may not know how to Some Chinese patients may not know how to

solve their problems in America. They may have a solve their problems in America. They may have a different idea about what’s acceptable or not different idea about what’s acceptable or not acceptable in this country. For example, I know of acceptable in this country. For example, I know of one patient that might come up with a solution of one patient that might come up with a solution of hitting his wife if she’s making trouble.”hitting his wife if she’s making trouble.”

– RecommendationsRecommendations• 11stst generation patients generation patients may generate solutions that are may generate solutions that are

culturally incongruentculturally incongruent and don’t work in the US. and don’t work in the US.• Therapists may need to highlight cultural conflicts and Therapists may need to highlight cultural conflicts and

educate/guide towards a more culturally appropriate educate/guide towards a more culturally appropriate solutionsolution

Involving others“My patient and her husband spend all their time

together. She was clear from the beginning that she wanted him to remain with her during therapy.”

Recommendations– Involve other family members as necessary

Trouble-shooting and questions