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  • ProblemSolvingTreatmentforPrimaryCare.

    National Network of PST Clinicians, Trainers and Researchers

    UCSF 2013

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    Chapter1

    ProblemSolvingTreatmentforPrimaryCareMedicine.

    ProblemSolvingTherapyforPrimaryCareMedicine(PSTPC)wasoriginaldevelopedintheU.K.byaresearchteamheadedbyProfessorMynorsWallisin1998.ItisimportantforanyoneusingthismanualtoreadandrefertotwoexcellentbooksonSocialProblemSolvingTherapy:SocialProblemSolvingTherapy:Theory,ResearchandPractice(Nezu,NezuandPerri,1989)andProblemSolvingTherapy:Asocialcompetenceapproachtoclinicalintervention(DZurillaandNezu,1999).Overthepastfewyears,wehavemadeanumberofmodificationtoPSTPCtomakeitmoreuserfriendlytothetypicalpatientinprimarycaremedicine.ThesemodificationswereinformedbyourexperienceinusingPST,aswellasfromfeedbackfromourpastpatientsandcaremanagers/behavioralistsinthesesettings.PSTPCcanbedoneindividuallyorinagroupsetting.InorderforPSTPCtobeeffective,onemustmakesurethepatient(1)understandstherationalebehindthemodeland(2)understandsitsapplication.Educatingandsocializingthepatienttotherapyisoftenimportantwithprimarycarepatients.Somehaveneverbeenintherapybefore,andthereforeanexplanationofhowthetreatmentwillwork,howoftenyouwillmeet,theimportanceofactionplanningandsoforthwillbeveryimportanttodetailinthefirstsession.Agoodcaremanageralwaysaskspatientswhattheirexpectationsareoftherapy,andtriestoallayanyconcernsormisconceptions.Somepeoplehavehadpsychotherapyinthepast,butmostlikelywillnothavebeenexposedtoastructuredtherapylikePSTPC.Itisimportant,inthiscase,thatthepatientunderstandthedifferencebetweenPSTPCandtraditionalpsychotherapy.TellingthepatientthattheywillbelearninganewsetofskillsratherthanrelyingexclusivelyondiscussionofproblemsisakeydifferencebetweenPSTPCandtraditionaltherapies.

    PSTPCconsistsofsevenstagesthatefficientlyaddresspsychosocialproblems.

    Thesestagesare(1)selectinganddefiningtheproblem,(2)establishingrealisticandachievablegoals(3)generatingalternativesolutions(4)implementingdecisionmakingguidelines,(5)evaluatingandchoosingsolutions(6),implementingthe

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    preferredsolutionand(7)evaluatingtheoutcome.TheuniquefeatureofPSTPCoverotherpsychotherapiesisitsfitwiththecasemanagementprocess.Therapistscanusethesestagesincreatingalinkbetweentheirpatientsandsocialprograms,andindoingso,demonstratethePSTPCprocesstotheirpatientswiththeintentofpatientsusingtheprocesstosolvenoncasemanagementproblems.Thus,therapistsandpatientsworktogether,usingthesamelogicmodeltosolvebothsocialandpsychologicalproblems.

    Chapter2ofthemanualdescribestheproblemsolvingprocess.Inchapter3weprovidegeneralinformationregardingofresourcesandorganizationsshouldhelpindevelopingactionplansforpatientswithsocioeconomicneed.Inchapter4,wediscussissuesrelatedtoworkingwitholderadults,includingtheimpactofageismonmotivationforchangeandhowdisabilityaffectstreatment.AlsoincludedarethePSTformandtheProblemList,describedinChapter2.

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    Chapter2

    ProblemSolvingTreatment

    ThischapterdescribesthespecificstagesofPSTPCandhowtousethePSTPCformtosolvebothcasemanagementandpatientproblems.ThischapterwillgothroughthestepbystepofhowtousePSTPCwithpatients,frominitialsessiontorelapseprevention.

    TheTherapeuticFrame:

    TimeFrame:PSTPCisabrieftreatment,itcanbeasbriefas4sessionsandasmanyas12sessions.HowlongyouofferPSTPCwillbedeterminedbypatientrecovery,clinicmandateordesign.Inourresearch,wehavefoundthatthesmallesteffectivedoseofPSTPCis4sessions,offeredoveran8weekperiodoftime.Themostidealnumberis6sessions,thisiswhenwetendtoseethebiggestdifferenceintreatmentoutcomeswhenPSTPCiscomparedtootherpsychotherapies,butwebelievethat9sessionsbethePSTPCsweetspotformostpatients.Eachsessionis45inusualmentalhealthcareand30minutesinprimarycaremedicine.

    Setting:PSTPCiseffectiveinavarietyofsettingsandpresentations.ThereisevidencethatPSTPCisaneffectivetelephonetherapy,primarycareintervention,homebasedtreatmentandfinallyasaninternetintervention.WeareintheprocessofdeterminingPSTPCseffectasamobilehealthapp.

    Format:PSTPCisdividedintothreephases:Introduction/Education,Training,andPreventionphases.Thefirst12PSTPCsessionsisspentgettingtoknowthepatient,theproblemstheyareexperiencing,howtheirsymptomsinterferewithdailyactivities,andiftheyneedremedialproblemorientationwork.Additionally,patientsbecomefamiliarwiththePSTPCprocessandsocializedtothetherapy.ThemiddlesessionsarespentencouragingtheuseofthePSTPCskills.ThelastsessionortwoisspenthelpingpatientsdeveloparelapsepreventionplanbasedonthePSTPCformat.

    Structure:Tobeeffective,brieftreatmentsneedstructure,butyoudonthavetoloseyourtherapeuticstyleoractlikearobotwhenyoudoPSTPC.Youcanuseyourclinicaljudgment,justdontgoofftherails.Thetypicalsessionstructurelookslikethis:

    1.SettingtheAgenda

    2.Reviewprogress(PHQ9,ActionPlans,PleasantActivities)

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    3.Selectingaproblemandsolvingit

    4.Reviewingtheactionplanandactivities

    5.Sessionwrapup.

    IntroductoryPSTPCStages:Education,ActivationandProblemOrientation.

    Educateandactivateyourpatient;ORHowtoestablishaworkingallianceinabriefperiodoftime.

    Likealltherapies,forPSTPCtobeeffective,patientshavetounderstandthetreatmentandbuyintothetherapeuticrationale.Thisisdonethroughbriefeducationofboththetherapeuticframe(howyouwillworktogether)andthetherapeuticrationale(whyweusethismodel).Youdonotneedtospendmuchtimeonthis,justenoughtoexplaintothepatienthowPSTPCworks,andtoansweranyquestionsorconcernstheymayhaveabouttreatment.ThebasicthingsyouwanttocoverinyoureducationofPSTPCis:

    IntroducingPSTPCCheckList1. Explaintreatmentstructure

    Numberofsessions

    Lengthofvisits

    Howoftenwillmeet

    Structureofmeeting

    o Startwithagenda

    o ReviewPHQ9

    o 15minutesproblemsolving

    o Endeachsessionwithanactionplan

    ImportanceofPHQ9

    Usingaworksheetinitiallytosolveproblems

    Workiscollaborative

    2. ExplainPStheoryofdepression

    Everyonehasproblems

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    Wemaybecomedepressedwhenhavetoomanyproblemsorfacedwithproblemswedonotknowhowtohandle

    Whenwebecomedepressed,wewithdrawanddontfeellikedoinganything

    Thismakesusfeelhopelessandhelpless

    Thelesswedo,theworsewefeelitsacycle,butwecanbreakit

    WithPSTPC,wewillbetargetingoneproblematatime,becausethemorewedo,thebetterwefeel.

    3. ExplainedPSTPCprocess

    o PSTPCissevensteps

    o Startswithabriefproblemlist

    o Thenwepickoneproblem

    o Defineit,whichmeansgettingdetailsabouttheproblem

    o Wesetagoal

    o Comeupwithalistofwaystomeetthatgoal

    o Talkaboutthelistofoptionsandevaluatethembasedonwhat ismostfeasibleforyoutodo

    o Wecreateastepbystepplan

    o Youdotheplanandwetalkaboutitatthenextsession

    o Youwillalsosolveotherproblemsonyourownbetween sessions

    o Dontworryifaplandoesntworkperfectly,thatsallpartofl earningmoreabouttheproblem,andhelpsuscomeupwitha betterideaofwhatisgoingon.

    4. ExplanationProcess

    Checkinwithpatientaboutunderstandingaftereachsection

    Askpatientifhaveanyquestions

    Useeasytounderstandlanguage

    Beempathic

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    Stanceiscollaborative,notdidactic

    SettingtheproblemList:

    ThenextsteptoprepareforPSTPCistomakealistoftheproblemspatientsfeelarecontributingtoorsufferingfromtheirdepression.Inthisphase,keepthelistsimpleandstructurethediscussionaroundthesecommonareas:Problemswithfriends,family,finances,work,school,chores,health,thelaw,andhousing.UsetheProblemListintheappendixtoguidethisdiscussion.

    ProblemOrientation(Optional):

    Forsomepatients,theveryideathattheirproblemshavesolutionsisbeyondcomprehension.Whenaskedtothinkabouttheirproblems,somepatientsbecomeemotionallyoverwhelmedandhavedifficultyfocusingonthedetailsoftheproblem,othersaresohopelessandpessimisticthattheysimplydonotbelievetheirproblemscanbesolvedortheybelievetherearesolutionsbuttheoutcomeisnotgoodenough.Althoughemotionmanagement,negativityandhopelessnessarecommonfeaturesofdepression,peopleexperiencethesesymptomsinvaryingdegrees.WehavefoundthatmostpeoplesufferingfromdepressioncancontroltheiremotionsandpessimismenoughthattheycanstartthesevenstepPSTPCprocessrightawayanddonotneedextrahelporientingtheirthinkingtoactivelysolveproblems.Othershoweveraredisabledbytheirnegativethinkingandemotions,andwillneedalittleextrahelporientingtheirthoughtstowardsolvingproblems.Forthisreason,wehaveincluded,intheinitialstagesofPSTPC,afocusonmanagingemotionsandnegativethinking(calledProblemOrientationintheNezuPSTPCmodel)buthavemadeitanoptionalstepintheprocessforpatientswhoareabletostartsolvingproblemsandaremorehopefulabouttheoutcome.

    Thepurposesofproblemorientationaretomakepatientsawareoftheirparticularproblemswithdailyliving,tominimizetheemotionalcontentoftheproblemstheyface,andtoincreasetheirmotivationinproblemsolving.Theprocessoforientationconsistsoffivedistinctvariables:problemperception,problemattribution,problemappraisal,personalcontrolbeliefs,andapproach/avoidancestyle(Nezu,Nezu,Perri,1989).Inproblemperception,thepatientmustidentifyaproblem,andthecontextinwhichitisfaced.Thoughtheproblemmightbringupemotionsforthepatient,itisessentialthattheytrytoputtheemotionalbaggageasidesotheycanattendtotheprobleminastrategic,methodicalfashion.Withproblemattribution,thepatient,withtheaidofthetherapist,musttrytoachievearealisticperspectiveofthecauseoftheproblem.Theymighthaveanoverlynegativisticperspectiveandconsequentlyattributeanunrealisticpercentageoftheblameoninternalfactors.Conversely,patientsmight

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    haveanattributionalstylethatgivestoomuchcredencetoexternalfactorsthatmightalsobeunrealistic.Thepatientmust,then,attempttofindtherealisticbalanceinordertodisentangletheprobleminapragmaticfashion.Inproblemappraisal,thepatientevaluatestheprobleminitssignificanceandvaluetotheirpersonalwellbeing.Thepersonalcontrolvariableisalsoimportanttoaddressfromtheoutsetbecausepatientsmustlear

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