Problem Solving Treatment for Primary Care. - Solving Treatment for Primary Care ... In chapter 4, we ... problem perception, problem attribution, problem appraisal, personal control

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<ul><li><p>ProblemSolvingTreatmentforPrimaryCare.</p><p>National Network of PST Clinicians, Trainers and Researchers </p><p>UCSF 2013 </p></li><li><p> 2</p><p>Chapter1</p><p>ProblemSolvingTreatmentforPrimaryCareMedicine.</p><p>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.</p><p> PSTPCconsistsofsevenstagesthatefficientlyaddresspsychosocialproblems.</p><p>Thesestagesare(1)selectinganddefiningtheproblem,(2)establishingrealisticandachievablegoals(3)generatingalternativesolutions(4)implementingdecisionmakingguidelines,(5)evaluatingandchoosingsolutions(6),implementingthe</p></li><li><p> 3</p><p>preferredsolutionand(7)evaluatingtheoutcome.TheuniquefeatureofPSTPCoverotherpsychotherapiesisitsfitwiththecasemanagementprocess.Therapistscanusethesestagesincreatingalinkbetweentheirpatientsandsocialprograms,andindoingso,demonstratethePSTPCprocesstotheirpatientswiththeintentofpatientsusingtheprocesstosolvenoncasemanagementproblems.Thus,therapistsandpatientsworktogether,usingthesamelogicmodeltosolvebothsocialandpsychologicalproblems.</p><p>Chapter2ofthemanualdescribestheproblemsolvingprocess.Inchapter3weprovidegeneralinformationregardingofresourcesandorganizationsshouldhelpindevelopingactionplansforpatientswithsocioeconomicneed.Inchapter4,wediscussissuesrelatedtoworkingwitholderadults,includingtheimpactofageismonmotivationforchangeandhowdisabilityaffectstreatment.AlsoincludedarethePSTformandtheProblemList,describedinChapter2.</p></li><li><p> 4</p><p>Chapter2</p><p>ProblemSolvingTreatment</p><p> ThischapterdescribesthespecificstagesofPSTPCandhowtousethePSTPCformtosolvebothcasemanagementandpatientproblems.ThischapterwillgothroughthestepbystepofhowtousePSTPCwithpatients,frominitialsessiontorelapseprevention.</p><p>TheTherapeuticFrame:</p><p>TimeFrame:PSTPCisabrieftreatment,itcanbeasbriefas4sessionsandasmanyas12sessions.HowlongyouofferPSTPCwillbedeterminedbypatientrecovery,clinicmandateordesign.Inourresearch,wehavefoundthatthesmallesteffectivedoseofPSTPCis4sessions,offeredoveran8weekperiodoftime.Themostidealnumberis6sessions,thisiswhenwetendtoseethebiggestdifferenceintreatmentoutcomeswhenPSTPCiscomparedtootherpsychotherapies,butwebelievethat9sessionsbethePSTPCsweetspotformostpatients.Eachsessionis45inusualmentalhealthcareand30minutesinprimarycaremedicine.</p><p>Setting:PSTPCiseffectiveinavarietyofsettingsandpresentations.ThereisevidencethatPSTPCisaneffectivetelephonetherapy,primarycareintervention,homebasedtreatmentandfinallyasaninternetintervention.WeareintheprocessofdeterminingPSTPCseffectasamobilehealthapp.</p><p>Format:PSTPCisdividedintothreephases:Introduction/Education,Training,andPreventionphases.Thefirst12PSTPCsessionsisspentgettingtoknowthepatient,theproblemstheyareexperiencing,howtheirsymptomsinterferewithdailyactivities,andiftheyneedremedialproblemorientationwork.Additionally,patientsbecomefamiliarwiththePSTPCprocessandsocializedtothetherapy.ThemiddlesessionsarespentencouragingtheuseofthePSTPCskills.ThelastsessionortwoisspenthelpingpatientsdeveloparelapsepreventionplanbasedonthePSTPCformat.</p><p>Structure:Tobeeffective,brieftreatmentsneedstructure,butyoudonthavetoloseyourtherapeuticstyleoractlikearobotwhenyoudoPSTPC.Youcanuseyourclinicaljudgment,justdontgoofftherails.Thetypicalsessionstructurelookslikethis:</p><p>1.SettingtheAgenda</p><p>2.Reviewprogress(PHQ9,ActionPlans,PleasantActivities)</p></li><li><p> 5</p><p>3.Selectingaproblemandsolvingit</p><p>4.Reviewingtheactionplanandactivities</p><p>5.Sessionwrapup.</p><p>IntroductoryPSTPCStages:Education,ActivationandProblemOrientation.</p><p>Educateandactivateyourpatient;ORHowtoestablishaworkingallianceinabriefperiodoftime.</p><p>Likealltherapies,forPSTPCtobeeffective,patientshavetounderstandthetreatmentandbuyintothetherapeuticrationale.Thisisdonethroughbriefeducationofboththetherapeuticframe(howyouwillworktogether)andthetherapeuticrationale(whyweusethismodel).Youdonotneedtospendmuchtimeonthis,justenoughtoexplaintothepatienthowPSTPCworks,andtoansweranyquestionsorconcernstheymayhaveabouttreatment.ThebasicthingsyouwanttocoverinyoureducationofPSTPCis:</p><p>IntroducingPSTPCCheckList1. Explaintreatmentstructure</p><p> Numberofsessions</p><p> Lengthofvisits</p><p> Howoftenwillmeet</p><p> Structureofmeeting </p><p>o Startwithagenda</p><p>o ReviewPHQ9</p><p>o 15minutesproblemsolving</p><p>o Endeachsessionwithanactionplan</p><p> ImportanceofPHQ9</p><p> Usingaworksheetinitiallytosolveproblems</p><p> Workiscollaborative</p><p>2. ExplainPStheoryofdepression</p><p> Everyonehasproblems</p></li><li><p> 6</p><p> Wemaybecomedepressedwhenhavetoomanyproblemsorfacedwithproblemswedonotknowhowtohandle</p><p> Whenwebecomedepressed,wewithdrawanddontfeellikedoinganything</p><p> Thismakesusfeelhopelessandhelpless</p><p> Thelesswedo,theworsewefeelitsacycle,butwecanbreakit</p><p> WithPSTPC,wewillbetargetingoneproblematatime,becausethemorewedo,thebetterwefeel.</p><p>3. ExplainedPSTPCprocess</p><p>o PSTPCissevensteps</p><p>o Startswithabriefproblemlist</p><p>o Thenwepickoneproblem</p><p>o Defineit,whichmeansgettingdetailsabouttheproblem</p><p>o Wesetagoal</p><p>o Comeupwithalistofwaystomeetthatgoal</p><p>o Talkaboutthelistofoptionsandevaluatethembasedonwhat ismostfeasibleforyoutodo</p><p>o Wecreateastepbystepplan</p><p>o Youdotheplanandwetalkaboutitatthenextsession</p><p>o Youwillalsosolveotherproblemsonyourownbetween sessions</p><p>o Dontworryifaplandoesntworkperfectly,thatsallpartofl earningmoreabouttheproblem,andhelpsuscomeupwitha betterideaofwhatisgoingon.</p><p>4. ExplanationProcess</p><p> Checkinwithpatientaboutunderstandingaftereachsection</p><p> Askpatientifhaveanyquestions</p><p> Useeasytounderstandlanguage</p><p> Beempathic</p></li><li><p> 7</p><p> Stanceiscollaborative,notdidactic</p><p>SettingtheproblemList:</p><p>ThenextsteptoprepareforPSTPCistomakealistoftheproblemspatientsfeelarecontributingtoorsufferingfromtheirdepression.Inthisphase,keepthelistsimpleandstructurethediscussionaroundthesecommonareas:Problemswithfriends,family,finances,work,school,chores,health,thelaw,andhousing.UsetheProblemListintheappendixtoguidethisdiscussion.</p><p>ProblemOrientation(Optional):</p><p>Forsomepatients,theveryideathattheirproblemshavesolutionsisbeyondcomprehension.Whenaskedtothinkabouttheirproblems,somepatientsbecomeemotionallyoverwhelmedandhavedifficultyfocusingonthedetailsoftheproblem,othersaresohopelessandpessimisticthattheysimplydonotbelievetheirproblemscanbesolvedortheybelievetherearesolutionsbuttheoutcomeisnotgoodenough.Althoughemotionmanagement,negativityandhopelessnessarecommonfeaturesofdepression,peopleexperiencethesesymptomsinvaryingdegrees.WehavefoundthatmostpeoplesufferingfromdepressioncancontroltheiremotionsandpessimismenoughthattheycanstartthesevenstepPSTPCprocessrightawayanddonotneedextrahelporientingtheirthinkingtoactivelysolveproblems.Othershoweveraredisabledbytheirnegativethinkingandemotions,andwillneedalittleextrahelporientingtheirthoughtstowardsolvingproblems.Forthisreason,wehaveincluded,intheinitialstagesofPSTPC,afocusonmanagingemotionsandnegativethinking(calledProblemOrientationintheNezuPSTPCmodel)buthavemadeitanoptionalstepintheprocessforpatientswhoareabletostartsolvingproblemsandaremorehopefulabouttheoutcome.</p><p>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</p></li><li><p> 8</p><p>haveanattributionalstylethatgivestoomuchcredencetoexternalfactorsthatmightalsobeunrealistic.Thepatientmust,then,attempttofindtherealisticbalanceinordertodisentangletheprobleminapragmaticfashion.Inproblemappraisal,thepatientevaluatestheprobleminitssignificanceandvaluetotheirpersonalwellbeing.Thepersonalcontrolvariableisalsoimportanttoaddressfromtheoutsetbecausepatientsmustlearnthattheycannotchangethebehaviorofothersormanyexternalcircumstances.Instead,theyhavetheopportunitytoalterthewaytheyreacttothesituationstheycannotcontrol,andtocopeeffectivelywithinevitablestressors.Additionally,theattitudewithwhichthepatientchoosestoaddresstheproblemcanmakeadifference.Theymustbeproactive,ratherthanavoidant.Theymustnotavoidissuesthatarise,butrathersystematicallyaddressthem.ThisissuemightbeparticularlydifficultforthepatientwithExecutiveDysfunctiontoaccomplish.Thetherapistmustthenmakeaconcertedefforttoencouragethepatienttobemotivated.Oncethesetaskshavebeenaccomplished,thepatientandtherapistwillbereadytomoveontothesevenproblemsolvingsteps.</p><p>ProblemOrientationStrategies.</p><p>Emotionmanagement:Strategiesforemotionmanagementcanbeanythingthathelpscalmemotionsandredirectattentionawayfromnegativefeelingstoarelaxationstate.Typicalemotionmanagementstrategiesare:</p><p>Selectionofanappropriatestrategyforagivenpatientshouldfollowafterweighingprosandconsinaproblemsolvingformatbasedonpreviouslyhelpfulexperiencestothepatient.Theselectedstrategyismeanttobepracticedbypatientsovertimesothatwhentheybegintofeeloverwhelmedbyemotion,theycanusethesetechniqueseasily.Withallthesestrategies,patientswillneedaquietplacetopracticeforabout10minutesaday.Patientsrecordtheirmoodbeforepracticeandafterpractice.Theyarealsoinstructedtoincorporatethestrategiesbeforeeachstepoftheactionplan.</p><p>NegativityBias:Strategiesforcopingwithnegativefocushelpthepatientevaluatetheirsituationinabalancedwaybyteachingpatientstorecognizewhentheyareoverattendingtonegativeenvironmentalcuesandhowtodrawattentiontoneutralorpositiveaspectsofthesituation.InPSTPC,weusemodifiedCognitiveBehavioralStrategies(CB)toovercomethisbarrier.RatherthanapplyingCBstrategiesforallsituations,however,weaskpatientstousethestrategiesspecifically</p><p>Emotion management strategies </p><p>Meditation Relaxation Exercises Deep Breathing Prayer Imagery </p></li><li><p> 9</p><p>whentheyencountertroubleimplementingtheiractionplans.Ifthepatientdecidestousethestrategiesforothersituations,thatterrific;butitisnotnecessary.Thenegativefocusstrategiesare:DevilsAdvocate:Thedevilsadvocatetechniqueisonewaytohelppatientscounteracttheirnegativethinking.Allthisinvolvesisafewsteps:</p><p>1. Writedownthereasonswhyyouwouldnotdotheactionplan;</p><p>2. Taketheoppositeviewfromthenegativereasons:whatwouldyousaytogetsomeoneelsewhoismakingthesameargumentyouaremakingtodotheactionplan.</p><p>3. Organizethepositiveargumentsandrefertothemwheneveryouwantto</p><p>abandontheactionplan.WeighingtheEvidence:Thisisarelativelyeasyexercisethatcanenhancemotivationtoengageinactionplansandovercomenegativitybiases.UsingtheWeighingtheEvidenceworksheetintheappendix,allyouaskthepatienttodois:</p><p>1. Estimatethepatientspredictedprobabilitythatworstexpectationswillcometrue;</p><p>2. Askthepatienttothinkbacktoallthetimestheyengagedinasimilaractionplanoractivityandhavethemstatehowoftenthepatientactuallyexperiencedtheexpectednegativeoutcome,theestimateifthatwaslessandaboutormorethanhalfthetime;</p><p>3. Thepatientsassignmentistoengageintheactionplanandthendocumentifthenegativeoutcomeactuallyoccurred.Talktothepatientaboutthedifferencebetweentheirassumed,predictedandactuallyexperiencethatthenegativeeventhappened.</p><p>Practiceusingapositivefocus:Havingapositivefocusisthebrainstendencytoseek</p><p>Negative focus strategies Devils Advocate Weighing the evidence </p><p>Practice seeing positivity bias </p></li><li><p> 10</p><p>outandpayparticularattentiontopleasurableandpositiveenvironmentalcues.Likenegativefocus,thisisanaturalbrainfunction.Whenpeoplearedepressed,apositivefocusismuted,andpatientswillneedtoworkhardtostrengthenthiscognitiveprocesstoovercometheirdepression.Patientswhochosetocontroltheirnegativefocusbyengagingapositivefocuswillneedtopracticeusingthestrategiesbelowuntiltheyfeelcomfortable(somepatientsclaimitneverfeelsnatural,amajorityclaimtheyarehelpful).Patientscanchosetouseoneorallofthefollowingtoolstohelpthemimplementtheiractionplans</p><p> Thinkoutsideyourself.Askyourselfifyoudtrytotalkotherpeopleoutofasimilaractionplan.Ifyouwouldnt,stopbeingsohardonyourself.Thinkaboutlessnegativestatementsthatoffermorerealisticexpectationsabouttheactionplanssuccess.</p><p> Keepanegativethoughtlog.Wheneveryouexperienceanegativethoughtwhenimplementinganactionplan,jotdownthethoughtinanotebook.Reviewyourlogwhenyoureinagoodmood.Considerifthenegativitywastrulywarranted.Forasecondopinion,youcanalsoaskafriendortherapisttogooveryourlogwithyou.</p><p> Changingperspectives.Reviewyournegativethoughtlog.Then,foreachnegativethought,writedownsomethingpositiveorfindanalternativeexplanation.Forinstance,Mybosshatesme.Hegavemethisimpossibletasktodo.couldbereplacedwith,Mybossmusthavealotoffaithinmetogivemesomuchresponsibility,,MybosshasgivenmesomuchworkbecausethisisanimportantprojectwithanimpendingdeadlineorOtherpeoplehavebeengivensimilarassignments.</p><p> Socializewithpositivepeople.Noticehowpeoplewhoalwayslookonthebrightsidedealwithchallenges,evenminorones,likenotbeingabletofindaparkingspace.Thenconsiderhowyouwouldreactinthesamesituation.Evenifyouhavetopretend,trytoadopttheiroptimismandpersistencewhenimplementingyourplan.</p><p>REMEMBER:THESESTRATEGIESAREOPTIONAL.ITSBETWEENYOUANDYOURPATIENTTODECIDEIFTHISWOULDBEHELPFUL.</p></li><li><p> 11</p><p>TheSevenStagesofPSTPCTreatment</p><p>ItisimportanttoreviewthestagesinvolvedinPSTPC.Theyare</p><p>1.Selectinganddefiningtheproblem 5.Evaluatingandchoosingsolutions</p><p>2.Establishrealisticandachievablegoals 6.Implementingthepreferredsolution</p><p>3.Generatingalternativesolutions 7.Evaluatingtheoutcome</p><p>4.Implementingdecisionmakingguidelines 8.ActivityScheduling</p><p> EachstageofPSTPCisrepresentedonthe...</p></li></ul>

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