PROBLEM-SOLVING THERAPY

Social problem-solving therapy (PST) is a cognitive-behavioral intervention that is an efficacious treatment for depression. According to this model, depression is multifaceted, the result of an interaction between daily stress, major life events, weak coping skills, and depressive affect (Nezu: see Figure 1). People most vulnerable to depression either have inadequate problem-solving skills or problem-solving skills that are not being used because they feel unable to change their situation. According to PST, the ideal way to intervene in this depression-producing cycle is to teach patients how to mobilize their coping resources and begin tackling the problems in their lives. Once they begin to solve problems, depression lifts and the motivation to face other problems increases.

Application to older adults

Older people are often at risk for developing depression because of the number of life changes, such as disability, loss, daily stresses, and managing chronic illnesses and living on a fixed income. However, very few older people develop clinical levels of depression (Kessler et al.). According to the problem-solving model, the deciding factor in who becomes depressed and who does not is whether or not the person facing so many life changes has the ability to solve problems effectively and believes that problems are solvable. Some studies have shown that older people with active problem-solving skills (seeking information, asserting oneself) are less inclined to become depressed than older people who engage in passive problem-solving (praying, waiting for someone to offer help). These data support the notion that Nezu et al. propose: if you teach someone how to actively solve problems, that person will become more able to negotiate his or her environment and hence will be less likely to become depressed.

Social problem-solving therapy

According to D'Zurilla and Nezu, problem solving consists of five skills. The first is problem orientation, which is concerned with how one views his or her ability to cope with a problem. The second is problem definition, which is concerned with the specific and concrete definition of the problem, and setting achievable and definable goals. The third skill, generation of alternative solutions, involves creating various methods for solving problems and meeting one's goals while withholding judgment on their effectiveness. The fourth skill, decision making, involves a systematic process to select the best solution for a problem from the list generated. The fifth and final skill, solution implementation and evaluation, involves planning and initiation of solutions, and subsequently evaluating the success of the solution. The intervention is delivered over ten to twelve sessions. The first session covers education about depression and explication of the model. It is important to educate older people about what depression is and how this therapy works because so many older adults hold inaccurate ideas about depression and are afraid of psychotherapy. After this introduction, the next five sessions focus on teaching each of the skills. It is important that these skills be taught sequentially, rather than all at once. Older people generally need a longer period to process new information, and allowing more time for discussion of each step facilitates learning. After each skill is taught and practiced, the remaining sessions are spent using the model to solve the patient's problems. Guided practice is particularly important in teaching new psychosocial skills. The more opportunities older people have to practice new behavior, the more likely they are to retain the skills and use them in the future.

Support for PST in older adults

Thus far only three empirical studies have evaluated the efficacy of PST in older, depressed adults. The first study was conducted by Hussain and Lawrence on older nursing home patients. In this study patients received either PST or supportive therapy. Patients who received PST showed fewer symptoms of depression after treatment than those who received the supportive care. The second study, conducted by Areán et al., compared PST to reminiscence therapy (RT), a treatment that at the time of the study was a common geriatric intervention. Although both interventions were superior to no treatment, PST resulted in far fewer symptoms and more remission of depression than RT. A study by Barrett et al. compared PST to Paxil and placebo in older medical patients with mild depression. This study found that PST was equivalent to placebo. It should be noted that the version of PST used in this study was one developed by Mynors-Wallis. This version of PST presents the problem-solving skills in one session, rather than allowing older patients an opportunity to practice each skill individually. It is likely that this mode of presentation is ineffective with older patients, and thus the more traditional presentation of PST is necessary for there to be any benefit for older people. More research into the process of delivery is needed to fully answer this question.

Patricia AreÁn

See also Depression; Interpersonal Therapy; Stress and Coping.

BIBLIOGRAPHY

AreÁn, P. A; Perri, M. G.; Nezu, A. M.; Schein, R. L.; Chrisptopher, F.; and Joseph, T. "Comparative Effectiveness of Social Problem-Solving Therapy and Reminiscence Therapy as Treatment for Depression in Older Adults." Journal of Consulting and Clinical Psychology 61, no. 6 (1993): 1003–1010.

Barrett, J. E.; Williams, J. W., Jr.; Oxman, T. E.; Katon, W.; Frank, E.; Hegel, M. T.; Sullivan, M.; and Schulberg, H. C. "The Treatment Effectiveness Project. A Comparison of the Effectiveness of Paroxetine, Problem-Solving Therapy, and Placebo in the Treatment of Minor Depression and Dysthymia in Primary Care Patients: Background and Research Plan." General Hospital Psychiatry 21, no. 4 (1999): 260–273.

D'Zurilla, T. J., and Nezu, A. M. Problem-Solving Therapy: A Social Competence Approach to Clinical Intervention. New York: Springer, 1999.

Hussain, R. A., and Lawrence, P. S. "Social Reinforcement of Activity and Problem Solving Training in the Treatment of Depressed Institutionalized Elderly Patients." Cognitive Therapy and Research 5, no. 1 (1981): 57–69.

Kessler R. C.; McGonagle, K. A.; Zhao, S.; Nelson, C. B.; Hughes, M.; Eshelman, S.; Wittchen, H. U.; and Kendler, K. S. "Lifetime and 12-Month Prevalence of DSM-III-R Psychiatric Disorders in the United States: Results from the National Comorbidity Survey." Archives of General Psychiatry 51 (1994): 8–19.

Lerner, M. S., and Clum, G. A. "Treatment of Suicide Ideators: A Problem-Solving Approach." Behavior Therapy 21, no. 4 (1990): 403–411.

Mynors-Wallis, L. "Problem-Solving Treatment: Evidence for Effectiveness and Feasibility in Primary Care." International Journal of Psychiatry in Medicine 26, no. 3 (1996): 249–262.

Mynors-Wallis, L.; Davies, I.; Gray, A.; and Barbour, F. "A Randomized Controlled Trial and Cost Analysis of Problem-Solving Treatment for Emotional Disorders Given by Community Nurses in Primary Care." British Journal of Psychiatry 170, no. 2 (1997): 113–119.

Mynors-Wallis, L. M.; Gath, D. H.; Day, A.; and Baker, F. "Randomized Controlled Trial of Problem-Solving Treatment, Antidepressant Medication and Combined Treatment for Major Depression in Primary Care." British Medical Journal 320, no. 7226 (2000): 26–30.

Nezu, A. M. "Efficacy of Social Problem-Solving Therapy Approach for Unipolar Depression." Journal of Consulting and Clinical Psychology 54, no. 2 (1986): 196–202.

Nezu, A. M., and Perri, M. G. "Social Problem-Solving Therapy for Unipolar Depression: An Initial Dismantling Investigation." Journal of Consulting and Clinical Psychology 57, no. 3 (1989): 408–413.

Nezu, A. M.; Nezu, C. M.; and Perri, M. Social Problem Solving Therapy: Theory, Research, and Practice. New York: John Wiley and Sons, 1989.