Editor’s Note: As part of the Center for Deployment Psychology’s ongoing mission to provide high-quality education on military- and deployment-related psychology, we are proud to present our latest “Guest Perspective.” Every Tuesday, we will be presenting blogs by esteemed guests and subject matter experts from outside the CDP. This allows us to offer more insight and opinions on a variety of topics of interest to behavioral health providers.
As these blog entries are written by outside authors, one important disclaimer: all of the opinions and ideas expressed in them are strictly those of the author alone and should not be taken as those of the CDP, Uniformed University of the Health Sciences (USUHS), or the Department of Defense (DoD).
That being said, we’re very happy to offer a platform where we can feature these individuals and the information they have to share. We’d like to make this an ongoing dialogue. If you have questions, remarks, or would like more information on a topic, please feel free to leave comments below or on our Facebook page, and we’ll pass them along to the author.
It’s a troublesome world,
All the people who’re in it,
Are troubled with troubles
Almost every minute.
The above quote by the very popular Dr. Seuss suggests that problems in living are ubiquitous. While conducting workshops for decades around the world for many different types of individuals, both professionals and laypeople, the answer to the question I frequently pose to attendees—“Who here had a week recently devoid of problems?” leads consistently to an absence of raised hands. We all have problems—some small, and unfortunately at times, some being quite overwhelming. Based on this common sense consensus, we would all further agree that it is not abnormal or unusual to have problems. However, the key point to this blog is simple—how one reacts to problems is the key to whether such problems, no matter how large or small, can lead to positive, neutral or negative consequences. It is within this context that I would like to briefly describe an evidenced-based protocol—Problem-Solving Therapy (PST)—that teaches people to become more effective problems solvers within real-world settings in order to increase their resilience, decrease or prevent long-lasting negative emotional reactions, and enhance their adjustment to life changes.
What is Problem-Solving Therapy?
Problem-Solving Therapy (PST; Nezu, Nezu, & D’Zurilla, 2013) is a psychosocial intervention that focuses on enhancing one’s recovery from, and resilience to, the negative effects of stressful events and life changes. For those readers who are familiar with PST based on training experiences of several years ago, you may wish to continue reading, as the current version (termed “Contemporary PST”) has been revised to accommodate more recent advances in the fields of affective neuroscience, stress, and psychopathology.
In general, the conceptual justification for the efficacy of PST comes from three bodies of related research: (a) continuous findings of a significant association between ineffective social problem solving (SPS; i.e., problem solving that occurs in real-world situations) and a vast array of health and mental health problems (e.g., depression, pain, generalized anxiety/worry, suicidal ideation and behaviors, hypertension, PTSD symptoms, anger proneness, substance abuse), (b) evidence that effective SPS buffers and attenuates the negative effects of both stressful major life events and chronic daily problems, and (c) multiple demonstrations of PST as an evidenced-based psychotherapy that is effective in helping a wide variety of individuals and their problems. With regard to the latter area, several recent meta-analyses of the PST literature provide summary evidence for its efficacy across various health and mental health problems (e.g., Bell & D’Zurilla, 2009; Kirkham, Choi, & Seitz, 2015; Malouff, Thorsteinsson, & Schutte, 2007). Relevant to this venue, the effectiveness of PST has been recognized by VA and DoD as represented by its inclusion in the VA/DoD Clinical Practice Guideline for the Management of Major Depressive Disorder (2009).
Why is PST Relevant for Military Psychology?
Beyond the notion that the above research suggests that PST can be potentially helpful to people in general, we have previously suggested that various premorbid factors, plus the experience of moderate to severe stressful events experienced during service, especially deployment, can potentially serve to increase a Service member or Veteran’s vulnerability to experience intense, immediate, negative distress symptoms (e.g., arousal, anger, sadness, anxiety) when confronted with daily stress. Premorbid vulnerability factors include both biological/physiological (e.g., genetic background, physiologic arousal, emotional reactivity) and behavioral/psychological (e.g., prior exposure trauma, emotional dysregulation, low self-efficacy) factors (see Nezu et al., 2013, for a full description of these vulnerability factors). Further, military service, especially if it includes multiple deployments, can represent a series of major life events (e.g., exposure to combat, significant time away from family) that can influence future emotional and health outcomes. In addition, post-deployment adjustment and the demands of day-to-day life, continuous service or civilian employment, significant others, and the individual’s physical health, all serve as potential stressors, which can further increase the likelihood of experiencing significant distress. This potentially creates a multitude of challenges and problems on a daily basis that in turn serve as additional sources of stress, thus further increasing the likelihood of experiencing an actual clinical syndrome, such as major depression, PTSD, or substance abuse.
We further hypothesized that an important influence that potentially mediates the likelihood that psychological and emotional distress will actually emerge is the degree to which individuals can effectively adapt to such stressors as a function of their problem-solving abilities and skills. How one reacts to the immediate arousal can predict the length and intensity of negative reactions. For example, does the individual view the initial arousal as a signal that a problem exists, which can then activate attempts to effectively cope with the stressor, or does he or she allow this negative arousal to go unchallenged, and thus, trigger further negative thoughts, emotions, behavior, and physical arousal? Within this context, we view effective SPS as helping to minimize the possibility that the individual will experience clinical levels of distress and stress-related barriers to successful coping. For persons who are already experiencing symptoms of emotional distress or beginning to develop styles of avoidance or impulsive behavior, this framework suggests that PST interventions may be an important means to decrease such symptoms, enhance their resilience to stress, and potentially have an important impact on their quality of life, and possibly, prevent more serious emotional or physical problems from occurring.
How Does PST Work?
The overarching goal of PST is to foster the adoption and effective implementation of adaptive problem-solving attitudes (i.e., optimism, enhanced self-efficacy) and behaviors (i.e., adaptive emotional regulation, planful problem solving). According to this model, we suggest that several major obstacles can potentially exist for a given individual when attempting to successfully resolve real-life stressful problems. These include:
In order to overcome such barriers, PST teaches people to learn and effectively apply four major problem-solving “toolkits.” These include (a) Problem-Solving Multitasking, (b) the “Stop, Slow Down, Think, and Act” (SSTA) method of approaching problems, (c) Healthy Thinking and Imagery, and (c) Rational or Planful Problem Solving. These are briefly described below.
The Problem-Solving Multitasking Toolbox. This set of tools is geared to help an individual overcome the ubiquitous human problem when attempting to cope with stressful situations in real life— cognitive overload. Due to basic human limitations in our ability to manipulate large amounts of information in our working memory simultaneously while attempting to solve complex problems or make effective decisions, especially when under stress, individuals are taught to use three multitasking skills: externalization, visualization, and simplification. These skills are considered foundational to effective problem solving, similar to those skills that may be taught as foundational to effective aerobic exercise, such as stretching, breathing, and maintaining a healthy diet.
Externalization involves displaying information “externally” as often as possible. Simply put, people are taught to write ideas down, draw diagrams or charts to determine relationships, make lists, audiotape ideas, and so forth. In this manner, one’s working memory is not overly taxed and allows one to concentrate more on other activities, such as creatively thinking of various solutions. The visualization tool is presented as using one’s “mind’s eye” or visual imagery to help solve a problem, practice carrying out a solution, and/or reduce stress (i.e., a form of guided imagery whereby one is directed imaginally to go on a peaceful vacation). Simplification involves “breaking down” or simplifying problems in order to make them more manageable. People are taught to focus only on the most relevant information, break down complex problems into more manageable smaller problems, and translate complex, vague, and abstract concepts into more simple, specific, and concrete language.
The “Stop, Slow Down, Think, and Act” (SSTA) Toolkit. In situations where the primary goal of PST for a particular population involves the decrease of clinically significant emotional distress (e.g., major depressive disorder, suicidal ideation, generalized anxiety), emphasizing this toolkit is especially important. It is also useful for training individuals as a means of preventing extant emotional concerns from becoming particularly problematic. In essence, people are taught a series of steps in order to enhance their ability to modulate (as opposed to “eradicate”) negative emotional arousal in order to more effectively apply a planful approach to solving problems (i.e., to be able to optimally use the various rational problem-solving skills). It is also presented to clients as the overarching “map” to follow when attempting to cope with stressful problems that engender strong emotional reactions and is included as the major treatment strategy geared to foster adaptive emotional regulation skills. It is also included in PST as a means of minimizing impulsive/careless attempts at problem solving.
According to the SSTA method, individuals are first taught to become “emotionally mindful” by being more aware of when and how they experience negative emotional arousal by focusing on changes in physical (e.g., headache, fatigue, pain), mood (e.g., sadness, anger, tension), cognitive (e.g., worry, thoughts of negative outcomes), and/or behavioral (e.g., urge to run away, yelling, crying) indicators. For certain individuals, additional training may be necessary to increase their accuracy in actually identifying and labeling emotional phenomena. Next, they are taught to “STOP,” that is, to engage in behaviors (e.g., shouting out loud, raising one’s hands, holding up a stop sign) that help them to “put on the brakes” in order to better modulate their emotional arousal (i.e., prevent the initial arousal from evoking a more intense form of the emotion together with its “full blown” concomitant negative thinking, state-dependent negative memories, negative affect, and maladaptive behaviors).
Next, in order to meaningfully be able to “STOP,” clients are further taught to “Slow Down,” that is, to decrease the accelerated rate at which one’s negative emotionality can occur. Various specific techniques are provided and practiced with clients in order to offer them a choice among a pool of potentially effective “slowing down tools.” These include counting down from 10 to 1, diaphragmatic breathing, guided imagery or visualization, “fake yawning” (in keeping with recent neuroscience research demonstrating the efficacy of directed yawning as both a stress management strategy and a means to enhance cognitive awareness, e.g., Walusinski, 2006), meditation, exercise, talking to others, and prayer (if relevant to a particular individual). The “Thinking” and “Acting” steps in SSTA refer to applying the four specific rational or planful problem-solving tasks (i.e., defining the problem and setting realistic goals, generating alternative solutions, decision making, solution implementation and verification) once one is “slowed down,” in attempting to resolve or cope with the stressful problem situation that initially evoked the negative emotional stress reaction.
Healthy Thinking and Imagery Toolkit. This toolbox is included to specifically address additional problem orientation issues, namely negative thinking and feelings of hopelessness. Similar to cognitive restructuring strategies, clients are taught that how one thinks can affect how one feels. Specifically, this toolkit entails a variety of cognitive change techniques geared to enhance optimism and enhanced self-efficacy. For example, people are taught to use the “ABC Model of Thinking” (where “A” = activating or triggering event, “B” = a given belief, attitude, or viewpoint, and “C” = the emotional consequence that is based on that belief, as compared to “reality”) in order to determine whether one needs to change such negative beliefs. They are provided with a series of “healthy thinking” rules (e.g., “Nothing is 100% perfect . . . problems are a normal part of life . . . everyone makes mistakes . . . every minute I spend thinking negatively takes away from enjoying my life”), as well as a list of “realistically optimistic self-statements” (e.g., “I can solve this problem;” “I’m okay—feeling sad under these circumstances is normal;” “I can’t direct the wind, but I can adjust the sails;” “Difficult and painful does not equal hopeless!”), as more optimistic examples of ways to think in order to re-adjust their orientation. In addition, if a given individual has particular difficulty with changing his or her their negative thinking, we also advocate having the PST counselor conduct a “reverse advocacy role play” exercise surrounding a given person’s unique negative thinking patterns. In this exercise, a given maladaptive attitude is temporarily “adopted” by the PST counselor using a role-play format. The individual, who now has to adopt the role of “counselor,” has to provide reasons or arguments for such an attitude being incorrect, maladaptive, or dysfunctional. In this manner, the person begins to actually verbalize those aspects of a positive problem orientation. The process of identifying a more appropriate set of beliefs toward problems and providing justification for the validity of these attitudes helps the individual to begin to personally adopt this perspective.
The second tool in this toolbox focuses on using visualization to enhance motivation and to decrease feelings of hopelessness. The use of visualization here is to help people to sensorially experience what it “feels” like to successfully solve a difficult problem; in other words to “see the light at the end of the tunnel or the ribbon across the finishing line.” With this strategy, the goal is to help individuals create the experience of success in their “mind’s eye,” and vicariously experience the potential reinforcement to be gained. The central goal of this strategy is to have individuals create their own positive consequences (in the form of affect, thoughts, physical sensations, behavior, and interpersonal reactions) associated with solving a difficult problem as a major motivational step toward overcoming low motivation and feelings of hopelessness, as well as minimizing the tendency to engage in avoidant problem solving.
Planful Problem-Solving Toolkit. This last toolbox provides training in the four rational problem-solving steps, the first being Problem Definition. This step involves teaching people to separate facts from assumptions when describing a problem, delineate a realistic and attainable problem-solving goal, and to especially identify those obstacles that prevent one from reaching such goals. Note that this model advocates delineating both problem-focused goals, which include objectives that entail changing the nature of the situation so that it no longer represents a problem, as well as emotion-focused goals, which entail those objectives that involve moderating one’s cognitive-emotional reactions to those situations that cannot be changed. Strategies that might be effective in reaching such emotion-focused goals can include stress management, forgiveness of others, and acceptance that the situation cannot be changed.
The second step, Generation of Alternatives, teaches individuals to creatively think of a range of possible solution strategies geared to overcome the identified obstacles to their goals using various brainstorming techniques. Decision Making, the third planful problem-solving task, involves predicting the likely consequences of the various alternatives previously generated, conducting a cost-benefit analysis based on these identified outcomes, and developing a solution plan geared to achieve the articulated problem-solving goal(s). The last step, Solution Implementation and Verification, entails having the person optimally carry out the solution plan, monitor and evaluate the consequences of the plan and determine whether his or her problem-solving efforts have been successful or need to continue.
Guided Practice of the Problem-Solving Tools. A substantial portion of PST training is devoted to the practice of the various tools with real-life problems experienced by the person. In addition, PST also encourages individuals to “forecast” future stressful situations, whether positive (e.g., getting a promotion and moving to a new city) or negative (e.g., the break-up of a relationship) in order to anticipate how such tools can be applied in the future in order to minimize potential negative consequences.
Application to Veterans and Active Service Members
We recently reported program evaluation data that supports the efficacy of a PST-based group program specifically developed for Veterans and active Service members. The program, entitled Moving Forward, is a 4-session group protocol geared to foster resilience, improve adjustment and prevent clinical levels of emotional distress, taking into account the unique aspects of military culture, including having been exposed to combat situations (Nezu & Nezu, 2013a,b). Results of the program’s first three years provide significant support for its potential efficacy (Tenhula et al., 2014). During this period, 621 Veterans enrolled in the program and participated in 155 differing groups led by 75 differing VA therapists implemented across the continental U.S. Retention rates were close to 80%. Results from a series of confidentially obtained self-report inventories indicated statistically and clinically significant improvements in depression, general distress, social functioning, social problem solving and resilience to future stress. Feedback from participating Veterans indicated that they felt the program increased their optimism for the future and overall sense of self-efficacy, and would strongly recommend the program to other Veterans. In addition, it appeared that this program was also viewed with less stigma, especially since it was presented as a skills-oriented approach to “achieving life’s goals” and not as “psychotherapy for mental health problems” per se. This program also has sustainability as it continues to be rolled throughout the VA given that we developed protocols that trains individuals previously implementing Moving Forward to be “master trainers” for future professionals (Nezu, Nezu, Miller, & Williams-Washington, 2015).
Additional means of teaching Veterans and Service members to become more effective problem solvers that involve substantially less face-to-face contact include a web course (www.veterantraining.va.gov/movingforward), as well as a smartphone app for the iPhone platform (search for Moving Forward on the iTunes App Store).
I began this blog with a quote from Dr. Seuss suggesting that “life is full of problems.” I would like to end by offering a more optimistic quote, this time from Helen Keller, the woman who struggled with becoming deaf and blind due to a childhood illness and who eventually became a strong role model for millions of people given her resilience and charitable work:
All the world is full of suffering;
It is also full of overcoming it.
Bell, A. C., & D’Zurilla, T. J. (2009). Problem-solving therapy for depression: A meta-analysis. Clinical Psychology Review, 29, 348-353.
Department of Veterans Affairs & Department of Defense (2009). Clinical practice guideline for management of major depressive disorder. Washington DC.
Kirkham, J. G., Choi, N., and Seitz, D. P. (2015) Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults. International Journal of Geriatric Psychiatry, DOI: 10.1002/gps.4358. Article first published on line on October 5, 2015.
Malouff, J. M., Thorsteinsson, E. B., & Schutte, N. S. (2007). The efficacy of problem solving therapy in reducing mental and physical health problems: A meta-analysis. Clinical Psychology Review, 27, 46-57.
Nezu, A. M., Nezu, C. M., & D’Zurilla, T. J. (2013). Problem-solving therapy: A treatment manual. New York: Springer Publishing.
Nezu, A. M., & Nezu, C. M. (2013a). Moving Forward: A problem-solving approach to achieving life’s goals. Instructor’s manual. Unpublished manual. Washington, DC: Veterans Health Administration Mental Health Services.
Nezu, A. M., & Nezu, C. M. (2013b). Moving Forward: A problem-solving approach to achieving life’s goals. Participant’s guidebook. Unpublished manual. Washington, DC: Veterans Health Administration Mental Health Services.
Nezu, A. M., Nezu, C. M., Miller, S., & Williams-Washington, K. (2015). Problem-solving training program: Manual for trainers. Unpublished manual. Washington, DC: Veterans Health Administration Mental Health Services.
Tenhula, W. N., Nezu, A. M., Nezu, C. M., Stewart, M. O., Miller, S. A., Steele, J., & Karlin, B. E. (2014).
Moving Forward: A Problem-solving training program to foster Veteran resilience. Professional Psychology: Research & Practice, 45, 416-424.
Walusinski, O. (2006). Yawning: An unsuspected avenue for a better understanding of arousal and interoception. Medical Hypotheses, 67, 6-14.
Arthur M. Nezu, Ph.D., DHL (Hon), ABPP is Distinguished University Professor of Psychology, Professor of Medicine, and Professor of Public Health at Drexel University in Philadelphia, PA. He is currently Editor of the Journal of Consulting and Clinical Psychology and Associate Editor for both the Archives of Scientific Psychology and the American Psychologist. Along with Dr. Christine Maguth Nezu, Art is the co-developer of Contemporary Problem-Solving Therapy, as well as the co-developer of Moving Forward, the problem-solving training-based program currently being rolled out across the VA system and parts of the DoD.