Question 1

Is it true that PST is a preferred choice for treating depression in older adults with deficits in executive functioning?

Arthur Nezu · Accepted Answer

I’m always reluctant to suggest that any treatment is the “preferred choice” for any psychological difficulty because the research is far from being conclusive. For example, there might be significant differences in efficacy as a function of various client characteristics, such as sex, gender, severity of depression, severity of executive dysfunction problems, etc. The field has not yet done this type of exhaustive studies. However, to best answer your question, PST has been found to be a very effective approach for this population and I would certainly suggest that it be strongly considered if you are working with such an individual.

In general, PST has been found to be highly effective for older adults with major depressive disorder as found in a meta-analysis by Kirkham et al. (2016; International Journal of Geriatric Psychiatry, 31(5), 526-535). Two clinical trials provide direct support for applying PST for older depressed adults with executive dysfunction (Alexopoulos et al., 2011, Archives of General Psychiatry, 68, 33-41; Gustavson et al., 2016, The American Journal of Geriatric Psychiatry, 24, 11-17).

Question 2

What are the key mechanisms of change in PST?

Arthur Nezu · Accepted Answer

We recently revised our version of PST to incorporate recent research from affective neuroscience as well as our own clinical experience with multiple populations. We call this new iteration “Emotion-Centered Problem-Solving Therapy” to underscore the complex interplay among emotions, cognitions, and behavior. In our current version, we believe that the key mechanisms of change involve the ability to handle or cope with stressful events, including acute, chronic, and traumatic problems. Inherent in our approach involves teaching people to (a) adopt a more realistic framework regarding problems in living and their ability to cope with them, (b) effectively manage strong emotional responses to such stressful events in their everyday living, and (c) develop plans for handling problems in living using a systematic approach.

For additional information, see invited article by Nezu et al. (2019). (Emotion-centered) problem-solving therapy: An update. Australian Psychologist, 54, 361-371 and recent treatment manual (Nezu & Nezu, 2019. Emotion-centered problem-solving therapy: Treatment guidelines. New York: Springer Publishing).
https://www.springerpub.com/emotion-centered-problem-solving-therapy-9780826143143.html

Question 3

What are some usual reasons why people are unable to solve their problems successfully?

Arthur Nezu · Accepted Answer

We believe that there are four major reasons why some people consistently have difficulty solving problems in living. First, most significant problems create emotional stress that can easily interfere with people’s ability to think rationally and logically. If one is unable to handle such stress (e.g., poor emotion regulation), then difficulties in solving problems can ensue. Second, sometimes difficult problems lead to “brain overload,” meaning that people can feel overwhelmed with multiple sources of information “bombarding” their brains making it more difficult to address problems in a focused manner. Third, at times, difficulty coping with stressful problems leads to feelings of hopelessness, causing people to want to “give up.” Last, often times people do not apply a planful and systematic approach to solving life’s problems, thus leading to ineffective solutions.

Out latest version of problem-solving therapy (i.e., Emotion-Centered Problem-Solving Therapy, Nezu & Nezu, 2019. Emotion-centered problem-solving therapy: Treatment guidelines. New York: Springer Publishing; https://www.springerpub.com/emotion-centered-problem-solving-therapy-9780826143143.html) teaches a series of skills aimed at helping people to overcome each of these major difficulties.

Question 4

Is this approach contraindicated when problems are unchangeable e.g., terminal illness or existential problems?

Arthur Nezu · Accepted Answer

Not at all. PST-based approaches are not only geared to help people who are experiencing problems that ultimately can be changed (e.g., financial difficulties, relationship problems, emotional issues), but for problems that are not changeable themselves. It is not only the problem itself that causes concerns, but the myriad of consequences emanating from the problem, including significant emotional reactions to such problems. For example, being terminally ill cannot “be solved,” but the plethora of related issues can be “grist for the PST mill.” These may include one’s emotional reactions, financial difficulties, related physical problems, dealing with family and friends, and so forth. It is the cascade of difficulties associated with such a major stressor that impacts one’s emotional health. PST can be applied to help people wrestle and cope with these related issues. Further, PST can serve to provide a structured approach for individuals experiencing existential difficulties. This includes helping people to better identify the major issues related to confusion, offering a systematic way of aiding individuals to view life from multiple perspectives, and outlining various decision-making tools to foster their ability to make effective choices.

Question 5

Can PST be used in suicide prevention and risk reduction?

Arthur Nezu · Accepted Answer

Yes, increasingly, research is identifying an important link between social problem-solving deficits (SPS) and suicidal ideation and behaviors. We recently proposed a model of suicidality that posits three major factors that collectively increase the vulnerability for suicide: (a) stressful events (acute, chronic, traumatic), (b) strong negative emotion arousal in reaction to such stress, and (c) SPS deficits that lead to ineffective coping with both the stressful event (i.e., life problem) itself and one’s heightened negative arousal (e.g., see Nezu et al., 2017, Military Behavioral Health, 5, 417-426).

Research supporting the efficacy of PST to reduce suicidality include Choi et al. (2016), Suicide and Life-Threatening Behavior, 46, 323-336 and  Gustavson et al., 2016, The American Journal of Geriatric Psychiatry, 24(1), 11-17. Recently, Barnes et al. (2017, Rehabilitation Psychology, 62, 600-608) developed a protocol for veterans based on our treatment manual (e.g., Nezu et al., 2013, NY: Springer Pub.) geared to aid in the development of safety plans during a suicidal crisis.

Question 6

Is rumination a sign of deficits in problem solving ability?

Arthur Nezu · Accepted Answer

Yes. A substantial amount of research has identified a strong association between social problem-solving (SPS) deficits and depressive rumination. Remember that SPS is the type of problem solving that people engage in when attempting to handle or cope with problems in living, rather than solving intellectual, math, or insight problems. SPS is composed of both an orientation (i.e., how people perceive problems in living and their ability to handle them) and specific skills (i.e., how people define the problem, generate various solutions to a problem, etc.). A negative orientation (e.g., believing that problems are catastrophes) has been found to be strongly associated with depressive rumination. State-oriented rumination, rather than process-oriented rumination, has also been found to linked to SPS deficits. The lack of autobiographical memory specificity has been shown to mediate the relationship between rumination and poor SPS.

Question 7

What is the theoretical underpinning for PST?

Arthur Nezu · Accepted Answer

The theoretical underpinnings of PST assume that much of what is conceptualized as psychopathology and behavioral difficulties, including significant emotional problems, is a function of continuous ineffective coping (i.e., poor social problem solving) with such life stressors. Thus, it is hypothesized that teaching individuals to become better problem solvers can serve to reduce extant physical and mental health difficulties. The overarching goal of this approach is to promote the successful adoption of adaptive problem-solving attitudes (i.e., optimism, enhanced self-efficacy) and the effective implementation of certain behaviors (i.e., adaptive emotional regulation, planful problem solving) as a means of coping with life stressors to attenuate the negative effects of such events on physical and mental well-being. Note that ineffective problem solving can result from a myriad of biological, psychological, and sociocultural factors.

For a detailed description of the theory and research behind the above conceptualization, see , Nezu & Nezu (2019). Emotion-centered problem-solving therapy: Treatment guidelines. New York: Springer Publishing; https://www.springerpub.com/emotion-centered-problem-solving-therapy-9780826143143.html)

Question 8

Can PST be combined with other treatment approaches?

Arthur Nezu · Accepted Answer

Definitely. PST, as a member of the family of cognitive and behavioral therapies, can easily be combined with other CBT interventions. Among these types of treatment approaches, various similarities exist, including the role of various constructs, the use of language, the tendency to be directive, the use of didactics and “homework” as treatment tools, and so forth. Cognitive therapy and dialectic behavior therapy, as examples, both include aspects of PST already. Because these interventions should be viewed as psychotherapy approaches per se, rather than as a set of treatment techniques, it is important is to use a structured case formulation approach that specifies (and justifies) why a particular treatment approach is being applied and for what goal with each client.

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