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"Sad is How I Am!" Treating Dysthymia in Children and Adults
Dysthymia continuing education psychology CEUs

Section 11
Problem Solving and Depressive Symptoms

CEU Question 11 | CEU Test | Table of Contents | Depression
Social Worker CEUs, Counselor CEUs, Psychologist CEs, MFT CEUs

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In the previous tracks, we discussed the steps in the KISS, Keep It Small and Simple, technique with a depressed child or adult to assist them in setting an attainable goal and keep it simple.

Part of you client's inability to set attainable goals is clients who are depressed oftentimes are wrought with indecision. Would you agree? Because of this indecision, I find that sessions dealing with problem solving processes are beneficial.

I divide this problem-solving process into five components. As I review these five components of problem solving, think of a depressed child or adult you are treating and if you may have overlooked any these components in your Cognitive Behavior Therapy treatment of this client.

5 Components of Problem-Solving:
1. Creating a Problem "Horoscope"
2. Generation of Alternatives,
3. Decision Making,
4. Problem Definition and Formulation, and
5. Solution Implementation and Verification.

We will discuss component #1 on this track. Components # 2, 3, 4, and 5 will be on the tracks that follow.

5 Components of Problem Solving

Component #1 - Creating a Problem "Horoscope"
Component one is Creating a Problem "Horoscope." Here's an example of how I explained to Elsa that having a rational, realistic, and positive attitude towards problems was both healthy and normal.

Elsa, age 67, reported continuation of depressive symptoms that included suicidal thoughts. She was experiencing a severe dysphoric mood. I realized that she did not know how to recognize the parts of her life that were causing her problems. Her life had become dominated by obsessive and compulsive rituals in attempts to control her suicidal thoughts. The triggering event was the death of her aunt, whom she had been named after.

Elsa would obsess, "If Aunt Elsa can die so suddenly in the night, so can I. People said we looked and acted a lot alike all of my life." Elsa would compulsively check her facial appearance in the mirror to compare her appearance with Aunt Elsa's chin line, eyes, forehead, etc., for likenesses and differences.

I used the CBT therapeutic strategy of Creating a Problem Horoscope to help Elsa to realize that a problem actually does exist. Realizing that a problem exists is often the most difficult part of solving it. Agree? This Creating a Problem Horoscope strategy helps your client find the point of the problem. The Creating a Problem Horoscope technique trained Elsa to more easily recognize problem situations in her life.

Accurately appraising and labeling problem situations is a necessary prerequisite to future problem-solving. The ability to label a situation as a problem is an ability that helps inhibit your client's tendency to react automatically to these problems. In other words, accurate identification of a personal problem becomes a metaphoric "red light" that can be followed by self-instruction to "STOP and THINK" before reacting.

Creating a Problem Horoscope includes two CBT therapeutic exercises:
--Exercise 1 consists of constructing a list of various areas of Elsa's life in which potential problems frequently can occur. This technique reinforces accepting problems as a normal part of life, and also helped facilitate Elsa's problem-perception skills.
--Exercise 2 asked Elsa to predict the specific areas from the list where she is most likely to experience problems, either currently or in the future. Problem Orientation Worksheet

Whereas, the first exercise alerts the client to potential life stresses that may exist for Elsa; the second list provides predictions or a Horoscope, if you will, unique to Elsa.

Because Elsa experienced catastrophic thinking, I felt it important to assist Elsa to narrow down the specific areas of concern in her life. To do this, I had Elsa identify and list areas of for her that were problems. Here's the checklist I presented to Elsa as a means to limit her catastrophic thinking: job, friendships, relationships with opposite sex, spouse, religion, moral values, recreation, finances, career, children, parents, sex, self-image, education, fears, anxieties, aging, community, environment, and loneliness

After completing this general list, Elsa and I developed a more specific list. It was constructed with attention to both an assessment of current life problems and the prediction or "Horoscope" of particular areas of future vulnerability for Elsa.

The 3-Step Problem Orientation Worksheet
In our next session, Elsa agreed to complete a Problem Orientation worksheet. The three step worksheet had Elsa...
-- First briefly describe the problem situation,
-- Second describe her initial reaction to the problem, and
-- Third predict how she would react to a list of problems.
The purpose of the exercise was to encourage Elsa to "Stop and Think" before acting compulsively.

After completing the worksheet, I discussed with Elsa how to use her feelings as cues or signals, like a "red light flashing," that something was going wrong. Recognizing that a problem existed allowed her to attempt to resolve it effectively. It assured her that having problems simply meant that she was a human being. I asked her if solving problems would make her happier.

Elsa's risk of suicide had been confirmed during several initial interviews but was determined to be minimal at the time of this particular session. Additionally, Elsa had agreed to contact me immediately if there was any increase in her suicidal intention. Our session went as follows:

I started with, "Well, we have here a rather thorough list of potential areas where people are likely to experience problems. The next step for us is to focus on topics that will allow us to predict unique areas of vulnerability for you."

Elsa's response was: "That makes sense. As we were listing those general problems, I got to thinking about how my family, community, and some friends, like my landlord, don't really cause any problems for me. In fact, I do pretty well in the finance department, too; that is when I don't blow my whole paycheck on gambling. But when I saw you write down aging, I didn't even want to think about it - yet I do think about it all the time. I guess even with the antidepressant medication, I still think about things pretty negatively."

I responded, "And from the time we've spent during discussions about your problem orientation or horoscope, when analyzing the distortions you often make in your reactions to problems, would you say that your fears of aging and thoughts about growing older are problems that you find particularly distressing?"

Elsa replied, "Even as you say it, I don't want to discuss it. It feels better to avoid the subject, or I'll get depressed about Aunt Elsa's death again. I guess that means we better list it as one of my more difficult problems."

I replied, "Congratulations, Elsa, it takes courage to confront a tough problem like the loss of a relative!"

Elsa stated, "And my job as a waitress, we should list that too - but I honestly think my problems with work are there because of my stroke last year. God, sometimes I think about getting old and sick and not being able to go to work. I'd really feel like killing myself then! My job at the restaurant is all I have, except for my gambling, but that's another problem in and of itself. I don't feel good after I gamble."

I replied, "Let's review the list now, including the areas we've just talked about. You mentioned aging again, so we know that this is a predictable problem area. From what you're saying, we should probably add your waitress job, experiencing suicidal thoughts, gambling, and lack of activities or interests that help you to feel good. As you look at the list, can you think of anything else?”

Elsa answered, "Well, it's probably the age thing again, but I've always liked men and sex. I get depressed when I think about not having a man in my life."

I said, "From the description you've given me, loneliness seems to be a rather new problem area."

Elsa replied, "I never was lonely. I was always a very independent woman! And I always did things that other women were afraid of doing. That's why morals and religion don't bother me. I did what I wanted to do. But when you get older, you're not attractive to men anymore. I know there goes my negative thinking again. But I get so mad about getting old sometimes. It's a real problem!”

I replied, "I noticed you caught your first statement as an example of extreme negative thinking. It sounds as if your feelings are telling you to add self-image, loneliness, and lack of enjoyable activities to the list as well."

Elsa admitted, "Yes. That really has become a problem for me. I guess some people would have problems from all areas on this list!"

I said, "If you remember, we generated the original list in the first place because we wanted to predict the most frequent areas in which you experience difficulties."

Elsa asked while laughing, "My list has some areas, but not all of them. Did we make this list on purpose, so that I'd start to feel normal?"

I replied, "Your humor is a great asset, Elsa! But if you're starting to think of experiencing problems as normal, you're not only accurate, you're thinking realistically and productively!"

Although Elsa was originally referred for her gambling problem, depression on the death of her Aunt Elsa, her continued dysphoria, and suicidal thinking, this exercise revealed that Elsa's hopeless evaluations of her life were associated with the overwhelming losses she perceived as part of the aging process. I found it became important for Elsa to identify the other areas of her life where she experienced problems. This problem-perception skill allowed her to stop the labeling of all distressful experiences as hopeless side-effects of aging. She began to identify problems that were not related to her age.

As it turned out, she was doing all the things that a typical 67-year-old woman would do to avoid aging. During subsequent sessions, treatment was aimed at applying the problem-solving model toward a wide range of separate problem areas identified during this exercise, only some of which were directly related to aging.

Peer-Reviewed Journal Article References:
Bird, B. M., & Jonnson, M. R. (2020). Have a seat: Supervisee perspectives on using chair-based role plays in clinical supervision. Journal of Psychotherapy Integration, 30(1), 25–35.

Chesin, M. S., Brodsky, B. S., Beeler, B., Benjamin-Phillips, C. A., Taghavi, I., & Stanley, B. (2018). Perceptions of adjunctive mindfulness-based cognitive therapy to prevent suicidal behavior among high suicide-risk outpatient participants. Crisis: The Journal of Crisis Intervention and Suicide Prevention, 39(6), 451–460.

Cummings, J. A., Ballantyne, E. C., & Scallion, L. M. (2015). Essential processes for cognitive behavioral clinical supervision: Agenda setting, problem-solving, and formative feedback. Psychotherapy, 52(2), 158–163.

Geschwind, N., Bosgraaf, E., Bannink, F., & Peeters, F. (2020). Positivity pays off: Clients’ perspectives on positive compared with traditional cognitive behavioral therapy for depression. Psychotherapy, 57(3), 366–378.

Klein, D. N., Leon, A. C., Li, C., D'Zurilla, T. J., Black, S. R., Vivian, D., Dowling, F., Arnow, B. A., Manber, R., Markowitz, J. C., & Kocsis, J. H. (2011). Social problem solving and depressive symptoms over time: A randomized clinical trial of cognitive-behavioral analysis system of psychotherapy, brief supportive psychotherapy, and pharmacotherapy. Journal of Consulting and Clinical Psychology, 79(3), 342–352. 

Online Continuing Education QUESTION 11
What are two purposes for a problem horoscope? To select and enter your answer go to CEU Test.

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