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Problem Solving in Nursing: Strategies for Your Staff

4 min read • September, 15 2023

Problem solving is in a nurse manager’s DNA. As leaders, nurse managers solve problems every day on an individual level and with their teams. Effective leaders find innovative solutions to problems and encourage their staff to nurture their own critical thinking skills and see problems as opportunities rather than obstacles.

Health care constantly evolves, so problem solving and ingenuity are skills often used out of necessity. Tackling a problem requires considering multiple options to develop a solution. Problem solving in nursing requires a solid strategy.

Nurse problem solving

Nurse managers face challenges ranging from patient care matters to maintaining staff satisfaction. Encourage your staff to develop problem-solving nursing skills to cultivate new methods of improving patient care and to promote  nurse-led innovation .

Critical thinking skills are fostered throughout a nurse’s education, training, and career. These skills help nurses make informed decisions based on facts, data, and evidence to determine the best solution to a problem.

Problem-Solving Examples in Nursing

To solve a problem, begin by identifying it. Then analyze the problem, formulate possible solutions, and determine the best course of action. Remind staff that nurses have been solving problems since Florence Nightingale invented the nurse call system.

Nurses can implement the  original nursing process  to guide patient care for problem solving in nursing. These steps include:

• Assessment . Use critical thinking skills to brainstorm and gather information.
• Diagnosis . Identify the problem and any triggers or obstacles.
• Planning . Collaborate to formulate the desired outcome based on proven methods and resources.
• Implementation . Carry out the actions identified to resolve the problem.
• Evaluation . Reflect on the results and determine if the issue was resolved.

How to Develop Problem-Solving Strategies

Staff look to nurse managers to solve a problem, even when there’s not always an obvious solution. Leaders focused on problem solving encourage their team to work collaboratively to find an answer. Core leadership skills are a good way to nurture a health care environment that supports sharing concerns and  innovation .

Here are some essentials for building a culture of innovation that encourages problem solving:

• Present problems as opportunities instead of obstacles.
• Strive to be a positive role model. Support creative thinking and staff collaboration.
• Encourage feedback and embrace new ideas.
• Respect staff knowledge and abilities.
• Match competencies with specific needs and inspire effective decision-making.
• Offer opportunities for  continual learning and career growth.
• Promote research and analysis opportunities.
• Provide support and necessary resources.
• Recognize contributions and reward efforts .

Embrace Innovation to Find Solutions

Try this exercise:

Consider an ongoing departmental issue and encourage everyone to participate in brainstorming a solution. The team will:

• Define the problem, including triggers or obstacles.
• Determine methods that worked in the past to resolve similar issues.
• Explore innovative solutions.
• Develop a plan to implement a solution and monitor and evaluate results.

Problems arise unexpectedly in the fast-paced health care environment. Nurses must be able to react using critical thinking and quick decision-making skills to implement practical solutions. By employing problem-solving strategies, nurse leaders and their staff can  improve patient outcomes  and refine their nursing skills.

Images sourced from Getty Images

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• Research article
• Open access
• Published: 07 October 2020

Impact of social problem-solving training on critical thinking and decision making of nursing students

• Soleiman Ahmady 1 &
• Sara Shahbazi   ORCID: orcid.org/0000-0001-8397-6233 2 , 3  

BMC Nursing volume  19 , Article number:  94 ( 2020 ) Cite this article

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The complex health system and challenging patient care environment require experienced nurses, especially those with high cognitive skills such as problem-solving, decision- making and critical thinking. Therefore, this study investigated the impact of social problem-solving training on nursing students’ critical thinking and decision-making.

This study was quasi-experimental research and pre-test and post-test design and performed on 40 undergraduate/four-year students of nursing in Borujen Nursing School/Iran that was randomly divided into 2 groups; experimental ( n  = 20) and control (n = 20). Then, a social problem-solving course was held for the experimental group. A demographic questionnaire, social problem-solving inventory-revised, California critical thinking test, and decision-making questionnaire was used to collect the information. The reliability and validity of all of them were confirmed. Data analysis was performed using SPSS software and independent sampled T-test, paired T-test, square chi, and Pearson correlation coefficient.

The finding indicated that the social problem-solving course positively affected the student’ social problem-solving and decision-making and critical thinking skills after the instructional course in the experimental group ( P  < 0.05), but this result was not observed in the control group ( P  > 0.05).

Conclusions

The results showed that structured social problem-solving training could improve cognitive problem-solving, critical thinking, and decision-making skills. Considering this result, nursing education should be presented using new strategies and creative and different ways from traditional education methods. Cognitive skills training should be integrated in the nursing curriculum. Therefore, training cognitive skills such as problem- solving to nursing students is recommended.

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Continuous monitoring and providing high-quality care to patients is one of the main tasks of nurses. Nurses’ roles are diverse and include care, educational, supportive, and interventional roles when dealing with patients’ clinical problems [ 1 , 2 ].

Providing professional nursing services requires the cognitive skills such as problem-solving, decision-making and critical thinking, and information synthesis [ 3 ].

Problem-solving is an essential skill in nursing. Improving this skill is very important for nurses because it is an intellectual process which requires the reflection and creative thinking [ 4 ].

Problem-solving skill means acquiring knowledge to reach a solution, and a person’s ability to use this knowledge to find a solution requires critical thinking. The promotion of these skills is considered a necessary condition for nurses’ performance in the nursing profession [ 5 , 6 ].

Managing the complexities and challenges of health systems requires competent nurses with high levels of critical thinking skills. A nurse’s critical thinking skills can affect patient safety because it enables nurses to correctly diagnose the patient’s initial problem and take the right action for the right reason [ 4 , 7 , 8 ].

Problem-solving and decision-making are complex and difficult processes for nurses, because they have to care for multiple patients with different problems in complex and unpredictable treatment environments [ 9 , 10 ].

Clinical decision making is an important element of professional nursing care; nurses’ ability to form effective clinical decisions is the most significant issue affecting the care standard. Nurses build 2 kinds of choices associated with the practice: patient care decisions that affect direct patient care and occupational decisions that affect the work context or teams [ 11 , 12 , 13 , 14 , 15 , 16 ].

The utilization of nursing process guarantees the provision of professional and effective care. The nursing process provides nurses with the chance to learn problem-solving skills through teamwork, health management, and patient care. Problem-solving is at the heart of nursing process which is why this skill underlies all nursing practices. Therefore, proper training of this skill in an undergraduate nursing program is essential [ 17 ].

Nursing students face unique problems which are specific to the clinical and therapeutic environment, causing a lot of stresses during clinical education. This stress can affect their problem- solving skills [ 18 , 19 , 20 , 21 ]. They need to promote their problem-solving and critical thinking skills to meet the complex needs of current healthcare settings and should be able to respond to changing circumstances and apply knowledge and skills in different clinical situations [ 22 ]. Institutions should provide this important opportunity for them.

Despite, the results of studies in nursing students show the weakness of their problem-solving skills, while in complex health environments and exposure to emerging diseases, nurses need to diagnose problems and solve them rapidly accurately. The teaching of these skills should begin in college and continue in health care environments [ 5 , 23 , 24 ].

It should not be forgotten that in addition to the problems caused by the patients’ disease, a large proportion of the problems facing nurses are related to the procedures of the natural life of their patients and their families, the majority of nurses with the rest of health team and the various roles defined for nurses [ 25 ].

Therefore, in addition to above- mentioned issues, other ability is required to deal with common problems in the working environment for nurses, the skill is “social problem solving”, because the term social problem-solving includes a method of problem-solving in the “natural context” or the “real world” [ 26 , 27 ]. In reviewing the existing research literature on the competencies and skills required by nursing students, what attracts a lot of attention is the weakness of basic skills and the lack of formal and systematic training of these skills in the nursing curriculum, it indicates a gap in this area [ 5 , 24 , 25 ]. In this regard, the researchers tried to reduce this significant gap by holding a formal problem-solving skills training course, emphasizing the common social issues in the real world of work. Therefore, this study was conducted to investigate the impact of social problem-solving skills training on nursing students’ critical thinking and decision-making.

Setting and sample

This quasi-experimental study with pretest and post-test design was performed on 40 undergraduate/four-year nursing students in Borujen nursing school in Shahrekord University of Medical Sciences. The periods of data collection were 4 months.

According to the fact that senior students of nursing have passed clinical training and internship programs, they have more familiarity with wards and treatment areas, patients and issues in treatment areas and also they have faced the problems which the nurses have with other health team personnel and patients and their families, they have been chosen for this study. Therefore, this study’s sampling method was based on the purpose, and the sample size was equal to the total population. The whole of four-year nursing students participated in this study and the sample size was 40 members. Participants was randomly divided in 2 groups; experimental ( n  = 20) and control (n = 20).

The inclusion criteria to take part in the present research were students’ willingness to take part, studying in the four-year nursing, not having the record of psychological sickness or using the related drugs (all based on their self-utterance).

Intervention

At the beginning of study, all students completed the demographic information’ questionnaire. The study’s intervening variables were controlled between the two groups [such as age, marital status, work experience, training courses, psychological illness, psychiatric medication use and improving cognitive skills courses (critical thinking, problem- solving, and decision making in the last 6 months)]. Both groups were homogeneous in terms of demographic variables ( P  > 0.05). Decision making and critical thinking skills and social problem solving of participants in 2 groups was evaluated before and 1 month after the intervention.

All questionnaires were anonymous and had an identification code which carefully distributed by the researcher.

To control the transfer of information among the students of two groups, the classification list of students for internships, provided by the head of nursing department at the beginning of semester, was used.

Furthermore, the groups with the odd number of experimental group and the groups with the even number formed the control group and thus were less in contact with each other.

The importance of not transferring information among groups was fully described to the experimental group. They were asked not to provide any information about the course to the students of the control group.

Then, training a course of social problem-solving skills for the experimental group, given in a separate course and the period from the nursing curriculum and was held in 8 sessions during 2 months, using small group discussion, brainstorming, case-based discussion, and reaching the solution in small 4 member groups, taking results of the social problem-solving model as mentioned by D-zurilla and gold fried [ 26 ]. The instructor was an assistant professor of university and had a history of teaching problem-solving courses. This model’ stages are explained in Table  1 .

All training sessions were performed due to the model, and one step of the model was implemented in each session. In each session, the teacher stated the educational objectives and asked the students to share their experiences in dealing to various workplace problems, home and community due to the topic of session. Besides, in each session, a case-based scenario was presented and thoroughly analyzed, and students discussed it.

Instruments

In this study, the data were collected using demographic variables questionnaire and social problem- solving inventory – revised (SPSI-R) developed by D’zurilla and Nezu (2002) [ 26 ], California critical thinking skills test- form B (CCTST; 1994) [ 27 , 28 ] and decision-making questionnaire.

SPSI-R is a self - reporting tool with 52 questions ranging from a Likert scale (1: Absolutely not – 5: very much).

The minimum score maybe 25 and at a maximum of 125, therefore:

The score 25 and 50: weak social problem-solving skills.

The score 50–75: moderate social problem-solving skills.

The score higher of 75: strong social problem-solving skills.

The reliability assessed by repeated tests is between 0.68 and 0.91, and its alpha coefficient between 0.69 and 0.95 was reported [ 26 ]. The structural validity of questionnaire has also been confirmed. All validity analyses have confirmed SPSI as a social problem - solving scale.

In Iran, the alpha coefficient of 0.85 is measured for five factors, and the retest reliability coefficient was obtained 0.88. All of the narratives analyzes confirmed SPSI as a social problem- solving scale [ 29 ].

California critical thinking skills test- form B(CCTST; 1994): This test is a standard tool for assessing the basic skills of critical thinking at the high school and higher education levels (Facione & Facione, 1992, 1998) [ 27 ].

This tool has 34 multiple-choice questions which assessed analysis, inference, and argument evaluation. Facione and Facione (1993) reported that a KR-20 range of 0.65 to 0.75 for this tool is acceptable [ 27 ].

In Iran, the KR-20 for the total scale was 0.62. This coefficient is acceptable for questionnaires that measure the level of thinking ability of individuals.

After changing the English names of this questionnaire to Persian, its content validity was approved by the Board of Experts.

The subscale analysis of Persian version of CCTST showed a positive high level of correlation between total test score and the components (analysis, r = 0.61; evaluation, r = 0.71; inference, r = 0.88; inductive reasoning, r = 0.73; and deductive reasoning, r = 0.74) [ 28 ].

A decision-making questionnaire with 20 questions was used to measure decision-making skills. This questionnaire was made by a researcher and was prepared under the supervision of a professor with psychometric expertise. Five professors confirmed the face and content validity of this questionnaire. The reliability was obtained at 0.87 which confirmed for 30 students using the test-retest method at a time interval of 2 weeks. Each question had four levels and a score from 0.25 to 1. The minimum score of this questionnaire was 5, and the maximum score was 20 [ 30 ].

Statistical analysis

For analyzing the applied data, the SPSS Version 16, and descriptive statistics tests, independent sample T-test, paired T-test, Pearson correlation coefficient, and square chi were used. The significant level was taken P  < 0.05.

The average age of students was 21.7 ± 1.34, and the academic average total score was 16.32 ± 2.83. Other demographic characteristics are presented in Table  2 .

None of the students had a history of psychiatric illness or psychiatric drug use. Findings obtained from the chi-square test showed that there is not any significant difference between the two groups statistically in terms of demographic variables.

The mean scores in social decision making, critical thinking, and decision-making in whole samples before intervention showed no significant difference between the two groups statistically ( P  > 0.05), but showed a significant difference after the intervention ( P  < 0.05) (Table  3 ).

Scores in Table  4 showed a significant positive difference before and after intervention in the “experimental” group ( P  < 0.05), but this difference was not seen in the control group ( P  > 0.05).

Among the demographic variables, only a positive relationship was seen between marital status and decision-making skills (r = 0.72, P  < 0.05).

Also, the scores of critical thinking skill’ subgroups and social problem solving’ subgroups are presented in Tables  5 and 6 which showed a significant positive difference before and after intervention in the “experimental” group (P < 0.05), but this difference was not seen in the control group ( P  > 0.05).

In the present study conducted by some studies, problem-solving and critical thinking and decision-making scores of nursing students are moderate [ 5 , 24 , 31 ].

The results showed that problem-solving skills, critical thinking, and decision-making in nursing students were promoted through a social problem-solving training course. Unfortunately, no study has examined the effect of teaching social problem-solving skills on nursing students’ critical thinking and decision-making skills.

Altun (2018) believes that if the values of truth and human dignity are promoted in students, it will help them acquire problem-solving skills. Free discussion between students and faculty on value topics can lead to the development of students’ information processing in values. Developing self-awareness increases students’ impartiality and problem-solving ability [ 5 ]. The results of this study are consistent to the results of present study.

Erozkan (2017), in his study, reported there is a significant relationship between social problem solving and social self-efficacy and the sub-dimensions of social problem solving [ 32 ]. In the present study, social problem -solving skills training has improved problem -solving skills and its subdivisions.

The results of study by Moshirabadi (2015) showed that the mean score of total problem-solving skills was 89.52 ± 21.58 and this average was lower in fourth-year students than other students. He explained that education should improve students’ problem-solving skills. Because nursing students with advanced problem-solving skills are vital to today’s evolving society [ 22 ]. In the present study, the results showed students’ weakness in the skills in question, and holding a social problem-solving skills training course could increase the level of these skills.

Çinar (2010) reported midwives and nurses are expected to use problem-solving strategies and effective decision-making in their work, using rich basic knowledge.

These skills should be developed throughout one’s profession. The results of this study showed that academic education could increase problem-solving skills of nursing and midwifery students, and final year students have higher skill levels [ 23 ].

Bayani (2012) reported that the ability to solve social problems has a determining role in mental health. Problem-solving training can lead to a level upgrade of mental health and quality of life [ 33 ]; These results agree with the results obtained in our study.

Conducted by this study, Kocoglu (2016) reported nurses’ understanding of their problem-solving skills is moderate. Receiving advice and support from qualified nursing managers and educators can enhance this skill and positively impact their behavior [ 31 ].

Kashaninia (2015), in her study, reported teaching critical thinking skills can promote critical thinking and the application of rational decision-making styles by nurses.

One of the main components of sound performance in nursing is nurses’ ability to process information and make good decisions; these abilities themselves require critical thinking. Therefore, universities should envisage educational and supportive programs emphasizing critical thinking to cultivate their students’ professional competencies, decision-making, problem-solving, and self-efficacy [ 34 ].

The study results of Kirmizi (2015) also showed a moderate positive relationship between critical thinking and problem-solving skills [ 35 ].

Hong (2015) reported that using continuing PBL training promotes reflection and critical thinking in clinical nurses. Applying brainstorming in PBL increases the motivation to participate collaboratively and encourages teamwork. Learners become familiar with different perspectives on patients’ problems and gain a more comprehensive understanding. Achieving these competencies is the basis of clinical decision-making in nursing. The dynamic and ongoing involvement of clinical staff can bridge the gap between theory and practice [ 36 ].

Ancel (2016) emphasizes that structured and managed problem-solving training can increase students’ confidence in applying problem-solving skills and help them achieve self-confidence. He reported that nursing students want to be taught in more innovative ways than traditional teaching methods which cognitive skills training should be included in their curriculum. To this end, university faculties and lecturers should believe in the importance of strategies used in teaching and the richness of educational content offered to students [ 17 ].

The results of these recent studies are adjusted with the finding of recent research and emphasize the importance of structured teaching cognitive skills to nurses and nursing students.

Based on the results of this study on improving critical thinking and decision-making skills in the intervention group, researchers guess the reasons to achieve the results of study in the following cases:

In nursing internationally, problem-solving skills (PS) have been introduced as a key strategy for better patient care [ 17 ]. Problem-solving can be defined as a self-oriented cognitive-behavioral process used to identify or discover effective solutions to a special problem in everyday life. In particular, the application of this cognitive-behavioral methodology identifies a wide range of possible effective solutions to a particular problem and enhancement the likelihood of selecting the most effective solution from among the various options [ 27 ].

In social problem-solving theory, there is a difference among the concepts of problem-solving and solution implementation, because the concepts of these two processes are different, and in practice, they require different skills.

In the problem-solving process, we seek to find solutions to specific problems, while in the implementation of solution, the process of implementing those solutions in the real problematic situation is considered [ 25 , 26 ].

The use of D’zurilla and Goldfride’s social problem-solving model was effective in achieving the study results because of its theoretical foundations and the usage of the principles of cognitive reinforcement skills. Social problem solving is considered an intellectual, logical, effort-based, and deliberate activity [ 26 , 32 ]; therefore, using this model can also affect other skills that need recognition.

In this study, problem-solving training from case studies and group discussion methods, brainstorming, and activity in small groups, was used.

There are significant educational achievements in using small- group learning strategies. The limited number of learners in each group increases the interaction between learners, instructors, and content. In this way, the teacher will be able to predict activities and apply techniques that will lead students to achieve high cognitive taxonomy levels. That is, confront students with assignments and activities that force them to use cognitive processes such as analysis, reasoning, evaluation, and criticism.

In small groups, students are given the opportunity to the enquiry, discuss differences of opinion, and come up with solutions. This method creates a comprehensive understanding of the subject for the student [ 36 ].

According to the results, social problem solving increases the nurses’ decision-making ability and critical thinking regarding identifying the patient’s needs and choosing the best nursing procedures. According to what was discussed, the implementation of this intervention in larger groups and in different levels of education by teaching other cognitive skills and examining their impact on other cognitive skills of nursing students, in the future, is recommended.

Social problem- solving training by affecting critical thinking skills and decision-making of nursing students increases patient safety. It improves the quality of care because patients’ needs are better identified and analyzed, and the best solutions are adopted to solve the problem.

In the end, the implementation of this intervention in larger groups in different levels of education by teaching other cognitive skills and examining their impact on other cognitive skills of nursing students in the future is recommended.

Study limitations

This study was performed on fourth-year nursing students, but the students of other levels should be studied during a cohort from the beginning to the end of course to monitor the cognitive skills improvement.

The promotion of high-level cognitive skills is one of the main goals of higher education. It is very necessary to adopt appropriate approaches to improve the level of thinking. According to this study results, the teachers and planners are expected to use effective approaches and models such as D’zurilla and Goldfride social problem solving to improve problem-solving, critical thinking, and decision-making skills. What has been confirmed in this study is that the routine training in the control group should, as it should, has not been able to improve the students’ critical thinking skills, and the traditional educational system needs to be transformed and reviewed to achieve this goal.

Availability of data and materials

The datasets used and analyzed during the present study are available from the corresponding author on reasonable request.

Abbreviations

California critical thinking skills test

Social problem-solving inventory – revised

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Acknowledgments

This article results from research project No. 980 approved by the Research and Technology Department of Shahrekord University of Medical Sciences. We would like to appreciate to all personnel and students of the Borujen Nursing School. The efforts of all those who assisted us throughout this research.

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Soleiman Ahmady

Virtual School of Medical Education and management, Shahid Beheshty University of Medical Sciences, Tehran, Iran

Sara Shahbazi

Community-Oriented Nursing Midwifery Research Center, Shahrekord University of Medical Sciences, Shahrekord, Iran

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Contributions

SA and SSH conceptualized the study, developed the proposal, coordinated the project, completed initial data entry and analysis, and wrote the report. SSH conducted the statistical analyses. SA and SSH assisted in writing and editing the final report. All authors read and approved the final manuscript.

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Correspondence to Sara Shahbazi .

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This study was reviewed and given exempt status by the Institutional Review Board of the research and technology department of Shahrekord University of Medical Sciences (IRB No. 08–2017-109). Before the survey, students completed a research consent form and were assured that their information would remain confidential. After the end of the study, a training course for the control group students was held.

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Ahmady, S., Shahbazi, S. Impact of social problem-solving training on critical thinking and decision making of nursing students. BMC Nurs 19 , 94 (2020). https://doi.org/10.1186/s12912-020-00487-x

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DOI : https://doi.org/10.1186/s12912-020-00487-x

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What Is Problem-Solving Therapy?

Verywell / Madelyn Goodnight

Problem-Solving Therapy Techniques

How effective is problem-solving therapy, things to consider, how to get started.

Problem-solving therapy is a brief intervention that provides people with the tools they need to identify and solve problems that arise from big and small life stressors. It aims to improve your overall quality of life and reduce the negative impact of psychological and physical illness.

Problem-solving therapy can be used to treat depression , among other conditions. It can be administered by a doctor or mental health professional and may be combined with other treatment approaches.

At a Glance

Problem-solving therapy is a short-term treatment used to help people who are experiencing depression, stress, PTSD, self-harm, suicidal ideation, and other mental health problems develop the tools they need to deal with challenges. This approach teaches people to identify problems, generate solutions, and implement those solutions. Let's take a closer look at how problem-solving therapy can help people be more resilient and adaptive in the face of stress.

Problem-solving therapy is based on a model that takes into account the importance of real-life problem-solving. In other words, the key to managing the impact of stressful life events is to know how to address issues as they arise. Problem-solving therapy is very practical in its approach and is only concerned with the present, rather than delving into your past.

This form of therapy can take place one-on-one or in a group format and may be offered in person or online via telehealth . Sessions can be anywhere from 30 minutes to two hours long. 

Key Components

There are two major components that make up the problem-solving therapy framework:

• Applying a positive problem-solving orientation to your life
• Using problem-solving skills

A positive problem-solving orientation means viewing things in an optimistic light, embracing self-efficacy , and accepting the idea that problems are a normal part of life. Problem-solving skills are behaviors that you can rely on to help you navigate conflict, even during times of stress. This includes skills like:

• Knowing how to identify a problem
• Defining the problem in a helpful way
• Trying to understand the problem more deeply
• Setting goals related to the problem
• Generating alternative, creative solutions to the problem
• Choosing the best course of action
• Implementing the choice you have made
• Evaluating the outcome to determine next steps

Problem-solving therapy is all about training you to become adaptive in your life so that you will start to see problems as challenges to be solved instead of insurmountable obstacles. It also means that you will recognize the action that is required to engage in effective problem-solving techniques.

Planful Problem-Solving

One problem-solving technique, called planful problem-solving, involves following a series of steps to fix issues in a healthy, constructive way:

• Problem definition and formulation : This step involves identifying the real-life problem that needs to be solved and formulating it in a way that allows you to generate potential solutions.
• Generation of alternative solutions : This stage involves coming up with various potential solutions to the problem at hand. The goal in this step is to brainstorm options to creatively address the life stressor in ways that you may not have previously considered.
• Decision-making strategies : This stage involves discussing different strategies for making decisions as well as identifying obstacles that may get in the way of solving the problem at hand.
• Solution implementation and verification : This stage involves implementing a chosen solution and then verifying whether it was effective in addressing the problem.

Other Techniques

Other techniques your therapist may go over include:

• Problem-solving multitasking , which helps you learn to think clearly and solve problems effectively even during times of stress
• Stop, slow down, think, and act (SSTA) , which is meant to encourage you to become more emotionally mindful when faced with conflict
• Healthy thinking and imagery , which teaches you how to embrace more positive self-talk while problem-solving

What Problem-Solving Therapy Can Help With

Problem-solving therapy addresses life stress issues and focuses on helping you find solutions to concrete issues. This approach can be applied to problems associated with various psychological and physiological symptoms.

Mental Health Issues

Problem-solving therapy may help address mental health issues, like:

• Chronic stress due to accumulating minor issues
• Complications associated with traumatic brain injury (TBI)
• Emotional distress
• Post-traumatic stress disorder (PTSD)
• Problems associated with a chronic disease like cancer, heart disease, or diabetes
• Self-harm and feelings of hopelessness
• Substance use
• Suicidal ideation

Specific Life Challenges

This form of therapy is also helpful for dealing with specific life problems, such as:

• Death of a loved one
• Dissatisfaction at work
• Everyday life stressors
• Family problems
• Financial difficulties
• Relationship conflicts

Your doctor or mental healthcare professional will be able to advise whether problem-solving therapy could be helpful for your particular issue. In general, if you are struggling with specific, concrete problems that you are having trouble finding solutions for, problem-solving therapy could be helpful for you.

Benefits of Problem-Solving Therapy

The skills learned in problem-solving therapy can be helpful for managing all areas of your life. These can include:

• Being able to identify which stressors trigger your negative emotions (e.g., sadness, anger)
• Confidence that you can handle problems that you face
• Having a systematic approach on how to deal with life's problems
• Having a toolbox of strategies to solve the issues you face
• Increased confidence to find creative solutions
• Knowing how to identify which barriers will impede your progress
• Knowing how to manage emotions when they arise
• Reduced avoidance and increased action-taking
• The ability to accept life problems that can't be solved
• The ability to make effective decisions
• The development of patience (realizing that not all problems have a "quick fix")

Problem-solving therapy can help people feel more empowered to deal with the problems they face in their lives. Rather than feeling overwhelmed when stressors begin to take a toll, this therapy introduces new coping skills that can boost self-efficacy and resilience .

Other Types of Therapy

Other similar types of therapy include cognitive-behavioral therapy (CBT) and solution-focused brief therapy (SFBT) . While these therapies work to change thinking and behaviors, they work a bit differently. Both CBT and SFBT are less structured than problem-solving therapy and may focus on broader issues. CBT focuses on identifying and changing maladaptive thoughts, and SFBT works to help people look for solutions and build self-efficacy based on strengths.

This form of therapy was initially developed to help people combat stress through effective problem-solving, and it was later adapted to address clinical depression specifically. Today, much of the research on problem-solving therapy deals with its effectiveness in treating depression.

Problem-solving therapy has been shown to help depression in: 

• Older adults
• People coping with serious illnesses like cancer

Problem-solving therapy also appears to be effective as a brief treatment for depression, offering benefits in as little as six to eight sessions with a therapist or another healthcare professional. This may make it a good option for someone unable to commit to a lengthier treatment for depression.

Problem-solving therapy is not a good fit for everyone. It may not be effective at addressing issues that don't have clear solutions, like seeking meaning or purpose in life. Problem-solving therapy is also intended to treat specific problems, not general habits or thought patterns .

In general, it's also important to remember that problem-solving therapy is not a primary treatment for mental disorders. If you are living with the symptoms of a serious mental illness such as bipolar disorder or schizophrenia , you may need additional treatment with evidence-based approaches for your particular concern.

Problem-solving therapy is best aimed at someone who has a mental or physical issue that is being treated separately, but who also has life issues that go along with that problem that has yet to be addressed.

For example, it could help if you can't clean your house or pay your bills because of your depression, or if a cancer diagnosis is interfering with your quality of life.

Your doctor may be able to recommend therapists in your area who utilize this approach, or they may offer it themselves as part of their practice. You can also search for a problem-solving therapist with help from the American Psychological Association’s (APA) Society of Clinical Psychology .

If receiving problem-solving therapy from a doctor or mental healthcare professional is not an option for you, you could also consider implementing it as a self-help strategy using a workbook designed to help you learn problem-solving skills on your own.

During your first session, your therapist may spend some time explaining their process and approach. They may ask you to identify the problem you’re currently facing, and they’ll likely discuss your goals for therapy .

Keep In Mind

Problem-solving therapy may be a short-term intervention that's focused on solving a specific issue in your life. If you need further help with something more pervasive, it can also become a longer-term treatment option.

Get Help Now

We've tried, tested, and written unbiased reviews of the best online therapy programs including Talkspace, BetterHelp, and ReGain. Find out which option is the best for you.

Shang P, Cao X, You S, Feng X, Li N, Jia Y. Problem-solving therapy for major depressive disorders in older adults: an updated systematic review and meta-analysis of randomized controlled trials .  Aging Clin Exp Res . 2021;33(6):1465-1475. doi:10.1007/s40520-020-01672-3

Cuijpers P, Wit L de, Kleiboer A, Karyotaki E, Ebert DD. Problem-solving therapy for adult depression: An updated meta-analysis . Eur Psychiatry . 2018;48(1):27-37. doi:10.1016/j.eurpsy.2017.11.006

Nezu AM, Nezu CM, D'Zurilla TJ. Problem-Solving Therapy: A Treatment Manual . New York; 2013. doi:10.1891/9780826109415.0001

Owens D, Wright-Hughes A, Graham L, et al. Problem-solving therapy rather than treatment as usual for adults after self-harm: a pragmatic, feasibility, randomised controlled trial (the MIDSHIPS trial) .  Pilot Feasibility Stud . 2020;6:119. doi:10.1186/s40814-020-00668-0

Sorsdahl K, Stein DJ, Corrigall J, et al. The efficacy of a blended motivational interviewing and problem solving therapy intervention to reduce substance use among patients presenting for emergency services in South Africa: A randomized controlled trial . Subst Abuse Treat Prev Policy . 2015;10(1):46. doi:doi.org/10.1186/s13011-015-0042-1

Margolis SA, Osborne P, Gonzalez JS. Problem solving . In: Gellman MD, ed. Encyclopedia of Behavioral Medicine . Springer International Publishing; 2020:1745-1747. doi:10.1007/978-3-030-39903-0_208

Kirkham JG, Choi N, Seitz DP. Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults . Int J Geriatr Psychiatry . 2016;31(5):526-535. doi:10.1002/gps.4358

Garand L, Rinaldo DE, Alberth MM, et al. Effects of problem solving therapy on mental health outcomes in family caregivers of persons with a new diagnosis of mild cognitive impairment or early dementia: A randomized controlled trial . Am J Geriatr Psychiatry . 2014;22(8):771-781. doi:10.1016/j.jagp.2013.07.007

Noyes K, Zapf AL, Depner RM, et al. Problem-solving skills training in adult cancer survivors: Bright IDEAS-AC pilot study .  Cancer Treat Res Commun . 2022;31:100552. doi:10.1016/j.ctarc.2022.100552

Albert SM, King J, Anderson S, et al. Depression agency-based collaborative: effect of problem-solving therapy on risk of common mental disorders in older adults with home care needs . The American Journal of Geriatric Psychiatry . 2019;27(6):619-624. doi:10.1016/j.jagp.2019.01.002

By Arlin Cuncic, MA Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

Creative Problem Solving in Healthcare

CREATIVE PROBLEM SOLVING IN THE HEALTHCARE SETTING

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There are 5 primary strategies to use when looking for creative ways to solve problems in healthcare:

• Brainstorming
• Thinking hats
• Problem reversal
• Role-playing

We all have to deal with problems, not only at work, but also in our personal lives. Planning a wedding or a party, finding child care, paying bills, trying to arrange transportation for family members to get where they need to go…all of these are frequent problems that we have to deal with.

As a healthcare worker, your workplace is always changing. It is full of challenges and new clients. You must monitor your client’s condition and perform prescribed treatments. You must know when to inform health professionals about your client’s condition. You must help your clients to make decisions.

Problems can quickly arise and you will have to solve these problems. You need to know what to do and when to do it. Some of these problems will require creative solutions. Being able to creatively problem-solve is an important skill for today’s healthcare workers. Knowing the types of problems that can arise and planning for them in case they do happen will help you to deal with problems effectively.

ABOUT PROBLEM SOLVING

Problem-solving requires critical thinking skills and creativity. What is a problem? What does creativity mean? What is critical thinking?

A problem is a gap or difference in what the situation now is and what you would like it to be.

Creativity is basically the production of order out of chaos. Creativity is developing new, flexible, open-minded approaches or solutions to a problem.

Critical thinking is examining and reflecting on ideas and thinking. Then judgments are made and a course of action decided upon. By combining critical thinking and problem solving, the problem is identified, information is gathered, beliefs and ideas are challenged, and different options are examined creatively. Asking questions is the way to build critical thinking into problem solving.

CREATIVE PROBLEM-SOLVING STRATEGIES

Several strategies that you can use to solve problems creatively are brainstorming, thinking hats, problem reversal, S.W.O.T., and role playing.

Brainstorming Brainstorming is often used by groups, but can also be used by you alone. It is used to create as many possible solutions to a problem as possible. To be effective, the ideas must not be judged or evaluated in any way as they are being developed, no matter how bizarre they seem. Wild ideas are welcomed. Ideas can build on other ideas. New ideas can be created by changing ideas already mentioned.

The more solutions that can be created, the more likely you are to find an effective one. Also, the more variety there is in the solutions, the more likely you are to find an effective one. Once all possible ideas have been created, they are considered for possible consequences. A solution is then selected.

Consider for a moment Divide a square into 4 equal parts. How many possible ways can you think of to divide a square into 4 equal parts?

Below are 4 of the possible answers to this exercise. There are actually many different ways to divide a square into 4 equal parts. This exercise helps to develop your creative thinking skills. It also shows that there is often more than one right answer to a problem.

Thinking hats Thinking hats can also be used in groups, or by you alone. It was originally designed by Edward de Bono. It uses six colored (imaginary) hats. Each hat stands for a different way of thinking about a problem or issue. Using all of the hats will help you to consider the problem more creatively. You will be able to think about the problem from a different viewpoint than you usually take. If it is being used with a group, all members have on the same colored hat at the same time.

1. The white hat is neutral. Facts, figures, and information are examined. It helps to decide if more information is needed.

2. The red hat is for feelings, hunches, and intuition. There is no need to explain your feelings.

3. The yellow hat is for optimism and a logical, positive view of things. It looks at the benefits. It also helps during the evaluation of ideas.

4. The black hat is the logical negative. It uses caution and judgement. It does not encourage creativity. It helps during the evaluation of ideas. It is usually better to use the yellow hat before the black one, to look at the benefits first.

5. The green hat is for creative thinking and new ideas.

6. The blue hat is used to think about the problem-solving process. It ensures the process is being followed. It helps to decide what should be done next.

Problem reversal Sometimes, you will get a different view of a problem if you look at it from the opposite direction. State the problem in reverse. Change a positive statement into a negative one. For example, if there is a problem with a co-worker and you want to improve the situation, consider what would make the situation worse.

S.W.O.T. Analyzing the strengths, weaknesses, opportunities, and threats (S.W.O.T.) is another way of evaluating a problem. It can also be used when evaluating the solutions. What are the possible benefits? What strengths are present? What are the weaknesses? What new opportunities or situations can be created? How can we take advantage of these opportunities? What is the possible harm in the problem? What is the possible harm in the solution?

TIPS TO HELP WITH PROBLEM-SOLVING

1. Think before acting. Use a problem-solving process.

2. Think clearly – stay open-minded. Recognize the effects your emotions can have on your thinking. Separate facts from opinions. Look for errors in reasoning. Consider the evidence (information) – do not jump to conclusions. Don’t try to make the facts fit the solution you want to use.

3. Ask as many questions as you can. Make sure you are asking the right questions to find out what the problem really is. Find out all you can about the problem.

4. Get good ideas from everyone and from everywhere. Edward Land was taking photographs of his family on vacation. His daughter asked him, “Why do we have to wait to see the pictures?” Land thought about this and came up with the idea of instant photography and the Polaroid Camera.

5. Be selective. You cannot solve every problem. Make sure the problem is yours to solve.

6. If a problem seems to be overwhelming, break it into parts.

7. Make the best use of what you have. People often waste a lot of time and energy on “if only.” When you are solving problems, focus on what you have available and what you can change or fix. Spending time on “if only” will just waste time. Spending time and energy saying, “It wouldn’t be a problem if only we had twice as much money for equipment” does not solve the problem – especially if you know you are not going to get twice as much money. Gather the facts as they exist and develop realistic solutions.

8. Look for the opportunity in the problem. Developing creative solutions takes advantage of the opportunity in the problem. For example, a long-term institution for the elderly is looking at the possibility of having to lay-off employees. At the same time, there is a community need for daycare services for the elderly. Perhaps a creative solution would be to develop a daycare program for the elderly instead of laying the employees off.

9. Don’t wait for a problem to occur. If you can take action before a situation turns into a problem, do so.

10. Plan for problems before they occur.

11. Negotiate. Negotiation means that those involved have some of their needs met. This is usually a good strategy in problem-solving. Everybody gets something.

12. Ensure the solution fits the problem. Once the solution has been put into action, it is important to evaluate the plan to ensure the problem has actually been solved and not just hidden for a while.

13. Expect success. Believe in your ability. Work towards realistic goals rather than trying to save the world. Use your skills, time, and energy wisely.

14. Look forward, not backward. Don’t always count on strategies that worked in the past. Be curious. Have the self-confidence to try new things.

15. Although we would like to have all of our problems solved quickly, don’t expect to be able to solve every problem, especially with the first strategy used.

16. Keep your sense of humor.

17. Avoid judging during the gathering of information and development of ideas. The most important question in the creative process is “How might we…?” “We can’t because …” is a barrier to creative problem solving.

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I look upon the “Herb Interaction” book as a “quickie” for my pharmacy team, no need to get bogged down on the computer.

The book on “foot ulcers” spoke to me, I now understand the importance of foot care.

We forget sometimes the power of the patient for healing through compliance and self care habits. We should provide understandable information.

The Dr’ Guide books were a great door opener and relationship builder with the allergy medical team. Our reps loved them.

We had the highest BRC (business Reply Card) return rate of all time – it built up great customer goodwill and easier repeat calls.

The distribution of the Dr. Guide books was the most cost effective, most quickly integrated and best ROI program I have had in years – no committee development meetings, no sky high “creative” costs and so appropriate for our product / treatment messages.

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Social problem-solving might also be called ‘ problem-solving in real life ’. In other words, it is a rather academic way of describing the systems and processes that we use to solve the problems that we encounter in our everyday lives.

The word ‘ social ’ does not mean that it only applies to problems that we solve with other people, or, indeed, those that we feel are caused by others. The word is simply used to indicate the ‘ real life ’ nature of the problems, and the way that we approach them.

Social problem-solving is generally considered to apply to four different types of problems:

• Impersonal problems, for example, shortage of money;
• Personal problems, for example, emotional or health problems;
• Interpersonal problems, such as disagreements with other people; and
• Community and wider societal problems, such as litter or crime rate.

A Model of Social Problem-Solving

One of the main models used in academic studies of social problem-solving was put forward by a group led by Thomas D’Zurilla.

This model includes three basic concepts or elements:

Problem-solving

This is defined as the process used by an individual, pair or group to find an effective solution for a particular problem. It is a self-directed process, meaning simply that the individual or group does not have anyone telling them what to do. Parts of this process include generating lots of possible solutions and selecting the best from among them.

A problem is defined as any situation or task that needs some kind of a response if it is to be managed effectively, but to which no obvious response is available. The demands may be external, from the environment, or internal.

A solution is a response or coping mechanism which is specific to the problem or situation. It is the outcome of the problem-solving process.

Once a solution has been identified, it must then be implemented. D’Zurilla’s model distinguishes between problem-solving (the process that identifies a solution) and solution implementation (the process of putting that solution into practice), and notes that the skills required for the two are not necessarily the same. It also distinguishes between two parts of the problem-solving process: problem orientation and actual problem-solving.

Problem Orientation

Problem orientation is the way that people approach problems, and how they set them into the context of their existing knowledge and ways of looking at the world.

Each of us will see problems in a different way, depending on our experience and skills, and this orientation is key to working out which skills we will need to use to solve the problem.

An Example of Orientation

Most people, on seeing a spout of water coming from a loose joint between a tap and a pipe, will probably reach first for a cloth to put round the joint to catch the water, and then a phone, employing their research skills to find a plumber.

A plumber, however, or someone with some experience of plumbing, is more likely to reach for tools to mend the joint and fix the leak. It’s all a question of orientation.

Problem-Solving

Problem-solving includes four key skills:

• Defining the problem,
• Coming up with alternative solutions,
• Making a decision about which solution to use, and
• Implementing that solution.

Based on this split between orientation and problem-solving, D’Zurilla and colleagues defined two scales to measure both abilities.

They defined two orientation dimensions, positive and negative, and three problem-solving styles, rational, impulsive/careless and avoidance.

They noted that people who were good at orientation were not necessarily good at problem-solving and vice versa, although the two might also go together.

It will probably be obvious from these descriptions that the researchers viewed positive orientation and rational problem-solving as functional behaviours, and defined all the others as dysfunctional, leading to psychological distress.

The skills required for positive problem orientation are:

Being able to see problems as ‘challenges’, or opportunities to gain something, rather than insurmountable difficulties at which it is only possible to fail.

For more about this, see our page on The Importance of Mindset ;

Believing that problems are solvable. While this, too, may be considered an aspect of mindset, it is also important to use techniques of Positive Thinking ;

Believing that you personally are able to solve problems successfully, which is at least in part an aspect of self-confidence.

See our page on Building Confidence for more;

Understanding that solving problems successfully will take time and effort, which may require a certain amount of resilience ; and

Motivating yourself to solve problems immediately, rather than putting them off.

See our pages on Self-Motivation and Time Management for more.

Those who find it harder to develop positive problem orientation tend to view problems as insurmountable obstacles, or a threat to their well-being, doubt their own abilities to solve problems, and become frustrated or upset when they encounter problems.

The skills required for rational problem-solving include:

The ability to gather information and facts, through research. There is more about this on our page on defining and identifying problems ;

The ability to set suitable problem-solving goals. You may find our page on personal goal-setting helpful;

The application of rational thinking to generate possible solutions. You may find some of the ideas on our Creative Thinking page helpful, as well as those on investigating ideas and solutions ;

Good decision-making skills to decide which solution is best. See our page on Decision-Making for more; and

Implementation skills, which include the ability to plan, organise and do. You may find our pages on Action Planning , Project Management and Solution Implementation helpful.

There is more about the rational problem-solving process on our page on Problem-Solving .

Potential Difficulties

Those who struggle to manage rational problem-solving tend to either:

• Rush things without thinking them through properly (the impulsive/careless approach), or
• Avoid them through procrastination, ignoring the problem, or trying to persuade someone else to solve the problem (the avoidance mode).

This ‘ avoidance ’ is not the same as actively and appropriately delegating to someone with the necessary skills (see our page on Delegation Skills for more).

Instead, it is simple ‘buck-passing’, usually characterised by a lack of selection of anyone with the appropriate skills, and/or an attempt to avoid responsibility for the problem.

An Academic Term for a Human Process?

You may be thinking that social problem-solving, and the model described here, sounds like an academic attempt to define very normal human processes. This is probably not an unreasonable summary.

However, breaking a complex process down in this way not only helps academics to study it, but also helps us to develop our skills in a more targeted way. By considering each element of the process separately, we can focus on those that we find most difficult: maximum ‘bang for your buck’, as it were.

Continue to: Decision Making Creative Problem-Solving

See also: What is Empathy? Social Skills

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The Development of Problem-Solving Knowledge for Social Care Practice

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Peter Marsh, Mike Fisher, The Development of Problem-Solving Knowledge for Social Care Practice, The British Journal of Social Work , Volume 38, Issue 5, July 2008, Pages 971–987, https://doi.org/10.1093/bjsw/bcm116

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The continuing modernization of social care in the UK has placed a high premium on evidence. However, there is a lack of investment in social care research in general, and in practice-based research in particular. The paper argues that there is a need to make better connections between research and practice if there are to be substantial improvements in services. The implications of these improved links include more efficient translation of research into action, and more embedding of research within the range of literature that supports service development. The necessary increase in research can be achieved by building on the substantial, albeit piecemeal, achievements of social work research, and by enhancing the practice literacy of the academic workforce as well as the research literacy of the practice workforce. In the context of a new strategy for social work research in UK universities, this paper examines the obstacles to achieving a voice for social work research and how these obstacles are being addressed.

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‘Nurses and students are driving sustainability improvements’

STEVE FORD, EDITOR

• You are here: Archive

Thinking your way to successful problem-solving

13 September, 2001 By NT Contributor

VOL: 97, ISSUE: 37, PAGE NO: 36

Jacqueline Wheeler, DMS, MSc, RGN, is a lecturer at Buckinghamshire Chilterns University College

Problems - some people like them, some do not think they have any, while others shy away from them as if they were the plague. Opportunities, in the form of problems, are part of your life.

The most difficult decision is deciding to tackle a problem and implement a solution, especially as it is sometimes easier to ignore its existence. Problem-solving takes time and effort, but once a problem has been addressed the nurse can feel satisfied that the issue has been resolved and is therefore less likely to re-emerge.

Nurses make clinical decisions using two different approaches. The first is the rationalist approach, which involves an analysis of a situation so that subsequent actions are rational, logical and based on knowledge and judgement. The second approach is based on a phenomenological perspective, where a fluid, flexible and dynamic approach to decision-making is required, such as when dealing with an acutely ill patient.

Types of problems

Problems come in different guises and the solver can perceive them either as a challenge or a threat. One of the most common types of problem is when the unexpected happens. As a nurse you plan and implement care for a patient based on your knowledge and experience, only to find that the patient’s reaction is totally different from that expected but without any apparent reason.

Another type of problem is an assignment where others set a goal or task. Throughout your working life you will be required to undertake duties on behalf of other people. For some this is difficult as they feel unable to control their workload. Others see it as an opportunity to develop new skills or take on additional responsibilities. Opportunities can be perceived as problems by those who fear failure.

A third type of problem is when a dilemma arises. This is when it is difficult to choose the best solution to a problem because the nurse is confronted with something that challenges his or her personal and/or professional values.

Diagnosing problems

The sooner a problem is identified and solutions devised, the better for all involved. So try to anticipate or identify problems when they occur through continuously monitoring staff performance and patient outcomes.

Listening to and observing junior staff will help you to detect work or organisational concerns, because when there are problems staff are likely to behave in an unusual or inconsistent manner.

Initial analysis

Remember that people view things differently, so what you perceive as a problem may not be one to anyone else. So before you begin thinking about what to do - whether to keep it under surveillance, contain it or find a solution - you should undertake an initial analysis. This will help you to understand the problem more clearly.

An analysis will also enable you to prioritise its importance in relation to other problems as problems do not occur one at a time.

Routine problems often need little clarification, so an initial analysis is recommended for non-routine problems only. Even then, not all problems justify the same degree of analysis. But where it is appropriate, an initial analysis will provide a basis from which to generate solutions.

Perception is also important when dealing with patients’ problems. For example, if a patient gives up reading because he or she cannot hold the book (objective), the nurse may assume it is because the patient has lost interest (subjective, one’s own view).

Generating solutions

It is essential for the problem-solver to remember that, where possible, solutions must come from those connected with the problem. If it is to be resolved, agreement must be owned by those involved as they are probably the best and only people who can resolve their differences. The manager should never feel that he or she must be on hand to deal with all disputes.

To solve a problem you need to generate solutions. However, the obvious solution may not necessarily be the best. To generate solutions, a mixture of creative and analytical thinking is needed (Bransford, 1993).

Creativity is about escaping from preconceived ideas that block the way to finding an innovative solution to a problem. An effective tool for assisting in this process is the technique of lateral thinking, which is based largely on the work of Edward de Bono, who regards thinking as a skill.

There are several ways to encourage creative decision-making. One method that works best for specific or simple problems is brainstorming. If the ground rules of confidentiality and being non-judgemental are applied, it will produce a free flow of ideas generated without fear of criticism (Rawlinson, 1986).

Time constraints and staff availability may make it difficult for all those involved in a problem to meet. In such cases an adaptation of brainstorming - where a blank piece of paper is given to those involved and each writes down four solutions to the problem - may be the answer. A similar technique is the collective notebook, where people are asked to record their thoughts and ideas about a problem for a specified period.

An alternative is where one person writes down a list of solutions in order of priority, which is then added to by others. This helps to prioritise the ideas generated. All these methods produce data that can then be analysed by the problem-solver.

When the problem affects people in different geographical areas, solutions can be generated by obtaining the opinion of experts through the use of a questionnaire, which is known as the Delphi technique (McKenna, 1994).

When an apparently insurmountable problem presents itself, it is often useful to divide it into smaller pieces. This is known as convergent thinking. Using divergent thinking - where you consider a problem in different ways to expand your view - may also help. 

A final alternative is the stepladder technique, which is time-consuming but effective if the issue is stirring up strong feelings. This requires the people involved in the problem to be organised into groups. First, two people try to solve the problem, then a third member is drawn in, to whom the solution reached by the first two is presented. All three then try to agree a solution. More people are added to the group, if necessary, in a similar way, until there is agreement of all involved. Provided the individuals are motivated to solve the problem, this technique creates ownership and commitment to implementing the agreed solution.

Analytical thinking, which follows a logical process of eliminating ideas, will enable you to narrow the range down to one feasible solution.

Although someone has to make the ultimate decision on which solution to implement, there are advantages to group decision-making: a greater number of possible solutions are generated and conflicts are resolved, resulting in decisions being reached through rational discussion.

This does, however, require the group to be functioning well or the individuals involved may feel inhibited in contributing to the decision-making. One individual may dominate the group or competition between individuals may result in the need to win taking precedence over deciding on an agreed practical solution.

As nursing becomes less bureaucratic individuals are being encouraged to put forward their own ideas, but social pressures to conform may inhibit the group. We do not solve problems and make decisions in isolation, but are influenced by the environment in which we work and the role we fulfil in that environment. If group members lack commitment and/or motivation, they may accept the first solution and pay little attention to other solutions offered.

Making a decision

There are three types of decision-making environments: certain, risk and uncertain. The certain environment, where we have sufficient information to allow us to select the best solution, is the most comfortable within which to make a decision, but it is the least often encountered.

We usually encounter the risk environment, where we lack complete certainty about the outcomes of various courses of action.

Finally, the uncertain environment is the least comfortable within which to make decisions as we are almost forced to do this blind. We are unable to forecast the possible outcomes of alternative courses of action and, therefore, have to rely heavily on creative intuition and the educated guess.

Taking this into consideration, you should not contemplate making a decision until you have all the information needed. Before you make your decision, remind yourself of the objective, reassess the priorities, consider the options and weigh up the strengths, weaknesses, opportunities and threats of each solution.

An alternative is to use the method that Thomas Edison used to solve the problem of the electric light bulb. Simply focus on your problem as you drift off to sleep, and when you wake up your subconscious mind will have presented you with the answer. But bear in mind that this is not a scientific way of solving problems - your subconscious can be unreliable.

If you are not sure about your decision, test the solution out on others who do not own the problem but may have encountered a similar dilemma. Once you have made your choice stick to it, or you may find it difficult to implement because those involved will never be sure which solution is current. They will also be reluctant to become involved in any future decision-making because of your uncertainty.

The next step is to ensure that all the people involved know what decision has been made. Where possible, brief the group and follow this up with written communication to ensure everyone knows what is expected of them. You may need to sell the decision to some, especially if they were not involved in the decision-making process or the solution chosen is not theirs.

Implementing the solution

Finally, to ensure the solution is implemented, check that the people involved know who is to do what, by when and that it has happened. Review the results of implementing your solution (see Box) and praise and thank all those involved.

- Part 1 of this series was published in last week’s issue: Wheeler, J. (2001) How to delegate your way to a better working life. Nursing Times; 97: 36, 34-35.

Next week. Part three: a step-by-step guide to effective report writing.

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Essential Skills and Attributes in Health and Social Care

• by [email protected]
• 1 January 2024 1 January 2024

Table of Contents

Introduction, key skills in health and social care, essential attributes required, impact of skills and attributes.

What skills and attributes make a difference in health and social care? Explore the core qualities essential for success in this vital field.

Discover the fundamental skills crucial for practitioners in health and social care. From communication to problem-solving, explore their significance in delivering quality care.

Uncover the essential attributes needed in the health and social care landscape. Empathy, adaptability, and resilience—explore how these traits influence effective care provision.

Understand how possessing these skills and attributes can shape a professional’s impact in health and social care. Witness firsthand how these qualities contribute to better outcomes for individuals in need.

By delving into the significance of skills and attributes in health and social care, discover the crucial role they play in providing exceptional support and service. Gain insights into how mastering these qualities can enhance your career in this field.

For further guidance on excelling in health and social care, visit Healthcarediploma.org .

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How Health Care Organizations Should Support Social Services

• 1 The Brookings Institution, Washington, DC

In a recent JAMA Health Forum article, Glied and D’Aunno ask whether health sector investment in social services is “a bridge too far” and raise concerns about differing priorities, skills, finances, and functions of the 2 sectors that question whether this is a good match for collaboration. 1

As health care organizations ponder their role, if any, in supporting social services, there is growing evidence of health benefits from certain investments in social services (including housing and nutrition). But it is hard to make a traditional return-on-investment (ROI) case for many instances of health systems funding social service programs. For instance, to the extent that this “upstream” social funding helps improve household and community health, it means reduced revenues to hospitals and fee-for-service medical practices—so, not good for business. Managed care organizations do have a stronger business incentive to address their enrollees’ health-influencing social conditions. Still, although there is evidence that certain investments in housing, nutrition, etc do yield health care savings , the direct ROI to the health sector is often questionable. 2

The ROI Conundrum

This does not actually mean such investments have a poor return; it’s just that the principal returns often do not accrue to the investor. Health organization investments typically have positive spillover effects in areas beyond immediate health savings, such as economic improvement, better school graduation rates, and better long-term community health. But this form of value-added is not captured as revenue or savings by the health sector investor—a classic “ wrong pockets ” problem. In the same way, improvements in housing conditions financed by a housing authority, or a reduction in violence-caused injuries from new policing programs, can generate large spillover health care savings, yet the financial value of those health benefits do not accrue to the budget bottom line of housing authorities or police departments. The result in each case is usually suboptimal levels of investment in the general well-being of a community.

The key to achieving an optimal level of health system funding of social services, in which public funding is supplemented with health sector funding aimed at improving health, is to organize these investments through multisector partnerships in a community, with each partner strategically investing in community needs that generate spillover benefits to all partners. If designed and implemented well, this partnership approach encourages investments by all community partners to create a strong social return on investment ( SROI ), with benefits and savings shared by each partner as it advances its goal. Of course, reaching that result requires the investing partners to agree on their shares. That can easily lead to difficult negotiations and heightened distrust. Nichols and Taylor are among those testing procedures in communities to create a positive climate, in their case through an innovative bidding process run by a neutral broker and designed to align each partner’s investment commitment with the benefits it will receive from joint action.

Government Encouragement

There are several ways to encourage appropriate health sector investments in social services.

Government initiatives can help in several ways. At the state and local level, the government can act as an honest broker to foster joint investments within communities; states can use Medicaid contracts to require managed care plans to include community engagement, with community partners involved from the beginning. Tweaking community benefit requirements is another way. As a condition of their tax exemption, nonprofit hospitals are already required by law to invest in their communities to improve general health. The Internal Revenue Service (IRS) establishes the rules and over many years has broadened the types of community investments that qualify, including “community building activities.” The IRS could and should encourage nonprofit hospitals to be more creative in supporting innovative social service investments that appear to improve the long-term health and vitality of their communities.

The federal government can provide much clearer guidance on how programs can be used to foster local partnerships with braided funds . It can also help the development of community-level referral systems between health and social services through pilots and more grants to states and communities. More sophisticated referral infrastructure would help facilitate better coordination of social and medical care for households. It would also create important data to help improve our ability to quantify the multisector impacts of investments. In addition, analyzing the impact of recent Medicaid 1115 waivers allowing states, such as Arkansas and New Jersey , more flexibility to mix medical and social services to improve health outcomes will also generate valuable insights on how to best structure health sector investments in social services that will improve community health.

Taking a Back Seat in Partnerships

Effective partnerships require trust, understanding, and the effective use of complementary skills. Indeed, a review of health-human services partnerships suggests that the quality of the relationship is key. This is not easy to achieve between health and social service organizations when communities often doubt the motives and commitment of large health institutions that, in turn, can be skeptical of the expertise of community organizations.

Health systems need to adapt to this reality for their investments to be most beneficial. In 2017, Kaiser Permanente considered supporting a public health and economic development project in Baltimore, Maryland; however, the organization was not then well known in the mid-Atlantic area. So it first partnered with Bon Secours hospital , a very small but highly respected institution in the community; essentially, Bon Secours “credentialled” Kaiser within the community.

CommonSpirit Health has been a pioneer in developing trusted partnerships with social service organizations in communities. CommonSpirit recognizes that there is a critically important difference between functioning as a catalyst for action and being in the driver’s seat. It has partnered with the Pathways Community HUB Institute (PCHI) in 6 communities. In the PCHI model, a neutral hub operated by a local entity links a network of community organizations, health systems, and community health workers to help coordinate care and address health-related social needs. CommonSpirit, along with competing health systems in each area, funds a “community bank” that helps fund the hub’s operating costs and covers otherwise nonreimbursable service costs. It is an intriguing example of how a community partnership can function and how competing health systems can collaborate in a “co-opetition” model for their common benefit. 3

We have come to appreciate that achieving healthier communities requires a larger focus on social factors contributing to ill health. For that to happen, we need to design better SROI techniques and ways in which community savings are distributed. Health systems need to deploy investment resources in ways that prevent illness as well as treat it. Their levels and type of investment should also reflect the broad economic value of prevention and better health. And they must appreciate the importance of sharing control of decision-making over the use of their own investments.

That is not an easy equation to get right. But we have been making steady progress and should be encouraging health systems to explore more partnerships.

Published: November 9, 2023. doi:10.1001/jamahealthforum.2023.4569

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2023 Butler SM. JAMA Health Forum .

Corresponding Author: Stuart M. Butler, PhD, The Brookings Institution, Economic Studies, 1775 Massachusetts Ave NW, Washington, DC, 20036 ( [email protected] ).

Conflict of Interest Disclosures: None reported.

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Butler SM. How Health Care Organizations Should Support Social Services. JAMA Health Forum. 2023;4(11):e234569. doi:10.1001/jamahealthforum.2023.4569

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Social Problem Solving and Health

Counseling psychology is committed to helping people meet the challenges and solve the problems they encounter in daily routines and in stressful circumstances. To a great extent, this holds true for other professional psychology specialties (including clinical, educational and health psychology) as clients usually seek professional assistance in solving the problems they face. Thus, the study of problem-solving abilities—their measurement and correlates—and efficient ways to improve these abilities is of keen interest to clinicians and researchers.

Counseling psychology has played an influential role in this area of inquiry. Historically guided by early cognitive-behavioral theorists (D’Zurilla & Goldfried, 1971), counseling psychology contributed essential theoretical refinements ( Heppner & Krauskopf, 1987 ) and measurement tools ( Heppner, 1988 ) that remain landmark events. However, related and subsequent theoretical and empirical contributions—appearing primarily in outlets associated with clinical and health psychology, and in the larger, multidisciplinary literature—have yet to be sufficiently integrated with contributions from counseling psychology. This lack of scholarly integration has not necessarily impeded advancements and applications, but it has thwarted a deeper theoretical understanding of the mechanisms at work in the learning and application of social problem-solving abilities.

Historical Backdrop

The historical backdrop of theory and research must be considered for us to appreciate the subsequent developments in the current literature. The D’Zurilla and Goldfried (1971) is the intellectual wellspring for this area: In this paper, the authors described the elements that would eventually characterize the problem-solving process. Specifically, it was argued that successful problem-solving consists of identifying a problem, defining the characteristics and important aspects of the problem, generating possible solutions and alternatives for the problem, choosing a viable solution and implementing it, and then monitoring and evaluating the progress of the solution.

Two important features of this paper should be emphasized. First, as Nezu (2004) observes, the proposed model of this work was prescriptive rather than descriptive ; that is, D’Zurilla and Goldfried construed effective problem solving principles as they should be and as they should operate, in theoretical terms. Second, the authors did not recommend a specific measure for assessing problem solving skills; their essay was primarily concerned with the ramifications of their straightforward model for cognitive-behavioral interventions.

The implications of this model for counseling psychology were spelled out in an important conceptual review by Heppner (1978) and demonstrated in an impressive intervention study by Richards and Perri (1978) . These papers—both published in the same volume of Journal of Counseling Psychology —exemplified the two different approaches to the study of problem-solving abilities that persist to this day. In the former, Heppner considered the larger cognitive-behavioral framework in which problem solving was a part, drawing out implications for counseling practice and research. Eventually, Heppner’s work produced the Problem Solving Inventory (PSI; Heppner, 1988 ), accompanied by an impressive program of empirical research that demonstrated the correlates and properties of the PSI (for reviews of this work see Heppner & Baker, 1997 ; Heppner, Witty, & Dixon, 2004 ). In contrast, Richards and Perri took initiative from the prescription of problem-solving abilities stipulated by D’Zurilla and Goldfried, developed an intervention based on these principles, and provided evidence of their utility in significantly improving self-management skills of undergraduates ( Richards & Perri, 1978 ).

In surveying the current landscape, we find relevant research that extends from the Heppner research program. This influence is rather easy to identify, as most of this work relies on the PSI (perhaps the most frequently used problem solving measure). This work appears predominately in the counseling psychology literature. The most comprehensive theoretical commentary on this scholarship appears in Heppner and Krauskopf (1987) , in which an information-processing model is used to help us understand how individuals learn, regulate, and execute problem-solving abilities.

Running parallel to this stream of work (with a few intriguing moments of empirical overlap) are studies that integrate the problem-solving principles into interventions with considerable success. Although D’Zurilla and colleagues were apparently uninterested in developing a measure of problem solving abilities at first—indeed, some of the initial intervention studies used Heppner’s PSI ( Nezu & Perri, 1989 )— this camp provided theoretical refinements of the cognitive-behavioral mechanisms of the problem-solving process ( D’Zurilla & Nezu, 2007 ). A measure of social problem-solving abilities was eventually developed (featuring 70 items; D’Zurilla & Nezu, 1990 ) and empirically refined (52 items; D’Zurilla, Nezu, & Maydeu-Olivares, 2002 ). However, this research stream is best characterized by the number of intervention studies that appeared in journals associated with clinical and counseling psychology, and the far-reaching implications of this work are now being realized by multidisciplinary research teams across the health professions.

Theoretical Distinctions

Although these two streams of work often compliment the other, a few compelling theoretical distinctions should be noted. In the Heppner and Krauskopf (1987) model, for example, problem solving is construed as a metacognitive variable that has organizational properties. In a manner akin to Bandura’s self-efficacy model ( Bandura, 1986 ), problem solving is a self-appraisal process, as behavior is influenced by subjective beliefs and perceptions of abilities, competencies, and potential. These cognitions regulate emotional experiences and expression, overt behavior, personal goals and goal-directed activity. The PSI features three empirically derived factors (Personal Control, Problem-Solving Confidence, and Approach-Avoidance), but it is not construed as a measure of actual problem-solving abilities, per se. The favored terminology emphasizes the phenomenological processes stipulated in this model (e.g., “problem-solving appraisal” and “self-appraised problem-solving abilities”).

The Social Problem-Solving Inventory-Revised (SPSI-R; D’Zurilla & Nezu, 1990 ) was developed as the authors recognized two broad functions of social problem-solving abilities they termed problem orientation and problem-solving skills (see Nezu & D’Zurilla, 1989 ). The problem orientation component, based on converging evidence from research at that time, served to regulate emotions, maintain a positive attitude necessary for solving problems, and motivate a person toward solving problems in routine and stressful circumstances. The problem-solving skills component encompassed the actual skills individuals use in solving problems, including rational skills, avoidance, and impulsive and careless styles. This model guided much of the contemporary research that has used this scale. The theoretical and clinical focus of this group centers on the prescriptive nature of the original model ( D’Zurilla & Nezu, 1999 ; Nezu, 2004 ) and consistently uses the term “social problem-solving abilities.” Recently, D’Zurilla and colleagues recognize the strong associations that have occurred between the positive orientation scale on the SPSI-R measure and the rational-problem solving scale, and between the negative problem orientation scale and the impulsive/careless and the avoidance scales ( D’Zurilla, Nezu, & Maydeu-Olivares, 2004 ). They use the terms “constructive problem-solving style” and “dysfunctional problem-solving style” in their recent conceptualization.

PERSONAL ADJUSTMENT AND HEALTH

We acknowledge that personal adjustment is an important aspect of “health,” generally, and it is a dubious enterprise to separate adjustment into dualistic notions of “mental” and “physical” health. The study of social problem-solving and emotional adjustment has largely dominated the relevant counseling literature, and only recently have we begun to appreciate the theoretical and clinical implications of social problem-solving abilities and physical health. From our perspective, we are fairly confident in the established associations between ineffective problem-solving abilities and depression, anxiety, and distress among people in general ( Heppner, et al., 2004 ; Nezu, 2004 ). However, ineffective problem-solving abilities are inconsistently associated with indicators of health-compromising behaviors (e.g., sedentary behavior, substance abuse; Elliott et al., 2004 ). Social problem-solving abilities can be significantly predictive of important self-reported outcomes (e.g., disability, well-being; Elliott, et al., 2004 ) and with objectively-rated indicators of therapeutic adherence (although the directions of these relationships are not always clear; see Herrick & Elliott, 2001 ).

In the remainder of this chapter, we address recent advancements in our understanding of social problem-solving abilities from recent research in emotional, interpersonal and social adjustment associated with health, with health outcomes and secondary complications, and from problem-solving interventions among persons with various health conditions. We then turn our attention to major issues and findings raised in published reviews of the research to date, and conclude with a discussion of the problems we see in this work and offer our recommendations for future research. We use the term “social problem-solving abilities” in deference to the original model and in light of the currency of this concept in the larger multidisciplinary literature (in which much of the research relevant to our discussion has appeared).

Emotional, Interpersonal, and Social Adjustment

In a previous survey of problem-solving abilities and health, the connections between dysfunctional social problem-solving styles and depression and distress were theoretically consistent across the relevant literature; data linking effective problem-solving abilities with optimal adjustment were decidedly mixed ( Elliott, et al., 2004 ). Empirical research over the ensuing years has yielded similar results. A negative problem orientation has been associated with higher depression scores among older persons with vision loss ( Dreer, Elliott, Fletcher, & Swanson, 2005 ) and among family caregivers of persons with severe disabilities ( Grant et al., 2006 ; Rivera, Elliott et al., 2006 ). A dysfunctional problem-solving style—as measured by the SPSI-R—may be particularly characteristic of individuals who meet diagnostic criteria for a suspected major depressive disorder ( Dreer, Elliott, Shewchuk, Berry, & Rivera, in press ; Grant, Weaver, Elliott, Bartolucci, & Giger, 2004 ; Rivera, Elliott, Berry, Oswald, & Grant, 2007 ).

Indicators of function and quality of life among persons with debilitating conditions rely heavily on self-report measures of these constructs. These measures may be influenced by respondent problem-solving styles, independent of objectively-defined indicators of disability severity ( Elliott, Godshall, Herrick, Witty, & Spruell, 1991 ; Shaw, Feuerstein, Haufler, Berkowitz, & Lopez, 2001 ). Consistent with these data, Rath and colleagues found ineffective problem-solving abilities were significantly associated with self-reported psychosocial impairment among persons with traumatic brain injuries (TBI; Rath, Langenbahn, Simon, Sheer, Fletcher, & Diller, 2004 ). Similar results have been found among persons in a chronic pain rehabilitation program ( Witty, Heppner, Bernard, & Thoreson, 2001 ). A negative problem orientation is a stronger predictor of psychosocial impairment than health locus of control variables ( Shanmugham, Elliott & Palmatier, 2004 ).

In fact, among persons with TBI, there is evidence that social problem-solving abilities may be a better predictor of community integration following medical rehabilitation than several neuropsychological measures often used to predict adjustment in this population ( Rath, Hennessy, & Diller, 2003 ). These results—consistent with prior evidence of the social adaptability associated with effective problem-solving (see Heppner, et al., 1982 , and Neal & Heppner, 1986 )—may prove particularly enlightening in our appreciation of interpersonal and social dynamics of adjustment following disease and disability.

Although the results from these studies have been largely consistent with previous research, the evidence linking social problem-solving abilities and optimal adjustment remains thin. For example, prospective research has found a positive orientation predictive of well-being among family caregivers of stroke survivors over thirteen weeks after discharge from an inpatient rehabilitation program ( Grant et al., 2006 ). Cross-sectional research has found a negative orientation to be inversely associated with caregiver mental health and life satisfaction ( Rivera et al., 2006 ), and Dreer et al. (2005) found elements of constructive and dysfunctional problem-solving styles were associated with the life satisfaction reported by individuals in an outpatient low vision rehabilitation program.

A more detailed analysis of subgroups within a large sample of individuals with disabilities suggests that the relationship of problem-solving abilities to measures of distress and well-being may be theoretically consistent at the extremes: Effective problem-solving abilities are associated with a more optimal profile, and ineffective abilities are associated with opposite clinical picture ( Elliott, Shewchuk, Miller, & Richards, 2001 ). However, two other clusters revealed that some individuals who harbor a negative orientation and who report rational problem-solving skills also experience considerable distress. Our lack of insight into the actual mechanisms by which problem solving influences adjustment in routine, daily experiences hinders our interpretation of these data and their implications.

A similarly complicated pattern emerges in our understanding of self-reported health and social problem-solving abilities. Prospective research has found a negative orientation to be productive of family caregiver health complaints over the course of a year ( Elliott, Shewchuk, & Richards, 2001 ). Yet cross-sectional study with family caregivers of persons with various disabilities did not replicate this finding ( Rivera et al., 2006 ), and Grant et al. (2006) found a significant—albeit tenuous and diminishing—relationship between a positive orientation and general health over 13 weeks. Despite early evidence that a negative orientation is predictive of self-reported health complaints in cross-sectional and prospective designs ( Elliott & Marmarosh, 1994 ), it appears that several unmeasured factors may account for these inconsistent findings.

There is reason to believe that social problem-solving abilities operate within interpersonal and social contexts to exert an influence on adjustment. An effective problem-solving style has been associated with greater relationship satisfaction among family caregivers of stroke survivors ( Shanmugham, et al., 2007 ). Related research suggests that children of families that rely on problem-solving coping fare better over time than families who rely less on these strategies ( Kinsella, Ong, Murtagh, Prior, & Sawyer, 1999 ; Rivara, Jaffe, Polissar, Fay, Liao, & Martin, 1996 ). Furthermore, persons living with severe disability and with family caregivers who have impulsive and careless ways of solving problems were more likely to have a pressure sore within the first year of acquired disability than other individuals ( Elliott, Shewchuk, & Richards, 1999 ). Caregiver dysfunctional styles have also been implicated in the distress and decreased life satisfaction reported by patients with congestive heart failure ( Kurylo, Elliott, DeVivo, & Dreer, 2004 ).

A comprehensive study by Johnson and colleagues (2006) suggests that the effects of problem solving on distress may be defined by several adaptive correlates of social problem-solving abilities. In this study, distress—as a latent construct—was composed of decreased social support, elevations in depression and negative mood, and high stress among 545 HIV+ adults, and distress was predicted by constructive and dysfunctional problem-solving styles (accounting for over 60% of the variance). Although prior research has indicated that social problem-solving abilities are usually related to these separate variables in a theoretically consistent fashion, this was the first study to demonstrate these relationships in a comprehensive model, and the associations were best understood within the context of this model.

Health Outcomes and Secondary Complications

In many respects, social problem-solving abilities have demonstrated considerable utility as a predictor of important health outcomes in several studies of depression among persons living with chronic health conditions. Depression is often conceptualized as an important health outcome because it is associated with increased heath care costs and it compromises the overall health of persons with conditions as varied as diabetes, paralysis, and congestive heart failure.

It has been difficult to ascertain the ways in which problem-solving abilities might influence other, more objectively-defined health outcomes. Data concerning the relations of problem solving to substance use, exercise, and other health behaviors have been mixed (see Elliott et al., 2004 ), although among individuals who live with a disability there is some indication that a dysfunctional style may be associated with health-compromising behaviors ( Dreer, Elliott, & Tucker, 2004 ).

The Johnson et al. (2006) study again informs us of the ways in which problem-solving abilities may influence health outcomes. In this attempt to predict adherence to antiretroviral therapy (assessed by a survey of the number of pills skipped during a 3-day period), the final model revealed no significant, direct paths from the two social problem-solving latent variables (constructive, dysfunctional) to adherence. Rather, social problem-solving exerted significant indirect effects to adherence through its substantive effects on distress. Thus, social problem-solving abilities were significantly associated with therapeutic adherence through its palliative, beneficial (and perhaps, regulatory) effects on personal stress, distress and social support.

Studies that demonstrate connections between social problem-solving abilities and objectively diagnosed biomedical variables are particularly impressive, but the lack of clarity (or, in some cases, theory) raise intrigue and speculation about the nature of these relationships. Social problem-solving abilities were significantly predictive of pressure sores diagnosed over the first 3 years of traumatically acquired spinal cord injury (SCI), and these associations were more influential than clinically important variables like severity of disability and demographic characteristics (e.g., race, gender, age; Elliott, Bush, & Chen, 2006 ). These data are among the first to document the potential of social problem-solving abilities to prospectively predict individuals who may be at risk for expensive and often preventable health complications, above and beyond the predictive value of variables deemed medically important. Nevertheless, the exact mechanisms by which problem solving exerted this observed effect cannot be determined from this study.

We can speculate from other relevant studies that problem-solving abilities may have prevented pressure sores (and promoted healthier skin) among participants in the Elliott et al. (2006) study in a couple of ways. Effective problem-solvers may have had fewer health compromising behaviors than persons who had dysfunctional styles (e.g., less sedentary, inactive behaviors, less alcohol intake; Godshall & Elliott, 1997 ); perhaps they were more successful in regulating their emotions and stress levels so they were more likely to attend to recommended regimens for skin care and maintenance (i.e., therapeutic adherence; Johnson, et al., 2006 ). However, a compelling study of glycemic control among African American men raises other possibilities.

In a study of 65 African American men with diabetes, Hill-Briggs and colleagues (2006) found avoidant and impulsive/careless styles (as measured by a short form of the SPSI-R) were significantly predictive of elevated hemoglobin A1C levels, indicative of poor glycemic control. The relationship between avoidant scores and A1C levels was not mediated by participant depression. These data are further supported by focus group research, in which a group of persons with poor glycemic control reported more avoidant and impulsive/careless responses to a problem-solving task than a group of individuals with good glycemic control ( Hill-Briggs, Cooper, Loman, Brancati, & Cooper, 2003 ). It is possible that a dysfunctional problem solving style—in the context of chronic disease and stress—may have definite correlates with impaired immune system functioning (these correlations do not permit causal explanations; glycemic control may have been influenced by unmeasured variables such as diet, exercise and distress that may, too, be influenced by problem-solving abilities).

Lessons Learned from Intervention Research

Problem-solving therapy (or training; PST) has promulgated as an attractive therapeutic option in many multidisciplinary health care settings. Indeed, the broader concept of “problem solving” is considered an essential element in chronic disease education and self-management programs ( Hill-Briggs, 2003 ). PST grounded explicitly in the principles espoused by D’Zurilla and Goldfried has been applied with notable success in alleviating distress among persons with cancer ( Nezu, Felgoise, McClure, & Houts, 2003 ; Nezu, Nezu, Friedman, & Faddis, 1998 ) and in improving coping and self-regulation skills among persons with TBI ( Rath, Simon, Langenbahn, Sherr, & Diller, 2003 ). Problem-solving interventions have documented success in individual sessions provided in primary care settings ( Mynors-Wallis, Garth, Lloyd-Thomas, & Tomlinson, 1995 ), in structured group therapy ( Rath, et al., 2003 ), in telephone sessions with community-residing adults ( Grant, Elliott, Weaver, Bartolucci, & Giger, 2002 ), and in online Web sessions for parents of children with TBI ( Wade, Corey, & Wolfe, 2006a ; and with observed benefits on child functioning, Wade, Corey, & Wolfe, 2006b ). When null effects have appeared in the peer-review literature, these may be attributable in part to a perceived lack of relevance or lack of “tailoring” of the intervention to problems—as they are perceived and experienced—of immediate concern to participants ( Shanmugham, et al., 2004 ; Study 2).

The positive effects of PST are usually ascribed to the treatment, particularly when significant increases are observed on self-appraised ( Grant et al., 2002 ) and observed problem-solving abilities ( Rath et al., 2003 ). There is some evidence that decreases in dysfunctional styles may be particularly essential in realizing significant decreases in depression ( Rivera, Elliott, Berry, & Grant, 2007 ). Participants may display increased skills in finding more solutions to their problems following PST than persons assigned to a control group ( Lesley, 2007 ). In one impressive multisite clinical trial, Sahler et al. (2005) found the beneficial effects of PST on lowering negative affect among mothers of children with cancer were pronounced among young, single mothers; Spanish-speaking mothers demonstrated continued improvements over a 3-month period. Nevertheless, there is perplexing evidence that PST can be associated with lower depression scores over time with no corresponding changes in social problem-solving abilities ( Elliott, Brossart, Berry, & Fine, 2007 ).

Critical reviews point out that this work has recurring problems with the theoretical integrity of interventions, a lack of methodological details, and a lack of clarity regarding the “dosage” sufficient for therapeutic change. Nezu (2004) has been especially critical of the lack of theoretical integrity, as the general flexibility of the original D’Zurilla and Goldfried model may be melded into or added on to any loosely defined cognitive-behavioral intervention. In some cases, it may appear that a published report used a “problem solving intervention” but there is no elaboration of principles of the model or how these were implemented in any replicable fashion (e.g., Smeets et al., in press ). There are some high-profile trials in which training in “problem solving” was presented as a marquee feature of the multisite intervention, and this evidently meant training in rational, instrumental ways to cope with certain problems, but there is no mention or recognition of the problem orientation component and its theoretical function in self-regulation and motivation (e.g., Project REACH, Wisniewski et al., 2003 ). Nezu (2004) adamantly argues that PST must address issues germane to the problem orientation component, and strategies that strictly address the problem solving skills component will not be successful.

The broad range in the number of sessions across studies frustrates our ability to determine the dosage sufficient for therapeutic change. Some studies report clinical success with after a few sessions ( Mynor-Wallis, et al., 1995 ) but other work shows no effects after two sessions administered six months apart ( Elliott & Berry, 2007 ). Weekly sessions seem to have considerable benefits over several weeks ( Grant et al., 2002 ; Rath, et al., 2003 ; Sahler et al., 2005 ). In some clinical scenarios, however, therapeutic change may occur with monthly sessions over the course of a year ( Rivera, Elliott, Berry & Grant, 2007 ). Currently, we cannot conclude from the extant literature the minimal dosage of PST sufficient to effect beneficial, therapeutic changes. This is an issue that should be addressed in future work.

A critical review of problem solving interventions for family caregivers of stroke survivors concluded that the inconsistent use of a theoretical framework and concepts, and a recurring neglect in measuring participant problem-solving abilities limits our understanding of PST in this area ( Lui, Ross, & Thompson, 2005 ). Very few of the studies reviewed used standardized measures of problem solving abilities despite their availability; many studies use the term without regard to the prevailing theoretical models and corresponding directives for training and assessment. Multidisciplinary research teams are often unfriendly to psychological theories. The Lui et al. critique reveals a high regard for cognitive-behavioral theories and a considerable respect for conducting theory-driven research and service. In particular, this critique conveys a premium on theory for organizing and interpreting multidisciplinary research, and for guiding service programs and their evaluation.

The most critical and informative review of this literature appeared in a recent meta-analysis of 31 studies of PST ( Malouff, Thorsteinsson, & Schutte, 2007 ). This paper stayed true to the basic, organizing principles of the social problem-solving model and recognized the theoretical fidelity of authors across studies. PST demonstrated a significant effect size across studies, indicating a superiority over no treatment and treatment-as-usual. Although no moderating effects were found by mode of delivery (group, individual) or in the number of hours of PST (further confounding our ability to determine adequate “dosage”), these colleagues found significant effects for the presence of problem orientation training (consistent with the Nezu position) and homework assignments. Unfortunately, they also found an “investigator” effect: Studies conducted by one of the developers of PST had a significant contribution to the overall effects of PST. This contribution was stronger than the contributions of homework assignment and problem orientation training. Finally, PST was not significantly different from bona fide treatment alternatives.

Identifying and Solving Problems in the Research Base

As these recent reviews and preceding comments attest, there are several problems that have lingered in this literature that impede our appreciation of social problem-solving abilities and the mechanisms by which they have beneficial effects on health. Yet the available research is generally supportive, as we continue to see positive and theoretically consistent findings in multidisciplinary outlets (e.g., Stroke, Journal of Behavioral Medicine, Pain, British Medical Journal, Patient Education and Counseling ) that signify an acceptance of social problem solving far beyond the usual confines of counseling psychology research (which also may signify the far-reaching impact of counseling psychology research). With these optimistic thoughts in mind, we assert the following issues should receive greater theoretical and empirical scrutiny in future work.

Utilize and Promote Theory-Driven Research and Instrumentation

Exploratory studies are unquestionably compelling and intriguing, and they arguably broaden our vision and stoke our intellectual curiosity (e.g., Hill-Briggs et al., 2006 ). But the ordinary, rank-and-file, “stopgap” studies do not advance our understanding of social problem-solving abilities if they fail to make explicit ties to the prevailing theoretical models, ignore instruments tied to these models (PSI, SPSI-R), or make vague, obscure references to “problem solving” with no appreciation for the implications of prior work, subsequently squandering the opportunity for informed, relevant research that advances existing knowledge. It is frustrating to read studies that ignore prior work, and wonder how the results could have differed if proper attention had been given to the implications of previous theory-driven research (e.g., De Vliegu, et al., 2006).

These are not trivial matters: The most egregious and harmful incidents occur in large, multisite clinical trials that purport to use “problem solving interventions” with no ties to relevant theory-driven research, and then report null effects for their intervention (as in the case of Project REACH). For those invested in policy-relevant research, small-scale studies that yield positive results are held in suspicion because smaller samples often overestimate actual treatment effects (and thereby dismiss the convergence of data across methodologically diverse studies); large-scale, multisite randomized controlled trials (like Project REACH) are assumed to be more robust, generalizeable, and necessary for determining the true efficacy of an intervention ( Califf, 2002 ). Consequently, a perceived lack of evidence from a multisite clinical trial can irreparably smear the reputation of theory-driven PST, and cultivate unjustified disinterest among funding sources and policymakers for further study of PST.

There is some concern that the primary measures of problem-solving abilities—the PSI and the SPSI-R—may be too time-consuming and cumbersome for use in many clinical settings. Interestingly, a shorter, 25-item form of the SPSI-R has been used successfully in several studies (e.g. Grant et al., 2002 ) and some researchers have read the SPSI-R aloud to participants to ensure administration (with theoretical consistently results among persons with visual impairments, Dreer et al., 2005 , and with disabling mobility impairments, Elliott, 1999 ). This may be asking too much for everyday clinical applications and shorter versions should be developed for telehealth applications and in primary care clinics. Preliminary item analysis of the SPSI-R suggests that a briefer version for greater use may be possible, with results generally consistent with contemporary reformulations of the social problem-solving model ( Dreer et al., 2007 ).

Broaden the Scope of PST across Research Teams and Clinical Settings

The effects of PST on depression and distress permeate the literature ( Malouff et al., 2007 ). Recent applications have unsuccessfully tried to use PST to elevate life satisfaction ( Rivera, Elliott, Berry, & Grant, 2007 ). More promising areas include the use of PST principles to promote healthier diets and lifestyles ( Lesley, 2007 ; Perri et al., 2001 ) and to facilitate the use of problem-solving strategies in social interactions (essential for community reintegration; Rath et al., 2003 ). Although much of this work is hampered by the lack of specificity about the actual implementation of PST and relevant theory (rendering the results suspect and thwarting generalizability and replicability; e.g., Van den Hout et al., 2003 ), these studies collectively illustrate the potential of PST in various applications. Other colleagues, for example, incorporate PST in promoting healthier lifestyles (including matters of impulse control, adherence, mood regulation) among persons who are HIV+ (the Health Living project, Gore-Felton et al., 2005 ) and who have substance abuse histories ( Latimer, Winters, D’Zurilla, & Nichols, 2003 ). PST may prove to be quite adaptable in long-distance, community-based telehealth programs, in which ongoing services may be provided to underserved people and to those in remote areas (e.g., Grant et al., 2002 ; Wade et al., 2006a ).

Identify the Mechanisms of Therapeutic Change

It appears that there is no clear evidence of the “dosage” of PST necessary to effect change. Moreover, when change occurs, it is unclear if the changes are uniquely attributable to PST. One persistent issue concerns the intricate relationship between a negative orientation and self-report measures of distress. Even when we find evidence linking effective problem-solving abilities with objectively defined outcomes (e.g., skin ulcers), we do not know if effective problem-solving abilities influenced greater behavioral adherence to therapeutic regimens, or if the problem orientation component was instrumental in regulating emotional adjustment and prevented distress that could have compromised health. We do know that PST is more successful when the issues germane to the problem orientation component are addressed, and there is evidence that decreases in negative orientation and dysfunctional problem-solving styles can be associated with decreases in depression in response to PST ( Rivera, Elliott, Berry, & Grant, 2007 ).

There is legitimate concern that—with respect to social problem-solving abilities—the “absence of the negative” may be more powerful than the “presence of the positive.” It is important for us to understand how and why a negative, dysfunctional style is associated with negative outcomes (and a greater likelihood of a positive outcome), and why and under what conditions a constructive problem-solving style proves uniquely beneficial. This could entail studies of social problem solving abilities and biomedical indicators of stress and adjustment. We believe this is a pressing issue given current interest in social problem-solving as an important variable in positive psychology ( Heppner & Wang, 2003 ).

Attend to Matters of Diversity

Few cognitive-behavioral variables appear to be as culturally resilient as social problem-solving abilities ( Heppner et al., 2004 ). Large-scale studies that have controlled for possible effects of ethnicity have shown the relationships of social problem-solving abilities to distress and adherence ( Johnson et al., 2006 ) and to health outcomes ( Elliott et al., 2006 ) are not mediated by race. Studies of race-specific issues have yielded some of the most intriguing data to date among problem-solving and biomedical markers of health (among African-American men; Hill-Briggs, et al., 2006 ); other work has shown some effects for PST tailored to address health promotion issues among african Americans with hypertension ( Lesley, 2007 ). There is also some indication that Spanish-speaking participants may experience greater benefits from PST than others ( Sahler, et al., 2005 ).

There are many health problems that are disproportionately experienced by ethnic minorities in the United States (e.g., diabetes, stroke, disability incurred in acts of violence). Collectively, available evidence suggests that PST may be used in prevention and remedial programs to assist persons from minority backgrounds who live with these conditions. Although this work is promising, we have yet to see robust effects of PST across health conditions and research has yet to be conducted in any substantive fashion with certain ethnic groups (e.g., Chinese, although initial work has been consistent with extant theoretical models; see Siu & Shek, 2005 ). Ideally, the next wave of intervention research will document effects of PST among people across ethnic groups and cultures.

Problem Solving for the People

Research to date suggests that PST can be effectively provided by psychologists, physicians, nurses and counselors. As the needs of our society demand greater attention to and support for the increasing number of people who live with a chronic health conditions that necessitates routine adherence to prescribed regimens (and currently this number constitutes almost 50% of the population of the United States; Partnerships for Solutions, 2004 ), health promotion programs will increasingly rely on paraprofessionals and community health workers to reach a larger number of individuals. These public health efforts already work with community groups (schools, churches) and with respected paraprofessionals within certain communities (e.g., promotoras in Latino communities) to educate people about health and health promotion skills. We believe problem-solving principles can be taught in public health interventions to reach a greater percentage of people who are affected by chronic health conditions (including family members of an individual with a diagnosable condition). We also know that PST can be effectively provided in the community via telehealth, so a greater use of existing technologies is expected in community-based programs. PST can be a useful modality for prevention programs for teaching health promotion skills (e.g., nutrition, sexual health and behaviors, exercise and activity) to individuals, generally.

A real concern lurking in this sea of possibility is the difficulty in determining when and how to best apply PST: People experience a wide range of problems in our communities, and paraprofessionals may be overwhelmed by the depth and severity of certain problems they will inevitably encounter in their clientele. Furthermore, we know that some individuals live with considerable distress and face many problems that have a restricted range of options and solutions. In these clinical scenarios, a strict reliance on the rather linear application of PST principles may be frustrating to paraprofessionals and clients. Research is needed to determine the best and optimal use of PST by paraprofessionals in public health interventions, and when doctoral-level providers are best suited for using PST in more complex cases that demand greater clinical expertise.

The study and application of social problem-solving abilities has matured beyond its early years in the counseling psychology literature to be embraced by a larger, multidisciplinary audience. Many theoretical issues remain for counseling psychologists to examine and refine, and an influx of new researchers would do much to assuage concerns of “investigator” effects in PST research. Perhaps the next wave of PST research will be conducted in public health programs. It behooves counseling psychology to be involved in this activity so that the theoretical tenets of social problem-solving are accurately integrated and realized in this work, and in the process, ensure a more accurate realization of the effects and applicability of social problem-solving theory and research for the public good.

Acknowledgments

This chapter was supported by grants to the first author awarded by the National Institute on Child Health and Human Development (#T32HD07420), the National Institute on Disability and Rehabilitation Research (H133A020509), and from the National Center for Injury Prevention and Control (#R49/CE000191) to the Injury Control Research Center at the University of Alabama at Birmingham.

The contents of this study are solely the responsibility of the authors and do not necessarily represent the official views of the funding agencies.

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Program Profile: Cognitive-Behavioral, Group-Mentoring Intervention for Children with Emotional and Behavioral Disturbances

Evidence Rating: Promising | One study

Program Summary

This cognitive–behavioral, group-mentoring intervention was designed to improve child behavior and family functioning among 8- to 12-year olds with mental health disorders, and their primary caregivers. This program is rated Promising. Although there were statistically significant improvements on measures of social problem solving and behavior problems, there were no improvements on measures of social skills among children in the intervention group, compared with the control group.

A Promising rating implies that implementing the program may result in the intended outcome(s).

Program Description

Program goals/target population.

The Cognitive–Behavioral, Group-Mentoring Intervention for Children with Emotional and Behavioral Disturbances program aimed to improve child behavior (externalizing and internalizing behavior problems, social problem solving) and family functioning (parenting stress, perceived social support, and attachment to parents) by using mentors to provide training, coaching, modeling, and reinforcement in social communication and problem solving. The program targeted 8- to 12-year-olds with emotional and behavioral disturbances, and their primary caregivers.

Program Components

This program was set within a rural community mental health center. Mentors met with children in a group format once a week for 3 to 4 hours over a 12-week period. During each  session, mentors used a combination of didactics and discussions related to social problem-solving and social-interaction skills followed by child-determined activities based on the specific group’s interests. All sessions occurred at the community center, and participants were transported to sessions by their mentors. Activities provided an opportunity to shape, rehearse, and reinforce appropriate interaction skills. Mentors used praise and a token economy to further reinforce appropriate use of problem-solving skills (children earned bonus points when they were observed engaging in positive behaviors).

Mentors also used live coaching and goal-directed, supportive conversations with children to encourage use of appropriate social-communication and problem-solving skills during sessions. At the end of each session, mentors spoke briefly with parents to discuss completed activities, the child’s behavior, and the extent of the child’s progress. Children were also provided with opportunities to engage in activities with their mentors outside of the community center, including going to the park, watching movies, and going to the library.

Key Personnel

Mentors were employed by the community mental health center and received a minimum of 24 hours of initial training covering program guidelines, positive reinforcement, live coaching, implementing token economies, and strategies for developing a positive mentoring relationship.

Program Theory

The focus of this cognitive–behavioral mentoring program is consistent with the social learning theory (Bandura, 1977). Additionally, the focus on improving the parent–child relationship is consistent with the emphasis accorded to the influence of familial relationships on developmental outcomes as well as on the child’s relationship with others within his or her social network, as in the ecological model of development (Bronfenbrenner, 1979, 1986).

Evaluation Outcomes

The findings from the study by Jent and Niec (2009) showed that children in the cognitive–behavioral, group-mentoring intervention had statistically significant improvements in the frequency of externalizing and internalizing problems, social problem solving, and frequency of appropriate social skills and behaviors, compared with children in the control group. There were, however, no statistically significant differences between the groups on measures of attachment to parents or levels of stress reported by their parents. 

Social Skills

Mentored children did not differ statistically significantly from children in the control group in their change from pretest to posttest on the measure of social skills.

Attachment to Parents

Mentored children did not differ statistically significantly from children in the control group in their change from pretest to posttest on the measure of attachment to parents.

Parenting Stress

Maternal caregivers of mentored children did not differ statistically significantly from maternal caregivers of children in the control group in their change from pretest to posttest on the measure of parental stress.

Internalizing Behavior Problems

Mentored children differed statistically significantly from children in the control group in their change from pretest to posttest on the measure of internalizing behavior problems. The scores decreased for children in the mentored group, but increased for children in the control group (the associated effect size indicated an impact of a small magnitude).

Externalizing Behavior Problems

Mentored children differed statistically significantly from children in the control group in their change from pretest to posttest on the measure of externalizing behavior problems. Although scores decreased for both groups, they decreased to a larger extent for children in the mentored group (the associated effect size indicated an impact of a large magnitude).

Social Problem Solving

Mentored children differed statistically significantly from children in the control group in their change from pretest to posttest on the measure of social problem-solving skills. Scores increased for both groups, but to a larger extent for children in the mentored group (the associated effect size indicated an impact of a large magnitude).

Evaluation Methodology

Jent and Niec (2009) assessed the effects of the cognitive–behavioral, group- mentoring intervention on multiple measures of functioning among 8- to 12-year-olds and their families. Participating children were referred for mentoring services at a rural Midwestern community mental health center. Families who could not commit to attending a 12-session, weekly group- mentoring program and/or whose children scored 2 or more standard deviations lower than the mean on the Peabody Picture Vocabulary Test–Third Edition were excluded from the study. Eligible families ( n =86) were assigned randomly to either the intervention ( n =45) or control condition ( n =41). A total of six participants (three in the intervention and three in the control condition) withdrew from the study. Mentoring was provided to intervention youths in eight separate groups. Mentor-to-child ratios in these groups ranged from two mentors to eight children to two mentors to four children. Each session covered a particular topic and lasted about 4 hours. During each session, children received didactics related to social problem-solving and social-interaction skills and participated in group discussions. At the end of each session, one of the mentors completed a log, which tracked the activities and discussions completed, and the data administered and collected; activities related to the mentoring protocol were reported by mentors to have been completed 92 percent of the time. Youths in the control condition were placed on a 3-month wait list and received no contact with group mentors during the study period. 

Participants with data at pre- and post-intervention were included in the analyses (42 in the intervention group and 38 in the control group). The mentored group was 60 percent boys; 90.5 percent were white and 9.5 percent were Hispanic. The control group was 74 percent boys; 68.4 percent were white, 21.1 percent were Hispanic, and 10.5 percent were African American. There were no differences between intervention and control groups in child age or gender, child receptive language ability, number of hours of mental health services received in the last year, number of hours of mental health services received during the study period, or number of children prescribed psychotropic medication. Race and ethnicity significantly differed between participants in the intervention and control groups, with the intervention group having significantly more white participants than the control group. 

Outcome measures were completed by each participating child and the child’s maternal caregiver at baseline and at the end of the intervention. Children completed measures of parent attachment (Parent Scale of the Inventory of Parent and Peer Attachment) and social problem solving (Social Problem-Solving Inventory–Adolescents). Maternal caregivers completed the Behavior Assessment System for Children–Parent Report Form (BASC), the Parenting Stress Index–Short Form (PSI–SF), and the Social Skills Rating System (SSRS)–Parent Report Form. The BASC assessed the frequency with which children portrayed three domains of behavior including externalizing problems, internalizing problems, and adaptive skills; the SSRS–Parent Report Form assessed the frequency with which a child portrayed appropriate social skills and behaviors; and the PSI–SF assessed the level of stress a parent was experiencing in relation to her parenting and the sources of stress in the areas of personal parental distress, parent–child interactions, and child behavioral characteristics.

Fixed effects linear mixed models were used to test for effects of the intervention, with adjustments for the number of hours of mental health services received during the study period and child’s prescribed psychiatric medication status. Race and ethnicity, however, were not included in the final outcome analyses; these were reported not to have an effect on the results.

Implementation Information

Mentors were employed by the community mental health center and  received a minimum of 24 hours of initial training covering program guidelines, positive reinforcement, live coaching, implementing token economies, and strategies for developing a positive mentoring relationship. Mentors also had weekly supervision sessions of a minimum of 30 minutes with a master’s-level clinician with substantial clinical experience in treating externalizing problems in children. Two of the mentors were completing graduate coursework in clinical social work or counseling and six were enrolled in a 4-year college (Jent and Niec 2009).

Evidence-Base (Studies Reviewed)

These sources were used in the development of the program profile:

Jent, Jason F., and Larissa N. Niec. 2009. “Cognitive Behavioral Principles Within Group Mentoring: A Randomized Pilot Study.” Child & Family Behavior Therapy 31:203–19.

Additional References

Bronfenbrenner, Urie. 1979.  The Ecology of Human Development: Experiments by Nature and Design . Cambridge, Mass.: Harvard University Press.

Bronfenbrenner, Urie. 1986. “Ecology of the Family as a Context for Human Development: Research Perspectives.” Developmental Psychology 22 :723–42.

Bandura, Albert. 1977. Social Learning Theory . Englewood Cliffs, N.J.: Prentice-Hall.

Related Practices

Following are CrimeSolutions-rated programs that are related to this practice:

This practice provides youth with a positive and consistent adult or older youth relationship to promote healthy youth development and social functioning and to reduce risk factors. The practice is rated Effective in reducing delinquency and improving educational outcomes; Promising in improving psychological outcomes and cognitive functioning; and No Effects in reducing substance use.

Evidence Ratings for Outcomes

Why might a practice's outcome ratings differ from the ratings of specific programs encompassed by that practice?

Age: 8 - 12

Gender: Male, Female

Race/Ethnicity: Hispanic, White

Geography: Rural

Setting (Delivery): Other Community Setting

Program Type: Cognitive Behavioral Treatment, Mentoring

Current Program Status: Not Active

1601 NW 12th Street FL 33136 United States

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Anxiety Disorders

What is anxiety.

Occasional anxiety is a normal part of life. Many people worry about things such as health, money, or family problems. But anxiety disorders involve more than temporary worry or fear. For people with an anxiety disorder, the anxiety does not go away and can get worse over time. The symptoms can interfere with daily activities such as job performance, schoolwork, and relationships.

There are several types of anxiety disorders, including generalized anxiety disorder, panic disorder, social anxiety disorder, and various phobia-related disorders.

What are the signs and symptoms of anxiety?

Generalized anxiety disorder.

Generalized anxiety disorder (GAD) usually involves a persistent feeling of anxiety or dread, which can interfere with daily life. It is not the same as occasionally worrying about things or experiencing anxiety due to stressful life events. People living with GAD experience frequent anxiety for months, if not years.

Symptoms of GAD include:

• Feeling restless, wound-up, or on-edge
• Being easily fatigued
• Having difficulty concentrating
• Being irritable
• Having headaches, muscle aches, stomachaches, or unexplained pains
• Difficulty controlling feelings of worry
• Having sleep problems, such as difficulty falling or staying asleep

Panic disorder

People with panic disorder have frequent and unexpected panic attacks. Panic attacks are sudden periods of intense fear, discomfort, or sense of losing control even when there is no clear danger or trigger. Not everyone who experiences a panic attack will develop panic disorder.

During a panic attack, a person may experience:

• Pounding or racing heart
• Trembling or tingling
• Feelings of impending doom
• Feelings of being out of control

People with panic disorder often worry about when the next attack will happen and actively try to prevent future attacks by avoiding places, situations, or behaviors they associate with panic attacks. Panic attacks can occur as frequently as several times a day or as rarely as a few times a year.

Social anxiety disorder

Social anxiety disorder is an intense, persistent fear of being watched and judged by others. For people with social anxiety disorder, the fear of social situations may feel so intense that it seems beyond their control. For some people, this fear may get in the way of going to work, attending school, or doing everyday things.

People with social anxiety disorder may experience:

• Blushing, sweating, or trembling
• Stomachaches
• Rigid body posture or speaking with an overly soft voice
• Difficulty making eye contact or being around people they don’t know
• Feelings of self-consciousness or fear that people will judge them negatively

Phobia-related disorders

A phobia is an intense fear of—or aversion to—specific objects or situations. Although it can be realistic to be anxious in some circumstances, the fear people with phobias feel is out of proportion to the actual danger caused by the situation or object.

People with a phobia:

• May have an irrational or excessive worry about encountering the feared object or situation
• Take active steps to avoid the feared object or situation
• Experience immediate intense anxiety upon encountering the feared object or situation
• Endure unavoidable objects and situations with intense anxiety

There are several types of phobias and phobia-related disorders:

Specific phobias (sometimes called simple phobias) : As the name suggests, people who have a specific phobia have an intense fear of, or feel intense anxiety about, specific types of objects or situations. Some examples of specific phobias include the fear of:

• Specific animals, such as spiders, dogs, or snakes
• Receiving injections

Social anxiety disorder (previously called social phobia) : People with social anxiety disorder have a general intense fear of, or anxiety toward, social or performance situations. They worry that actions or behaviors associated with their anxiety will be negatively evaluated by others, leading them to feel embarrassed. This worry often causes people with social anxiety to avoid social situations. Social anxiety disorder can manifest in a range of situations, such as within the workplace or the school environment.

Agoraphobia: People with agoraphobia have an intense fear of two or more of the following situations:

• Using public transportation
• Being in open spaces
• Being in enclosed spaces
• Standing in line or being in a crowd
• Being outside of the home alone

People with agoraphobia often avoid these situations, in part, because they think being able to leave might be difficult or impossible in the event they have panic-like reactions or other embarrassing symptoms. In the most severe form of agoraphobia, an individual can become housebound.

Separation anxiety disorder: Separation anxiety is often thought of as something that only children deal with. However, adults can also be diagnosed with separation anxiety disorder. People with separation anxiety disorder fear being away from the people they are close to. They often worry that something bad might happen to their loved ones while they are not together. This fear makes them avoid being alone or away from their loved ones. They may have bad dreams about being separated or feel unwell when separation is about to happen.

Selective mutism: A somewhat rare disorder associated with anxiety is selective mutism. Selective mutism occurs when people fail to speak in specific social situations despite having normal language skills. Selective mutism usually occurs before the age of 5 and is often associated with extreme shyness, fear of social embarrassment, compulsive traits, withdrawal, clinging behavior, and temper tantrums. People diagnosed with selective mutism are often also diagnosed with other anxiety disorders.

What are the risk factors for anxiety?

Researchers are finding that both genetic and environmental factors contribute to the risk of developing an anxiety disorder.

The risk factors for each type of anxiety disorder vary. However, some general risk factors include:

• Shyness or feeling distressed or nervous in new situations in childhood
• Exposure to stressful and negative life or environmental events
• A history of anxiety or other mental disorders in biological relatives

Anxiety symptoms can be produced or aggravated by:

• Some physical health conditions, such as thyroid problems or heart arrhythmia
• Caffeine or other substances/medications

If you think you may have an anxiety disorder, getting a physical examination from a health care provider may help them diagnose your symptoms and find the right treatment.

How is anxiety treated?

Anxiety disorders are generally treated with psychotherapy, medication, or both. There are many ways to treat anxiety, and you should work with a health care provider to choose the best treatment for you.

Psychotherapy

Psychotherapy or “talk therapy” can help people with anxiety disorders. To be effective, psychotherapy must be directed at your specific anxieties and tailored to your needs.

Cognitive behavioral therapy

Cognitive behavioral therapy (CBT) is an example of one type of psychotherapy that can help people with anxiety disorders. It teaches people different ways of thinking, behaving, and reacting to situations to help you feel less anxious and fearful. CBT has been well studied and is the gold standard for psychotherapy.

Exposure therapy is a CBT method that is used to treat anxiety disorders. Exposure therapy focuses on confronting the fears underlying an anxiety disorder to help people engage in activities they have been avoiding. Exposure therapy is sometimes used along with relaxation exercises.

Acceptance and commitment therapy

Another treatment option for some anxiety disorders is acceptance and commitment therapy (ACT). ACT takes a different approach than CBT to negative thoughts. It uses strategies such as mindfulness and goal setting to reduce discomfort and anxiety. Compared to CBT, ACT is a newer form of psychotherapy treatment, so less data are available on its effectiveness.

Medication does not cure anxiety disorders but can help relieve symptoms. Health care providers, such as a psychiatrist or primary care provider, can prescribe medication for anxiety. Some states also allow psychologists who have received specialized training to prescribe psychiatric medications. The most common classes of medications used to combat anxiety disorders are antidepressants, anti-anxiety medications (such as benzodiazepines), and beta-blockers.

Antidepressants

Antidepressants are used to treat depression, but they can also be helpful for treating anxiety disorders. They may help improve the way your brain uses certain chemicals that control mood or stress. You may need to try several different antidepressant medicines before finding the one that improves your symptoms and has manageable side effects.

Antidepressants can take several weeks to start working so it’s important to give the medication a chance before reaching a conclusion about its effectiveness. If you begin taking antidepressants, do not stop taking them without the help of a health care provider. Your provider can help you slowly and safely decrease your dose. Stopping them abruptly can cause withdrawal symptoms.

In some cases, children, teenagers, and adults younger than 25 may experience increased suicidal thoughts or behavior when taking antidepressant medications, especially in the first few weeks after starting or when the dose is changed. Because of this, people of all ages taking antidepressants should be watched closely, especially during the first few weeks of treatment.

Anti-anxiety medications

Anti-anxiety medications can help reduce the symptoms of anxiety, panic attacks, or extreme fear and worry. The most common anti-anxiety medications are called benzodiazepines. Although benzodiazepines are sometimes used as first-line treatments for generalized anxiety disorder, they have both benefits and drawbacks.

Benzodiazepines are effective in relieving anxiety and take effect more quickly than antidepressant medications. However, some people build up a tolerance to these medications and need higher and higher doses to get the same effect. Some people even become dependent on them.

To avoid these problems, health care providers usually prescribe benzodiazepines for short periods of time.

If people suddenly stop taking benzodiazepines, they may have withdrawal symptoms, or their anxiety may return. Therefore, benzodiazepines should be tapered off slowly. Your provider can help you slowly and safely decrease your dose.

Beta-blockers

Although beta-blockers are most often used to treat high blood pressure, they can help relieve the physical symptoms of anxiety, such as rapid heartbeat, shaking, trembling, and blushing. These medications can help people keep physical symptoms under control when taken for short periods. They can also be used “as needed” to reduce acute anxiety, including to prevent some predictable forms of performance anxieties.

Choosing the right medication

Some types of drugs may work better for specific types of anxiety disorders, so people should work closely with a health care provider to identify which medication is best for them. Certain substances such as caffeine, some over-the-counter cold medicines, illicit drugs, and herbal supplements may aggravate the symptoms of anxiety disorders or interact with prescribed medication. People should talk with a health care provider, so they can learn which substances are safe and which to avoid.

Choosing the right medication, medication dose, and treatment plan should be done under an expert’s care and should be based on a person’s needs and their medical situation. Your and your provider may try several medicines before finding the right one.

Support groups

Some people with anxiety disorders might benefit from joining a self-help or support group and sharing their problems and achievements with others. Support groups are available both in person and online. However, any advice you receive from a support group member should be used cautiously and does not replace treatment recommendations from a health care provider.

Stress management techniques

Stress management techniques, such as exercise, mindfulness, and meditation, also can reduce anxiety symptoms and enhance the effects of psychotherapy. You can learn more about how these techniques benefit your treatment by talking with a health care provider.

How can I find a clinical trial for anxiety?

Clinical trials are research studies that look at new ways to prevent, detect, or treat diseases and conditions. The goal of clinical trials is to determine if a new test or treatment works and is safe. Although individuals may benefit from being part of a clinical trial, participants should be aware that the primary purpose of a clinical trial is to gain new scientific knowledge so that others may be better helped in the future.

Researchers at NIMH and around the country conduct many studies with patients and healthy volunteers. We have new and better treatment options today because of what clinical trials uncovered years ago. Be part of tomorrow’s medical breakthroughs. Talk to your health care provider about clinical trials, their benefits and risks, and whether one is right for you.

To learn more or find a study, visit:

• NIMH’s Clinical Trials webpage : Information about participating in clinical trials
• Clinicaltrials.gov: Current Studies on Anxiety Disorders  : List of clinical trials funded by the National Institutes of Health (NIH) being conducted across the country
• Join a Study: Adults - Anxiety Disorders : List of studies being conducted on the NIH Campus in Bethesda, MD
• Join a Study: Children - Anxiety Disorders : List of studies being conducted on the NIH Campus in Bethesda, MD

Where can I learn more about anxiety?

Free brochures and shareable resources.

• Generalized Anxiety Disorder (GAD): When Worry Gets Out of Control : This brochure describes the signs, symptoms, and treatment of generalized anxiety disorder.
• I’m So Stressed Out! : This fact sheet intended for teens and young adults presents information about stress, anxiety, and ways to cope when feeling overwhelmed.
• Obsessive-Compulsive Disorder: When Unwanted Thoughts Take Over : This brochure describes the signs, symptoms, and treatment of OCD.
• Panic Disorder: When Fear Overwhelms : This brochure describes the signs, symptoms, and treatments of panic disorder.
• Social Anxiety Disorder: More Than Just Shyness : This brochure describes the signs, symptoms, and treatment of social anxiety disorder.
• Shareable Resources on Anxiety Disorders : Help support anxiety awareness and education in your community. Use these digital resources, including graphics and messages, to spread the word about anxiety disorders.
• Mental Health Minute: Anxiety Disorders in Adults :Take a mental health minute to watch this video about anxiety disorders in adults.
• Mental Health Minute: Stress and Anxiety in Adolescents : Take a mental health minute to watch this video about stress and anxiety in adolescents.
• NIMH Expert Discusses Managing Stress and Anxiety : Learn about coping with stressful situations and when to seek help.
• GREAT : Learn helpful practices to manage stress and anxiety. GREAT was developed by Dr. Krystal Lewis, a licensed clinical psychologist at NIMH.
• Getting to Know Your Brain: Dealing with Stress : Test your knowledge about stress and the brain. Also learn how to create and use a “ stress catcher ” to practice strategies to deal with stress.
• Guided Visualization: Dealing with Stress : Learn how the brain handles stress and practice a guided visualization activity.
• Panic Disorder: The Symptoms : Learn about the signs and symptoms of panic disorder.

Federal resources

• Anxiety Disorders   (MedlinePlus – also en español  )

Research and statistics

• Journal Articles   : References and abstracts from MEDLINE/PubMed (National Library of Medicine).
• Statistics: Anxiety Disorder : This webpage provides information on the statistics currently available on the prevalence and treatment of anxiety among people in the U.S.

Last Reviewed: April 2024

Unless otherwise specified, the information on our website and in our publications is in the public domain and may be reused or copied without permission. However, you may not reuse or copy images. Please cite the National Institute of Mental Health as the source. Read our copyright policy to learn more about our guidelines for reusing NIMH content.

Watch CBS News

The facts about Kamala Harris' role on immigration in the Biden administration

By Camilo Montoya-Galvez

Updated on: July 23, 2024 / 11:48 AM EDT / CBS News

Following President Biden's decision to abandon his reelection campaign and endorse Vice President Kamala Harris to be the Democratic nominee for president, Harris' role on immigration has come under scrutiny.

Soon after Mr. Biden's announcement, Republicans sought to blame Harris for the Biden administration's woes at the U.S.-Mexico border, where American officials have reported record levels of illegal crossings in the past three years. In a phone conversation with CBS News on Saturday, former President Donald Trump said Harris presided over the "worst border ever" as "border czar," a title her Republican detractors often give her.

Harris is all but certain to face even more criticism over the Biden administration's record on immigration, one of American voters' top concerns ahead of the election. And Harris does have an immigration-related role in the Biden White House, but her responsibilities on the issue are often mischaracterized. 

What exactly is Harris' immigration role?

In March 2021, when the Biden administration faced the early stages of an influx in illegal crossings at the U.S. southern border, Mr. Biden tasked Harris with leading the administration's diplomatic campaign to address the "root causes" of migration from Guatemala, Honduras and El Salvador, including poverty, corruption and violence.

The region, known as Central America's Northern Triangle, has been one of the main sources of migration to the U.S.-Mexico border over the past decade. 

Harris was not asked to be the administration's "border czar" or to oversee immigration policy and enforcement at the U.S.-Mexico border. That has mainly been the responsibility of Homeland Security Secretary Alejandro Mayorkas and his department, which oversees the country's main three immigration agencies, including Customs and Border Protection.

In reality, the only role close to that of a "border czar" under the Biden administration was held for only a few months by Roberta Jacobson, a longtime diplomat who served as coordinator for the Southwest border until April 2021.

In her immigration role, Harris' main line of work has focused on convincing companies to invest in Central America and promoting democracy and development there through diplomacy. In March of this year, the White House announced Harris had secured a commitment from the private sector to invest over $5 billion to promote economic opportunities and reduce violence in the region.

Efforts to reduce migration by improving conditions in migrants' home countries have always been viewed as a long-term strategy by U.S. officials. In its "root causes"  framework , the Biden administration conceded the "systemic change" it envisions for Central America "will take time to achieve."

Questions about her work on immigration

There are some legitimate questions about Harris' work on immigration.

Before the COVID-19 pandemic, most non-Mexican migration to the U.S. southern border originated from the Northern Triangle. In 2021, it made sense for the administration to focus on the root cases of migration in those countries. But migration flows have changed dramatically in recent years. Record numbers of migrants have been coming from places outside of Central America, including from countries like Cuba, Colombia, China, Ecuador and Venezuela.

In fiscal year 2023, for example, Border Patrol apprehensions of migrants from Guatemala, Honduras and El Salvador made up 22% of all crossings during that time period, down from 41% in fiscal year 2021, government statistics show. On the flip side, however, the administration could point to the fact that illegal crossings along the U.S. southern border by migrants from Guatemala, Honduras and El Salvador have decreased significantly every year since 2021.

While most of her critics have been Republicans, Harris' work on immigration has also garnered some criticism from the left. During a visit to Guatemala in June 2021, Harris told those intending to migrate, "Do not come," a statement that drew ire from some progressives and advocates for migrants.

As the second-highest ranking member of the Biden administration, Harris will also likely face questions over the all-time levels of unlawful border crossings reported in 2021, 2022 and 2023. Those crossings, however, have plunged this year, reaching a three-year low in June , after Mr. Biden issued an executive order banning most migrants from asylum.

Camilo Montoya-Galvez is the immigration reporter at CBS News. Based in Washington, he covers immigration policy and politics.

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