Abstract
Objective
To outline the rationale for implementing training in structured problem solving as a primary prevention strategy for major mental disorders.
Method
The evidence that training people in a structured method of solving their personal problems is an effective strategy in the treatment of established cases of schizophrenic and major mood disorders, is selectively reviewed.
Results
Most of the relevant research focused on the prevention of major recurrent episodes of psychosis. There is some evidence to support the hypothesis that this strategy may assist many people to achieve a full and sustained recovery from the clinical and social impairments of these disorders, especially when patients are taught to use structured problem solving with members of their personal resource groups, and they continue to take optimal doses of psychoactive medication. There is support for the hypothesis that the key therapeutic factor associated with these benefits is the improved efficiency of the management of life stress.
Conclusions
The simplicity of problem solving, the educational methods used, and the widespread application to a person's lifestyle would appear to make this a possible candidate for a primary prevention program for major mental disorders. Guidebooks and teaching aids have been developed and show excellent consumer acceptance.
A program of mental health education has been developed for secondary school curriculum that combines problem solving training for coping with life stresses with education about the nature of major mental disorders and encourages early intervention. A similar program has been provided as part of antenatal classes. It is proposed that this mental health education may help reduce the incidence of mental disorders as well as enhance their early detection and intervention. The approach differs only in terms of its intensity for those cases who require long-term treatment to promote recovery from established psychoses.
Structured problem solving and stress management
The structured problem solving approach was introduced by D'Zurilla and Goldfried for the psychosocial rehabilitation of institutionalised chronic psychotic patients [1]. There are several versions of the approach, but most are minor variations of the original six-step model [2]. The problem is stated in a clear way; all potential solutions are brainstormed and listed; each possible solution is evaluated in terms of its main advantages and disadvantages; the most practical solution is chosen; implementation is carefully planned; and the outcome of the implementation efforts are reviewed and refined until the problem has been resolved (Table 1).
Solving problems and achieving goals
This model of problem solving is extremely robust and has been widely used in therapeutic programs. It forms the basis for the carer-based stress management of schizophrenic and affective disorders [3], social skills training [4], and the management of generalised anxiety [5]. An even more interesting development from the primary prevention point of view has been the widespread application of this structured problem solving approach in business management training programs.
All these applications have used an experiential educational approach, in which people are trained to use structured problem solving to solve those problems that they find are causing them the most stress in their lives, to prioritise their current personal goals, and to engage the support of those people in their social networks who are most willing and able to assist in resolving each particular problem. Integrating this problem solving training into family or work groups has been a key component in sustaining its benefits.
Applications of problem solving training in psychotic disorders
The power of the problem solving approach in modifying the course of major psychotic disorders has been clearly established. A series of studies shows that problem solving training that includes the patient and his or her family members more than halves the rate of recurrent episodes of schizophrenic and bipolar disorders in patients maintained on optimal doses of medication [6,7]. Moreover, in one small, well-controlled study that evaluated this, two-thirds of cases had recovered fully from all clinical features of schizophrenia after 2 years of continued training, and all of those recovered cases continued to maintain this progress during the third year of follow-up when their medication had been withdrawn gradually. In addition, 40% were functioning without any evidence of social disability [8]. Clinical and social recovery was associated with improved problem solving efficiency and stress management within the family resource group [9].
There are substantial limitations to be considered from these data. First, the efficacy of problem solving training in the short term is closely associated with its combination with psychoactive medication. Second, problem solving training was implemented within the context of a comprehensive program of rehabilitation that included mental health education; interpersonal communication and social skills training; and specific psychological strategies for residual psychotic and neurotic problems [8]. Finally, the clinical and social recovery rates have been observed in only one controlled study, which awaits replication.
One further application of problem solving training may have important implications for a primary prevention approach. This was an epidemiological study conducted in a semirural English county. The Buckingham Project aimed to replicate the results of the controlled studies of family-based stress management and extend them to other major disorders, such as affective disorders, eating disorders, OCD and chronic anxiety states. Small teams of mental health professionals were integrated into all the primary care services and provided mental health education and structured problem solving training to all cases with established or prodromal mental disorders. A ten-fold reduction in the number of emerging cases of psychosis was observed [10], as well as a similar substantial reduction in the incidence of major depression [11]. These benefits appeared after very few sessions of education and training with the patient and his/her intimate social resource group (family or close friends), and were sustained. Once again, these data have not been replicated and the problem solving training was only one of the core ingredients.
It may be concluded that problem solving training may be associated with substantial clinical and social benefits for people with major mental disorders and their key caregivers. These benefits have been observed most clearly in the long-term training of established schizophrenic disorders, but seem to occur with relatively brief applications in the earliest phases of psychotic and affective disorders. In both instances, low doses of psychoactive medication have been used as well, but the benefits appear to continue after withdrawal of pharmacotherapy.
Resource group collaboration
Although stress management approaches have demonstrated benefits when they have been applied in individual approaches, the close collaboration with the patient's interpersonal support group in the training appears to enhance the benefits achieved by similar problem solving training with the patient alone [12–16]. An added benefit of collaboration with the families has been the reduction of stress on the key caregivers. Studies have shown that carers of the mentally disordered themselves have a very high risk of mental disorders [17] and that carer-based stress management may contribute to enhancement of their mental and physical health [8,18]. For these reasons it may be helpful to consider the feasibility of a prevention approach that involves family collaboration.
The concept of a family intervention is one that is often stereotyped in people's minds. The term ‘family therapy’ usually conjures up an image of one or two therapists meeting with two parents and two or three children. But this family unit has virtually ceased to exist in Western cultures and has never existed in many parts of the world. It may be more useful to consider the concept of ‘family’ in a broader and more tribal context, which includes not merely the first-degree relatives, but also other family members, neighbours and close friends. In the context of a prevention strategy it may be important to consider the key collaborators as those people who provide psychosocial support for the at-risk individual on a day-to-day basis. We have termed these people as the person's ‘Resource Group’.
Each person's Resource Group is dynamic and changes at different phases of a person's life, and according to the goals and stresses that they may be dealing with at any time. The Resource Group of adolescents may include teachers, best friends and their parents, sports coaches, cousins, aunts and uncles, grandparents, as well as their parents. At later stages in life different people move in and out of our personal Resource Groups as partnerships in life and work develop and break up. To discover who comprises a person's Resource Group at present we ask the person to identify the people they seek out when they have a stressful problem to resolve or when they want help setting or achieving a personal goal.
Education about mental disorders is a core component of almost all the effective family interventions. The approaches with the most potent effect sizes are those that employ a psycho-educational approach that continues for several months [6]. This is an exchange of information and understanding that helps patients and their Resource Groups, as well as their therapists, clarify the nature of their specific disorders and the benefits and difficulties associated with the treatment they are receiving. The most effective approaches are based on the vulnerability/stress diathesis model of health problems, which postulates that any major disorder results from an interaction between physiological and psychosocial factors. Expressed in simple terms, mental disorders are caused by a weakness in the way the body functions that is made worse by life stress. Paradoxically, the evidence for specific pathophysiological factors in major mental disorders is rather weak, whereas the research findings on stress factors, such as family stress and life events, are extremely robust [8]. However, some pathophysiological factors, such as abuse of alcohol and stimulant drugs; head injury due to birth trauma (often associated with poor antenatal care) or motor vehicle accidents (poor use of seat belts or motorcycle helmets); and neuroviral infections (poor adherence to vaccination programs, preventable HIV infections), offer clear targets for prevention through an educational approach.
Thus, it may be concluded that a prevention program that: (i) included education about mental disorders relevant to the person's phase of life; (ii) included a stress management component that could be easily learned and usefully applied to the current life problems and personal goals of each individual; and (iii) involved the person's Resource Group and was applied on a long-term basis, might be expected to have clinical and social benefits. Brief training in structured problem solving may be an efficient method of enhancing stress management.
The development and pilot application of a primary prevention program
The final part of the present paper describes the development of a primary prevention program that is based on the rationale provided earlier.
Two early efforts to apply an educational program about mental disorders combined with training in structured problem solving were conducted as part of the Buckingham Project from 1985 to 1992 [19,20]. The first of these was a six-session program for children attending their last year of secondary school. This group was targeted because they were about to take their final school examination, which determined their future opportunities for work and university placement. It had been noted that during these months a high rate of mental health consultation was sought, with serious suicide attempts and stress-related symptoms, including prodromal psychotic features. An occupational therapist and a psychiatrist conducted the training, which was integrated into the teaching curriculum. As well as providing a few sessions describing the major symptoms of mental disorders and their treatment, the teaching focused on training in structured problem solving on the current life stresses of the students. Most of the students made plans to cope with the impending examinations and their need to develop efficient study programs. The students and teachers were extremely positive about these lessons, and although no formal evaluation of their outcome was made, a notable decline in social and clinical crises presenting to the mental health service over this period appeared to be associated with this project.
A second pilot project was conducted by a nurse specialist in collaboration with a group practice primary care team. This involved antenatal education about mental health and the risk for postnatal depression and psychosis. The education was conducted in a group setting with the Resource Groups of the pregnant women. Training in structured problem solving was a core part of the course that was integrated into the antenatal curriculum. Again, consumer satisfaction was very high, and there was anecdotal evidence of improved mental health in participants, with lowered incidence of mental health consultation.
These two early projects were conducted within the everyday practice of a community-based mental health service, with low staff numbers and without any additional resources. They demonstrated the feasibility of a targeted approach to prevention that appeared useful and potentially efficacious. The resources required to evaluate such an approach in a well-controlled fashion are substantial and could not be obtained at that time. At the time, the Buckingham Project, which provided evidence-based treatment for all major mental disorders in community-based settings, including early detection and intervention, was considered too speculative to attract such funding from the main research agencies.
However, these encouraging projects led to the development of an educational package for schools, which aims to provide a series of interactive lessons for each of 7 years with children from the ages of 10–11 to 17–18 years [21]. The aims of this education program are to:
Provide students with skills to help them maintain their mental health when faced with the demands of everyday living.
To help students to achieve a better understanding of mental disorders; to recognise the early signs of mental illness in themselves and their peers; to encourage help-seeking and earlier effective treatment; and to reduce the stigma attached to those who suffer from these disorders and the people in their personal Resource Groups.
The lessons are designed in such a way that they allow information and skills taught at a senior primary school level to be reiterated and built upon at a secondary school level.
This approach was adopted in recognition of the need for health programs to deliver more than a ‘one-off lesson, or group of lessons, if they are to have a significant long-term effect. It is believed that a program that reiterates skills and information throughout adolescent schooling may improve the retention both of cognitive changes and of attitudinal and behavioural changes in students. It has also been adopted in order to match the different levels of knowledge and skill demanded by the lessons with the different educational levels of the students, and to be in accordance with the structure of the existing health education syllabus.
At each level students receive lessons on both mental health and mental disorders. At all levels the program consists of exercises and discussions, which encourage students to use the skills and information introduced in the lessons. Lessons include interactive discussion and role playing. It is generally accepted that students learn best from situations in which they are encouraged to think about and use the information they are provided with, rather than simply listening to and absorbing it.
The content of the program focuses on topics associated with the maintenance of mental health, the early recognition of mental illness and the reduction of the stigma. The mental health component of this program teaches skills that enable students to cope satisfactorily with the stresses in their lives. These include structured problem solving, anger management and conflict resolution.
The education about mental illness targets the age group to which it is most relevant. The senior primary school students receive a lesson that concentrates on basic concepts of mental disorders, while secondary school students have lessons that deal more specifically with particular disorders. These include anxiety disorders, depression, obsessive-compulsive disorder, eating disorders, manic-depressive disorder and schizophrenia. The related issues of substance use and abuse and suicide are also introduced.
In several schools where this program has been piloted, teachers and students have been highly positive about its utility. However, as yet no school has implemented the program fully, and no evaluation of its benefits has been made. Once again, efforts to obtain research funding to support such a venture have been greeted with unrelenting skepticism.
Conclusion
It can be concluded that a powerful, yet simple, psychosocial stress management strategy, such as structured problem solving, could form the basis for a universal primary prevention program for major mental disorders, including psychotic and affective disorders. The educational nature of the approach makes it attractive to the healthy population, including adolescents and pregnant couples. Integrating this general purpose stress management strategy into an ongoing health education program for adolescent school children that aims to educate about the features and effective treatments for mental disorders, to reduce stigma and promote early intervention appears feasible. Intensive reiterations could be targeted to times of specific high stress, such as the perinatal period, school or university examinations, marriage and family break-up, threatened unemployment and retirement, relocation, or the stresses associated with incurable illnesses.
In addition to the development of an educational program for schools, we have devised a comprehensive series of educational sessions for use in mental health services [22]. A series of session guides have been designed to be followed by patients with symptoms of mental disorders and people in their Resource Groups, with or without professional guidance. Education about their symptoms and treatment, including optimal pharmacotherapy, is combined with training in the use of structured problem solving methods to deal with life stresses and to facilitate achievement of personal goals. Specific problem solving strategies are outlined for coping with psychosis, depression, mania, anxiety, OCD, eating disorders, substance abuse, sleep problems, anger, developing friendships and sexual partnerships, work and constructive hobbies. This approach aims at promoting the skills associated with mental health and recovery from established mental disorders. It has the great asset of being flexibly applied at all stages of all major disorders, from prodromal states through to major episodes and long-term rehabilitation of residual symptoms and disability. This comprehensive prevention approach has been piloted successfully. The next phase will require considerable courage and funding to establish controlled outcome evaluations of the specific clinical, social and economic benefits associated with its implementation.