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Cognition, Cognitive Rehabilitation, and Occupational Performance

Gordon Muir Giles, PhD, OTR/L, FAOTA

Mary Vining Radomski, PhD, OTR/L, FAOTA

Timothy J. Wolf, OTD, PhD, OTR/L, FAOTA

With contributions to the case studies by

Tina Champagne, OTD, OTR/L, FAOTA

Mary A. Corcoran, PhD, OT/L, FAOTA

Heather Miller Kuhaneck, PhD, OTR/L, FAOTA

M. Tracy Morrison, OTD, OTR/L

Barbara Nadeau, PhD, OTR/L

Izel Obermeyer, MS, OTR/L, FAOTA

Joan Toglia, PhD, OTR/L, FAOTA

The Commission on Practice

Julie Dorsey, OTD, OTR/L, CEAS, Chairperson

Adopted by the Representative Assembly Coordinating Council (RACC) for the Representative Assembly, 2019.

Note. This revision replaces the 2013 document “Cognition, Cognitive Rehabilitation, and Occupational Performance” previously published and copyrighted in 2013 by the American Occupational Therapy Association in American Journal of Occupational Therapy, 67, S9–S31. https://doi.org/10.5014/ajot.2013.67S9

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Cognition, Cognitive Rehabilitation, and Occupational Performance. Am J Occup Ther November/December 2019, Vol. 73(Supplement_2), 7312410010p1–7312410010p25. doi: https://doi.org/10.5014/ajot.2019.73S201

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The American Occupational Therapy Association (AOTA) asserts that occupational therapists and occupational therapy assistants, through the use of occupations and activities, facilitate clients’ cognitive functioning to enhance occupational performance, self-efficacy, participation, and perceived quality of life. Cognitive processes are integral to effective performance across the broad range of daily occupations such as work, educational pursuits, home management, and play and leisure. Cognition plays an integral role in human development and in the ability to learn, retain, and use new information to enable occupational performance across the lifespan.

This statement defines the role of occupational therapy in evaluating and addressing cognitive functioning to help clients maintain and improve occupational performance. The intended primary audience is practitioners 1 within the profession of occupational therapy. The statement also may be used to inform recipients of occupational therapy services, practitioners in other disciplines, and the wider community regarding occupational therapy theory and methods and to articulate the expertise of occupational therapy practitioners in addressing cognition and challenges in adapting to cognitive dysfunction.

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Problem Solving: A Teaching and Therapeutic Tool for Older Adults and Their Families

• First Online: 26 November 2014

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• Laura N. Gitlin 2  

Problem solving is integral to clinical reasoning and everyday occupational therapy practices. It can also be a systematic therapeutic modality for identifying client or family caregiver concerns and teaching new approaches to self-management. This chapter presents a systematic approach to help occupational therapists (OTs) identify target problem areas and potential modifiable contributing factors when working with older adults and families. The approach is applicable to a broad range of clinical problems associated with the consequences and management of chronic illness and provides therapists with an important tool for actively engaging clients in self-management.

The OT needs to have effective communication skills, respecting a family’s values and understanding where they’re coming from.… That’s critical, even more than knowing her intervention strategies.Family caregiver

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Department of Community-Public Health, Center for Innovative Care in Aging, Johns Hopkins University, 525 N. Wolfe Street, Suite 316, Baltimore, MD, 21205, USA

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Ingrid Söderback

The Case Study of Using Problem Solving for Marie, Living with Alzheimer’s Disease and her daughter Donna

Keywords: Behavioral symptoms, Caregiver burden, Caregiving, Problem solving

Introduction

The theme of this case study concerns family challenges associated with caring for a person with moderate stage dementia and the use of problem solving to identify discrete problem areas and potential solutions.

The students’ tasks include:

To determine strategies to help Donna manage her mother’s behavioral symptoms and to also be able to take better care of herself.

To work with Donna to identify underlying patterns and mutable factors that may be contributing to her mother’s behaviors.

To apply problem solving to come up with a set of strategies Donna agrees to try.

As a starting point, students should use the following references to gather background information.

Important references are:

Gitlin LN, Hodgson N (in press) Caregivers as therapeutic agents in dementia care: The evidence-base for interventions supporting their role. In: Gauglher J and Kane R (eds) Family Caregiving in the New Normal, Elsevier

Gitlin LN (2011) Problem solving in health and illness. In: Craft-Rosenberg M, Pehier S (eds) Encyclopedia of family health, Sage

Gitlin LN (in press) Problem solving: a teaching and therapeutic tool for older adults and family members. In: Söderback I (ed) International handbook of occupational therapy interventions, 2nd edn. Springer, New York, pp 205–216

Overview of the Content

Major goal of the actual interventions are to

Enable the caregiver to prevent, minimize, or reduce behavioral symptoms of her mother

Enhance the mother and the caregiver’s quality of life

Enable the caregiver to find time for herself

Learning Objectives

By the end of studying this chapter the learner will:

Understand how to apply problem solving with families caring for persons with dementia

Identify potential strategies (behavioral, environmental) that can minimize behavioral symptoms

Examine the interactions of persons with dementia, their care environment, and impact on families

The Background History of Mary and Her family

Personal information.

Marie is an 80-year-old female diagnosed with Alzheimer’s disease 4 years ago. She lives with her daughter, Donna, and her daughter’s husband and two teenage sons in a ranch house in a suburban area. Marie has her own bedroom, sitting room, bathroom, and kitchenette in an “in law” suite attached to the family home. Marie was a full-time wife and homemaker who never worked outside the home. Her husband passed away in 2000, and she came to live with Donna a year later as she was having difficulty keeping up with her finances, shopping, and other basic tasks of daily living.

Marie prided herself on her homemaking skills. She was a great cook and loved to bake. She enjoyed knitting and was an active community volunteer first with the children’s school and later (as they grew older) with her local church. She stopped driving her car right after her diagnosis, as she was afraid to drive.

Marie’s daughter reports that she appears to be easily agitated, highly anxious, and keeps repeating the same questions over and over with her (e.g., where are you going? When are we eating?). She has been resisting going out of the house for family dinners at the local restaurant or to attend church. She tends to become anxious and fearful when it is time to leave the house for anything (appointments, outings, etc.).

Donna is finding it increasingly difficult caring for her mother and attending to her other responsibilities including a part time job in her local school system, being there for her two sons and husband, attending to her household responsibilities, and taking care of herself. She is feeling very stretched and indicated she is having difficulty sleeping, feels very tired and alone, and feels very sad everyday to see her mom the way she is now. Donna wants help but is reluctant to ask anyone else to help her with her mom. She also can be a perfectionist and wants things done a certain way in her home.

Medical Diagnoses and Prognoses

Marie has dementia , most likely of the Alzheimer’s type. She is in the moderate stage of the disease, which is a progressively degenerative disease process. Her short-term memory is poor and she is having increasing difficulty initiating, planning, and organizing activities she used to do (e.g., cook a meal) demonstrating executive functional challenges. She continues to have some insight, although limited, of her cognitive changes. She is becoming increasingly agitated and confused as she loses her cognitive abilities. She is in relatively good physical condition with no other chronic conditions. Her vision is good with glasses but she is experiencing some hearing loss although she does not wear a hearing aid. While her ambulation in general is good, she did fall 6 months ago—she tripped over the carpet and fell to the ground. She was bruised but no bones were broken.

Reason for Seeking Occupational Therapy

Marie is experiencing behavioral symptoms, which prompted her physician to be concerned about her home safety and daily function. She suggested occupational therapy to assess Marie’s safety at home and to work with the caregiver to teach her behavioral management skills.

Occupational Performance Issues

Marie used to cook but is having difficulty knowing what to do in the kitchen. This frustrates her. She is also having increasing difficulty dressing and bathing herself, but she does not want any help from her daughter. She is starting to look a little raggedy which is not like her previous self.

The Student’s Report

The following guiding questions have been identified in developing possible solutions for Marie and Donna. These questions are generated from the available literature references and our clinical experiences:

What specific questions would you ask the caregiver to learn about her mother’s presenting behaviors?

What would you like to learn about Marie’s day?

What would you like to learn about the relationship of Donna and her mother?

What aspects of the physical and social environment would you want to learn about and/or for which you may have potential concerns?

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Gitlin, L. (2015). Problem Solving: A Teaching and Therapeutic Tool for Older Adults and Their Families. In: Söderback, I. (eds) International Handbook of Occupational Therapy Interventions. Springer, Cham. https://doi.org/10.1007/978-3-319-08141-0_27

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Published : 26 November 2014

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Clinical Reasoning in Occupational Therapy: A Comprehensive Guide

Clinical reasoning is the backbone of effective decision-making and problem-solving in occupational therapy (OT). It enables therapists to analyze complex situations, gather information, and develop tailored treatment plans for their clients. In this blog post, we will delve into the intricacies of clinical reasoning in occupational therapy, exploring its importance, key components, and practical strategies. Whether you’re a seasoned occupational therapist or a student just starting your journey, this guide will empower you to enhance your clinical reasoning skills and deliver optimal outcomes for your patients.

Important of Clinical Reasoning in OT

The Significance of Clinical Reasoning in Occupational Therapy At the core of occupational therapy lies the process of clinical reasoning. This cognitive process allows therapists to integrate knowledge, clinical expertise, and patient values to make informed decisions. Here’s why clinical reasoning is paramount in occupational therapy:

• Promotes Personalized Treatment: Clinical reasoning enables occupational therapists to individualize treatment plans based on the unique needs and goals of each client. By analyzing client factors, activity demands, and environmental considerations, therapists can tailor interventions to maximize functional outcomes.
• Enhances Problem-Solving Abilities: Occupational therapists face diverse challenges and must navigate complex client situations. Clinical reasoning equips them with the skills to identify problems, explore potential solutions, and make sound judgments that optimize intervention effectiveness.
• Facilitates Evidence-Based Practice: Clinical reasoning guides therapists in critically evaluating research evidence and integrating it with their clinical expertise. This ensures that therapeutic interventions are grounded in the latest scientific knowledge and align with best practices.

Components of Clinical Reasoning in OT

Components of Clinical Reasoning in Occupational Therapy To fully grasp clinical reasoning in occupational therapy, it’s essential to understand its core components. Here are the key elements involved:

Strategy of Clinical Reasoning for OT

Strategies for Enhancing Clinical Reasoning in Occupational Therapy

• Continual Professional Development: Engage in ongoing learning and attend relevant workshops, conferences, and seminars to stay updated with the latest evidence-based practices and research.
• Reflective Practice: Regularly reflect on clinical experiences, seeking to understand the reasoning behind your decisions and analyzing the outcomes. This introspection helps refine your clinical reasoning skills over time.
• Collaborative Approach: Foster open communication and collaboration with colleagues, clients, and other healthcare professionals to gain diverse perspectives and enhance your problem-solving abilities.
• Utilize Clinical Tools: Make use of standardized assessment tools, clinical guidelines, and evidence-based resources to support your clinical reasoning process.

FAQ: Frequently Asked Questions about Clinical Reasoning in Occupational Therapy

Q1: What role does clinical reasoning play in the occupational therapy process?

A1: Clinical reasoning serves as the foundation for decision-making in occupational therapy. It guides therapists in analyzing client information, identifying problems, setting goals, planning interventions, and evaluating outcomes.

Q2: How can I improve my clinical reasoning skills?

A2: Enhancing clinical reasoning skills requires a combination of ongoing learning, reflective practice, collaboration, and utilization of clinical tools. Engaging in professional development activities and

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Interventions Within the Scope of Occupational Therapy Practice to Improve Performance of Daily Activities for Older Adults With Low Vision: A Systematic Review

Chiung-ju liu.

Chiung-ju Liu, PhD, OTR/L, FGSA, was Associate Professor, School of Human and Health Sciences, Indiana University, Indianapolis, at the time of the study. She is now Associate Professor, College of Public Health and Health Professions, University of Florida, Gainesville; [email protected]

Megan C. Chang

Megan C. Chang, PhD, OTR/L, is Associate Professor, College of Health and Human Sciences, San Jose State University, San Jose, CA.

Importance: The prevalence of low vision increases with age. Low vision has detrimental effects on older adults’ independence.

Objective: To identify the effectiveness of interventions within the scope of occupational therapy practice to maintain, restore, and improve performance in daily activities for older adults with low vision.

Data Sources: Literature published between 2010 and 2017 was searched in CINAHL, Cochrane Databases, MEDLINE, OTseeker, and PsycINFO.

Study Selection and Data Collection: The authors screened and appraised studies following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) protocol. Studies were eligible if the participants’ mean age was 55 yr or older, the level of evidence was Level III or higher, the intervention was within the scope of occupational therapy practice, and the outcome measures assessed the performance of daily activities.

Findings: Fourteen studies met the review criteria. Three intervention themes were identified: low vision rehabilitation services ( n = 6), self-management approach ( n = 6), and tango ( n = 2). Moderate evidence was found for low vision rehabilitation services. Low evidence was found for using the self-management approach or adding the self-management approach to existing low vision rehabilitation services. Low evidence was found for tango.

Conclusion and Relevance: This systematic review supports the use of low vision rehabilitation services as an effective approach. Occupational therapy practitioners are encouraged to be part of multidisciplinary teams that offer comprehensive low vision evaluations and multicomponent services.

What This Article Adds: Low vision rehabilitation that offers multidisciplinary services, including occupational therapy, is effective in promoting independence among older adults with low vision.

Vision loss caused by age-related macular degeneration, diabetic retinopathy, and glaucoma is progressive and irreversible and often leads to low vision. Low vision refers to vision loss that results in difficulty in everyday life activities even with regular glasses, contact lenses, medicine, or surgery ( National Eye Institute, 2018a ). The prevalence of low vision increases drastically with age, from 1% of people in their late 60s to 17% of people in their 80s and older ( National Eye Institute, 2018b ). The adverse effects of low vision on older adults’ independence and emotional health have been well documented ( Brown et al., 2014 ; Kempen et al., 2012 ; Popescu et al., 2011 ; Taylor et al., 2016 ; van der Aa et al., 2015 ).

The top functional complaints among people with vision loss include difficulty reading, driving, recognizing faces, and performing in-home activities ( Brown et al., 2014 ). Activities such as functional mobility, shopping, meal preparation, cleaning, and self-care are negatively affected ( Taylor et al., 2016 ). Older adults with low vision report not only poorer performance in activities in daily living (ADLs) but also higher levels of depression and anxiety compared with older adults in the general population and with chronic conditions ( Kempen et al., 2012 ). A population-based study showed that community-dwelling Medicare beneficiaries with vision impairment were more likely to be hospitalized than those without vision impairment ( Bal et al., 2017 ). Clearly, the impact of vision loss on older adults’ independence and quality of life is profound. Although the pathological process of low vision cannot be reversed by current surgical or medical procedures, the functional decline associated with low vision may be attenuated through nonsurgical intervention provided by occupational therapy practitioners.

A prior systematic review that examined the effectiveness of occupational therapy interventions in improving ADLs and instrumental activities of daily living (IADLs) in older adults with low vision identified a positive effect of using multicomponent approaches to increase knowledge and build skills to overcome the disablement process ( Liu et al., 2013 ). The review also suggested that multiple sessions of training in the use of low vision devices and eccentric viewing are necessary to have a positive effect on clients’ daily activity performance. One of the national vision health objectives in Healthy People 2020 is to increase vision rehabilitation services and comprehensive vision health services ( U.S. Department of Health and Human Services, 2018 ). The demand for occupational therapy services for older adults with low vision will increase in parallel with the increased availability of vision rehabilitation and health services.

The purpose of this systematic review was to update the prior review and provide the most current empirical evidence to support occupational therapy practice in low vision rehabilitation. The question for the updated systematic review was, What is the evidence for the effectiveness of interventions within the scope of occupational therapy practice to maintain, restore, and improve performance in ADLs and IADLs for older adults with low vision?

This systematic review is one of three updated reviews supported by the American Occupational Therapy Association (AOTA) as part of the Evidence-Based Practice (EBP) Project (see also Nastasi, 2020 , and Smallfield & Kaldenberg, 2020 , in this issue). The methods for the review were specified in advance and documented in a protocol followed by the authors.

Literature Search

The search terms were the same as those used in the last review ( Liu et al., 2013 ; Table 1 ). These search terms were developed by the methodology consultant to the EBP Project and AOTA staff, in consultation with review authors and an advisory group. An experienced medical research librarian conducted the literature search in CINAHL, Cochrane Databases, MEDLINE, OTseeker, and PsycINFO. The search duration for published articles was set at January 2010 to January 2017, and the publication language was limited to English.

Search Terms for Daily Activity Performance for Older Adults With Low Vision

Suggested citation: Liu, C.-j., & Chang, M. C. (2020). Interventions within the scope of occupational therapy to improve performance of daily activities for older adults with low vision: A systematic review ( Table 1 ). American Journal of Occupational Therapy, 74, 7401185010. https://doi.org/10.5014/ajot.2019.038372

Literature Screening

The EBP Project methodology consultant reviewed the article titles and removed articles that were not relevant to the review before passing the search results to the authors. The two authors then individually screened each article title and abstract to determine eligibility. An article was included for further review if the average age of study participants was >55; the level of evidence provided was Level I (randomized controlled trials [RCTs], systematic reviews, or meta-analyses), Level II (nonrandomized studies with two or more groups), or Level III (one-group pretest–posttest studies); participants had low vision; the intervention was within the scope of occupational therapy practice; and the outcome measures assessed ADL or IADL performance. Articles were excluded if the publication format was a dissertation, thesis, or conference presentation or proceeding; the research design was not an intervention study; the intervention content was outside the scope of occupational therapy practice; or the publication language was not English. If the title and abstract did not provide sufficient information, the full text was retrieved for screening. Articles cited in the systematic reviews and meta-analyses included in the search results were also screened for eligibility.

Articles that passed the initial screening were retained for full-text screening. The two authors used the same eligibility criteria for the full-text screening. Any discord in eligibility decisions was resolved through discussion between the authors.

Risk-of-Bias Assessment, Data Extraction, and Synthesis of Intervention Themes

The two authors independently rated the risk of bias of each eligible study using the Cochrane risk-of-bias guidelines ( Higgins et al., 2011 ). The risk of selection bias, performance bias, detection bias, attrition bias, and reporting bias was rated as high, low, or unclear ( Table 2 , at the end of this article). The authors discussed any discord in bias rating until they reached a consensus.

Risk-of-Bias Table

Note . Categories for risk of bias are as follows: + = low risk of bias; ? = unclear risk of bias; – = high risk of bias. N/A = not applicable because no objective outcome measures were used. Risk-of-bias table format adapted from “Assessing Risk of Bias in Included Studies,” by J. P. T. Higgins, D. G. Altman, and J. A. C. Sterne , in Cochrane Handbook for Systematic Reviews of Interventions (Version 5.1.0), by J. P. T. Higgins and S. Green (Eds.), 2011 , London: Cochrane Collaboration. Retrieved from http://handbook-5-1.cochrane.org . Copyright © 2011 by The Cochrane Collaboration.

Suggested citation: Liu, C.-j., & Chang, M. C. (2020). Interventions within the scope of occupational therapy to improve performance of daily activities for older adults with low vision: A systematic review ( Table 2 ). American Journal of Occupational Therapy, 74, 7401185010. https://doi.org/10.5014/ajot.2019.038372

After the risk-of-bias rating, the authors extracted and summarized study information, including level of evidence, research design, participant characteristics, intervention, outcome measures, and results, in an evidence table ( Table 3 , at the end of this article). One author extracted and entered the information, and the other checked the accuracy of the entered information.

Evidence Table for Daily Activity Performance for Older Adults With Low Vision

Note . AMD = age-related macular degeneration; IADLs = instrumental activities of daily living; M = mean; Mdn = median; NEI VFQ–25 = National Eye Institute Visual Function Questionnaire–25; NR = not reported; RCT = randomized controlled trial.

Suggested citation: Liu, C.-j., & Chang, M. C. (2020). Interventions within the scope of occupational therapy to improve performance of daily activities for older adults with low vision: A systematic review ( Table 3 ). American Journal of Occupational Therapy, 74, 7401185010. https://doi.org/10.5014/ajot.2019.038372

The authors worked together to identify intervention themes in included studies. The strength of evidence in each intervention theme was rated as high, moderate, or low according to the grade definitions by the U.S. Preventive Services Task Force (2014) . High strength of evidence indicates that the available evidence includes consistent results from well-designed, well-conducted studies and is unlikely to be strongly affected by the results of future studies. Moderate strength of evidence indicates that the available evidence is sufficient to determine the effects; however, confidence in the evidence is constrained by factors such as the number, size, or quality of individual studies; lack of coherence in the chain of evidence; or limited generalizability, and the magnitude or direction of the observed effect could change when more information becomes available. Low strength of evidence indicates that the available evidence is insufficient to assess effects because of the limited number of studies, significant flaws in study design or methods, inconsistency of findings across studies, or limited generalizability.

The database searches identified 10,549 records. After removing irrelevant articles and duplicates, the authors reviewed 469 titles and abstracts and excluded 433 articles. The authors then reviewed the full text of the remaining 36 articles. Fourteen articles met the inclusion criteria and were included in the final review. Figure 1 shows the flow of the articles through the literature screening and selection process.

Flow of articles through the selection process.

Note. Figure format from “Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement,” by D. Moher, A. Liberati, J. Tetzlaff, & D. G. Altman; The PRISMA Group, 2009, PLoS Medicine, 6 (7), e1000097. https://doi.org/10.1371/journal.pmed.1000097

Suggested citation: Liu, C.-j., & Chang, M. C. (2020). Interventions within the scope of occupational therapy to improve performance of daily activities for older adults with low vision: A systematic review ( Figure 1 ). American Journal of Occupational Therapy, 74, 7401185010. https://doi.org/10.5014/ajot.2019.038372

The 14 articles include 6 Level I RCTs ( Hackney et al., 2015 ; Pearce et al., 2011 ; Rees et al., 2015 ; Rovner et al., 2013 , 2014 ; Stelmack et al., 2012 ) and 8 Level III studies ( Alma et al., 2012 ; Coulmont et al., 2013 ; Goldstein et al., 2015 ; Hackney et al., 2013 ; Renieri et al., 2013 ; Ryan et al., 2013 ; Tay et al., 2014 ; Whitson et al., 2013 ). All trials included participants of both genders, and participants’ mean age was in the 80s in 8 studies ( Coulmont et al., 2013 ; Hackney et al., 2013 , 2015 ; Rees et al., 2015 ; Rovner et al., 2013 , 2014 ; Ryan et al., 2013 ; Whitson et al., 2013 ), in the 70s in 5 studies ( Alma et al., 2012 ; Goldstein et al., 2015 ; Pearce et al., 2011 ; Renieri et al., 2013 ; Stelmack et al., 2012 ), and in the 60s in 1 study ( Tay et al., 2014 ). Four studies specified a low vision condition (i.e., age-related macular degeneration) as an inclusion criterion ( Rovner et al., 2013 , 2014 ; Stelmack et al., 2012 ; Whitson et al., 2013 ). The rest of the studies did not specify a low vision condition and recruited participants who attended low vision service clinics, met a specific visual acuity criterion, or had any visual impairment.

Intervention approaches were categorized into three themes: (1) low vision rehabilitation services (6 studies, 1,130 participants), (2) self-management approach (6 studies, 603 participants), and (3) tango (2 studies, 45 participants). Outcome measures that assessed ADLs or IADLs were almost exclusively self-reported. The National Eye Institute Visual Function Questionnaire 25-item version (NEI VFQ–25; Mangione et al., 2001 ) was the most frequently used outcome measure. Key findings are presented by intervention theme in the sections that follow.

Low Vision Rehabilitation Services

Studies that evaluated outcomes of low vision rehabilitation services provided in clinics include 2 Level I studies ( Pearce et al., 2011 ; Stelmack et al., 2012 ) and 4 Level III studies ( Coulmont et al., 2013 ; Goldstein et al., 2015 ; Renieri et al., 2013 ; Ryan et al., 2013 ). All studies were high in risk of selection bias, performance bias, and detection bias.

In the Level I study by Pearce et al. (2011 ), participants who received low vision rehabilitation services completed a low vision assessment (the modified Massof Activity Inventory, on which they rated their difficulty performing daily activities) and then visited an optician to review low vision devices and discuss problems noted at home and available services. An attention control group completed the same low vision assessment, but instead of visiting the optician, they visited a nurse who measured biometrics. Although both groups showed improvement on the selected outcome, there was no difference between the groups.

In the Level I study by Stelmack et al. (2012 ), participants received five weekly low vision rehabilitation therapy sessions and a home visit from a visual therapist who taught strategies for using remaining vision and low vision devices. Participants also completed 5 hr of homework each week. Intervention participants showed significantly higher visual ability as measured by the 48-item Veterans Affairs Low-Vision Visual Functioning Questionnaire at 4 and 12 mo than did wait-list control participants.

Two Level III studies examined low vision rehabilitation services provided by a multidisciplinary team that included an occupational therapist ( Coulmont et al., 2013 ; Goldstein et al., 2015 ). Coulmont et al. (2013 ) found that the improvement on the Functional Global Profile was positively correlated with the number of direct service hours. Goldstein et al. (2015 ) found that half of participants showed a clinically meaningful difference as measured by the Activity Inventory and that the effect size of overall visual ability was large (Cohen’s d = 0.87).

Two Level III studies ( Renieri et al., 2013 ; Ryan et al., 2013 ) examined comprehensive low vision rehabilitation services that included some combination of vision assessment and education, fitting and training for magnifying devices and vision aids, advice about lighting and other methods of enhancing vision, suggestions for managing daily activities, and referral to additional services, reassessment, and follow-up. Both studies reported positive outcomes on the NEI VFQ–25.

Although 5 of the 6 studies in this theme showed positive outcomes for daily activity performance, the strength of evidence is weakened by the poor methodological quality of the studies. Thus, moderate strength of evidence supports using a multidisciplinary low vision rehabilitation team and a comprehensive low vision rehabilitation program to improve ADL or IADL performance.

Self-Management Approach

Three Level I studies ( Rees et al., 2015 ; Rovner et al., 2013 , 2014 ) and 3 Level III studies ( Alma et al., 2012 ; Tay et al., 2014 ; Whitson et al., 2013 ) examined interventions using the self-management approach. The Level I studies had low risk of bias in all categories, and the Level III studies had high risk of selection bias, performance bias, and detection bias.

Interventions in this theme shared the common feature of teaching study participants specific knowledge or a set of specific skills to manage problems related to vision loss as the problems arise. The interventions were not part of the usual low vision rehabilitation services participants received. Some interventions were multicomponent ( Alma et al., 2012 ; Rees et al., 2015 ; Rovner et al., 2014 ; Tay et al., 2014 ; Whitson et al., 2013 ), and one had a single component ( Rovner et al., 2013 ). Common intervention components across these studies included problem-solving skills ( Alma et al., 2012 ; Rees et al., 2015 ; Rovner et al., 2013 ), goal-setting or goal-planning skills ( Alma et al., 2012 ; Rees et al., 2015 ; Whitson et al., 2013 ), and encouragement of social connection ( Alma et al., 2012 ; Rovner et al., 2014 ; Tay et al., 2014 ). These components were delivered weekly in a program format ranging in duration from 6 wk ( Tay et al., 2014 ) to 20 wk ( Alma et al., 2012 ). The interventions were delivered in a group ( Alma et al., 2012 ; Rees et al., 2015 ; Rovner et al., 2013 ; Tay et al., 2014 ), individually in a one-on-one format ( Rovner et al., 2014 ), or individually with the involvement of a friend or family member ( Whitson et al., 2013 ).

Two Level I studies compared a self-management program combined with usual low vision rehabilitation services to usual low vision rehabilitation services alone ( Rees et al., 2015 ; Rovner et al., 2014 ). Rees et al. (2015 ) examined an 8-wk self-management program focused on problem-solving skills training and goal planning added to usual low vision rehabilitation services, which offered an initial assessment by a multidisciplinary team member, an optometric assessment and prescription of optical aids, and further intervention by the multidisciplinary team. Rovner et al. (2014 ) evaluated outcomes from six in-home weekly occupational therapy sessions focused on behavior activation, which emphasizes the relationships among action, mood, and mastery and promotes self-efficacy and social connection as means to improve mood and function, added to usual low vision rehabilitation services, which offered assessments of vision function, prescription of devices, and device education. The combined intervention in both studies did not show significantly greater effects on the Impact of Vision Impairment Questionnaire ( Rees et al., 2015 ) or on the Activities Inventory and the NEI VFQ–25 ( Rovner et al., 2014 ), compared with those of usual low vision rehabilitation services alone.

In the other Level I study, Rovner et al. (2013 ) compared problem-solving therapy to supportive therapy, an attention control condition. The study did not detect a difference between the intervention group and the control group on the Targeted Vision Function or the NEI VFQ–25.

In a Level III study, Alma et al. (2012 ) evaluated an intervention delivered over 20 wk by a multidisciplinary group that included two occupational therapists. The intervention focused on four components: (1) practical skills training; (2) education, social interaction, counseling, and training in problem-solving skills; (3) individual and group goal setting; and (4) a home-based exercise program. In another Level III study, by Tay et al. (2014 ), an occupational therapist delivered a 6-wk intervention focused on understanding vision loss; maximizing remaining vision and using other senses; staying in touch with others; managing personal care, medication, money, and household; participating in daily activities and hobbies; and maintaining safety and mobility. Neither study found a significant improvement in ADL-related outcomes, measured by the Utrecht Scale for Evaluation of Rehabilitation–Participation ( Alma et al., 2012 ) or the Low Vision Quality of Life Questionnaire ( Tay et al., 2014 ), after program completion.

In another Level III study, Whitson et al. (2013 ) evaluated an intervention program that was modified to enable older adults with cognitive deficits to benefit from low vision rehabilitation. The modifications included offering frequent and repetitive training sessions, simplifying the training experience, and involving a friend or family member, and the intervention was delivered by an occupational therapist over 6 wk. The study identified a positive outcome on the NEI VFQ–25—satisfaction with the ability to perform IADLS—and timed activity performance measures after intervention.

In summary, the strength of evidence to support interventions using the self-management approach is low. These studies did not show benefits of the self-management approach, alone or combined with usual low vision rehabilitation services, in improving ADLs or IADLs in older adults with low vision.

One Level I study and 1 Level III study from the same research team examined the effectiveness of an adapted tango intervention in improving balance and reducing falls in older adults with visual impairments ( Hackney et al., 2013 , 2015 ). The adapted tango program consisted of 20 1.5-hr lessons over 12 wk in which participants were paired with partners without vision loss. Both studies had high risk of selection bias, performance bias, and detection bias. In the Level III study, a feasibility study, participants showed significant improvement on the NEI VFQ–25 after the program ( Hackney et al., 2013 ). The Level I study compared the adapted tango program to a standard fall prevention exercise program ( Hackney et al., 2015 ). Although participants in both programs showed a significant improvement on the NEI VFQ–25, the Level I study did not show a superior effect of the adapted tango program relative to that of the standard fall prevention exercise program.

In summary, the strength of evidence to support the use of a tango intervention to improve ADLs and IADLs in older adults with low vision is low. The strength of evidence is weakened by the limited number of studies and poor methodological quality.

The purpose of this systematic review was to identify the effectiveness of interventions within the scope of occupational therapy practice to maintain, restore, and improve ADLs and IADLs for older adults with low vision. Fourteen studies were appraised, and three intervention themes were identified: low vision rehabilitation services, self-management approach, and tango. Moderate evidence was found in support of low vision rehabilitation services. Low evidence was found in support of the self-management approach and tango.

The themes of low vision rehabilitation services and the self-management approach overlap with the themes of multicomponent intervention, single-component intervention, and multidisciplinary intervention identified in the prior review ( Liu et al., 2013 ). Low vision rehabilitation often involves a multidisciplinary team who offer comprehensive evaluations and multicomponent services. The self-management approach can entail a single-component intervention to equip clients with one specific skill or a multicomponent intervention to provide clients with various knowledge and skills. The prior review reported robust evidence in the multicomponent intervention and single-component intervention themes, particularly for interventions delivered over multiple training sessions. The prior review also reported moderate evidence in the multidisciplinary intervention theme.

The results of the current review are consistent with those of the prior review for the multidisciplinary intervention theme and support the positive effect of low vision rehabilitation services. However, the results of the current review for the self-management approach are not as positive as those of the prior review for the multicomponent or single-component intervention themes. The discrepancy may reflect the expansion of study population age and visual impairment conditions, and lack of sensitivity of the outcome measures used in the studies included in the current review.

A wide array of low vision rehabilitation services are available, ranging from simple provision of optical and nonoptical aids to more holistic and comprehensive approaches (e.g., integrated multidisciplinary services) and from one-time service visits to multiple service visits. Prior systematic reviews have shown robust effects of low vision rehabilitation services on vision-related daily task performance regardless of service model or content ( Binns et al., 2012 ; Liu et al., 2013 ). For clients with mild visual impairments, basic low vision services, such as the prescription and provision of low vision devices, and comprehensive low vision rehabilitation services, such as low vision devices plus training in device use or eccentric viewing and environmental modifications, have been found to yield equivalent ADL outcomes ( Stelmack et al., 2017 ). For clients with more severe vision loss in the better-seeing eye, however, comprehensive low vision rehabilitation services have proved more beneficial than basic low vision services ( Stelmack et al., 2017 ). Thus, providing basic low vision services to older adults with mild vision loss is fundamental to promote ADL independence, even when the service content is simple, whereas for clients with more severe vision loss, expansion of service content and involved disciplines is necessary. One caveat of research findings on low vision rehabilitation services in general is that most studies lacked a control group, which weakens the strength of evidence.

Earlier research has shown that self-management skill training improves ADL performance in older adults with age-related vision loss, specifically vision loss caused by macular degeneration ( Eklund et al., 2004 , 2008 ; Girdler et al., 2010 ; Lee et al., 2008 ; Packer et al., 2009 ). Common components of such programs include education about age-related macular degeneration, training in the use of low vision devices, training in problem-solving skills, and provision of low vision information and resources. The self-management studies included in this review expanded the inclusion criteria from older adults with age-related macular degeneration to those with any visual impairment ( Alma et al., 2012 ; Rees et al., 2015 ; Tay et al., 2014 ). The self-management interventions thus were not tailored to participants’ low vision condition, which may have weakened the interventions’ effects ( Rees et al., 2015 ). For example, a client with central vision loss may benefit from training in face recognition, whereas a client with peripheral vision loss may not. In addition, the expansion of the visual impairment conditions addressed also resulted in samples with a wider age range. For example, in two studies ( Alma et al., 2012 ; Tay et al., 2014 ) that met the mean age inclusion criterion for this review, the lower value of the age range was in the 50s; adults in their 50s have different learning capabilities and require different self-management skills relative to adults in their 60s and older ( Tay et al., 2014 ). The effect of the self-management interventions might have been stronger if needs and learning capabilities of different age groups were taken into consideration. In short, the low evidence identified for the self-management approach might reflect the researchers’ interest in expanding the inclusion criteria to include participants with other visual impairment conditions, resulting in a heterogeneous sample who required self-management skill training tailored to each participant’s vision condition and learning capacity.

Another reason for the low strength of evidence for the self-management approach is the lack of sensitivity of the outcome measure used ( Alma et al., 2012 ; Rovner et al., 2014 ). Most studies used assessments of quality of life that include items addressing vision-related functional tasks, such as the NEI VFQ–25 ( Mangione et al., 2001 ). Strictly speaking, vision-related quality of life assessments are not functional assessments ( Ehrlich et al., 2017 ; Stelmack et al., 2002 ). Lack of sensitivity to detect change manifests through nonsignificant findings at the grand total score level but not at the item level ( Alma et al., 2012 ; Rovner et al., 2014 ; Stelmack et al., 2002 ). For example, Rovner et al. (2014) found a significant change only in NEI VFQ–25 items assessing near vision activities. Moreover, setting individualized goals and working to achieve these goals are part of the self-management programs included in the review ( Alma et al., 2012 ; Rees et al., 2015 ; Whitson et al., 2013 ), and the grand total score of a quality of life assessment might not be sufficiently sensitive to reflect improvements in these individualized goals.

Four studies that examined the self-management approach also reported high refusal rates of >40% by eligible participants ( Rees et al., 2015 ; Rovner et al., 2013 , 2014 ; Whitson et al., 2013 ). The high refusal rates are concerning because self-management is a new paradigm in health care to empower clients to be in charge of their own health. Rees et al. (2007 ) suggested that adults with low vision have low interest in participating in a self-management program because of time commitments, travel requirements, negative expectations, or perceived lack of need. The high refusal rate in Rovner et al.’s (2014) study might relate to the inclusion criterion of subthreshold depressive symptoms. Although self-management programs address emotional or psychosocial aspects of low vision and therefore may be more beneficial than low vision rehabilitation services alone ( Rovner et al., 2014 ), lack of accessibility to such programs means that low vision rehabilitation services are the frontline treatment option for older adults with vision loss. Future research should focus on increasing the accessibility and acceptability of self-management programs to older adults with low vision.

Although vision loss is a significant contributing factor to late-life disability, age-related decline in other body functions can accelerate the disablement process. Older adults with low vision also experience reduced endurance, mobility problems, and cognitive impairments ( Goldstein et al., 2015 ). Vision loss, cognitive and physical decline, and participation restrictions create a vicious circle in which relinquishing valued activities because of low vision increases the risk of cognitive decline and falls, leading to further activity limitations ( Lamoureux et al., 2010 ; Rovner et al., 2009 ). This review shows that researchers examining interventions for older adults with low vision have started to address cognitive and physical decline. Whitson et al. (2013) targeted people with low vision who also had cognitive deficits and included frequent and repetitive sessions, simplified training experience, and involvement of a companion in their self-management program. Alma et al. (2012) included home-based exercise in their self-management program, and Hackney et al. (2013 , 2015 ) examined the effect of tango on balance and mobility. Still, few studies have targeted multiple declines in older adults with low vision, and future studies are needed that focus on a multifaceted approach addressing physical and cognitive decline in addition to vision loss to reduce functional decline in older adults with low vision.

Our review findings are partially consistent with a recent scoping review that identified effective interventions to facilitate the occupational engagement of older adults with age-related vision loss ( McGrath et al., 2017 ). These interventions include self-management programs, compensatory interventions such as assistive device use, and social support. The differences in intervention themes and outcomes between the scoping review and this systematic review may be attributed to the different literature search period (2002–2015 vs. 2010–2017) and age cutoff (≥65 vs. ≥55). Our review indicates that the provision of assistive devices is often part of low vision rehabilitation services ( Pearce et al., 2011 ; Renieri et al., 2013 ; Ryan et al., 2013 ; Stelmack et al., 2012 ) and that increasing social networks is often part of self-management programs ( Alma et al., 2012 ; Rovner et al., 2014 ; Tay et al., 2014 ; Whitson et al., 2013 ).

Limitations

This systematic review has a few limitations. Given the wider age range we applied, participants in some studies may not have had age-related vision loss. In addition, although driving is an important IADL, we did not include any driving studies in this review because the samples in the located studies either were young adults or had conditions not limited to low vision.

Implications for Occupational Therapy Practice, Education, and Research

The findings of this review have the following implications for occupational therapy practice, education, and research:

• Basic low vision rehabilitation services, such as the provision of low vision devices, are effective to improve ADL performance in older adults with mild vision loss. Occupational therapy practitioners who are not low vision specialists can provide general services, such as home assessments, problem-solving training, or home exercise programs, to promote ADL performance in older adults with vision loss.
• Comprehensive low vision rehabilitation services are often provided by a multidisciplinary team. Occupational therapy education programs housed close to other vision care professional programs, such as optometry or ophthalmology, could initiate interprofessional education and practice collaboration. Such initiatives would build occupational therapy students’ capacity to work with other low vision care professionals ( Lucas Molitor & Mayou, 2018 ). Additionally, the curriculum could cover knowledge about how to apply general occupational therapy skills to better serve older adults with low vision.
• Performance-based vision-related occupational performance assessments that are sensitive to change are needed. An example is the Revised Self-Report Assessment of Functional Visual Performance ( Snow et al., 2018 ; Zemina et al., 2018 ), which includes a performance component. Performance-based assessments offer complementary information for evaluating intervention outcomes. Researchers in low vision are encouraged to include ADL and IADL measures or occupation-based performance assessments as functional outcome measures.
• Future research needs to continue examining the effectiveness of self-management programs for older adults with low vision. Specifically, the research focus could be shifted to what components to include to improve effectiveness and how to increase the accessibility and acceptability of such programs.

Low vision has detrimental effects on older adults’ independence in ADLs and IADLs. This systematic review supports the use of low vision rehabilitation services as the primary mean to promote independence in older adults with low vision. Occupational therapy services should continue to be part of low vision rehabilitation services, which provide comprehensive low vision evaluations and intervention. Although low evidence was identified for the self-management approach alone or combined with low vision rehabilitation services, increasing access to self-management programs for older adults with more severe vision loss could increase the impact of such programs. This review also shows an emerging trend of expansion of low vision intervention content by considering cognitive decline and physical decline in addition to vision loss. This expansion includes developing effective modes of intervention delivery to older adults with low vision who also experience cognitive deficits, as well as adding a physical component, such as exercise or tango, to address physical decline in older adults with low vision.

Acknowledgments

We thank Deborah Lieberman and Elizabeth Hunter for their guidance and support of this review.

* Indicates articles included in the systematic review.

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Strengthening problem-solving skills through occupational therapy to improve older adults' occupational performance - A systematic review

Affiliations.

• 1 Department of Occupational Therapy, VIA University College, Aarhus, Denmark.
• 2 Programme for rehabilitation, Research Centre for Health and Welfare Technology, VIA University College, Aarhus, Denmark.
• PMID: 35995214
• DOI: 10.1080/11038128.2022.2112281

Background: Evidence supports the role of occupational therapy (OT) for older adults, and therapeutic use of problem solving may provide a way to improve older adult's occupational performance. Aim: To assess the effectiveness and describe the contents of OT interventions aimed at improving older adults' occupational performance by strengthening their problem-solving skills. Material and Methods: This systematic review followed the phases recommended by the Cochrane Collaboration. The following databases were searched for clinical trials on OT for populations 65+ years: CINAHL, EMBASE, MEDLINE and PsycINFO. The Cochrane risk-of-bias tool (RoB-2) and the GRADE approach were used to assess the quality of the evidence. Results were presented in tables and by narrative syntheses. Results: Five studies were included comprising a total of 685 participants. In four studies, OT with a problem-solving approach outperformed control conditions post intervention. The interventions involved problem identification, analysis, strategy development and implementation. Although no serious risk of bias was detected in the individual studies, the quality of evidence was deemed low due to inconsistent and imprecise results. Conclusions: Low-quality evidence suggests that strengthening older adults' problem-solving skills may improve their occupational performance. Significance: Further investigation is required before firm practice recommendations can be prepared.

Keywords: ADL; Activities of daily living; cognitive strategies; elderly; functioning; occupation; problem solving; rehabilitation.

Publication types

• Systematic Review
• Occupational Therapy* / methods
• Problem Solving

10 Best Problem-Solving Therapy Worksheets & Activities

Cognitive science tells us that we regularly face not only well-defined problems but, importantly, many that are ill defined (Eysenck & Keane, 2015).

Sometimes, we find ourselves unable to overcome our daily problems or the inevitable (though hopefully infrequent) life traumas we face.

Problem-Solving Therapy aims to reduce the incidence and impact of mental health disorders and improve wellbeing by helping clients face life’s difficulties (Dobson, 2011).

This article introduces Problem-Solving Therapy and offers techniques, activities, and worksheets that mental health professionals can use with clients.

Before you continue, we thought you might like to download our three Positive Psychology Exercises for free . These science-based exercises explore fundamental aspects of positive psychology, including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

This Article Contains:

What is problem-solving therapy, 14 steps for problem-solving therapy, 3 best interventions and techniques, 7 activities and worksheets for your session, fascinating books on the topic, resources from positivepsychology.com, a take-home message.

Problem-Solving Therapy assumes that mental disorders arise in response to ineffective or maladaptive coping. By adopting a more realistic and optimistic view of coping, individuals can understand the role of emotions and develop actions to reduce distress and maintain mental wellbeing (Nezu & Nezu, 2009).

“Problem-solving therapy (PST) is a psychosocial intervention, generally considered to be under a cognitive-behavioral umbrella” (Nezu, Nezu, & D’Zurilla, 2013, p. ix). It aims to encourage the client to cope better with day-to-day problems and traumatic events and reduce their impact on mental and physical wellbeing.

Clinical research, counseling, and health psychology have shown PST to be highly effective in clients of all ages, ranging from children to the elderly, across multiple clinical settings, including schizophrenia, stress, and anxiety disorders (Dobson, 2011).

Can it help with depression?

PST appears particularly helpful in treating clients with depression. A recent analysis of 30 studies found that PST was an effective treatment with a similar degree of success as other successful therapies targeting depression (Cuijpers, Wit, Kleiboer, Karyotaki, & Ebert, 2020).

Other studies confirm the value of PST and its effectiveness at treating depression in multiple age groups and its capacity to combine with other therapies, including drug treatments (Dobson, 2011).

The major concepts

Effective coping varies depending on the situation, and treatment typically focuses on improving the environment and reducing emotional distress (Dobson, 2011).

PST is based on two overlapping models:

Social problem-solving model

This model focuses on solving the problem “as it occurs in the natural social environment,” combined with a general coping strategy and a method of self-control (Dobson, 2011, p. 198).

The model includes three central concepts:

• Social problem-solving
• The problem
• The solution

The model is a “self-directed cognitive-behavioral process by which an individual, couple, or group attempts to identify or discover effective solutions for specific problems encountered in everyday living” (Dobson, 2011, p. 199).

Relational problem-solving model

The theory of PST is underpinned by a relational problem-solving model, whereby stress is viewed in terms of the relationships between three factors:

• Stressful life events
• Emotional distress and wellbeing
• Problem-solving coping

Therefore, when a significant adverse life event occurs, it may require “sweeping readjustments in a person’s life” (Dobson, 2011, p. 202).

• Enhance positive problem orientation
• Decrease negative orientation
• Foster ability to apply rational problem-solving skills
• Reduce the tendency to avoid problem-solving
• Minimize the tendency to be careless and impulsive

D’Zurilla’s and Nezu’s model includes (modified from Dobson, 2011):

• Initial structuring Establish a positive therapeutic relationship that encourages optimism and explains the PST approach.
• Assessment Formally and informally assess areas of stress in the client’s life and their problem-solving strengths and weaknesses.
• Obstacles to effective problem-solving Explore typically human challenges to problem-solving, such as multitasking and the negative impact of stress. Introduce tools that can help, such as making lists, visualization, and breaking complex problems down.
• Problem orientation – fostering self-efficacy Introduce the importance of a positive problem orientation, adopting tools, such as visualization, to promote self-efficacy.
• Problem orientation – recognizing problems Help clients recognize issues as they occur and use problem checklists to ‘normalize’ the experience.
• Problem orientation – seeing problems as challenges Encourage clients to break free of harmful and restricted ways of thinking while learning how to argue from another point of view.
• Problem orientation – use and control emotions Help clients understand the role of emotions in problem-solving, including using feelings to inform the process and managing disruptive emotions (such as cognitive reframing and relaxation exercises).
• Problem orientation – stop and think Teach clients how to reduce impulsive and avoidance tendencies (visualizing a stop sign or traffic light).
• Problem definition and formulation Encourage an understanding of the nature of problems and set realistic goals and objectives.
• Generation of alternatives Work with clients to help them recognize the wide range of potential solutions to each problem (for example, brainstorming).
• Decision-making Encourage better decision-making through an improved understanding of the consequences of decisions and the value and likelihood of different outcomes.
• Solution implementation and verification Foster the client’s ability to carry out a solution plan, monitor its outcome, evaluate its effectiveness, and use self-reinforcement to increase the chance of success.
• Guided practice Encourage the application of problem-solving skills across multiple domains and future stressful problems.
• Rapid problem-solving Teach clients how to apply problem-solving questions and guidelines quickly in any given situation.

Success in PST depends on the effectiveness of its implementation; using the right approach is crucial (Dobson, 2011).

Problem-solving therapy – Baycrest

The following interventions and techniques are helpful when implementing more effective problem-solving approaches in client’s lives.

First, it is essential to consider if PST is the best approach for the client, based on the problems they present.

Is PPT appropriate?

It is vital to consider whether PST is appropriate for the client’s situation. Therapists new to the approach may require additional guidance (Nezu et al., 2013).

Therapists should consider the following questions before beginning PST with a client (modified from Nezu et al., 2013):

• Has PST proven effective in the past for the problem? For example, research has shown success with depression, generalized anxiety, back pain, Alzheimer’s disease, cancer, and supporting caregivers (Nezu et al., 2013).
• Is PST acceptable to the client?
• Is the individual experiencing a significant mental or physical health problem?

All affirmative answers suggest that PST would be a helpful technique to apply in this instance.

Five problem-solving steps

The following five steps are valuable when working with clients to help them cope with and manage their environment (modified from Dobson, 2011).

Ask the client to consider the following points (forming the acronym ADAPT) when confronted by a problem:

• Attitude Aim to adopt a positive, optimistic attitude to the problem and problem-solving process.
• Define Obtain all required facts and details of potential obstacles to define the problem.
• Alternatives Identify various alternative solutions and actions to overcome the obstacle and achieve the problem-solving goal.
• Predict Predict each alternative’s positive and negative outcomes and choose the one most likely to achieve the goal and maximize the benefits.
• Try out Once selected, try out the solution and monitor its effectiveness while engaging in self-reinforcement.

If the client is not satisfied with their solution, they can return to step ‘A’ and find a more appropriate solution.

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Positive self-statements

When dealing with clients facing negative self-beliefs, it can be helpful for them to use positive self-statements.

Use the following (or add new) self-statements to replace harmful, negative thinking (modified from Dobson, 2011):

• I can solve this problem; I’ve tackled similar ones before.
• I can cope with this.
• I just need to take a breath and relax.
• Once I start, it will be easier.
• It’s okay to look out for myself.
• I can get help if needed.
• Other people feel the same way I do.
• I’ll take one piece of the problem at a time.
• I can keep my fears in check.
• I don’t need to please everyone.

5 Worksheets and workbooks

Problem-solving self-monitoring form.

Answering the questions in the Problem-Solving Self-Monitoring Form provides the therapist with necessary information regarding the client’s overall and specific problem-solving approaches and reactions (Dobson, 2011).

Ask the client to complete the following:

• Describe the problem you are facing.
• What is your goal?
• What have you tried so far to solve the problem?
• What was the outcome?

Reactions to Stress

It can be helpful for the client to recognize their own experiences of stress. Do they react angrily, withdraw, or give up (Dobson, 2011)?

The Reactions to Stress worksheet can be given to the client as homework to capture stressful events and their reactions. By recording how they felt, behaved, and thought, they can recognize repeating patterns.

What Are Your Unique Triggers?

Helping clients capture triggers for their stressful reactions can encourage emotional regulation.

When clients can identify triggers that may lead to a negative response, they can stop the experience or slow down their emotional reaction (Dobson, 2011).

The What Are Your Unique Triggers ? worksheet helps the client identify their triggers (e.g., conflict, relationships, physical environment, etc.).

Problem-Solving worksheet

Imagining an existing or potential problem and working through how to resolve it can be a powerful exercise for the client.

Use the Problem-Solving worksheet to state a problem and goal and consider the obstacles in the way. Then explore options for achieving the goal, along with their pros and cons, to assess the best action plan.

Getting the Facts

Clients can become better equipped to tackle problems and choose the right course of action by recognizing facts versus assumptions and gathering all the necessary information (Dobson, 2011).

Use the Getting the Facts worksheet to answer the following questions clearly and unambiguously:

• Who is involved?
• What did or did not happen, and how did it bother you?
• Where did it happen?
• When did it happen?
• Why did it happen?
• How did you respond?

2 Helpful Group Activities

While therapists can use the worksheets above in group situations, the following two interventions work particularly well with more than one person.

Generating Alternative Solutions and Better Decision-Making

A group setting can provide an ideal opportunity to share a problem and identify potential solutions arising from multiple perspectives.

Use the Generating Alternative Solutions and Better Decision-Making worksheet and ask the client to explain the situation or problem to the group and the obstacles in the way.

Once the approaches are captured and reviewed, the individual can share their decision-making process with the group if they want further feedback.

Visualization

Visualization can be performed with individuals or in a group setting to help clients solve problems in multiple ways, including (Dobson, 2011):

• Clarifying the problem by looking at it from multiple perspectives
• Rehearsing a solution in the mind to improve and get more practice
• Visualizing a ‘safe place’ for relaxation, slowing down, and stress management

Guided imagery is particularly valuable for encouraging the group to take a ‘mental vacation’ and let go of stress.

Ask the group to begin with slow, deep breathing that fills the entire diaphragm. Then ask them to visualize a favorite scene (real or imagined) that makes them feel relaxed, perhaps beside a gently flowing river, a summer meadow, or at the beach.

The more the senses are engaged, the more real the experience. Ask the group to think about what they can hear, see, touch, smell, and even taste.

Encourage them to experience the situation as fully as possible, immersing themselves and enjoying their place of safety.

Such feelings of relaxation may be able to help clients fall asleep, relieve stress, and become more ready to solve problems.

We have included three of our favorite books on the subject of Problem-Solving Therapy below.

1. Problem-Solving Therapy: A Treatment Manual – Arthur Nezu, Christine Maguth Nezu, and Thomas D’Zurilla

This is an incredibly valuable book for anyone wishing to understand the principles and practice behind PST.

Written by the co-developers of PST, the manual provides powerful toolkits to overcome cognitive overload, emotional dysregulation, and the barriers to practical problem-solving.

Find the book on Amazon .

2. Emotion-Centered Problem-Solving Therapy: Treatment Guidelines – Arthur Nezu and Christine Maguth Nezu

Another, more recent, book from the creators of PST, this text includes important advances in neuroscience underpinning the role of emotion in behavioral treatment.

Along with clinical examples, the book also includes crucial toolkits that form part of a stepped model for the application of PST.

3. Handbook of Cognitive-Behavioral Therapies – Keith Dobson and David Dozois

This is the fourth edition of a hugely popular guide to Cognitive-Behavioral Therapies and includes a valuable and insightful section on Problem-Solving Therapy.

This is an important book for students and more experienced therapists wishing to form a high-level and in-depth understanding of the tools and techniques available to Cognitive-Behavioral Therapists.

For even more tools to help strengthen your clients’ problem-solving skills, check out the following free worksheets from our blog.

• Case Formulation Worksheet This worksheet presents a four-step framework to help therapists and their clients come to a shared understanding of the client’s presenting problem.
• Understanding Your Default Problem-Solving Approach This worksheet poses a series of questions helping clients reflect on their typical cognitive, emotional, and behavioral responses to problems.
• Social Problem Solving: Step by Step This worksheet presents a streamlined template to help clients define a problem, generate possible courses of action, and evaluate the effectiveness of an implemented solution.

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While we are born problem-solvers, facing an incredibly diverse set of challenges daily, we sometimes need support.

Problem-Solving Therapy aims to reduce stress and associated mental health disorders and improve wellbeing by improving our ability to cope. PST is valuable in diverse clinical settings, ranging from depression to schizophrenia, with research suggesting it as a highly effective treatment for teaching coping strategies and reducing emotional distress.

Many PST techniques are available to help improve clients’ positive outlook on obstacles while reducing avoidance of problem situations and the tendency to be careless and impulsive.

The PST model typically assesses the client’s strengths, weaknesses, and coping strategies when facing problems before encouraging a healthy experience of and relationship with problem-solving.

Why not use this article to explore the theory behind PST and try out some of our powerful tools and interventions with your clients to help them with their decision-making, coping, and problem-solving?

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

• Cuijpers, P., Wit, L., Kleiboer, A., Karyotaki, E., & Ebert, D. (2020). Problem-solving therapy for adult depression: An updated meta-analysis. European P sychiatry ,  48 (1), 27–37.
• Dobson, K. S. (2011). Handbook of cognitive-behavioral therapies (3rd ed.). Guilford Press.
• Dobson, K. S., & Dozois, D. J. A. (2021). Handbook of cognitive-behavioral therapies  (4th ed.). Guilford Press.
• Eysenck, M. W., & Keane, M. T. (2015). Cognitive psychology: A student’s handbook . Psychology Press.
• Nezu, A. M., & Nezu, C. M. (2009). Problem-solving therapy DVD . Retrieved September 13, 2021, from https://www.apa.org/pubs/videos/4310852
• Nezu, A. M., & Nezu, C. M. (2018). Emotion-centered problem-solving therapy: Treatment guidelines. Springer.
• Nezu, A. M., Nezu, C. M., & D’Zurilla, T. J. (2013). Problem-solving therapy: A treatment manual . Springer.

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