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

Section 13
Problem-Solving and Formative Feedback

CEU Question 13 | CEU Test | Table of Contents | Depression
Counselor CEUs, Psychologist CEs, Social Worker CEUs, MFT CEUs

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5 CBT Components of Problem Solving Continued

Component #3 - Decision Making
Here's how I applied these ideas with Wendy. Wendy is a 27-year-old divorced woman whose identified problems included dissatisfaction with her appearance. She was unhappy with the way she looked in general and with her weight in particular. She reported that she had gradually gained weight over the past few years.

At the initial session, she weighed 161 pounds; 30 pounds over her ideal weight. She reported that she felt trapped; she saw her weight as a major contributor to her depression. Yet when feeling depressed, she often used food to make herself "feel good." Often she engaged in nighttime eating episodes in which she consumed excessive amounts of calories. The following day she would not only feel depressed, but she would also feel guilty about her overeating.

Wendy's List of Alternatives to Deal with her Weight
-- Join Weight Watchers
-- Go on a total fast for 2 to 3 days
-- Try the Atkins Diet
-- Go to a diet doctor to get reducing pills
-- Stop eating breakfast and lunch
-- Become a vegetarian
-- Try the Cambridge Diet
-- Join a weight loss group at the local YMCA
-- Eliminate all sweets from my diet

The CBT "Brick Test" or Quantity of Thinking Principle
I found with Wendy that list-making is a simple and direct method to help her improve the quality of her thinking. Some may refer to it as the Brick Test. As you know, the Brick Test is a test that was used to make decisions about what to do with some bricks. The Brick Test was originally developed by J. P. Guilford, a corporate executive whose company manufactured red building bricks and was concerned about a drop in sales

--Quantity of thinking Exercise (Part 1): Here is an exercise based on Guilford's Brick Test. I told Wendy, "An employer has hired you to assist him in developing new uses for his products. Here's what I would like you to do. Spend the next few minutes thinking about this problem. After three minutes, I will ask you to tell me what you have come up with." After 3 minutes had elapsed, I asked Wendy to describe her ideas.

--Quantity of thinking Exercise (Part 2): For part two of the exercise, I instructed Wendy, "Now what I would like you to do is to use the next three minutes making a list of all the possible uses for bricks. This time, however, I would like you to take this piece of paper and make a written list, following two rules. First, you should generate as many responses as possible. Second, you should combine and improve responses to develop new possibilities."

When the quantity exercise is effective, patients typically are more productive using the "quantity-listing" instructions than the suggestion to "spend a few minutes." I have found that asking my clients to "spend the next few minutes thinking," typically results in five or fewer responses. Asking my clients to create a list increases their responses to 10-20. I have found that quantity training involves substantial practice. The use of impersonal examples facilitates practice in creativity and flexible thinking.

However, I have found it is also important to focus heavily on your client's real-life problems, so that this approach does not seem personally irrelevant. For personal situations, patients should be encouraged to produce as many ideas as possible for each identified goal or sub-goal. This often allows identification of a variety of effective solutions that can ultimately be implemented to attack the problem from a number of perspectives.

The Deferment-of-Judgment Principle
According to the deferment-of-judgment principle, productive thinking will be enhanced if the problem solver suspends critical evaluation of potential solutions during the generation-of-alternatives or brainstorming phase. The rationale for this principle suggests that if one analyzes or judges solution ideas too early in the problem solving process, many potentially effective ideas may be rejected prematurely.

Moreover, a judgmental stance may cause the patient to be overly concerned about producing the right answers, thereby inhibiting productive and creative thinking. In applying this principle, you should instruct your client to suspend judgment and to avoid criticism when generating alternatives. I encouraged Wendy to be creative by letting go of her imagination.

I have found that getting depressed clients to delay self-criticism of their thinking is often a difficult task. It was not unusual during the generation-of-alternatives for Wendy to be unable to think of a single possibility. I told Wendy, "It is OK to make up an answer." The process of making up something is virtually identical to creatively generating a potential solution. A key distinction, however, rests in the extra degree of permission granted by the instruction, "Make up a response."

For many of my clients, instructing them to "make up a response" enables them to establish some distance from their responses. They are less inhibited in generating made-up responses because such responses are not expected to be perfect. In effect, the instruction to make up something gives the patient the freedom to generate alternatives without responsibility for coming up with good solutions.

Strategy- Tactics Principle
In generating alternative solutions, I find it helpful to distinguish between two categories of solution possibilities, strategies and tactics. Strategies represent general courses of action that Wendy plans to take in order to resolve dissatisfaction with her appearance. Tactics represent the specific steps that detail how Wendy plans to implement the strategy in her situation. Based on my experience with the strategy-tactics principle, a greater number of solution alternatives will be generated if Wendy produces a wide variety of both strategies and tactics. I assisted Wendy in developing a range of different general approaches or strategies to the problem.

She also developed a variety of specific, concrete actions or tactics to implement the strategy. Using the strategy-tactics principle, I encouraged Wendy to think of a wide range of possible solutions across a variety of strategies rather than to focus on one or two narrow tactics. For example, in completing the brick exercise, Wendy could think only in terms of one common strategy, namely, using a brick as a construction material. Often the potential solutions that my clients generate are simply multiple tactics representing one general strategy (for example, constructing a fireplace or patio, or building a wall or garage).

In such an instance, the individual may generate a quantity of tactics, but overall problem-solving effectiveness is likely to be limited by the use of only one strategy. I have found that a more effective approach to generating alternatives includes several strategies along with multiple tactics for implementing those strategies. For instance, alternative strategies for the brick exercise might include their use as recreational objects like playground blocks for children, artistic substances such as raw material for sculptures, or athletic equipment such as a "brick shot put".

According to a National Institute of Health Publication, sadness, anxiety, or "empty" feelings, and overeating, and weight gain, or loss of weight or appetite are symptoms of depression. When you think about how your client feels about appearance, do you see or hear about a difference in their appetite or weight?

On first inspection, it would appear that Wendy had generated a quantity of reasonable solution ideas for dealing with the identified problem. In reviewing her list of alternatives, Wendy and I attempted to group her coping options into classes of strategies that reflected a common theme. We found that all her responses were related to dieting, and I was concerned that she had selected only one general strategy for coping with the problem. The strategies and tactics principle suggests that the greater the number of different approaches to the problem, the greater the chances of success.

In this case, the particular strategy that Wendy chose was one that was unlikely to be effective, simply because excessive dietary restraint is likely to prompt overeating and an eventual weight gain. After reviewing the strategy-tactics principle, Wendy and I attempted to generate a variety of strategies in addition to dieting. Furthermore, Wendy used the first two brainstorming techniques, the quantity and deferment-of-judgment principles, to generate several specific tactics for each new strategy that she devised.

Wendy's Revised List of Strategies and Tactics
--Strategy 1: Improve my physical appearance.
Tactics: Get a new hair style; color my hair; get a haircut; get a facial; get a makeup consultation; get a manicure; get a pedicure; go to a tanning salon; get a color analysis.
--Strategy 2: Use exercise to improve my body.
Tactics: Take up jogging; sign up for a tennis class; join a bowling league; buy an exercise bike; join a bicycle club; walk 2 miles a day; run 2 miles a day; do calisthenics; learn isometrics; join a health club; do stretching exercise; learn how to use free weights.
--Strategy 3: Find substitutes for nighttime eating.
Tactics: Take a bath; drink water; leave the house; call a friend; start a diary; clean a closet; call my therapist; call my mother; scream; yell; sing; play my guitar; go for a walk; exercise; go to a movie; polish my nails; give myself a facial; brush my teeth.
--Strategy 4: Accept my looks.
Tactics: Say to myself, "It doesn't matter how I look"; refuse to look in the mirror; refuse to get on a scale; refuse to buy new clothes; look in the mirror and say "You're all right just the way you are"; say to myself "It's not awful to be overweight."
--Strategy 5: Improve my wardrobe.
Tactics: Buy some new clothes; buy a jogging suit; ask friends what types of clothes look good on me; get a professional consultation on what clothes would help my appearance; wait until I lose some weight to buy new clothes; use buying clothes as a reward for losing weight.
--Strategy 6: Lose weight.
Tactics: Join Weight Watchers; go on a total fast for 2 to 3 days; try the Atkins diet; go to a diet doctor to get reducing pills; become a vegetarian; join a weight loss group at the local YMCA; eliminate all sweets from my diet.

3 Guiding Principles of Brainstorming
1. The quantity principle.
2. The deferment-of-judgment principle.
3. The strategy-tactics procedure.

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

Fernández-Theoduloz, G., Paz, V., Nicolaisen-Sobesky, E., Pérez, A., Buunk, A. P., Cabana, Á., & Gradin, V. B. (2019). Social avoidance in depression: A study using a social decision-making task. Journal of Abnormal Psychology, 128(3), 234–244.

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

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

Online Continuing Education QUESTION 13
What are three principles that will help with brainstorming? To select and enter your answer go to CEU Test.

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