Problem Statements

Steve Wood, Lecturer Practitioner

Body

FeelingsThoughts

Behaviour

Underpinning this is a

4-systems view of symptoms

cold sweat

tingling in extremities

numb extremities

thoughts of impending doom

fear of collapsing/losing control

feeling unreal

feeling faint

nausea

chest pain or discomfort feeling of choking

sense of immediate dangertrembling

urge to escape

palpitations

hot flushes

tingling in extremitiesfear of going crazy

feeling light-headed

feeling unsteady

images of losing control

stomach churning

feeling smothered

feeling detached from oneself

shaking

sudden intense fear

Panic attack symptoms

take deep breaths

escape from situation

undo buttons

open windows

Panic attack

checklist

Physical

AffectiveCognitive

Behavioural

Thoughts of impending doomImages of losing controlSense of immediate dangerUrge to escapeFeeling unreal

Intense fearFear of going crazy

Fear of collapsing/losing controlFeeling detached

PalpitationsStomach churning

Feeling faintHot flushesCold sweatTrembling

ShakingFeeling smotheredFeeling of choking

Feeling light-headedNumb extremities

Tingling in extremitiesNausea

Chest pain

Take deep breathsUndo buttonsOpen windowsEscape from situation

Angry thoughts

Brooding about the past

Suicidal thoughts

Reduced concentration & attention

Recurrently negative thoughts

Difficulty thinking

Mental slowing

Short-term memory problems

Excessive self-criticism

Pessimistic thoughts

Feelings of sadness

Feelings of worthlessness

Loss of pleasure or enjoyment out of life

Decreased self-confidence

Feelings of hopelessness

Feelings of helplessness

Excessive or unrealistic fear

Excessive guilt

Decreased libido

Loss of energy

Feeling physically “slowed down”

Somatic anxiety symptoms

Feeling physically unable to settle

Sleep disturbance

Weight loss (without dieting)

Appetite disturbance

Snapping at people

Difficulty setting goalsDecreased productivity

Social withdrawal

Agitated behaviour

Crying

Difficulty making decisions

Difficulty solving problems

Symptoms of depression

Depression checklist

Physical

AffectiveCognitive

Behavioural

Pessimistic & recurrently negative thoughtsExcessive self-criticismAngry thoughtsBrooding about the pastSuicidal thoughtsReduced concentration & attentionShort-term memory problemsDifficulty thinkingMental slowing

Loss of pleasure or enjoyment out of lifeFeelings of depression or sadness

Feeling pessimisticFeelings of worthlessnessFeelings of hopelessnessFeelings of helplessness

Excessive or unrealistic fearExcessive guilt

Decreased self-confidence

Loss of energyFeeling physically “slowed down”

Feeling physically unable to settle Sleep disturbance

Appetite disturbanceWeight loss (without dieting)

Somatic anxiety symptomsDecreased libido

CryingSnapping at peopleDecreased productivityApathy and indifferenceDifficulty solving problemsSocial withdrawalDifficulty setting goalsDifficulty making decisionsAgitated behaviour

Symptom checklists have their uses.

BUT - they do not show links between the symptom domains and don’t reveal

what is going on for the person.

A 4-systems view reveals the links between the symptom domains and

helps the person make sense of what is going on.

Jean has experienced panic attacks since the age of 19. Her panics are unpredictable and she lives in fear of the next one. At work, on the phone to a customer, she suddenly feels unreal, as if she’s not part of what’s going on.

Physical

FeelingsThoughts

Behavioural

Symptoms

Scared & anxious

Take deep breaths to try & slow things down.

Shaking, heart racing, breathless,

feeling unreal

Negative automatic thought

What if I panic?

I’m panicking and I can’t control it.

Panic

Shaking, heart racing, breathless, feeling

unreal increase

I’m having a heart attack. I’m going to die

Opens window, rushes out of room.

Paul has had 2 episodes of depression. He lost his job 3 months ago and hasn’t worked since. Trying to keep busy, he starts redecorating the house. While painting the living room, he drips paint on the carpet . . .

Physical

FeelingsThoughts

Behavioural

Symptoms

PessimisticFeelings of failureSelf-dislike

Avoid doing jobs around the houseAvoid challenges

LethargyLoss of appetite

Negative automatic thought

That’s just like me. I always mess things

up. I’m a failure

What’s the point in trying? It’ll only go wrong.

I can’t be bothered. I wouldn’t enjoy it anyway.

Depression

Problem statements enable us to add to the information gained from our basic mental health checklist by gaining the client’s perception of their current situation, in relation to their mental health.

Problem Statements

Problem statements should focus directly on difficulties that:

Have been identified by the client during the semi-structured assessment interviewHave been written, whenever possible, in the client's own words; this helps reduce the use of jargon and provides meaning to the clientDescribe the problem in observable behaviours Indicate the impact and consequences the problem has on the client's life-style.

Your task is . . .

To work collaboratively with the client to formulate a PROBLEM STATEMENTStart with the initial question –

“In relation to your mental health, how would you describe your main problem at the moment?”

When the client replies, ask –“Can you tell me how that is a problem for you?”

Then use appropriate skills of questioning, reflecting, paraphrasing, checking and summarising to develop the problem statement Make sure you finish with a written statement that the client can read back to you.

“Well, my main problem is that meeting people makes me very

anxious”

“In terms of your mental health, how would you

describe your main problem at the moment?”

Your task is help the client convert this…

“In terms of your mental health, how would you

describe your main problem at the moment?”

“My main problem is my feelings of anxiety and images of making a fool of myself, accompanied by

sweating, muscle tension and nausea and an urge to run away whenever I have to meet unfamiliar

people. The anxiety and physical symptoms are quite severe and it occurs at least twice each week. This is affecting my employment, as I have to deal with personal enquiries by members of the public; I

have stopped going out socially and my friends have started not to invite me; and it is causing rows

between myself and my partner.”

Into something like this…

“I worry about my

heart”

“In terms of your mental health, how would you

describe your main problem at the moment?”

and this…

Into something like this…

“In terms of your mental health, how would you

describe your main problem at the moment?”

My problem is that I worry excessively about my physical health, particularly about my heart. Whenever I need to do

anything that involves exertion I start to worry that it will cause a heart attack. I constantly tune in to my heart, take my pulse, and read everything I can about heart attacks and how to avoid them. My body is constantly tense and I tend to get headaches,

which I put down to high blood pressure and this makes me worry even more, in case it’s damaging my heart. I never exert myself – never run for a bus, run with the children, try to avoid sex and so on. It’s getting so bad that some days I hardly get

out of the house. It’s affecting life at home, because I don’t do anything around the house; social life, as I avoid doing sport and other things I used to do; it’s causing rows with my partner and affecting my

relationship with the kids.