problem solving

Looking beyond the immediate


When I graduated as an occupational therapist, I was told that my profession was “problem-solving” and “motivation”. At the time (early 1980’s) Lela Llorens‘ problem solving process was the fundamental approach taught during our training. This approach is straightforward: identify the problem, identify solutions, select a solution, implement the solution, and review. I’m not sure if this approach is still taught but it’s stayed with me (and those memories of painstakingly completing the problem solving process documentation…).

There’s one small step that I think is either not fully articulated, or maybe gets lost in the iterative process of identifying solutions, implementing them and reviewing: and that’s the process of identifying contributors to the problem. Let me take you through a case study as an example.

Luke is in his mid-20’s with widespread pain. He’s off work, and his diagnosis is “fibromyalgia”. It started when he hurt his back working on cars (he’s a true petrol-head!) about a year ago, and now his pain dominates his life as he finds his pain has permeated his body. He doesn’t know what’s wrong with him, and thinks that his pain is because someone didn’t “fix” him when he first hurt his back.

The main thing he wants to be able to do is get back to driving and working on cars. It’s all he’s ever wanted to do, apart from play computer games, and he’s most happy at the moment when he’s watching motor racing on the net, preferably with a can of some high-sugar, high caffeine drink and a bit of weed. He otherwise doesn’t smoke tobacco, drinks on occasion, but he’s isolated and feels at a loose end.

The referral to an occupational therapist read “Luke wants to get back driving, will you assess, and provide appropriate intervention?” Implied, but not explicitly stated in the referral is that if Luke can return to driving, it will help him in his job search. Luke isn’t terribly interested in returning to work right now, because his focus is on what’s wrong with him and driving for fun.

The occupational therapist saw Luke, and assessed his ability to sit in the car, reverse the car, and drive over normal highway conditions. She thought he needed a seat insert so he was more ergonomically positioned, and she also thought that he could do with a better chair in the lounge because he usually sat slouched on the sofa playing his video games.

So she found him a suitable cushion and ergonomic backrest for his car, and he was also provided with chair raisers to lift his sofa up, and some cushions behind him so he was in a more upright position.

Luke was happy with the changes, though secretly a bit worried that his mates would think he was soft if he had a special seat cushion, and that old people used chair raisers, so he wasn’t at all keen on them in his lounge. But he took them anyway.

Job done.

Oh really? Yes, the occupational therapist addressed his seating and yes, he can now drive a bit more comfortably and even play his video games and watch TV, but did she really identify the problems?

You see, she identified the problem as “Luke can’t drive the car”, and she even dug a little deeper and identified that “Luke can’t drive the car or play his video games because he’s in pain.”

And that much is true – he was sore, told her he was sore, and pointed out that the position he used in the car and on the sofa was the same.

The problem is that – that wasn’t the problem.

There were a few more questions the therapist could have asked if her focus went beyond the immediate “problem” and she unpacked the next question which might have been “why is pain such a problem for Luke, and why is it getting in the way of Luke’s driving?” She might have added another question too – “why is Luke presenting in this way at this time, and what is maintaining his situation?”

Luke is a fictitious character, but “Luke’s” are everywhere. People who present with problems of occupational performance, but the problems contributing to those problems are the real issue. And yet, I’ve seen so many occupational therapy reports recommending “solutions” for similar problems that solve very little and probably compound the problem.

Where did our fictitious occupational therapist go wrong? Well, included in the problem solving process (and the variants developed since then) is a section called “assessment”. What exactly should be assessed in this part? Of course the assessment components will differ depending on the model of “what’s going on” held by the occupational therapist. When a simplistic biomechanical model of pain is being used, all the understanding of Luke’s values and beliefs, all the importance he places on being able to drive, the environment (his car seating, his sofa) – so much of what’s commonly included in an occupational therapy assessment might have very little to do with the problems Luke is having in daily occupation.

Leaping in to solve the problem of being able to drive focuses our minds on that as the key problem – but what if we looked at it as a symptom, or an expression of, other problems? This means, as occupational therapists, we might need to do a couple of things: firstly, we might need to assess more widely than “driving” or even “sitting” as the occupational performance problem. While referrers use this kind of approach to ask us to help, it doesn’t do much for our professional clinical reasoning. It tends to anchor us on “The Problem” as defined by someone else.

Even being person-centred, and asking Luke what he needs and wants to do may mislead us if we forget to look at the wider impact of pain on daily doing. If, as occupational therapists, we’re ignorant of the bigger picture of what’s going on when someone is disabled and distressed by their pain. If we forget that there are underlying processes we are well-equipped to deal with. If we forget the wider body of research into pain as an experience.

Perhaps occupational therapists could take some time to think about our contribution to the pain management team. I’ve been banging on about our knowledge translation skills, our awareness of context and how much daily life context differs from a gym or a clinic or an office. I’m not seeing that knowledge being demonstrated by occupational therapists in practice. What I’m seeing are stop-gap solutions that skim the surface of how pain impacts a person’s daily doing.

If occupational therapists recognised what our profession can offer a team, we might look at how someone like Luke could benefit from our in-depth assessment of what he thinks is going on, of how he communicates when he’s seeing other health professionals, of how he’s coping with his pain and how these strategies are taking him away from what matters in his life. We’d look at not just his occupational performance, but also those pain-specific factors well-established in research: his beliefs, his attitudes, his emotional responses, his social context, his habits and routines, his way of processing what he learns from others. We’d begin to look at him as a whole person. We might even look at how he’s integrating into his daily life all the things other clinicians in the team are offering.

Occupational therapy is a profession with so much to offer AND we need to develop our confidence and knowledge about what we do and about pain. We need to step outside of the narrow focus on “finding solutions and implementing them” and extend our assessments to identify the problems contributing to occupational performance difficulties.

Cue cards for coping


One problem people have when learning coping skills is remembering what to do and when to do it.   In the heat of the moment it can be really difficult to recall exactly what the new strategy is!  We also know that pain interferes with recall because of the disruptive effect on attention, and this effect is heightened when people are anxious about their pain.  One good measure for whether attention and thinking processes are disrupted is the Pain Anxiety Symptoms Scale (McCracken & Dhingra, 2002).

There are a few techniques for helping people to remember what to do – including some of my favourites like a sticker on a doorframe, post-it notes on the computer or dashboard of the car, or reminders on a cellphone or computer.  But one way that has been helpful for several reasons is using a cue card. (more…)

Problem solving: A practical self-help strategy


Not surprisingly, lots of people I see with chronic pain feel like they’ve landed in a hole they can’t get out of. And one of the most positive things I think I can do is show people that change is possible.
Getting out of a hole is incredibly difficult all by yourself – but oh so necessary for life to move forward again.

Problem solving is a fundamental tool for many professions – not just occupational therapists who seem to have adopted it wholesale (see this article from November 2007!), but also engineers, mechanics – oh and psychologists! But occupational therapists have books (like this one by Jeanne E. Lewin and Colleen A. Reed, and this one (parts of which you can read online to get the drift) about the use of problem solving in mental health.

My main problem with ‘the problem solving process’ is the tendency to almost immediately focus on solving the problem rather than working to identify and manage contributing factors. So when I was trying to develop a problem solving process format for the people I work with who have chronic pain, I spent a bit of time trying to come up with something that would encourage them to go beyond the immediate. Here’s what I came up with.

At the top of the page:

  1. ‘the problem’ described briefly.
  2. Then a box below that with the label ‘factors contributing to the problem’
  3. Then a second box below that labelled ‘factors contributing to these factors’
  4. Then all around the outside I ask the participants to write possible solutions for each contributing factor with an arrow leading to the relevant factor.

This way, the tendency to prematurely close in on ‘The Solution’ is halted, and a range of options are generated. At the same time, there are two levels of problem solving – the immediate, and those that are underneath the immediate. (You could do this layering of contributing factors several times, but this gives you something not too complex to work with.)

To make it even more systematic, if you have a model to work with, you could use that to organise the layers of contributing factors…as in the ‘ishikawa’ fishtail model.
Or clinically, you might use a biopsychosocial model, or for cognitive behavioural pain management, you might use one of the Main & Spanswick models of disability to help yourself work your way through the relevant areas.

The astute amongst you might have noticed that the last two bear a striking resemblance to what can otherwise be called ‘case formulation’ – problem solving and case formulation are pretty much the same thing – well at least, they’re steps along the same track.

In each case you’re developing a set of hypotheses about what might be a factor relevant to the onset and maintenance of a problem.

The next step is, of course, to pick the hypothesis or possible solutions and DO IT! Clinically we would use evidence from the scientific literature to decide which approach to use first, based on which hypothesis appears to explain the majority of problems in the simplest way, with the fewest assumptions.

With clients, we would start with preferences, use logic, or work with available resources – especially if we’re trying to help the person develop self efficacy.

Clinical reasoning – more than problem solving…


Once upon a time, I was a baby occupational therapist, newly graduated, and I dutifully followed what I had learned as ‘the occupational therapy problem solving process’.  This process was:

  1. Identifying the problems (usually as identified by ‘the client’ who was often the person I ended up seeing, but just as easily could be the person who had referred the person I saw…) – this involved assessment
  2. Identifying the potential solutions (being creative, and based on clinical knowledge of ‘what works’ and included biomechanics, psychosocial factors, developmental stage and the end result that was being aimed for)
  3. Choosing a solution (that could be whatever was most pragmatic, least expensive, quick to implement, suited the client, or I had learned was ‘a good solution’)
  4. Implementing a solution (just getting on and ‘doing it’ – but it might involve selective grading of complexity of the activity or task or equipment or environment)
  5. Reviewing the satisfactoriness of the solution (often through ‘reassessment’, but even more often through asking ‘did it work?’)
  6. If it didn’t work, repeating the process…

What I developed through my undergraduate education was a working knowledge of anatomy, physiology, psychology (particularly developmental stages, cognition, and behaviourism), sociology (especially roles within society and responses to social environments), pathologies of various types – and the gift of learning about the value of ‘being active’ or engaged in ‘occupation’ or ‘valued activities’.  I can’t recall the exact wording, or even references now (it was HOW many years ago?!!), and I do remember graduating thinking ‘I’m not really sure what makes occupational therapy ‘different’ from other professionals, but I think it’s something to do with activity and of course, we do learn about how groups work’.

Very quickly I became quite disenchanted with occupational therapy – and quite abruptly had to face some hard facts about what I learned, and the way other professions (and this thing called ‘science’) worked.  And it was this: that problem solving process which I had hammered into me misses the point.  In fact, because of the way many occupational therapists practiced then (and I have to say, practice even now…), the profession suffered from the accusation that it couldn’t respond to – ‘jumping in with solutions before really knowing the problem’.  

Ouch!

I’ve pondered this for ages…why is it that occupational therapists, who are well-meaning, often very well educated, and have such laudable aims for their therapy, why do they ‘jump in’ with solutions so quickly?

Some of the thoughts I’ve had about this include:

– client-centred can mean that because of lack of insight by the client, contributory problems that underlie the problems the client identifies don’t get brought to light

– there is no specific step to specifically examine, through hypothesis generation, a number of competing explanations for the problem arising

– because of information processing heuristics, clinical reasoning can be shot by human characteristics common to all professions:

– the tendency to identify a pattern out of random data when it might actually be random

– the tendency to remember unusual or unique factors more readily than the familiar

– the effect of recency and primacy (information that is new or recently learned, information that comes first or is over-learned)

–  information provided/required by an ‘important’ team member is recalled quickly

– our difficulty setting aside a preliminary conclusion, along with our ability to seek confirmation that our hunches are correct (rather than waiting for more information before deciding on an option, and difficulty actively seeking disconfirmatory evidence)

– that we don’t recognise the context of the situation – why, who, what are defining ‘the problems’ – some ‘problems’ may be problematic for one party, but pretty good for another

– theory, and especially theory from other domains of information apart from ‘occupational science’ – such as neuroanatomical, cognitive, behavioural, family systems, attachment theory, biomechanics – I could go on!! need to be systematically reviewed in relation to how they might contribute to ‘the occupational performance problem’ – and this is an incredibly complex assessment model!

– the biomedical model continues to dominate and individual’s needs are ‘diagnosed’ often in terms of ‘deficits’ rather than interactions between an individual with values making daily choices of behaviours and that individuals’ environment

I’m drawing quite heavily on the abductive process in clinical reasoning now – what that means is that I have steeped myself in a number of models that appear to be relevant to pain and pain management.  One of the most prominent models is the cognitive behavioural model.  As a result, while I’m ‘assessing’ a person (translate this to ‘having a conversation with the person so I can begin to understand their situation’), I’m actively looking for patterns in their presentation.  Although they may describe their ‘problems’ at the same time I’m looking for both the good things and the not so good things about what they construe as a ‘problem’.  AND I’m looking at the various cognitive and behavioural (oh and biophysical) things that are potential explanations for the initiation and maintenance of their situation.  I’m actively seeking disconfirmatory evidence throughout the ‘assessment’ process for any hypotheses that I generate during the first contact – so, if they mention difficulty sleeping, feeling tearful, lacking energy – I’m also looking for information that might refute one of my initial assumptions that ‘they’re depressed’ – what else might explain their presentation?

Effectively, I’m broadening out the range of potential explanations that I’ll later need to systematically review.  I’m also eliminating things that I might initially think of as a ‘pattern’ but later I find to be a one-off, or unique event.

As a result of this, I look at both the client and what he or she identifies as ‘problems’, but at the same time attempting to look at strengths, possible explanations, and areas that can be explored in more detail.  This means a significantly increased emphasis on assessment (or, as I prefer to put it, learning to understand their situation).

It’s only once some explanations have been developed that possible options for changing the presentation can be identified.  Otherwise I (and the client) can risk prematurely applying a ‘solution’ that:

  1. doesn’t solve the problem, because it’s focusing on the ‘wrong’ mechanism
  2. creates other problems, because the interaction between that ‘solution’ and the rest of the system hasn’t been considered
  3. prevents uncovering deeper concerns that are maintaining (through inadvertent benefits) the situation

Well, that was a bit of a philosophical ponder!! I hope you followed it – and that you’ll think about dropping me a line to let me know what you think.