Impact Of Problem Solving

Others have also looked to problem-solving training as a potentially important intervention strategy to help cancer patients and their families. For example, Fawzy et al. developed a multicomponent treatment package that included PST and focused on patients who were newly diagnosed with malignant melanoma.60 Cancer patients were randomly assigned to one of two conditions—a 6-week structured group intervention that included PST, stress management training, group support, and health education, and a no-treatment control. At the end of six weeks, patients receiving the structured intervention began showing reductions in psychological distress as compared to control participants. However, six months posttreatment, the group differences were very pronounced. Moreover, five years following the intervention, treated patients continued to show significantly lower levels of anxiety, depression, and total mood disturbance.61

In addition, at the end of the original 6-week program, patients receiving the treatment evidenced significant increases in the percentage of large granular lymphocytes, suggesting a positive treatment effect on immune functioning. Further, six months posttreatment, this increase in granular lymphocytes continued and increases in natural killer cells were also evident. Last, although not originally structured to determine the effects of treatment on actual health outcomes, it was found six years posttreatment that treated patients experienced longer overall survival as compared to control participants, as well as a trend for a longer period to recurrence for the treated patients.62 This same intervention was later adapted for a Japanese population and found to be effective for Japanese women with breast cancer.63

Mishel et al. paired training in problem solving with a cognitive reframing strategy as a means of helping 134 Caucasian and 105 African-American men with localized prostate carcinoma to manage their levels of uncertainty and symptom control.64 Participants were randomly assigned to one of three experimental conditions—the combined psychosocial treatment provided only to the patient himself, treatment provided to the patient and a selected family member, and the control ("medical treatment as usual"). Both forms of treatment were provided by trained nurses through weekly phone calls for eight weeks. In general, regardless of ethnicity, participants who received either form of the intervention improved significantly as measured at the 4-month post-baseline assessment. It is during this period of time that cancer treatment side effects are most prevalent. As such, it is particularly noteworthy that the combined PST and cognitive reframing treatment led to significant improvement in control of incontinence at 4-months post-baseline.

Allen et al. assessed the efficacy of PST, as compared to a no-treatment control, with regard to a population of 164 women diagnosed with breast cancer and for whom a first course of chemotherapy had been recently initiated.65 PST consisted of two in-person and four telephone sessions with an oncology nurse who provided problem-solving skills training to the women over a 12-week period. This treatment program was designed to empower women with breast carcinoma to cope more effectively with a range of difficulties when diagnosed in mid-life. Participants in both conditions were assessed for physical and psychosocial adjustment.

At a 4-month evaluation, participants in general tended to have significantly less unmet needs and better mental health as compared to baseline. At the 8-month assessment, differences between the treated and control conditions emerged, pointing to the efficacy of the training. In general, PST led to improved mood and more effective coping with problems associated with daily living tasks. Further, the intervention was effective for the majority of women in resolving a range of problems related to cancer and its treatment, including physical side effects, marital and sexual difficulties, and psychological problems. However, an unexpected finding emerged with regard to women who had baseline scores characteristic of "poor problem solving." In essence, such individuals, relative to the control participants, were less likely to resolve such cancer-related problems. Qualitative analyses suggested that such individuals became especially overwhelmed by expectations to "go it alone" after only one in-person treatment session. As such, these authors concluded that an important outcome of this study was the advisability of prescribing treatment based on one's level of need or risk. In other words, for individuals who are initially identified as poor problem solvers, a more intensive program (e.g., more face-to-face sessions) may be necessary as compared to those who at baseline are average or good problem solvers.

A study by Given et al. focused on 237 adult cancer patients recently diagnosed with a solid tumor and who were undergoing a first course of chemotherapy.66 Participants were randomly assigned to either a "symptom management intervention" or conventional care. The cognitive-behavioral intervention was based on the PST model of D'Zurilla and Nezu67 in order to generate a listing of possible strategies to provide to patients and their caregivers in order to more effectively cope with a variety of cancer-related problems (e.g., alopecia, depression, fatigue, pain, insomnia). Based on discussions between a nurse and patient-caregiver dyad, various interventions were selected for implementation. Treatment occurred within ten contacts (in person and telephone) over the course of 20 weeks.

Results indicated that treated patients who had higher baseline symptom severity levels reported lower depression at ten, but not 20 weeks. Unexpectedly, patients in the experimental condition characterized by higher baseline depression were found to be more depressed at ten weeks that control patients. Further, the intervention was found to be more effective in lowering depression at ten weeks as a function ofits impact on other symptoms rather than on depression directly. However, at 20 weeks, a significant main effect for treatment on depression was not identified. As such, these authors concluded that the intervention influenced depression differentially over time. Specifically, it appeared to lower depression through enhanced ability to manage symptoms unrelated to depression and only later did it impact depression directly.

In a subsequent assessment of the impact of this intervention on the limitations imposed on patients by symptoms of cancer and its medical treatment, Doorenbos et al. recently reported that on average, after ten weeks, patients receiving the problem-solving based intervention reduced such symptom limitations by a statistically significant 13 points more than the control group.68 Moreover, this positive treatment effect was maintained over the course of the remainder of the treatment. Parenthetically, these authors concluded that this intervention was particularly helpful for younger individuals in managing cancer-related symptom limitations.

With regard to problem-solving interventions for family caregivers of cancer patients, Toseland et al. reported a study that evaluated the efficacy of an intervention for spouses of cancer patients that included support, problem-solving, and coping skills.69 Forty male and forty female spouses of cancer patients were randomly assigned to this intervention or a "usual treatment" condition. Results indicated that little change occurred over time for caregivers in either the treatment or control condition. However, this lack of effects were probably due to the low level of distress and problems that existed across this sample at pretreatment. Thus, when focusing on a subsample of distressed caregivers, significant effects were in fact evident. For example, distressed caregivers undergoing the PST-based intervention were found to significantly improve in their physical, role, and social functioning, as well as their ability to cope with pressing problems. The actual cancer patients related to this subsample of distressed caregivers receiving the intervention were also found to be significantly less depressed at posttreatment. Moreover, in a subsequent 6-month post-baseline follow-up, it was found that, overall, patients whose spouses received the PST intervention became significantly less depressed than did control patients.70

Schwartz et al. assessed the impact of a brief PST intervention regarding cancer-specific and general distress among 341 women with a first degree relative who had recently been diagnosed with breast cancer.71 This investigation included two conditions: PST and a general health counseling (GHC) protocol. Both interventions were conducted during a single 2-hour individual session with a health educator. Initial analyses indicated that both approaches equally led to decreases in cancer-specific and general distress. However, when PST participants were divided into those who practiced the skills and those who did not, significant differences did emerge. Specifically, "PST-practicers" had significantly greater decreases in cancer-specific distress compared to both "non-practicers" and GHC participants. In addition, controlling for baseline education and distress differences between the groups did not reduce the magnitude of these results.

Adding to this same sample to eventually include 510 women who had a first-degree relative with breast cancer, a different question was now asked—does a brief PST intervention increase the likelihood of adherence to breast self-examination?72 Whereas initial results found no differences between conditions, a cancer-specific distress by treatment interaction was identified. Specifically, among women who participated in the PST condition, those with high levels of distress were two times more likely to improve in adherence than women low in cancer-specific distress. No such effect was identified among control participants. The authors suggest that women with a family history of breast cancer who have high levels of distress may be most likely to benefit from PST when attempting to promote adherence to breast cancer screening.

Sahler et al. focused on the well-being of mothers of newly diagnosed pediatric cancer patients.73 Ninety-two such mothers were randomly assigned to one of two conditions—PST and a control (standard psychosocial care). The problem-solving intervention consisted of eight 1-hour individual sessions and was adapted for this population based on the work of D'Zurilla and Nezu.67 At posttreatment, results indicated that mothers in the PST condition has significantly enhanced problemsolving skills and significantly decreased negative affectivity as compared to their control counterparts. Moreover, analyses revealed that changes in self-reports of problem-solving behaviors accounted for 40% of the difference in mood scores between the two conditions. In addition, the intervention appeared to have the greatest impact on improving constructive problem solving, whereas improvement in mood was most influenced by decreases in dysfunctional problem solving.

In an extension of their previous investigation, Sahler et al. further assessed the efficacy of PST among a sample of 430 English- and Spanish-speaking mothers of pediatric cancer patients.74 Again, the 8-week PST condition was compared to a usual care control. Replicating their previous work, results from this study indicated that mothers receiving the PST protocol reported significantly enhanced problemsolving skills and significantly decreased negative affectivity. Whereas treatment effects appeared to be greatest at posttreatment, several differences were maintained at the 3-month follow-up. Interestingly, the efficacy of PST for Spanish-speaking mothers exceeded that for English-speaking mothers. Moreover, results suggest that young, single mothers befitted the most from the problem-solving intervention.

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