CEDAR

Clinical Education Development and Research

Problem Solving

in Low Intensity CBT

(Physical Health Series)

Paul Farrand & Hayley Foord

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 Acknowledgement:

This booklet is based on the material included within ‘Reach Out: National Programme Educator Materials to Support
the Delivery of Training for Psychological Wellbeing Practitioners Delivering Low Intensity Interventions’.

©2012 The right of Paul Farrand and Hayley Foord to be identified as the authors of this work has been asserted by
them in accordance with the Copyright, Designs and Patent Act, 1998. All rights reserved. The booklet has been
produced on the condition that it shall not, by way of trade or otherwise, be lent, sold, hired out or otherwise circulated
in any form binding or cover other than that in which it is published and without a similar condition including this
condition being imposed on the subsequent reader.

Providing the source is fully acknowledged, all materials in this work may be freely copied, but for clinical purposes
only.

Image above: Clinical Training (CEDAR) at the University of Exeter’s Streatham Campus. Image right: The Sir Henry
Wellcome Building for Mood Disorders Research at the University of Exeter.
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 Contents
Part 1
Doing Problem Solving: The Seven Steps

Part 2
Problem Solving Worksheet A

Part 3
Problem Solving Worksheet B

Part 4
Problem Solving Worksheet C

Part 5
Recovery Story of Derek

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 About the authors
Dr Paul Farrand is a BABCP accredited Cognitive
Behavioural Psychotherapist, Director of Psychological
Wellbeing Practitioner training within Clinical Education
Development and Research (CEDAR) at the University
of Exeter and a National Teaching Fellow of the Higher
Education Academy (HEA). His main clinical and research
interests are in the area of low intensity cognitive
behavioural therapy (CBT), especially in a self-help
format. Based upon his research and clinical practice he
has developed a wide range of written self-help
treatments for depression and anxiety. He has operated
at a national level with the Department of Health
education, training and accreditation committees and
within the British Association of Behavioural and
Cognitive Psychotherapies.

Hayley is an Associate Lecturer with the IAPT Low

Intensity teaching team training Psychological Wellbeing
Practitioners (PWPs). With a background of working
within mental health in a variety of settings, Hayley
started as a student on the Low Intensity Post Graduate
Certificate in Evidence Based Psychological Practice in
September 2009. Whilst working as a Senior PWP Hayley
obtained her BABCP accreditation and is currently
studying towards her Post Graduate Diploma. In
addition to training PWPs, Hayley delivers training on
Long Term Conditions throughout the region and will be
teaching on the new BSc Applied Psychology (Clinical)
programme at the University of Exeter beginning autumn
2012.

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 Part 1 Doing Problem Solving:
The Seven Steps

When we are depressed or anxious our problems can sometimes feel

overwhelming, like there are no solutions. Problem solving is an evidence-
based intervention that helps you initially distance yourself from your
problems to help you think about different types of practical solutions that
there may be. Problem solving has seven steps and can be supported by
your Psychological Wellbeing Practitioner.

Step 1: Identify the Problem Step 3: Analyse Strengths and

Weaknesses
Your Psychological Wellbeing Practitioner will help you
identify a problem to work on as clearly and precisely as
Use Worksheet B to subject each potential solution
possible. This may be working towards reaching one of
to an analysis of its strengths and weaknesses, to assess
your goals you will have already identified and
the main advantages and disadvantages of each
discussed. You should seek to break each problem
solution. Advantages and disadvantages can refer to
down into its major parts. For example a financial
the likelihood of success, possibility of being able to
problem can be broken down into the components of
undertake the solution, resources etc. In the final
debt, income and expenditure.
column, put a ‘yes’ for potential solutions you may
want to try out, ‘maybe’ for those you will give further
thought to later on and ‘no’ to those that you feel you
can reject at this time.
Step 2: Identify the Solution

You should then try to identify as many potential

solutions as possible. At this stage, nothing should be
rejected, no matter how apparently ridiculous solutions
Step 4: Select a Solution
may seem. Solutions can be generated to address
different parts of the problem identified in Step 1.
You should now choose a solution based on the
analysis of strengths and weaknesses in Step 3. Pay
attention to the resources available to undertake the
selected solution. This is important since choosing a
solution that cannot be undertaken will only lead to a
failure.

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 Step 5: Plan Implementation Remember the seven rules
of Problem Solving:
The solution you have chosen may require careful
planning. Therefore you should seek to outline the
steps you will take and any resources you have 1. Identify the Problem
identified may be needed. Try to ensure that the steps
are specific, linked and realistic. Your Psychological
Wellbeing Practitioner will likely help you to do this
2. Identify the Solution
using the ‘Four Ws’ – what, where, when, with whom –
to help you develop your implementation plan. 3. Analyse Strengths and
Weaknesses
Step 6: Implementation 4. Select a Solution
Now you have developed your solution, it is all about 5. Plan Implementation
putting your solution into action. Use Worksheet C
to record what you did and how it went. This will help 6. Implementation
you and your Psychological Wellbeing Practitioner
highlight things that went well or discuss things to do 7. Review
differently next time if needed.

Step 7: Review

You should also use Worksheet C to review how well

your solution worked. Maybe it worked a little or not
at all. The advantage of problem solving is that
alternative options always exist. With the aid of your
Psychological Wellbeing Practitioner this section will
be used to gather information on the progress of your
plan. If the solution has worked, you should continue
to apply the solution or think about generating new
ones, based on what you learnt here, to apply to other
problems. If it did not work, then perhaps go back to
Step 4 and consider adopting a new solution to try.

Remember

Keeping records of how you did using problem

solving is essential for you and your Psychological
Wellbeing Practitioner to review your progress and
help you problem solve any difficulties.

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 Part 2
Problem Solving
Worksheet A

Problem Solving
STEP 1 Problem Identification
Write the problem you want to try and solve here.

STEP 2 Solution Identification

What solutions are there? Don’t reject anything at this stage, however silly it may
seem!

STEP 3 Strengths and Weaknesses Analysis

What are the strengths and weaknesses for each solution?
Use worksheet B to write these down for each solution considered.
STEP 4 Solution Selection
Review strengths and weaknesses on worksheet B, select a solution and write it
below.

STEP 5 Implementation Plan

What steps will you take to apply your solution?

STEP 6 Implementation
What did you do? Use worksheet C to keep a diary of exactly what you did.
STEP 7 Review
How did it go? Use worksheet C to review how well your solution worked.
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Part 3 Problem Solving
Worksheet B
Strengths and Weaknesses Analysis
What are the strengths and weaknesses for each solution? For each solution considered write these below.
Solution Strengths Weaknesses Choice
yes/no/maybe

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Part 4 Problem Solving
Worksheet C

What Did You Do and How Did It Go?

STEP 6 Implementation
What did you do? Write below exactly what you did.

STEP 7 Review
How did it go? Write below how well your solution worked.

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 Part 5 Derek’s
Recovery Story

Derek’s story is about someone who used problem solving to help him
improve his low mood and quality of his life following his kidney failure and
having to undertake weekly dialysis.

Derek is 62 years old and four years ago was diagnosed having the appointment would likely be the lesser of
with end stage renal failure. As his illness progressed two evils especially when compared to the wrath of
over the course of these four years he slowly went from Vera.
working full time, being fully involved in family life
with a passion for indoor bowling to giving up work, Initially during the appointment Derek felt his
withdrawing from his family and no longer playing his scepticism was well deserved. He found that he was
beloved bowls. Now he had started dialysis three times talking to Sarah, a Psychological Wellbeing Practitioner,
per week, his life had basically been reduced to visiting about the things ‘going through his head’, and ‘what he
the hospital, watching tv and sleeping. This was was doing more or less of’, and how he ‘felt in his body’.
affecting his mood, his relationships with his family and To begin with none of this made sense or seemed to
in a strange sort of way he felt alone. recognise that he was down because he was ill.

One day whilst on dialysis, Tom, another dialysis However once Sarah began to explain how giving up
patient, started to talk about how he got so low that his on things or his common thoughts that ‘He could no
wife had ‘dragged him’ along to see the longer do anything now he was ill’ all impacted upon
psychologist in the renal unit. The psychologist had each other and could make him feel worse physically as
explained how there was help out there and could help well, he started to take notice. At the end of the
him make a referral to the local ‘Speak Easy’ service, assessment he could see more clearly how, although his
which could be accessed through his GP practice. Derek dialysis may indeed make him feel more exhausted
was very unsure about all of this however. How could and sleepy, his physical feelings could also be made
anyone help him with his low mood when anyone worse because of his low mood. Also for the first time
would be depressed having to be on dialysis most of Derek could begin to see that just being on dialysis
the time and feeling unwell the rest! However later that need not necessarily make him depressed.
evening when Derek was recounting this discussion to
his wife Vera, the conversation was hardly over before Discussing the appointment with Vera on the way
Vera was on the phone and had made an appointment home he also realised that being on dialysis did not
with the ‘Speak Easy’ service. necessarily have to lead to low mood. If it did how
come so many of his fellow patients were not
Ten days later Derek found himself in the waiting room depressed! Just as they entered the drive way, Vera
waiting for his ‘Speak Easy’ appointment. He was still thanked him for talking to her about his low mood.
very sceptical about all this. However, he felt that She noted that in the last year or so she had seen him

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getting lower and lower yet he had never mentioned
this to her. For the first time in a couple of years Derek
also felt that he was not so alone with his illness and
perhaps he was not a lost cause.

The following week Derek turned up to his

appointment, feeling a little less sceptical. During the
session Sarah first recapped his week and checked his
understanding about how the way he feels
emotionally about his illness may also be impacting
upon his physical health as well as the obvious This made a lot of sense to Derek as upon reflection he
consequences of his illness. After discussing this they realised his reluctance to revise goals often meant he
collaboratively discussed the range of interventions was setting hurdles too high.
that may be helpful for Derek. In particular they
discussed something called problem solving. Derek Sarah first encouraged Derek to select a problem that
found that he was particularly drawn to problem he felt he would like to work on. Although Derek was
solving, feeling that this was a good practical way to try aware it may have sounded silly, he really felt that were
and work his way out of his depression. he able to start playing bowls again then it would
really help to lift his mood. Whilst choosing this as the
At times he had felt a little helpless to try and deal with problem however Derek was less than convinced that
the many challenges that being a dialysis patient it could be solved as he had stopped playing in the first
presented him with. Sarah talked through problem place because he often felt so exhausted after dialysis.
solving and how there was good evidence to support
its use amongst people who had depression as well as With the aid of his Psychological Wellbeing Practitioner
a long term illness. She then discussed how to do it and Derek decided on the following goals, some of which
talked him through a ‘recovery guide’. he found were slightly revised from previous goals
given he had to take account of some of the physical
However before starting problem solving, Sarah limitations imposed by his dialysis.
highlighted the value in setting some goals, and
suggested how sometimes the goals set by patients Derek began by writing his problem into Step 1 on
with long term conditions had to be revised from those Worksheet A. Using the space below he was then
they had before they become ill. encouraged to identify as many solutions as possible to
help him solve his problem. Derek started off really
easily but after identifying a couple of solutions began
to struggle. Sarah really helped at this point
Problem solving helps encouraging him not to rule anything out too early on,
but to include everything.
patients to step back
This really helped as although Derek initially identified
from their problems, ‘Stop dialysing’, which even when writing it down
generate potential sounded like a silly idea, it did help him to think about
‘Change type of dialysis’ which may be a better
solutions and then idea. After Derek had identified a few solutions he was
encouraged to move on to Step 4 and start to think
choose and about the strengths and weaknesses for each. Sarah did

implement these. encourage him however to continue adding to the list

of potential solutions between sessions as they may
occur to him, or in conversation with Vera.

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 Derek’s Goals
Goal number 1

To play bowls again with John on Today’s date: 6th June

times when feeling physically able
I can do this now (circle a number):
0 1 2 3 4 5 6
Not at all Occasionally Often Anytime

Goal number 2
To do more less physically demanding Today’s date: 6th June
activities with my grandkids
I can do this now (circle a number):

0 1 2 3 4 5 6

Not at all Occasionally Often Anytime

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Derek’s Problem Solving
Worksheet A

Problem Solving

STEP 1 Problem Identification

Write the problem you want to try and solve here.
To be able to play bowls again with John even though I often feel tired and
exhausted after dialysis.
STEP 2 Solution Identification
What solutions are there? Don’t reject anything at this stage, however silly it may
seem!
-Give up bowls -Change type of dialysis
-Identify if during the week there -Identify different type of
are times I feel better to play bowls bowls to play
-Stop dialysing
STEP 3 Strengths and Weaknesses Analysis
What are the strengths and weaknesses for each solution?
Use Worksheet B to write these down for each solution considered.
STEP 4 Solution Selection
Review strengths and weaknesses on Worksheet B, select a solution and write it
below.
Identify if during the week there are times I feel better to play bowls
STEP 5 Implementation Plan
What steps will you take to apply your solution?
Develop a ‘how do I feel physically scale’
Use the scale every day over the next week to rate how I feel.
Next Tuesday identify if I have any better times to play bowls.
If any better times contact John on Tuesday to arrange a game of bowls for
the next week.
STEP 6 Implementation
What did you do? Use Worksheet C to keep a diary of exactly what you did.

STEP 7 Review
How did it go? Use Worksheet C to review how well your solution worked.
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 Derek now moved on to Worksheet B where he was
asked to write down all the potential solutions
identified in Step 2 and write down all the strengths
and weaknesses for each. Derek found this quite an
easy task to do and having to do it in a clear and
structured manner really helped. For some of the
solutions identified Derek was quickly able to realise
that there were no strengths and Sarah encouraged
him to leave these blank. After Derek had identified at
least one strength and/or weakness for each solution
Sarah encouraged him to carry on thinking about these
and adding them between sessions.

He was then asked to move to Step 3 and review the

strengths and weaknesses identified and to use this to
choose a solution to try out or reject ones that were
not appropriate. Two potential solutions jumped out
to Derek – ‘Change type of dialysis’ or ‘Identify
if during the week there are times I feel better to
play bowls’. Whilst both seemed good solutions Derek
decided to go with ‘Identify if during the week there
are times I feel better to play bowls’ as he felt this was
something he could start straight away. He wrote this
in Step 4 in Worksheet A. He was now encouraged
to think about the steps he needed to take to apply his
solution. The first thing that sprung to mind was how
would he know when he felt better or worse? Sarah
helped him to think about developing some type of
diary that he could use to rate how he felt, using a scale
from 1 to 10 where 1 equalled ‘terrible’ to 10 ‘great’.

After this Derek then broke the solution down into a

number of different steps, with Sarah helping him to
make his plan to do these as explicit as possible, where
necessary helping him to state a time. Derek found this
really helpful as he could see that by breaking a larger
solution down into smaller steps each step did not
seem so overwhelming.

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 Problem
Derek’s Worksheet B
Solving

Strengths and Weaknesses Analysis

What are the strengths and weaknesses for each solution? For each solution considered write these below.
Solution Strengths Weaknesses Choice
Yes/No/Maybe
Give up bowls I would not have to worry about I really used to enjoy bowls and would
not being well enough to play. lose all my friends. Maybe

Identify different type I really enjoy my indoor bowls. Can only

of bowls to play think about short mat bowls as an option Maybe
and don’t see how this would be easier.

Stop dialysing Really silly idea, I would be dead! No

Change type of dialysis Never thought of it before but the nurse did Even if I was able to change dialysis it would
mention different types of dialysis and take a long time and may need extra surgery Yes
perhaps one would be better suited to me? etc.

Identify if during the week Never really thought to see if there are What if I find out I feel really lousy all the
there are times I feel better times I feel better or worse after dialysis? time, this could make me feel even worse. Yes
to play bowls If there was, then knowing this would
help.

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 All that was now left was for Derek to actually put his
solution into action. He was encouraged to do this over
the course of the next week and to use Worksheet C
as a kind of diary, to record what he had done, and how
well things had gone for him.

The following week Derek turned up to the session

with Sarah, with Workbooks in hand. After reviewing
the problem statement and completing the measures
Derek was delighted to tell Sarah how he had got on.
Overall he had done what was planned and felt it was a
really positive experience. Discussing what he had
written in Worksheet C with Sarah, he could see that
he had learnt a lot. Not least that although he might
have thought he always felt ill; in fact his health did vary
during the week. Generally he felt very tired on the
mornings before he dialysed, exhausted afterwards
and later into the evenings. However he was surprised
to see that overall he felt a lot better the day following
dialysis, especially from lunchtime onwards. He also
noted that he felt quite good over most of the weekend
when he did not dialyse.

Using this knowledge Derek was able to put the final

part of his solution into play and phone John to
organise a bowling time based around times when he
felt better. Derek was now looking forward to his
bowling later that week and was keen to see how it
goes. He had also decided to use problem solving to
see about trying to select an activity for the weekend
he felt he could physically cope with for him to do with
his family and young grandchildren.

Later that week Derek went bowling with John and

thoroughly enjoyed it. Although he was a bit more tired
than he used to be at the end of the game he felt this
was well worthwhile and for this first time actually
began to see that possibly he could have a life on
dialysis.

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Problem Solving
Worksheet C
What Did You Do and How Did It Go?
STEP 6 Implementation
What did you do? Write below exactly what you did.
I used the scale developed with Sarah to rate how I felt physically during the
day. Although I started off finding it hard to think about this using a 10
point scale, I soon got used to it and actually found it helpful.

This morning I discussed the diary with Vera and noticed that how I feel
physically did vary during the week. Noticing that there were better and
worse times I was able to identify that I tend to feel more tired the morning
before dialysis, and after dialysis. However this made me aware that the day
I don’t dialyse, especially from lunchtime I tend to feel not too bad, and also
over most of the weekend when I don’t dialyse.

Knowing this I got in touch with John and we have now booked to go
bowling on Thursday lunchtime.

STEP 7 Review
How did it go? Write below how well your solution worked.
I think this went really well. It really helped knowing how I felt over the week,
not only as this helped me to solve how best to go bowling and link it with
my dialysis and how I felt, but also to help me realise that I don’t feel really
bad all the time. I can do things. I will see how I feel and do manage after
bowling, but at least I am going to give it a try.

Breaking things down really helped and it was good to include everything
when thinking about solutions. Doing this was also helpful as I involved
Vera, and had not realised really how I had cut her out of all this, when
previously we shared everything.

I am planning to organise a day out with my daughter and grandkids as

well now on Saturday. I am aware that this will be a bit more strenuous, so
plan to use problem solving again to think about different types of activities
to do, or different things I can do to help me keep up with an active 6 and 4
year old. This really helped thanks.

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 Part 2
Problem Solving
Worksheet A

Problem Solving
STEP 1 Problem Identification
Write the problem you want to try and solve here.

STEP 2 Solution Identification

What solutions are there? Don’t reject anything at this stage, however silly it may
seem!

STEP 3 Strengths and Weaknesses Analysis

What are the strengths and weaknesses for each solution?
Use worksheet B to write these down for each solution considered.
STEP 4 Solution Selection
Review strengths and weaknesses on worksheet B, select a solution and write it
below.

STEP 5 Implementation Plan

What steps will you take to apply your solution?

STEP 6 Implementation
What did you do? Use worksheet C to keep a diary of exactly what you did.
STEP 7 Review
How did it go? Use worksheet C to review how well your solution worked.
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 Part 2
Problem Solving
Worksheet A

Problem Solving
STEP 1 Problem Identification
Write the problem you want to try and solve here.

STEP 2 Solution Identification

What solutions are there? Don’t reject anything at this stage, however silly it may
seem!

STEP 3 Strengths and Weaknesses Analysis

What are the strengths and weaknesses for each solution?
Use worksheet B to write these down for each solution considered.
STEP 4 Solution Selection
Review strengths and weaknesses on worksheet B, select a solution and write it
below.

STEP 5 Implementation Plan

What steps will you take to apply your solution?

STEP 6 Implementation
What did you do? Use worksheet C to keep a diary of exactly what you did.
STEP 7 Review
How did it go? Use worksheet C to review how well your solution worked.
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Part 3 Problem Solving
Worksheet B
Strengths and Weaknesses Analysis
What are the strengths and weaknesses for each solution? For each solution considered write these below.
Solution Strengths Weaknesses Choice
yes/no/maybe

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 Part 3 Problem Solving
Worksheet B

Strengths and Weaknesses Analysis

What are the strengths and weaknesses for each solution? For each solution considered write these below.
Solution Strengths Weaknesses Choice
yes/no/maybe

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 Part 4 Problem Solving
Worksheet C

What Did You Do and How Did It Go?

STEP 6 Implementation
What did you do? Write below exactly what you did.

STEP 7 Review
How did it go? Write below how well your solution worked.

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Part 4 Problem Solving
Worksheet C

What Did You Do and How Did It Go?

STEP 6 Implementation
What did you do? Write below exactly what you did.

STEP 7 Review
How did it go? Write below how well your solution worked.

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 University of Exeter
Washington Singer Building
CEDAR
Clinical Education Development and Research
Perry Road
Exeter EX4 4QG
United Kingdom

To download a copy of this workbook go to:

www.exeter.ac.uk/cedar
Photography by: Sanja Gjenero, Jesse Therrien, Jesús Manuel Nieto Bobadilla

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