1. Problem Statements Steve Wood, Lecturer Practitioner

2. Body FeelingsThoughts Behaviour Underpinning this is a 4-systems view of symptoms

3. 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 danger trembling urge to escape palpitations hot flushes tingling in extremities fear 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

4. Panic attack checklist Physical AffectiveCognitive Behavioural Thoughts of impending doom Images of losing control Sense of immediate danger Urge to escape Feeling unreal Intense fear Fear of going crazy Fear of collapsing/losing control Feeling detached Palpitations Stomach churning Feeling faint Hot flushes Cold sweat Trembling Shaking Feeling smothered Feeling of choking Feeling light-headed Numb extremities Tingling in extremities Nausea Chest pain Take deep breaths Undo buttons Open windows Escape from situation

5. 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 goals Decreased productivity Social withdrawal Agitated behaviour Crying Difficulty making decisions Difficulty solving problems Symptoms of depression

6. Depression checklist Physical AffectiveCognitive Behavioural Pessimistic & recurrently negative thoughts Excessive self-criticism Angry thoughts Brooding about the past Suicidal thoughts Reduced concentration & attention Short-term memory problems Difficulty thinking Mental slowing Loss of pleasure or enjoyment out of life Feelings of depression or sadness Feeling pessimistic Feelings of worthlessness Feelings of hopelessness Feelings of helplessness Excessive or unrealistic fear Excessive guilt Decreased self-confidence Loss of energy Feeling physically “slowed down” Feeling physically unable to settle Sleep disturbance Appetite disturbance Weight loss (without dieting) Somatic anxiety symptoms Decreased libido Crying Snapping at people Decreased productivity Apathy and indifference Difficulty solving problems Social withdrawal Difficulty setting goals Difficulty making decisions Agitated behaviour

7. 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.

8. 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.

9. 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 Pessimistic Feelings of failure Self-dislike Avoid doing jobs around the house Avoid challenges Lethargy Loss 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

10. 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.

11. Problem Statements Problem statements should focus directly on difficulties that: Have been identified by the client during the semi- structured assessment interview Have been written, whenever possible, in the client's own words; this helps reduce the use of jargon and provides meaning to the client Describe the problem in observable behaviours Indicate the impact and consequences the problem has on the client's life-style.

12. Your task is... To work collaboratively with the client to formulate a PROBLEM STATEMENT Start 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.

13. “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…

14. “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…

15. “I worry about my heart” “In terms of your mental health, how would you describe your main problem at the moment?” and this…

16. 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.