Stroke. 2016 Jan;47(1):135-42.
Problem Solving Therapy during outpatient stroke rehabilitation improves coping and HRQoL: randomized controlled trial
Marieke M. Visser, MSc1,2; Majanka H. Heijenbrok-Kal, PhD1,2; Adriaan van ‘t Spijker, PhD3; Engelien Lannoo, PhD4; Jan JV Busschbach, PhD3; Gerard M. Ribbers, MD, PhD1,2
1Department of Rehabilitation Medicine, Erasmus University Medical Center, Rotterdam, the Netherlands
2Rotterdam Neurorehabilitation Research (RoNeRes), Rijndam Rehabilitation Center, Rotterdam, the Netherlands
3Department of Psychiatry, Section Medical Psychology and Psychotherapy, Erasmus University Medical Center, Rotterdam, the Netherlands
4Department of Physical and Rehabilitation Medicine, Ghent University Hospital, Belgium
Background and Purpose: This study investigated whether Problem Solving Therapy (PST) is an effective group intervention for improving coping strategy and health-related quality of life (HRQoL) in stroke patients.
Methods: In this multicenter randomized controlled trial, the intervention group received PST as add-on to standard outpatient rehabilitation, the control group received outpatient rehabilitation only. Measurements were performed at baseline, directly after the intervention, and 6 and 12 months later. Data were analyzed using linear mixed models. Primary outcomes were task-oriented coping as measured by the Coping Inventory for Stressful Situations (CISS) and psychosocial HRQoL as measured by the Stroke Specific Quality of Life Scale. Secondary outcomes were the EuroQol EQ-5D-5L utility score, emotion-oriented and avoidant coping as measured by the CISS, problem-solving skills as measured by the Social Problem Solving Inventory-Revised, and depression as measured by the Center for Epidemiologic Studies Depression Scale.
Results: Included were 166 stroke patients, mean age 53.06 years (SD 10.19), 53% men, median time post-stroke 7.29 months (IQR 4.90-10.61 months). Six months post-intervention the PST group showed significant improvement compared to the control group in task-oriented coping (p=.008), but not stroke-specific psychosocial HRQoL. Furthermore, avoidant coping (p=.039), and the utility value for general HRQoL (p=.034) improved more in the PST group compared to control after 6 months.
Conclusions: PST seems to improve task-oriented coping but not disease-specific psychosocial HRQoL after stroke over 6 months follow-up. Further, we found indications that PST may improve generic HRQoL recovery and avoidant coping.
Clinical Trial Registration–URL: http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=2509. Unique identifier: CNTR2509.
Many patients with stroke experience problems in daily life, which may result in a lower health-related quality of life (HR-QoL).1,2 During stroke rehabilitation HR-QoL improves. However, HR-QoL may decrease again after discharge from rehabilitation,3 because patients have to deal with the consequences of stroke in their home environment without professional support, which may cause frustration and psychological distress.
This study investigated whether Problem Solving Therapy (PST) is effective in improving coping strategy, health-related quality of life (HR-QoL) and depression in patients receiving outpatient stroke rehabilitation. This was investigated using a pragmatic randomized controlled trial, with one year follow-up. Patients were randomly assigned to the intervention or control group. Patients assigned to the intervention group received PST in addition to their standard rehabilitation program, during the last phase of their outpatient treatment. Patients assigned to the control group followed their standard rehabilitation program only.
Problem Solving Therapy (PST) is a widely used and practical intervention method based on a common model of coping with stress, which aims at active problem-focused coping.4,5 PST may provide structure in solving problems of daily life and thus in coping with the consequences of stroke. The intervention was provided in an open group design, with a continuous flow of patients, which means that patients can enter the group every week and leave the group after eight sessions.
The intervention in this study consisted of eight group sessions once a week, with homework exercises after each session. Solving problems was structured, by dividing the problem solving process in four steps:  Define problem and goal;  Generating multiple solutions;  Considering the possible consequences of the solutions systematically and select the best solution;  Implement the solution and evaluate. These steps were rehearsed several times in the interactive group sessions.
Patients who were assigned to the control condition received the standard rehabilitation program only, in order to study the additional effect of the intervention to the standard rehabilitation program. This standard rehabilitation program consisted of individualized treatment by a physical therapist, occupational therapist, speech therapist, psychologist, social worker, and rehabilitation physician, depending on the severity of stroke. On average, stroke patients in outpatient rehabilitation receive twelve hours of treatment a week during a nine week rehabilitation program.
Task-oriented coping and stroke-specific psychosocial HR-QoL were primary outcome measures in the study, depression a secondary outcome measure. The results showed that PST improved task-oriented coping but not disease-specific psychosocial HR-QoL over 6 months follow-up. Indications were found that PST also improves generic HR-QoL recovery, but not depression. This suggests that adding PST to outpatient stroke rehabilitation is effective in optimizing coping skills and HR-QoL recovery after discharge. PST additional to post-acute stroke rehabilitation seems to prevent a drop in HR-QoL after rehabilitation discharge, which was the aim of the study. It is promising that PST shows effect on coping strategy and general HR-QoL at 6 months follow-up. However, the effects were no longer significant after 12 months.
There are several components of the intervention which can explain the effects found. An important component will be the specific ingredients of PST combined with general psychological techniques such as the Socratic dialogue and cognitive behavioral techniques. An important specific aspect of the intervention might be repeating the four steps in the problem solving process multiple times. Although PST is highly manualized, the therapeutic alliance is important as well.6 The psychologist has important value in creating a therapeutic alliance, both with individuals in the group and between the members of the group, and in optimizing the group dynamics. These interactive group dynamics are as a strong component of the therapy. Positive aspects of group therapy are modeling, recognition, sharing and peer support.
The PST intervention in our study was designed as an open group intervention; new members participated in the group together with ‘experienced’ patients. This open group design has not been investigated in PST research before. To evaluate the subjective experience of the (open) intervention group, a subjective patient evaluation of the group therapy was conducted. The patients who followed the intervention evaluated the therapy with a mean ‘school grade’ of 7.4 on a scale from 0 to 10 (SD=1.0). This Dutch ‘school grade’ equals an A/A- in the United States. The results of the patient evaluation indicated that the majority of patients (80%) evaluated the training as useful and informative. Most patients (82%) appreciated the group interaction as positive and helpful. The professional skills of the PST teachers were good, according to 93% of the participants. The skills learned in PST training are applied in daily life situations by 61% of the participants. All patients would recommend the training to other stroke patients. These results indicate that PST group therapy is feasible and useful for patients with stroke from a patients perspective. The patient evaluations are obviously subjective, but the low dropout rate in our study supports this conclusion.
In summary, the results of our study showed that, from a patients perspective, PST is a useful and feasible therapy for patients with stroke in outpatient rehabilitation treatment. The results suggest that adding PST to standard outpatient rehabilitation is beneficial for patients within the first year after stroke; patients should try this type of therapy to improve their coping skills and to optimize general HR-QoL recovery.
- Smout S, Koudstaal PJ, Ribbers GM, Janssen WG, Passchier J. Struck by stroke: a pilot study exploring quality of life and coping patterns in younger patients and spouses. Int J Rehabil Res. 2001;24:261-8.
- Sturm JW, Donnan GA, Dewey HM, Macdonell RAL, Gilligan AK, Srikanth V, Thrift AG: Quality of life after stroke – The North East Melbourne Stroke Incidence Study (NEMESIS). Stroke 2004, 35(10):2340-2345.
- Ch’ng AM, French D, McLean N: Coping with the Challenges of Recovery from Stroke Long Term Perspectives of Stroke Support Group Members. Journal Of Health Psychology 2008, 13(8):1136-1146.
- Nezu AM, Perri MG, Nezu CM, Berking M: Problem-solving therapy for depression: theory, research, and clinical guidelines. New York: Wiley; 1989.
- Nezu AM, Nezu CM: Problem Solving Therapy. Journal of Psychotherapy Integration 2001, 11(2).
- Nezu CM, Nezu AM, Colosimo MM. Case formulation and the therapeutic alliance in contemporary problem-solving therapy (PST). J. Clin. Psychol. 2015;71(5):428-438.