PROJECT FOCUS: Problem-Solving Training for Family Caregivers with Spinal Cord Injuries

PROJECT FOCUS: Problem-Solving Training for Family Caregivers with Spinal Cord Injuries


Timothy R. Elliott, PhD
Department of Educational Psychology
Texas A&M University
College Station, TX


Developed in 1996 with support from the Centers for Disease Control, Project FOCUS is an individualized problem-solving intervention provided to family caregivers of persons with spinal cord injuries to benefit caregivers and their care recipients. FOCUS represents the essential principles of effective problem solving: obtaining Facts, being Optimistic, the benefits of Creativity, the importance of Understanding all aspects of a potential solution, and the steps associated with Solving the problem. Benefits to caregivers found in research trials include:

1) Decrease in dysfunctional problem-solving approaches
2) Beneficial effects on caregiver social functioning
3) Decreases in caregiver depression
4) Increases in care recipient social functioning
5) Benefits observed in brief (three sessions) face-to-face administrations and when provided in monthly sessions conducted via videoconferencing to caregivers in the home 

FOCUS can be modified for alternative models of delivery; evidence was obtained in three face-to-face sessions in addition to printed educational materials and phone boosters over 12 months, and in monthly sessions conducted via videoconferencing with caregivers. 

A critical and unique aspect of the FOCUS model is the use of a card sort technique to help caregivers identify their problems, prioritize problems, and to stimulate solutions to those problems. 


• Project FOCUS was patterned on an application of problem-solving training for cancer survivors (Nezu, Nezu, Friedman, Faddis, & Houts, 1998) and adapted for use with family caregivers of persons with spinal cord injuries. 
• Prior research by the principal investigator established the importance of effective problem-solving in caregiver adjustment and well-being (Elliott, Shewchuk, & Richards, 2001), and links between caregiver problem-solving abilities and care recipient adjustment were also established (Elliott, Shewchuk, & Richards, 1999). 
• To obtain detailed information about the nature and context of problems that caregivers face following spinal cord injury, focus groups were conducted with family caregivers and care recipients (Elliott & Shewchuk, 2002). This information was critical in assembling the card sort task to teach caregivers problem identification and prioritizing skills. 


• Recent spinal cord injury
• Chronic spinal cord injury
• Similar protocols have been developed by these researchers for other populations:
o Severe disabilities (including cerebral palsy, intellectual disabilities)
o Traumatic brain injuries



Descriptions of the brief (Kurylo, Shewchuk, & Elliott, 2001) and monthly applications via videoconferencing (Rivera, Shewchuk, & Elliott, 2003) were published in the peer-reviewed literature. More detail about the overall PST model and the card sort procedures can be found in Elliott and Shewchuk (2000). 


• Social Problem-Solving Inventory-Revised 
• Inventory to Diagnose Depression 
• SF-36
– administered at baseline, 6 months and 12 months.


Available upon request. 


12 months


Number of sessions range from three face-to-face in a brief application to monthly sessions in the videoconferencing application. 


The first session with the caregiver required approximately 2-3 hours in a face-to-face session to conduct the baseline assessment and provide the orientation. Subsequent sessions may range from 30 to 90 minutes, depending on the needs and issues presented by the caregiver. 


In the initial project with caregivers of persons with recent-onset SCI, the first session occurred either in the caregiver residence or in a clinic office in the event that the caregiver was on-site and wanted to begin. In the application using videoconferencing, caregivers were initially seen in the home. Manuals containing information about problem-solving principles were also provided in the first session. 

Subsequently, caregivers received (a) telephone contacts and booster sessions, as needed, (b) mailings of educational materials as deemed necessary by the project coordinator and as requested by a participant, and (c) follow-up booster sessions via telephone as requested by a participant.

In the initial session, participants were oriented to the basic steps of the problem solving process: (a) problem definition, (b) optimism and positive orientation toward problem solving, (c) creativity and generating alternatives, (d) understanding and decision-making, and (e) solving the problem with implementation and evaluation of a solution. The interventionist presented the principles of Project FOCUS: obtaining Facts, being Optimistic, the benefits of Creativity, the importance of Understanding all aspects of a potential solution, and the steps associated with Solving the problem identified in each card-sort administration (see Kurylo et al., 2001 for more details). 

Subsequent sessions were conducted as described in the separate applications. Materials that were mailed to caregivers upon request included information on matters related to SCI and its management (urinary tract infections, pressure sores, sexuality, bladder management, bowel management, and nutrition). These particular materials were routinely available to all caregivers and care recipients in the inpatient and outpatient settings. Other materials available for mailing addressed the topics germane to self-regulation (depression, stress management, cognitive distortions). 

During the 6th-month session, caregivers first completed the self-report measures. They were then asked about any progress made in the resolution of the problem identified during the previous session and were given the opportunity to ask questions or discuss any new concerns. The FOCUS principles and the five basic steps of problem solving were discussed as they pertained to the immediate problem reported by the caregiver. The final session—conducted at the 12th month—followed the same protocol, after which the caregiver was debriefed about the study.


For caregivers of person with recent-onset SCI, face-to-face problem-solving training sessions (PST), educational materials, and telephone contacts were provided over the first year of caregiving. In the videoconferencing study, sessions were conducted via videoconferencing and additional contacts occurred in the home when caregivers and care recipients completed the assigned assessments. 


Formal counseling training not essential; training in PST model is required



A video demonstration of the PST approach with family caregivers entitled, “Caregiving” (Elliott, 2006) can be purchased from the American Psychological Association. 


• An enhanced, post-discharge program for new caregivers—one that provides PST, education, and information as needed and telephone contacts with staff as requested—may have greater benefit for family caregivers than outpatient services typically provided at most rehabilitation facilities. 

• The present results indicate that a combination of PST and education can effectively lower caregiver dysfunctional problem-solving styles following their return to the community.


D’Zurilla, T.J., Nezu, A.M., & Maydeu-Olivares, A. (2002). Social Problem-Solving Inventory-Revised (SPSI-R): Technical Manual. North Tonawanda, NY: Multi-health Systems.

D’Zurilla, T.J., Nezu, A.M., & Maydeu-Olivares, A. (2004). Social problem solving: Theory and assessment. In E. Chang, T.J. D’Zurilla & L.J. Sanna (Eds.), Social problem solving: Theory, research, and training (pp. 11–27). Washington, D.C.: American Psychological Association.

Elliott, T. (June 2006). Caregiving. In the APA Psychotherapy Video/DVD Series IV – Relationships. American 
Psychological Association: Washington, D. C. 

Elliott, T., & Berry, J. W. (2009). Brief problem-solving training for family caregivers of persons with recent-onset spinal cord injury: A randomized controlled trial. Journal of Clinical Psychology, 65, 406-422.

Elliott, T., & Shewchuk, R. (2000). Problem solving therapy for family caregivers of persons with severe physical disabilities. In C. Radnitz (Ed.), Cognitive-Behavioral Interventions for Persons with Disabilities (pp. 309-327). New York: Jason Aronson, Inc.

Elliott, T., Shewchuk, R., & Richards, J. S. (1999). Caregiver social problem solving abilities and family member adjustment to recent-onset physical disability. Rehabilitation Psychology, 44, 104-123

Elliott, T., Shewchuk, R., & Richards, J.S. (2001). Family caregiver problem solving abilities and adjustment during the initial year of the caregiving role. Journal of Counseling Psychology, 48, 223-232.

Elliott, T., & Shewchuk, R. (2002). Using the nominal group technique to identify the problems experienced by persons who live with severe physical disability. Journal of Clinical Psychology in Medical Settings, 9, 65-76.

Elliott, T., Brossart, D., Berry, J. W. & Fine, P. R. (2008). Problem-solving training via videoconferencing for family caregivers of persons with spinal cord injuries: A randomized controlled trial. Behaviour Research and Therapy, 46, 1220-1229. 

Kurylo, M., Elliott, T. R., & Shewchuk, R. (2001). FOCUS on the family caregiver: A problem-solving training intervention. Journal of Counseling and Development, 79, 275–281.

Nezu, A. M., Nezu, C. M., Friedman, S. H., Faddis, S., & Houts, P. S. (1998). Helping cancer patients cope. Washington DC: American Psychological Association.

Rivera, P., Shewchuk, R., & Elliott, T. (2003). Project FOCUS: Using videoconferencing to provide problem solving training to family caregivers of persons with spinal cord injuries. Topics in Spinal Cord Injury Rehabilitation, 9(1), 53-62. 


caregivers, spinal cord injury, disability, randomized clinical trial, problem-solving