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1. Karen F. Pridham, Marc F. Hansen and Helen H. Conrad
Anticipatory problem solving: models for
clinical practice and research
Abstract FVoblem solving that anticipates a client's future is a fundamental
component of primary care. However, adequate models for clinical
practice and for research are needed. A paradigm of anticipatory care
conceptualized as an interpersonal problem solving process is used as a
framework for critical analysis of existing models and for the specifi-
cation of conceptual and practical bases of new models of anticipatory
care. The paper addresses questions concerning problem solving for the
model of anticipatory guidance presented by the American Public
Health Association and the model developed by Caplan, and the models
of preparatory communication developed by Janis and by Leventhal
and Johnson. The questions that are used to critique existing models
and to specify new ones deal with identification and specification of
issues for anticipatory care; its goals, functions, and intended out-
comes; appraisal of readiness to participate in and worthwhileness of
anticipatory care; the characteristic features of a model's solution
phases and strategies of preparation; and the evaluation ofthe adequacy
of anticipatory care.
Problem solving that anticipates a client's future is a fundamental
component of primary care (1). Both doctors and nurses believe that
estimating potential risks and challenges and preparing the client for
successful encounters with stressors that are likely to occur is a clinical
responsibility (2). Research that focuses on anticipatory care, most of
which has been published in the last five years, calls attention to a
growing interest in the study of preparation of clients for future
developmental tasks, stressful events, and responsibilities of living
(3, 4). However, anticipatory guidance, whether implemented as a
clinical or as a research objective, has not been clearly or adequately
conceptualized. As a consequence, care that anticipates the future is
likely to be inefficient and ineffective, and research fragmentary and
relatively noninformative.
A paradigm of anticipatory care is needed to provide a framework
for the critique of currently available models of anticipatory care as
well as a basis for specification of research designed to identify more
effective models. This paper proposes that anticipatory care be
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2. 178 Pridham, Hansen and Conrad
approached, both in clinical and research settings, as a problem-solving
process with conceptually distinct phases and problem-solving oper-
ations specific to each phase. Furthermore, we propose that the
paradigm of interpersonal, clinical problem solving which we have
developed using Boyd's (5) work can provide an effective framework
for critical analysis of existing models and for specification of con-
ceptual and practical bases of new models of anticipatory care. The
paradigm of interpersonal problem solving is presented and then used to
analyze existing models of anticipatory care.
The problem-solving paradigm
Development of the problem-solving paradigm was stimulated by the
fact that the Smith, Hansen, & GoUaday (6) observational methodology
for study of primary care practice lacked a means of characterizing
verbal problem-solving processes. The history and strategy of develop-
ment of the paradigm and the methodology, including reliability tests,
are described in another paper (7). Briefly described, the phases of the
clinical problem-solving process are as follows:
1. Scanning - The scanning phase is directed toward becoming alerted
to problems or goals important to the client.
2. Formulating - The formulating phase includes exploration of an
issue that is of concem, specifying it, and naming it.
3. Appraising - Decisions as to whether or not an issue is important
enough to work on must be made after a problem has been identi-
fied and/or formulated.
4. Developing Willingness or Readiness to Problem Solve - This phase
includes the work that is directed toward developing readiness and
commitment if either clinican or client thinks the issue is important
enough to problem solve, but the other for some reason is not ready
or willing to do so.
5. Planning - Planning involves decisions about the division of labor
and the mechanics of problem solving: Who will do the problem
solving and when? What strategies or techniques will be used? What
issues will be dealt with in what order?
6. Implementing - The solution phase of the problem solving may
include one or more sub-phases:
a. Orienting - This sub-phase is directed to developing or changing
specific understandings about a problem or expectations about
the future for the purpose of resolving the issue or problem.
b. Guiding - In guiding, the- decisions are concemed with what
actions the individual should or could take to solve the problem.

3. Anticipatory problem solving 179
The client may be instructed in how to take the desired steps, or
client and clinician together may examine alternative approaches.
c. Practicing - The client may practice, with the clinician's super-
vision, the steps of a plan of action, or develop and test skills.
d. Developing Decision Rules and Problem-Solving Strategies. In this
sub-phase, the clinician and client link expectations about the
anticipated event or circumstances to a plan of action by clarify-
ing and developing policies and strategies that the client will use.
The strategies focus on the learning of means to identify prob-
lems more precisely and to arrive at generahzed approaches to
solving problems.
7. Evaluating - The evaluating phase is concerned with establishing
whether or not the preparation provided in the implementing phase
is likely to enable the client to adequately cope with or solve his/her
problem. It includes a subsequent evaluation of outcome.
Each phase is separable from the others and has as its focus distinct
data to be gathered, decisions to be made, and feedback to be obtained.
Chent problem solving varies from one clinical encounter to another in
terms of the specific phases included, the character of each of the
phases included, the character of each ofthe phases that occurs, and
the sequence of phases.
Analysis and critique of anticipatory care models
Using the problem-solving phases as a framework, questions concerning
issues of anticipatory care can be formulated to guide the review of
anticipatory care models. These questions include:
1. How are issues or problems for anticipatory care identified and
specified?
2. What are the goals and functions of anticipatory care? What kind
of learning is intended as an outcome?
3. How is readiness or capacity to participate in anticipatory care
appraised? How is the importance and 'rightness' of doing antici-
patory care established with the client?
4. What are the characteristic features ofthe problem solution phase
of anticipatory care within the model? That is, what strategies are
used to prepare the client to deal with the anticipated issue?
5. How is the adequacy ofthe anticipatory care evaluated?
The models to be assessed, using the problem-solving paradigm, are an
anticipatory guidance model that originated in maternal-child health care
and the models developed by Janis, Caplan, and Leventhal and Johnson.

4. 180 Pridham, Hansen and Conrad
The anticipatory guidance model
The term 'anticipatory guidance' denotes a model of anticipatory care
that probably originated over 50 years ago in matemal-child health con-
ferences (8). The approach used to prepare women for the care of their
well babies and children has been generalized to a variety of prep-
arations, expectant couples for labor, delivery, and care of the new-
bom (9, 10, 11); school-age children for sexual development (12), and
middle-aged and elderly people for retirement (13). Rapaport (14)
describes anticipatory guidance that is used to help parents deal with
the birth of premature infants, and Neal (15) proposes anticipatory
guidance to help parents prepare their children who are mentally
retarded for school entry, sexual development, vocational adjustment,
marriage, and placement outside the home.
The objective of anticipatory guidance is defined in a 1955 American
Pubhc Health Association monograph as 'teaching the mother what to
expect before she begins to worry or make mistakes' (16). The func-
tions of anticipatory guidance include teaching mothers what to do
(e.g., when the new baby cries; when an older child must be prepared
for the arrival of a new baby) in addition to teaching mothers what to
expect to happen. The implied goal is to reduce or prevent the parent's
error or tension that may interfere with the child's growth and develop-
ment and/or the mother's self-confidence.
The clinical process of anticipatory guidance begins when the
clinician makes a decision about the issues that must be anticipated or
broached with this client. Data for the decision making is gathered by
listening for signals of worries or fears. The signals are sensed and inter-
preted in light of knowledge of issues that may be problematic for
persons in circumstances like those of this client. The clinician knows
for example:
that many (pregnant) women are uninformed about anatomy and reproduction,
that pregnancy is a period of strong feelings and mood changes, and that many
pregnant women have certain suppressed and irrational fears. (17)
Signs of problems are elicited by the clinician's open-ended questions
that address the anticipated issues (e.g.. What are you doing to prepare
your older child for the arrival ofthe new baby?) The client's response
informs the clinician about how much discussion of the subject is
needed (18). Receptivity to being informed (or 'taught') is determined
by the kinds of interests a client is presumed to have at a certain stage
of development. Once an issue that is pertinent to the individual's life
responsibilities is identified, the client is assumed to be receptive.
Actions toward problem solution may include any one or all of the
following strategies (19):

5. Anticipatory problem solving 181
1. The clinician describes the way things are likely to be and delib-
erately clears up misconceptions;
2. The clinician conveys a point of view about the issue (i.e., how
things should be);
3. The client is told how he/she is likely to behave when the event
occurs; or
4. The clinician makes suggestions about appropriate things to do.
The anticipatory guidance model has several assets. First, the model
acknowledges the importance of the client's need to know as a pre-
requisite of being prepared, and second, the clinician may approach
issues in an open-ended way that permits identification of the client's
worries and fears.
The model, however, has a number of deficiencies. First, it does not
include a means of scanning for and specifying the problems or issues
idiosyncratic to the client. Often, these issues cannot be anticipated
until the client communicates a verbal or nonverbal message that draws
attention to them and makes them significant. The client's potential
vulnerabilities or challenges may not be anticipatable or specifiable
solely on the basis of membership in a population group with known
susceptibility to specific risks and challenges. Second, the model does
not view the client's readiness to participate in the anticipatory care as
a matter that should be open for discussion. Third, the preparation
itself consists of information about what to expect and do, but does
not equip the client with skills, including decision-making and problem-
solving strategies, that make it possible to transform information into
action. Fourth, mechanisms for tailoring advice to the client's specific
circumstances and lifestyle are not developed. The model assumes
values, goals, and points of view that are the clinician's and that the
client is expected to accept. Fifth, the model does not address evalu-
ation of the adequacy and effectiveness of anticipatory care, a
deficiency which may, in part, explain the lack of discussion and
development of issues from one session to another. As it stands, antici-
patory guidance is described as if it were offered in unconnected, dis-
continuous encounters. In this form anticipatory guidance is made
routine and often considered to be 'patient education'.
Janis' reassuring concepts and realistic expectations model
Janis' (20, 21) model of anticipatory care, which he calls 'preparatory
communication', was developed and tested primarily through research
involving surgical patients. Preparatory communication is intended to
help people to resist the adverse emotional effects of a variety of

6. 182 Pridham, Hansen and Conrad
stressful events that threaten, damage, or deprive (22). It functions as
an 'emotional inoculation', a concept that is derived from the
psychoanalytic notion ofthe work of mourning. That is, effective inner
preparation is developed by means of an 'authoritative warning'. The
awareness that is aroused as a consequence generates fear that motivates
the person to do constructive worrying and mentally rehearse the
impending danger. The intended outcome is a better adjustment to a
state of stress than would have been likely without the preparation (23).
Janis identifies conditions for which preparatory communication is
not worthwhile or even desirable:
1. The stressful event is so sudden that there is no time to prepare
(24);
2. The stressful event is so mild that a severe fright reaction is
unlikely to be evoked, and the energy expenditure, either on the
part of the clinician or the client or both, to stimulate the work
of worrying is unwarranted (25), and
3. The stressful event is a procedure (e.g., an injection) for which the
patient can be best prepared by an authority figure at the time
the procedure is to begin (26).
Janis does not delineate a process of scanning by which potential
stressors that are idiosyncratic to a chent and unanticipated by the
clinician can be identified. Instead, a problem with obvious risks for
clearly vulnerable individuals is assumed and the chnical problem-
solving process begins with the solution phase. On the other hand, Janis
expects that reaction to the presentation of realistic and reassuring
concepts will be conditioned by the kinds of fears a specific chent has
(27). One individual, for example, may be most disturbed by the
prospect of postoperative physical incapacitation and passive helpless-
ness. Another individual may be most disturbed by the prospect of
being in a strange place and out of contact with family members. Janis
proposes that whoever attempts preparatory communication with a
client must 'be prepared to deal not only with typical patterns of mis-
understanding and emotional resistance but also with the highly unique
emotional needs of each individual' (28).
Some people are likely to either underreact or overreact to a warning
and, for these, special procedures of preparation are required. For the
underreacting individual, the clinician is advised to question the chent
about the facts of the event toward developing his/her awareness of
lack of appropriate fear. For the individual who is likely to overreact,
the content of the preparatory communication for any one session is
deliberately limited. The full preparation is given over a series of inter-
views. Although Janis does not delineate criteria by which to judge
under- or overreaction, he suggests that knowledge of how the individual

7. Anticipatory problem solving 183
has behaved in the past may help to predict who is most likely to
under- or overreact (29).
The solution phase of the model is characterized by three sequential
operations, each having a distinct function. First, the individual is given
'realistic information' (or 'purely factual statements') that precisely
describes and 'conveys a concrete personalized picture of the out-
standing danger events as the person will actually perceive them' (30).
The purpose of this information is to help the person know what to
expect as well as to arouse emotions - fear and anger - that are likely to
motivate the individual to do the necessary work of worrying. In the
next step, misconceptions about the event that might engender either
exaggerated fears or exaggerated expectations of positive outcomes are
corrected. Potential feelings of helplessness, hopelessness, and demoral-
ization are counteracted by 'discussing the person's image ofthe future,
asking pertinent questions, and calling attention to certain of the
known facts' (31). Concepts about resources and opportunities that will
be available when the stressful event occurs are developed in order to
reassure the individual and engender self-confidence. Finally, the client
is encouraged to make his own plans to protect himself and figure out
ways of reassuring himself. The objective is to counteract a tendency to
become passive and to rely almost exclusively on the protective powers
of authority figures and friends. The individual may also be informed
about actions that he can take and about decisions regarding actions
that he must take. The purpose of this information is to support the
belief that the client should and can do something (32, 33). Janis
evaluated the effectiveness of preparatory communication in helping
patients who had surgical operations to cope in terms of feelings of
anger or emotional disturbance expressed when recalling the operation
and complaints against the hospital staff after the surgery (34).
Preparatory communication may be offered in mass media format
(e.g., news releases, pamphlets, or television programs) as well as in
one-to-one encounters. However, Janis warns that, because of the
possibility of idiosyncratic, unpredictable and undesired responses,
face-to-face interaction between a chnician and the individual is likely
to be necessary for most people (35).
Janis' model makes a number of important contributions to the
theory and practice of anticipatory care. The major contributions are as
follows: (a) a taxonomy of the kinds of conditions for which antici-
patory care is not likely to be worthwhile; (b) a concept of the idio-
syncratic significance or meaning which a client may attribute to an
event; (c) a concept of the kind of feehngs and behaviors that may
occur in response to the preparatory message itself; (d) a delineation
of techniques to develop commitment to the work of getting prepared

8. 184 Pridham, Hansen and Conrad
when the client's response is either one that minimizes or exaggerates
the waming included in the message; (e) concepts that relate to devel-
oping the client's expectations for his/her own success in response to
the stressor event, as well as concepts that relate to developing knowl-
edge about the event, and (f) methods by which to study outcomes of
anticipatory care.
The model, however, has several limitations. The first has to do with
how features of the anticipated event that are hkely to be problematic
for the client are defined. Although Janis acknowledges that individuals
are likely to vary in regard to the aspects of events that are disturbing
or disorganizing, his model does not provide a means of identifying
these aspects. The clinician discusses the client's sense of the future
event for the purpose of counteracting feelings of helplessness and
hopelessness and not for the purpose of better defining future problems
using the client's point of view (36). Janis' solution to the problem of
identifying the features of an event that are likely to be distressing for a
specific individual is to cover all bets by describing every potentially
frightening aspect (37).
The second limitation relates to the solution phase of problem
solving in preparation for the stressful event. Janis emphasizes the
importance of the client having a sense of active control that is based in
knowledge of decisions that must be made. Janis suggests that the
individual may either be instructed about means of taking recommended
actions (e.g., the surgical patient is taught how to move in bed in such a
way as to minimize pain), or be taught the criteria for making specific
decisions (e.g., the patient is taught how to determine when a sedative
should be requested) (38). However, Janis does not identify strategies
of instruction nor does he specify approaches to developing criteria for
decision making with a chent. In short, his model does not identify
means by which the client is prepared to do the problem solving and to
make the decisions through which active control is achieved.
Furthermore, the concept of stress upon which Janis' model is
premised - a concept that concems confrontation with extraordinary
rather than ordinary events of living - limits the model's application in
primary care settings that are concerned with health maintenance and
chronic illness care. A model of anticipatory care that is useful for
primary care purposes must provide concepts that relate to goals for the
development of new skills in response to opportunities and challenges.
Furthermore, a model of anticipatory care to be used in primary care
settings must help to develop means of protecting oneself and preven-
ting damage or decrement in function in relation to health risks.
One of the most controversial features of Janis' model is the notion
that fear is necessary to the development of means of dealing with

9. Anticipatory problem solving 185
danger (39). Janis notes that disorganization of behavior is a potential
consequence of a clinician's intentionally evoking fear as a motivational
force. He warns that the energy expenditure required to deal with
emotionally disturbing information may be warranted by circumstances
and proposes 'a gradual, stepwise increase up to, but not beyond, a
moderate level of fear' (40). Janis (41) presents data collected in a
hospital surgical ward that demonstrates a curvilinear relationship
between amounts of preoperative stress. That is, a moderate amount of
fear was related to the least amount of stress, whereas either high or
low amounts of fear were related to relatively high amounts of stress.
Janis does not, however, state criteria with which to guide the clinician's
decision making about circumstances that warrant arousal of fear and
to gauge the level of fear that has been aroused.
Leventhal (42, 43) has used theoretical and empirical knowledge to
critique the notion that fear arousal functions as a drive of adaptive
responses. When Leventhal (44) attempted to replicate Janis' demon-
stration of a curvilinear relationship between fear and stress, he found
that patients who were lowest in preoperative fear were also lowest in
postoperative distress and, in addition, gave more favorable evaluations
of medical staff postoperatively. Furthermore, Leventhal and Rosen
(45) reported findings that indicate two types of reaction to threatening
situations. The response to infomiation about danger may either be fear
reaction or the response may be a cognitive one that assesses the danger
and the possibilities of dealing with it. These two reactions, if they both
occur, may either enhance or compete with each other. Both reactions
and their interactions must be assessed in order to understand a
response to a threat message.
Caplan's functional expectations and plans model
Caplan's model of anticipatory care is intended for application to crises
which include the events that are concomitatnt with maturation (e.g.,
pregnancy, aging, and dying) and experiences that an individual chooses
to have, such as those associated with Peace Corps Service (46, 47, 48,
49). Caplan's published accounts ofthe model are primarily descriptive
in character. Broussard (50) used a control group experimental design
to test a method of preparing new mothers for infant care responsi-
bilities and applied a model that most closely resembles Caplan's.
Caplan's model is directed toward development of expectations and
plans that are functional in terms of protecting and sustaining psycho-
logical well-being and interpersonal relationships.
Although Caplan's model, like Janis' work, is derived from psycho-

10. 186 Pridham, Hansen and Conrad
analytic theory, it draws on the more recent psychoanalytic psychology
that focuses on 'ego' or adaptational processes to a greater extent than
Janis' work does (51). The purpose of anticipatory care, which Caplan
labels 'anticipatory guidance', is to mobilize 'the patient's strength
beforehand so that she is able to meet a crisis situation more con-
structively' (52). For Janis, fear is the basic dynamic of action. How-
ever, Caplan's aim is to lower the anxiety that is a response to an antici-
pated event (53). Caplan believes that anxiety diminishes the effective-
ness of the individual's adaptational capabilities, stimulates maladaptive
and irrational responses, including fantasy and magical thinking, and is
likely to result in disintegration of problem-solving capacities and lead
to alienation from family, friends, or other supportive people. When
anxiety is lowered or prevented altogether, the individual's adaptational
capacities can be used for constructive action at the time the anticipated
event occurs (54). The method is to develop expectations and plans
that are likely to promote healthy or adaptive responses when a threat
or challenge occurs.
Although Caplan's model does not specify processes of determining
readiness and willingness to be prepared for an anticipated event, the
model suggests approaches to the preparation that are tailored to
specific styles of handling information. Caplan advises that the indi-
vidual who tends to distort (i.e., 'sexualize') information should not be
given explicitly detailed pictures of the event or process. Instead, either
diagrams or a sentimentalized, romanticized account help this individual
accept and tolerate an inevitable event such as labor. Caplan rec-
ommends that if preparation for a threatening event is done in a group,
it be kept small enough to identify individuals who are disturbed by the
preparation and who may need special help later.
The problem solution phase of Caplan's model consists of two
sequential processes (55, 56, 57):
1. Future events are described in the greatest detail possible in order
to evoke a vivid and realistic expectation of what the experience
will be like. The expectation includes associated feelings and how
the individual will view him/herself and others vis a vis the event.
2. The individual is then helped to think of possible ways of dealing
with the event and of mastering negative feelings.
Caplan presents techniques of problem solution most explicitly in a
description of the preparation given groups of Peace Corps trainees for
overseas work (58). The leader of the group undergoing preparation
that is described is an individual who is trained in psychiatry. This
leader helps make the anticipated event less abstract and more vivid by
discussing with the group experiences that members have had that are
similar to experiences they are likely to have once overseas. The group

11. Anticipatory problem solving 187
is helped to anticipate the negative feelings, particularly anxiety, and
maladaptive responses that are likely to be ehcited by the experience.
Moreover, the group identifies methods of dealing with both emotional
and behavioral responses to stressors that may be applicable to experi-
ence in the future. A major aim of preparation is to make expression of
discomfort and help-seeking behavior permissible. Furthermore, antici-
patory guidance may prepare the family members, friends, and co-
workers on whom an individual relies to give help at the time that
adaptation to a stressor is necessary (59).
Caplan's model develops concepts of anticipatory care that are appli-
cable to both ordinary and expected events of living (about which
people generally have some choice and in respect to which decisions
and competence are issues) and to the unexpected, immutable, and
traumatic events for which the outcomes of interest are survival or
return to a stable state. The model, however, lacks several important
processes. Although the chent is encouraged to verbahze fears and
negative feelings, procedures for systematically scanning and specifying
them are not identified. Formulating the details of an event that are
potentially most important to a specific individual is not an issue in this
model. However, the technique of describing an event in the greatest
possible detail in order to evoke a vivid anticipation of it may work
against the development of expectations that are functional, particu-
larly if the meaning ofthe details for the individual is not assessed. The
model, like the others reviewed, does not specify a process of appraising
readiness and willingness for the preparation, nor does it include a
process of evaluating its adequacy.
Caplan's model, although it clearly acknowledges the importance of
preparation for problem solving, is limited in concepts for the develop-
ment of problem-solving and decision-making strategies and skills.
Recall of techniques used to solve problems in the past may not always
support problem solving in the future, particularly if the anticipated
problem is ambiguous and difficult to formulate precisely prior to the
event.
The shared expectations model of Leventhal and Johnson
The model of anticipatory care that Leventhal initiated and that
Johnson developed for clinical applications is designed specifically for
preparing patients for medical diagnostic and treatment procedures.
The purpose of the 'preparatory communication' that Leventhal and
Johnson conceptualize is to minimize emotional and cognitive responses
that interfere with the procedure and with the clinician-patient com-
munication (60).

12. 188 Pridham, Hansen and Conrad
Johnson (61) reports data from several laboratory studies that
support the conjecture that sensations occurring during threatening
procedures, if unexpected, are assumed by the individual to be atypical.
Furthermore, unexpected and hence atypical sensations heighten the
emotional response to a procedure to a greater extent than does inac-
ruate information about sensations. Leventhal (62) acknowledges that
the highly personalized meanings that a procedure may have for a client
may quahfy the issues for which preparation may be important. How-
ever, he believes that exploring each client's 'subjective world' for the
purpose of specifying the anticipated event in precise, idiosyncratic
terms is time-consuming and, therefore, costly. Moreover, Leventhal
claims that making expectations public is not without risk, since
therapeutic outcomes are not always the consequence of sharing private
thoughts.
The problem-solution phase ofthe Leventhal-Johnson model includes
several components (63, 64). These components, which may be
presented via tape-recorded message or in face-to-face encounters, are
as follows: (a) the client is told what will happen during the procedure
and informed of the tactile, kinesthetic, auditory, and visual sensations
that others have associated with a procedure; and (b) the client is
instructed in what he/she needs to do during the procedure. The client
may be provided an opportunity to practice some aspect of a pro-
cedure. Johnson and Leventhal (65) and Johnson, Kirschoff, and
Endres (66) report that sensory infonnation combined with behavioural
instructions is more effective than either sensory information or
behavioural instructions alone in terms of both emotional and perform-
ance outcomes of preparatory care for a diagnostic procedure.
The attention that Leventhal and Johnson's model gives to the
expected sensations of a procedure advances anticipatory care beyond
the traditional information about what a procedure is to accomphsh,
how it will proceed, and what the client is to do. However, because the
model depends on the clinician's having identified the pertinent sensory
features of a procedure, its application is limited to clearly circum-
scribed and relatively unvarying situations. Furthermore, the model is
applicable only to procedures for which the clinician is responsible for
plans and outcomes and the chent only for following directions. As a
consequence, the model is not suited to anticipatory care for health
maintenance and promotion purposes. Both well and chronically ill
clients bear the major responsibility for specifying problems that
concem day-to-day living in terms of their own goals and for identifying
solutions in terms of their own circumstances and resources.
Leventhal (67) may be correct in assuming that the process of deter-
mining the meaning a client attributes to a procedural event is not

13. Anticipatory problem solving 189
important. If the goal of the preparatory communication is to get
through the procedure, once the procedure is over, the problem is
solved and no decisions remain to be made. On the other hand, if the
goal is to facilitate meanings about a procedure which are realistic and
shared by client and clinician, how the client views his own behavior vis
a vis the clinician and the expectations he has ofthe clinician in regard
to the way the procedure is done may be significant for subsequent
interpersonal relationships. The model, therefore, is inadequate to the
task of developing the shared or intersubjectively valid expectations
that Leventhal claims are the basis for prevention of misinterpretation
of client and clinician, depersonalization ofthe client and alienation of
the chent from the clinician. If the clinician is to be sure that the
client's expectations regarding a procedure are reasonable and
functional, the client's hypotheses must be shared.
Features of a more adequate model of anticipatory care
Each of the models reviewed contributes something that is important to
the concept of anticipatory care. The APHA model contributes the
notion of listening to the client for signals of worry and fear in order to
make decisions about the need for anticipatory care. Janis and Caplan's
models both include the emotional aspects of anticipatory care and
consider the variations from one individual to another of the meanings
of and consequent responses to a preparatory message. Caplan extends
the purpose of anticipatory care to mobilization of strength for mastery
of both the event itself and negative feelings. Furthermore, Caplan's
model includes concepts and methods to relate to potentially support-
ive people, as well as previously leamed problem-solving methods in the
implementation phase of the preparation. Johnson and Leventhal
contribute the idea that expectations about sensations that are likely to
be experienced during a diagnostic or therapeutic procedure are as
important as information about what is to be done.
However, gaps in specification of problem-solving processes limit the
usefulness of these models for research and clinical applications,
particularly for primary care settings. These gaps include lack of con-
cepts for scanning the client's experience in order to identify antici-
pated problems and what may be most important to the client. Further-
more, concepts pertinent to naming problems in terms that capture the
precise meaning for a specific client are lacking. Processes that are
central to problem solving in which client and clinician function as
partners lack specification. Concepts for interpersonal processes,
including appraising readiness and willingness to problem solve.

14. 190 Pridham, Hansen and Conrad
planning and evaluation, are missing. Furthermore, although Caplan
identifies processes of developing generalizable skills in problem-
solving as a component of anticipatory care, specification of these
processes is lacking.
The interpersonal problem-solving paradigm can be used to identify
and specify the features that make anticipatory care models responsive
to whatever health care goals they are intended to address. There are
several features which, we believe, on both theoretical grounds and the
grounds of our own experience, must be included in models of antici-
patory care that are intended for effective clinical problem solving in
any health care setting. These features, which address both content and
process issues, are as follows:
Scanning. The kinds and range of issues to which a clinician is to be
alert, as well as the means of helping a client to offer material to be
scanned, are both important features ofthe scanning phase. The client,
if he/she is to be a partner in the process, may require an explanation of
what is to be scanned and why. A model must also provide for specifi-
cation of circumstances for which such an explanation is important.
Formulating. An adequate model requires a means of identifying and
naming problems and goals that are idiosyncratic to a specific cUent.
Moreover, a means of specifying a problem in terms ofthe chent's goals
and the significance of an issue to him/her is essential. The processes
by which an issue is examined thoroughly enough to name it precisely
for both client and clinician are fundamental to problem-solving the
multifaceted, poorly defined issues of everyday life that clients in
primary care settings are likely to present. Bahnt (68) discusses the
issues for a primary care clinician of naming a problem when the client
knows that he/she has a problem but has not yet organized it in his/her
thinking.
Appraising of Readiness and Willingness to Problem-Solve. The bases
and means of appraising readiness and willingness for both the client
and the clinician are important components of an adequate model of
anticipatory care. The model must specify criteria for appraising readi-
ness, whether normative characteristics are used as the criteria for
determining readiness or whether each client's readiness is assessed in
terms of his/her own goals and strengths. An adequate model must also
specify the circumstances in which anticipatory problem-solving is
justifiable when the client's reponse is likely to be one of fear.
Developing Willingness or Readiness to Problem-Solve. Concepts of
how readiness and willingness to problem-solve are to be developed
when necessary are needed in any model that does not assume the
client's automatic interest and participation. Techniques that are
identified for this purpose will depend on a model's assumptions about

15. Anticipatory problem solving 191
methods that are suited to accomplish intended outcomes. Methods
range from those that are persuasive through means that sway emotions
to educational approaches.
Planning. How the preparation for dealing with an anticipated prob-
lem is to be done is not always clearcut and straightforward. An ad-
equate model of anticipatory care must define the conditions to be
considered in planning the solution phase of the process. One of these
conditions is always the client's characteristics that may interact in
some way with each specific method. One individual, for example, may
function best with an overall orientation to what things will be hke,
whereas another individual may be comfortable only with a very
specific description and an opportunity to think the occasion through,
step by step, in advance. Furthermore, selection of the clinician or
other person to do the preparation may require assessment of the
meaning that this individual has for the client and the kind of relation-
ship that is already estabhshed.
Implementing. The components of the implementing phase of antici-
patory problem-solving that are included in a model depend on the
assumptions about clinical objectives and client-clinician relationships
that underlie the model. The solution phase of the problem solving is
likely to require a means of assessing the kinds of expectations a
specific client requires in order to be adequately prepared. Expectations
that are related to knowledge of what to expect about the event itself
or about the kinds of thoughts, feelings, physical sensations, and
actions that the client or others may experience at the time of the
anticipated event may need to be developed. Furthermore, the extent
to which a client can and should participate in planning how to deal
with the event when it occurs is an issue that must be made exphcit in
an anticipatory care model. Practice, guided or unguided, and other
means of developing skills are suited to models that assume a more
extensive chnical responsibility than those that merely help the client
to formulate a plan. The development of problem-solving and decision-
making strategies and skills implies a clinical responsibility and an
investment in the client that continues over time. Methods for develop-
ment of problem-solving skills have been outlined by D'Zurella and
Goldfried (69). We think that, unless an anticipatory care model
includes concepts that are related to assessment of and development of
problem-solving and decision-making skills, the client may not be
sufficiently prepared to function autonomously and with confidence
and self-esteem. The problem-solving paradigm reminds model builders
of the need to think through the components of the solution phase of
problem-solving that may be essential to successful outcomes, as well as
identifying sequences of these components that are likely to be most

16. 192 Pridham, Hansen and Conrad
effective and those that are likely to be efficient by being generalizable.
Evaluating. An adequate model of anticipatory care includes con-
cepts for dealing with these questions: (a) Was the preparation ac-
complished? (b) How effective a job was it? How well or effectively was
the preparation done? and (c) Was the preparation worth doing in terms
of the experiences that the client actually had? Would we do the pre-
paration the next time, given similar conditions?
In this paper, models of anticipatory care in current use have been
analyzed using a paradigm of interpersonal problem-solving. Further-
more, the paradigm was used to identify the characteristic features of
models that are likely to be important chnically and that must be con-
sidered if a model is to be systematically tested, applied clinically, or
evaluated.
The notion of promoting health in the sense of advancing a client's
adaptive capability is likely to be an empty slogan without models of
anticipatory care that are conceptually adequate to the task. The pro-
cesses of anticipatory care must be delineated and specified precisely if
definitive hypothese are to be stated for theory building and testing
purposes, and effective strategies and techniques developed for clinical
practice.
School of Nursing and Department of Family Medicine,
University of Wisconsin
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