Problem-Solving Therapy
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In Problem-Solving Therapy , Drs. Arthur Nezu and Christine Maguth Nezu demonstrate their positive, goal-oriented approach to treatment. Problem-solving therapy is a cognitive–behavioral intervention geared to improve an individual's ability to cope with stressful life experiences. The underlying assumption of this approach is that symptoms of psychopathology can often be understood as the negative consequences of ineffective or maladaptive coping.
Problem-solving therapy aims to help individuals adopt a realistically optimistic view of coping, understand the role of emotions more effectively, and creatively develop an action plan geared to reduce psychological distress and enhance well-being. Interventions include psychoeducation, interactive problem-solving exercises, and motivational homework assignments.
In this session, Christine Maguth Nezu works with a woman in her 50s who is depressed and deeply concerned about her son's drug addiction. Dr. Nezu first assesses her strengths and weaknesses and then helps her to clarify the problem she is facing so she can begin to move toward a solution.
The overarching goal of problem-solving therapy (PST) is to enhance the individual's ability to cope with stressful life experiences and to foster general behavioral competence. The major assumption underlying this approach, which emanates from a cognitive–behavioral tradition, is that much of what is viewed as "psychopathology" can be understood as consequences of ineffective or maladaptive coping behaviors. In other words, failure to adequately resolve stressful problems in living can engender significant emotional and behavioral problems.
Such problems in living include major negative events (e.g., undergoing a divorce, dealing with the death of a spouse, getting fired from a job, experiencing a major medical illness), as well as recurrent daily problems (e.g., continued arguments with a coworker, limited financial resources, diminished social support). How people resolve or cope with such situations can, in part, determine the degree to which they will likely experience long-lasting psychopathology and behavioral problems (e.g., clinical depression, generalized anxiety, pain, anger, relationship difficulties).
For example, successfully dealing with stressful problems will likely lead to a reduction of immediate emotional distress and prevent long-term psychological problems from occurring. Alternatively, maladaptive or unsuccessful problem resolution, either due to the overwhelming nature of events (e.g., severe trauma) or as a function of ineffective coping attempts, will likely increase the probability that long-term negative affective states and behavioral difficulties will emerge.
Social Problem Solving and Psychopathology
According to this therapy approach, social problem solving (SPS) is considered a key set of coping abilities and skills. SPS is defined as the cognitive–behavioral process by which individuals attempt to identify or discover effective solutions for stressful problems in living. In doing so, they direct their problem-solving efforts at altering the stressful nature of a given situation, their reactions to such situations, or both. SPS refers more to the metaprocess of understanding, appraising, and adapting to stressful life events, rather than representing a single coping strategy or activity.
Problem-solving outcomes in the real world have been found to be determined by two general but partially independent processes—problem orientation and problem-solving style.
Problem orientation refers to the set of generalized thoughts and feelings a person has concerning problems in living, as well as his or her ability to successfully resolve them. It can either be positive (e.g., viewing problems as opportunities to benefit in some way, perceiving oneself as able to solve problems effectively), which serves to enhance subsequent problem-solving efforts, or negative (e.g.,viewing problems as a major threat to one's well-being, overreacting emotionally when problems occur), which functions to inhibit attempts to solve problems.
Problem-solving style refers to specific cognitive–behavioral activities aimed at coping with stressful problems. Such styles are either adaptive, leading to successful problem resolution, or dysfunctional, leading to ineffective coping, which then can generate myriad negative consequences, including emotional distress and behavioral problems. Rational problem solving is the constructive style geared to identify an effective solution to the problem and involves the systematic and planful application of specific problem-solving tasks. Dysfunctional problem-solving styles include (a) impulsivity/carelessness (i.e., impulsive, hurried, and incomplete attempts to solve a problem), and (b) avoidance (i.e.,avoiding problems, procrastinating, and depending on others to solve one's problems).
Important differences have been identified between individuals characterized as "effective" versus "ineffective" problem solvers. In general, when compared to effective problem solvers, persons characterized by ineffective problem solving report a greater number of life problems, more health and physical symptoms, more anxiety, more depression, and more psychological maladjustment. In addition, a negative problem orientation has been found to be associated with negative moods under both routine and stressful conditions, as well as pessimism, negative emotional experiences, and clinical depression. Further, persons with negative orientations tend to worry and complain more about their health.
Problem-Solving Therapy Goals
PST teaches individuals to apply adaptive coping skills to both prevent and cope with stressful life difficulties. Specific PST therapy objectives include
- enhancing a person's positive orientation
- fostering his or her application of specific rational problem-solving tasks (i.e., accurately identifying why a situation is a problem, generating solution alternatives, conducting a cost-benefit analysis in order to decide which ideas to choose to include as part of an overall solution plan, implementing the solution, monitoring its effects, and evaluating the outcome)
- reducing his or her negative orientation
- minimizing one's tendency to engage in dysfunctional problem-solving style activities (i.e., impulsively attempting to solve the problem or avoiding the problem)
PST interventions involve psychoeducation, interactive problem-solving training exercises, practice opportunities, and homework assignments intended to motivate patients to apply the problem-solving principles outside of the therapy sessions.
PST has been shown to be effective regarding a wide range of clinical populations, psychological problems, and the distress associated with chronic medical disorders. Scientific evaluations have focused on unipolar depression, geriatric depression, distressed primary-care patients, social phobia, agoraphobia, obesity, coronary heart disease, adult cancer patients, adults with schizophrenia, mentally retarded adults with concomitant psychiatric problems, HIV-risk behaviors, drug abuse, suicide, childhood aggression, and conduct disorder.
Moreover, PST is flexible with regard to treatment goals and methods of implementation. For example, it can be conducted in a group format, on an individual and couples basis, as part of a larger cognitive–behavioral treatment package, over the phone, as well as on the Internet. It can also be applied as a means of helping patients to overcome barriers associated with successful adherence to other medical or psychosocial treatment protocols (e.g., adhering to weight-loss programs, diabetes regulation).
Arthur M. Nezu, PhD, ABPP, is currently professor of psychology, medicine, and community health and prevention at Drexel University in Philadelphia. He is one of the codevelopers of a cognitive–behavioral approach to teaching social problem-solving skills and has conducted multiple RCTs testing its efficacy across a variety of populations. These populations include clinically depressed adults, depressed geriatric patients, adults with mental retardation and concomitant psychopathology, distressed cancer patients and their spousal caregivers, individuals in weight-loss programs, breast cancer patients, and adult sexual offenders.
Dr. Nezu has contributed to more than 175 professional and scientific publications, including the books Solving Life's Problems: A 5-Step Guide to Enhanced Well-Being , Helping Cancer Patients Cope: A Problem-Solving Approach , and Problem-Solving Therapy: A Positive Approach to Clinical Intervention . He also codeveloped the self-report measure Social Problem-Solving Inventory—Revised . Dr. Nezu is on numerous editorial boards of scientific and professional journals and a member of the Interventions Research Review Committee of the National Institute of Mental Health.
An award-winning psychologist, he was previously president of the Association for Advancement of Behavior Therapy, the Behavioral Psychology Specialty Council, the World Congress of Behavioral and Cognitive Therapies, and the American Board of Cognitive and Behavioral Psychology. He is a fellow of the American Psychological Association, the Association for Psychological Science, the Society for Behavior Medicine, the Academy of Cognitive Therapy, and the Academy of Cognitive and Behavioral Psychology. Dr. Nezu was awarded the diplomate in Cognitive and Behavioral Psychology from the American Board of Professional Psychology and currently serves as a trustee of that board.
He has been in private practice for over 25 years, and is currently conducting outcome studies to evaluate the efficacy of problem-solving therapy to treat depression among adults with heart disease.
Christine Maguth Nezu, PhD, ABPP, is currently professor of psychology, associate professor of medicine, and director of the masters programs in psychology at Drexel University in Philadelphia. She previously served as director of the APA-accredited Internship/Residency in Clinical Psychology, as well as the Cognitive–Behavioral Postdoctoral Fellowship Program, at the Medical College of Pennsylvania/Hahnemann University.
She is the coauthor or editor of more than 100 scholarly publications, including 15 books. Her publications cover a wide range of topics in mental health and behavioral medicine, many of which have been translated into a variety of foreign languages.
Dr. Maguth Nezu is currently the president-elect of the American Board of Professional Psychology, on the board of directors for the American Board of Cognitive and Behavioral Psychology, and on the board of directors for the American Academy of Cognitive and Behavioral Psychology. She is the recipient of numerous grant awards supporting her research and program development, particularly in the area of clinical interventions. She serves as an accreditation site visitor for APA for clinical training programs and is on the editorial boards of several leading psychology and health journals.
Dr. Maguth Nezu has conducted workshops on clinical interventions and case formulation both nationally and internationally. She is currently the North American representative to the World Congress of Cognitive and Behavioral Therapies. She holds a diplomate in Cognitive and Behavioral Psychology from the American Board of Professional Psychology and has been active in private practice for more than 20 years.
Her current areas of interest include the treatment of depression in medical patients, the integration of cognitive and behavioral therapies with patients' spiritual beliefs and practices, interventions directed toward stress, coping, and health, and cognitive behavior therapy and problem-solving therapy for individuals with personality disorders.
- D'Zurilla, T. J., & Nezu, A. M. (2007). Problem-solving therapy: A positive approach to clinical intervention (3rd ed.). New York: Springer Publishing Co.
- 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.
- Nezu, A. M. (2004). Problem solving and behavior therapy revisited. Behavior Therapy, 35 , 1–33.
- Nezu, A. M., & Nezu, C. M. (in press). Problem-solving therapy. In S. Richards & M. G. Perri (Eds.), Relapse prevention for depression . Washington, DC: American Psychological Association.
- Nezu, A. M., Nezu, C. M., & Clark, M. (in press). Problem solving as a risk factor for depression. In K. S. Dobson & D. Dozois (Eds.), Risk factors for depression . New York: Elsevier Science.
- Nezu, A. M., Nezu, C. M., & Perri, M. G. (2006). Problem solving to promote treatment adherence. In W. T. O'Donohue & E. Livens (Eds.), Promoting treatment adherence: A practical handbook for health care providers (pp. 135–148). New York: Sage Publications.
- Nezu, A. M., Nezu, C. M., & D'Zurilla, T. J. (2007). Solving life's problems: A 5-step guide to enhanced well-being . New York: Springer Publishing Co.
- Nezu, A. M., Nezu, C. M., Friedman, S. H., Faddis, S., & Houts, P. S. (1998). Helping cancer patients cope: A problem-solving approach . Washington, DC: American Psychological Association.
- Nezu, C. M., D'Zurilla, T. J., & Nezu, A. M. (2005). Problem-solving therapy: Theory, practice, and application to sex offenders. In M. McMurran & J. McGuire (Eds.), Social problem solving and offenders: Evidence, evaluation and evolution (pp. 103–123). Chichester, UK: Wiley.
- Nezu, C. M., Palmatier, A., & Nezu, A. M. (2004). Social problem-solving training for caregivers. In E. C. Chang, T. J. D'Zurilla, & L. J. Sanna (Eds.), Social problem solving: Theory, research, and training (pp. 223–238). Washington, DC: American Psychological Association.
- Cognitive–Behavioral Relapse Prevention for Addictions G. Alan Marlatt
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- Depression Michael D. Yapko
- Emotion-Focused Therapy for Depression Leslie S. Greenberg
- Relapse Prevention Over Time G. Alan Marlatt
- Behavioral Interventions in Cognitive Behavior Therapy: Practical Guidance for Putting Theory Into Action, Second Edition Richard F. Farmer and Alexander L. Chapman
- Chronic Depression: Interpersonal Sources, Therapeutic Solutions Jeremy W. Pettit and Thomas E. Joiner
- Cognitive Schemas and Core Beliefs in Psychological Problems: A Scientist-Practitioner Guide Edited by Lawrence P. Riso, Pieter L. du Toit, Dan J. Stein, and Jeffrey E. Young
- Experiences of Depression: Theoretical, Clinical, and Research Perspectives Sidney J. Blatt
- Preventing Youth Substance Abuse: Science-Based Programs for Children and Adolescents Edited by Patrick Tolan, José Szapocznik, and Soledad Sambrano
- The Prevention of Anxiety and Depression: Theory, Research, and Practice Edited by David J. A. Dozois and Keith S. Dobson
- Social Problem Solving: Theory, Research, and Training Edited by Edward C. Chang, Thomas J. D'Zurilla, and Lawrence J. Sanna
- Understanding Depression in Women: Applying Empirical Research to Practice and Policy Edited by Carolyn M. Mazure and Gwendolyn Puryear Keita
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What Is Problem-Solving Therapy?
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Daniel B. Block, MD, is an award-winning, board-certified psychiatrist who operates a private practice in Pennsylvania.
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Things to consider, how to get started.
Problem-solving therapy is a form of therapy that provides patients with tools to identify and solve problems that arise from life stressors, both big and small. Its aim is to improve your overall quality of life and reduce the negative impact of psychological and physical illness.
Problem-solving therapy can be used to treat depression , among other conditions. It can be administered by a doctor or mental health professional and may be combined with other treatment approaches.
Problem-solving therapy is based on a model that takes into account the importance of real-life problem-solving. In other words, the key to managing the impact of stressful life events is to know how to address issues as they arise. Problem-solving therapy is very practical in its approach and is only concerned with the present, rather than delving into your past.
This form of therapy can take place one-on-one or in a group format and may be offered in person or online via telehealth . Sessions can be anywhere from 30 minutes to two hours long.
There are two major components that make up the problem-solving therapy framework:
- Applying a positive problem-solving orientation to your life
- Using problem-solving skills
A positive problem-solving orientation means viewing things in an optimistic light, embracing self-efficacy , and accepting the idea that problems are a normal part of life. Problem-solving skills are behaviors that you can rely on to help you navigate conflict, even during times of stress. This includes skills like:
- Knowing how to identify a problem
- Defining the problem in a helpful way
- Trying to understand the problem more deeply
- Setting goals related to the problem
- Generating alternative, creative solutions to the problem
- Choosing the best course of action
- Implementing the choice you have made
- Evaluating the outcome to determine next steps
Problem-solving therapy is all about training you to become adaptive in your life so that you will start to see problems as challenges to be solved instead of insurmountable obstacles. It also means that you will recognize the action that is required to engage in effective problem-solving techniques.
One problem-solving technique, called planful problem-solving, involves following a series of steps to fix issues in a healthy, constructive way:
- Problem definition and formulation : This step involves identifying the real-life problem that needs to be solved and formulating it in a way that allows you to generate potential solutions.
- Generation of alternative solutions : This stage involves coming up with various potential solutions to the problem at hand. The goal in this step is to brainstorm options to creatively address the life stressor in ways that you may not have previously considered.
- Decision-making strategies : This stage involves discussing different strategies for making decisions as well as identifying obstacles that may get in the way of solving the problem at hand.
- Solution implementation and verification : This stage involves implementing a chosen solution and then verifying whether it was effective in addressing the problem.
Other techniques your therapist may go over include:
- Problem-solving multitasking , which helps you learn to think clearly and solve problems effectively even during times of stress
- Stop, slow down, think, and act (SSTA) , which is meant to encourage you to become more emotionally mindful when faced with conflict
- Healthy thinking and imagery , which teaches you how to embrace more positive self-talk while problem-solving
What Problem-Solving Therapy Can Help With
Problem-solving therapy addresses issues related to life stress and is focused on helping you find solutions to concrete issues. This approach can be applied to problems associated with a variety of psychological and physiological symptoms.
Problem-solving therapy may help address mental health issues, like:
- Chronic stress due to accumulating minor issues
- Complications associated with traumatic brain injury (TBI)
- Emotional distress
- Post-traumatic stress disorder (PTSD)
- Problems associated with a chronic disease like cancer, heart disease, or diabetes
- Self-harm and feelings of hopelessness
- Substance use
- Suicidal ideation
This form of therapy is also helpful for dealing with specific life problems, such as:
- Death of a loved one
- Dissatisfaction at work
- Everyday life stressors
- Family problems
- Financial difficulties
- Relationship conflicts
Your doctor or mental healthcare professional will be able to advise whether problem-solving therapy could be helpful for your particular issue. In general, if you are struggling with specific, concrete problems that you are having trouble finding solutions for, problem-solving therapy could be helpful for you.
Benefits of Problem-Solving Therapy
The skills learned in problem-solving therapy can be helpful for managing all areas of your life. These can include:
- Being able to identify which stressors trigger your negative emotions (e.g., sadness, anger)
- Confidence that you can handle problems that you face
- Having a systematic approach on how to deal with life's problems
- Having a toolbox of strategies to solve the problems you face
- Increased confidence to find creative solutions
- Knowing how to identify which barriers will impede your progress
- Knowing how to manage emotions when they arise
- Reduced avoidance and increased action-taking
- The ability to accept life problems that can't be solved
- The ability to make effective decisions
- The development of patience (realizing that not all problems have a "quick fix")
This form of therapy was initially developed to help people combat stress through effective problem-solving, and it was later adapted to specifically address clinical depression. Today, much of the research on problem-solving therapy deals with its effectiveness in treating depression.
Problem-solving therapy has been shown to help depression in:
- Older adults
- People coping with serious illnesses like breast cancer
Problem-solving therapy also appears to be effective as a brief treatment for depression, offering benefits in as little as six to eight sessions with a therapist or another healthcare professional. This may make it a good option for someone who is unable to commit to a lengthier treatment for depression.
Problem-solving therapy is not a good fit for everyone. It may not be effective at addressing issues that don't have clear solutions, like seeking meaning or purpose in life. Problem-solving therapy is also intended to treat specific problems, not general habits or thought patterns .
In general, it's also important to remember that problem-solving therapy is not a primary treatment for mental disorders. If you are living with the symptoms of a serious mental illness such as bipolar disorder or schizophrenia , you may need additional treatment with evidence-based approaches for your particular concern.
Problem-solving therapy is best aimed at someone who has a mental or physical issue that is being treated separately, but who also has life issues that go along with that problem that has yet to be addressed.
For example, it could help if you can't clean your house or pay your bills because of your depression, or if a cancer diagnosis is interfering with your quality of life.
Your doctor may be able to recommend therapists in your area who utilize this approach, or they may offer it themselves as part of their practice. You can also search for a problem-solving therapist with help from the American Psychological Association’s (APA) Society of Clinical Psychology .
If receiving problem-solving therapy from a doctor or mental healthcare professional is not an option for you, you could also consider implementing it as a self-help strategy using a workbook designed to help you learn problem-solving skills on your own.
During your first session, your therapist may spend some time explaining their process and approach. They may ask you to identify the problem you’re currently facing, and they’ll likely discuss your goals for therapy.
Problem-solving therapy may be a short-term intervention that's focused on solving a specific issue in your life. If you need further help with something more pervasive, it can also become a longer-term treatment option.
Pierce D. Problem solving therapy - Use and effectiveness in general practice . Aust Fam Physician . 2012;41(9):676-679.
Cuijpers P, Wit L de, Kleiboer A, Karyotaki E, Ebert DD. Problem-solving therapy for adult depression: An updated meta-analysis . Eur Psychiatry . 2018;48(1):27-37. doi:10.1016/j.eurpsy.2017.11.006
Nezu AM, Nezu CM, D'Zurilla TJ. Problem-Solving Therapy: A Treatment Manual . New York; 2013. doi:10.1891/9780826109415.0001
Hatcher S, Sharon C, Parag V, Collins N. Problem-solving therapy for people who present to hospital with self-harm: Zelen randomised controlled trial . Br J Psychiatry . 2011;199(4):310-316. doi:10.1192/bjp.bp.110.090126
Sorsdahl K, Stein DJ, Corrigall J, et al. The efficacy of a blended motivational interviewing and problem solving therapy intervention to reduce substance use among patients presenting for emergency services in South Africa: A randomized controlled trial . Subst Abuse Treat Prev Policy . 2015;10(1):46. doi:doi.org/10.1186/s13011-015-0042-1
Kirkham JG, Choi N, Seitz DP. Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults . Int J Geriatr Psychiatry . 2016;31(5):526-535. doi:10.1002/gps.4358
Garand L, Rinaldo DE, Alberth MM, et al. Effects of problem solving therapy on mental health outcomes in family caregivers of persons with a new diagnosis of mild cognitive impairment or early dementia: A randomized controlled trial . Am J Geriatr Psychiatry . 2014;22(8):771-781. doi:10.1016/j.jagp.2013.07.007
Hopko DR, Armento MEA, Robertson SMC, et al. Brief behavioral activation and problem-solving therapy for depressed breast cancer patients: Randomized trial . J Consult Clin Psychol . 2011;79(6):834-849. doi:10.1037/a0025450
Nieuwsma JA, Trivedi RB, McDuffie J, Kronish I, Benjamin D, Williams JW. Brief psychotherapy for depression: A systematic review and meta-analysis . Int J Psychiatry Med . 2012;43(2):129-151. doi:10.2190/PM.43.2.c
By Arlin Cuncic Arlin Cuncic, MA, is the author of "Therapy in Focus: What to Expect from CBT for Social Anxiety Disorder" and "7 Weeks to Reduce Anxiety."
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10 Best Problem-Solving Therapy Worksheets & Activities
Cognitive science tells us that we regularly face not only well-defined problems but, importantly, many that are ill defined (Eysenck & Keane, 2015).
Sometimes, we find ourselves unable to overcome our daily problems or the inevitable (though hopefully infrequent) life traumas we face.
Problem-Solving Therapy aims to reduce the incidence and impact of mental health disorders and improve wellbeing by helping clients face life’s difficulties (Dobson, 2011).
This article introduces Problem-Solving Therapy and offers techniques, activities, and worksheets that mental health professionals can use with clients.
Before you continue, we thought you might like to download our three Positive Psychology Exercises for free . These science-based exercises explore fundamental aspects of positive psychology, including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.
This Article Contains:
What is problem-solving therapy, 14 steps for problem-solving therapy, 3 best interventions and techniques, 7 activities and worksheets for your session, fascinating books on the topic, resources from positivepsychology.com, a take-home message.
Problem-Solving Therapy assumes that mental disorders arise in response to ineffective or maladaptive coping. By adopting a more realistic and optimistic view of coping, individuals can understand the role of emotions and develop actions to reduce distress and maintain mental wellbeing (Nezu & Nezu, 2009).
“Problem-solving therapy (PST) is a psychosocial intervention, generally considered to be under a cognitive-behavioral umbrella” (Nezu, Nezu, & D’Zurilla, 2013, p. ix). It aims to encourage the client to cope better with day-to-day problems and traumatic events and reduce their impact on mental and physical wellbeing.
Clinical research, counseling, and health psychology have shown PST to be highly effective in clients of all ages, ranging from children to the elderly, across multiple clinical settings, including schizophrenia, stress, and anxiety disorders (Dobson, 2011).
Can it help with depression?
PST appears particularly helpful in treating clients with depression. A recent analysis of 30 studies found that PST was an effective treatment with a similar degree of success as other successful therapies targeting depression (Cuijpers, Wit, Kleiboer, Karyotaki, & Ebert, 2020).
Other studies confirm the value of PST and its effectiveness at treating depression in multiple age groups and its capacity to combine with other therapies, including drug treatments (Dobson, 2011).
The major concepts
Effective coping varies depending on the situation, and treatment typically focuses on improving the environment and reducing emotional distress (Dobson, 2011).
PST is based on two overlapping models:
Social problem-solving model
This model focuses on solving the problem “as it occurs in the natural social environment,” combined with a general coping strategy and a method of self-control (Dobson, 2011, p. 198).
The model includes three central concepts:
- Social problem-solving
- The problem
- The solution
The model is a “self-directed cognitive-behavioral process by which an individual, couple, or group attempts to identify or discover effective solutions for specific problems encountered in everyday living” (Dobson, 2011, p. 199).
Relational problem-solving model
The theory of PST is underpinned by a relational problem-solving model, whereby stress is viewed in terms of the relationships between three factors:
- Stressful life events
- Emotional distress and wellbeing
- Problem-solving coping
Therefore, when a significant adverse life event occurs, it may require “sweeping readjustments in a person’s life” (Dobson, 2011, p. 202).
- Enhance positive problem orientation
- Decrease negative orientation
- Foster ability to apply rational problem-solving skills
- Reduce the tendency to avoid problem-solving
- Minimize the tendency to be careless and impulsive
D’Zurilla’s and Nezu’s model includes (modified from Dobson, 2011):
- Initial structuring Establish a positive therapeutic relationship that encourages optimism and explains the PST approach.
- Assessment Formally and informally assess areas of stress in the client’s life and their problem-solving strengths and weaknesses.
- Obstacles to effective problem-solving Explore typically human challenges to problem-solving, such as multitasking and the negative impact of stress. Introduce tools that can help, such as making lists, visualization, and breaking complex problems down.
- Problem orientation – fostering self-efficacy Introduce the importance of a positive problem orientation, adopting tools, such as visualization, to promote self-efficacy.
- Problem orientation – recognizing problems Help clients recognize issues as they occur and use problem checklists to ‘normalize’ the experience.
- Problem orientation – seeing problems as challenges Encourage clients to break free of harmful and restricted ways of thinking while learning how to argue from another point of view.
- Problem orientation – use and control emotions Help clients understand the role of emotions in problem-solving, including using feelings to inform the process and managing disruptive emotions (such as cognitive reframing and relaxation exercises).
- Problem orientation – stop and think Teach clients how to reduce impulsive and avoidance tendencies (visualizing a stop sign or traffic light).
- Problem definition and formulation Encourage an understanding of the nature of problems and set realistic goals and objectives.
- Generation of alternatives Work with clients to help them recognize the wide range of potential solutions to each problem (for example, brainstorming).
- Decision-making Encourage better decision-making through an improved understanding of the consequences of decisions and the value and likelihood of different outcomes.
- Solution implementation and verification Foster the client’s ability to carry out a solution plan, monitor its outcome, evaluate its effectiveness, and use self-reinforcement to increase the chance of success.
- Guided practice Encourage the application of problem-solving skills across multiple domains and future stressful problems.
- Rapid problem-solving Teach clients how to apply problem-solving questions and guidelines quickly in any given situation.
Success in PST depends on the effectiveness of its implementation; using the right approach is crucial (Dobson, 2011).
The following interventions and techniques are helpful when implementing more effective problem-solving approaches in client’s lives.
First, it is essential to consider if PST is the best approach for the client, based on the problems they present.
Is PPT appropriate?
It is vital to consider whether PST is appropriate for the client’s situation. Therapists new to the approach may require additional guidance (Nezu et al., 2013).
Therapists should consider the following questions before beginning PST with a client (modified from Nezu et al., 2013):
- Has PST proven effective in the past for the problem? For example, research has shown success with depression, generalized anxiety, back pain, Alzheimer’s disease, cancer, and supporting caregivers (Nezu et al., 2013).
- Is PST acceptable to the client?
- Is the individual experiencing a significant mental or physical health problem?
All affirmative answers suggest that PST would be a helpful technique to apply in this instance.
Five problem-solving steps
The following five steps are valuable when working with clients to help them cope with and manage their environment (modified from Dobson, 2011).
Ask the client to consider the following points (forming the acronym ADAPT) when confronted by a problem:
- Attitude Aim to adopt a positive, optimistic attitude to the problem and problem-solving process.
- Define Obtain all required facts and details of potential obstacles to define the problem.
- Alternatives Identify various alternative solutions and actions to overcome the obstacle and achieve the problem-solving goal.
- Predict Predict each alternative’s positive and negative outcomes and choose the one most likely to achieve the goal and maximize the benefits.
- Try out Once selected, try out the solution and monitor its effectiveness while engaging in self-reinforcement.
If the client is not satisfied with their solution, they can return to step ‘A’ and find a more appropriate solution.
Positive self-statements
When dealing with clients facing negative self-beliefs, it can be helpful for them to use positive self-statements.
Use the following (or add new) self-statements to replace harmful, negative thinking (modified from Dobson, 2011):
- I can solve this problem; I’ve tackled similar ones before.
- I can cope with this.
- I just need to take a breath and relax.
- Once I start, it will be easier.
- It’s okay to look out for myself.
- I can get help if needed.
- Other people feel the same way I do.
- I’ll take one piece of the problem at a time.
- I can keep my fears in check.
- I don’t need to please everyone.
5 Worksheets and workbooks
Problem-solving self-monitoring form.
Answering the questions in the Problem-Solving Self-Monitoring Form provides the therapist with necessary information regarding the client’s overall and specific problem-solving approaches and reactions (Dobson, 2011).
Ask the client to complete the following:
- Describe the problem you are facing.
- What is your goal?
- What have you tried so far to solve the problem?
- What was the outcome?
Reactions to Stress
It can be helpful for the client to recognize their own experiences of stress. Do they react angrily, withdraw, or give up (Dobson, 2011)?
The Reactions to Stress worksheet can be given to the client as homework to capture stressful events and their reactions. By recording how they felt, behaved, and thought, they can recognize repeating patterns.
What Are Your Unique Triggers?
Helping clients capture triggers for their stressful reactions can encourage emotional regulation.
When clients can identify triggers that may lead to a negative response, they can stop the experience or slow down their emotional reaction (Dobson, 2011).
The What Are Your Unique Triggers ? worksheet helps the client identify their triggers (e.g., conflict, relationships, physical environment, etc.).
Problem-Solving worksheet
Imagining an existing or potential problem and working through how to resolve it can be a powerful exercise for the client.
Use the Problem-Solving worksheet to state a problem and goal and consider the obstacles in the way. Then explore options for achieving the goal, along with their pros and cons, to assess the best action plan.
Getting the Facts
Clients can become better equipped to tackle problems and choose the right course of action by recognizing facts versus assumptions and gathering all the necessary information (Dobson, 2011).
Use the Getting the Facts worksheet to answer the following questions clearly and unambiguously:
- Who is involved?
- What did or did not happen, and how did it bother you?
- Where did it happen?
- When did it happen?
- Why did it happen?
- How did you respond?
2 Helpful Group Activities
While therapists can use the worksheets above in group situations, the following two interventions work particularly well with more than one person.
Generating Alternative Solutions and Better Decision-Making
A group setting can provide an ideal opportunity to share a problem and identify potential solutions arising from multiple perspectives.
Use the Generating Alternative Solutions and Better Decision-Making worksheet and ask the client to explain the situation or problem to the group and the obstacles in the way.
Once the approaches are captured and reviewed, the individual can share their decision-making process with the group if they want further feedback.
Visualization
Visualization can be performed with individuals or in a group setting to help clients solve problems in multiple ways, including (Dobson, 2011):
- Clarifying the problem by looking at it from multiple perspectives
- Rehearsing a solution in the mind to improve and get more practice
- Visualizing a ‘safe place’ for relaxation, slowing down, and stress management
Guided imagery is particularly valuable for encouraging the group to take a ‘mental vacation’ and let go of stress.
Ask the group to begin with slow, deep breathing that fills the entire diaphragm. Then ask them to visualize a favorite scene (real or imagined) that makes them feel relaxed, perhaps beside a gently flowing river, a summer meadow, or at the beach.
The more the senses are engaged, the more real the experience. Ask the group to think about what they can hear, see, touch, smell, and even taste.
Encourage them to experience the situation as fully as possible, immersing themselves and enjoying their place of safety.
Such feelings of relaxation may be able to help clients fall asleep, relieve stress, and become more ready to solve problems.
We have included three of our favorite books on the subject of Problem-Solving Therapy below.
1. Problem-Solving Therapy: A Treatment Manual – Arthur Nezu, Christine Maguth Nezu, and Thomas D’Zurilla
This is an incredibly valuable book for anyone wishing to understand the principles and practice behind PST.
Written by the co-developers of PST, the manual provides powerful toolkits to overcome cognitive overload, emotional dysregulation, and the barriers to practical problem-solving.
Find the book on Amazon .
2. Emotion-Centered Problem-Solving Therapy: Treatment Guidelines – Arthur Nezu and Christine Maguth Nezu
Another, more recent, book from the creators of PST, this text includes important advances in neuroscience underpinning the role of emotion in behavioral treatment.
Along with clinical examples, the book also includes crucial toolkits that form part of a stepped model for the application of PST.
3. Handbook of Cognitive-Behavioral Therapies – Keith Dobson and David Dozois
This is the fourth edition of a hugely popular guide to Cognitive-Behavioral Therapies and includes a valuable and insightful section on Problem-Solving Therapy.
This is an important book for students and more experienced therapists wishing to form a high-level and in-depth understanding of the tools and techniques available to Cognitive-Behavioral Therapists.
For even more tools to help strengthen your clients’ problem-solving skills, check out the following free worksheets from our blog.
- Case Formulation Worksheet This worksheet presents a four-step framework to help therapists and their clients come to a shared understanding of the client’s presenting problem.
- Understanding Your Default Problem-Solving Approach This worksheet poses a series of questions helping clients reflect on their typical cognitive, emotional, and behavioral responses to problems.
- Social Problem Solving: Step by Step This worksheet presents a streamlined template to help clients define a problem, generate possible courses of action, and evaluate the effectiveness of an implemented solution.
- 17 Positive Psychology Exercises If you’re looking for more science-based ways to help others enhance their wellbeing, check out this signature collection of 17 validated positive psychology tools for practitioners . Use them to help others flourish and thrive.
While we are born problem-solvers, facing an incredibly diverse set of challenges daily, we sometimes need support.
Problem-Solving Therapy aims to reduce stress and associated mental health disorders and improve wellbeing by improving our ability to cope. PST is valuable in diverse clinical settings, ranging from depression to schizophrenia, with research suggesting it as a highly effective treatment for teaching coping strategies and reducing emotional distress.
Many PST techniques are available to help improve clients’ positive outlook on obstacles while reducing avoidance of problem situations and the tendency to be careless and impulsive.
The PST model typically assesses the client’s strengths, weaknesses, and coping strategies when facing problems before encouraging a healthy experience of and relationship with problem-solving.
Why not use this article to explore the theory behind PST and try out some of our powerful tools and interventions with your clients to help them with their decision-making, coping, and problem-solving?
We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .
- Cuijpers, P., Wit, L., Kleiboer, A., Karyotaki, E., & Ebert, D. (2020). Problem-solving therapy for adult depression: An updated meta-analysis. European P sychiatry , 48 (1), 27–37.
- Dobson, K. S. (2011). Handbook of cognitive-behavioral therapies (3rd ed.). Guilford Press.
- Dobson, K. S., & Dozois, D. J. A. (2021). Handbook of cognitive-behavioral therapies (4th ed.). Guilford Press.
- Eysenck, M. W., & Keane, M. T. (2015). Cognitive psychology: A student’s handbook . Psychology Press.
- Nezu, A. M., & Nezu, C. M. (2009). Problem-solving therapy DVD . Retrieved September 13, 2021, from https://www.apa.org/pubs/videos/4310852
- Nezu, A. M., & Nezu, C. M. (2018). Emotion-centered problem-solving therapy: Treatment guidelines. Springer.
- Nezu, A. M., Nezu, C. M., & D’Zurilla, T. J. (2013). Problem-solving therapy: A treatment manual . Springer.
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Volume 41, Issue 9, September 2012
Problem solving therapy Use and effectiveness in general practice
Problem solving therapy has been described as pragmatic, effective and easy to learn. It is an approach that makes sense to patients and professionals, does not require years of training and is effective in primary care settings. 1 It has been described as well suited to general practice and may be undertaken during 15–30 minute consultations. 2
Problem solving therapy takes its theoretical base from social problem solving theory which identifies three distinct sequential phases for addressing problems: 3
- discovery (finding a solution)
- performance (implementing the solution)
- verification (assessing the outcome).
Initially, the techniques of social problem solving emerged in response to empirical observations including that people experiencing depression exhibit a reduced capacity to resolve personal and social problems. 4,5 Problem solving therapy specifically for use in primary care was then developed. 6
Problem solving therapy has been shown to be effective for many common mental health conditions seen by GPs, including depression 7–9 and anxiety. 10,11 Most research has focused on depression. In randomised controlled trials, when delivered by appropriately trained GPs to patients experiencing major depression, PST has been shown to be more effective than placebo and equally as effective as antidepressant medication (both tricyclics and selective serotonin reuptake inhibitors [SSRIs]). 7,8 A recent meta-analysis of 22 studies reported that for depression, PST was as effective as medication and other psychosocial therapies, and more effective than no treatment. 9 For patients experiencing anxiety, benefit from PST is less well established. It has been suggested it is most effective with selected patients experiencing more severe symptoms who have not benefited from usual GP care. 10 Problem solving therapy may also assist a group of patients often seen by GPs: those who feel overwhelmed by multiple problems but who have not yet developed a specific diagnosis.
Although PST has been shown to be beneficial for many patients experiencing depression, debate continues about the mechanism(s) through which the observed positive impact of PST on patient affect is achieved. Two mechanisms have been proposed: the patient improves because they achieve problem resolution, or they improve because of a sense of empowerment gained from PST skill development. 12 Perhaps both factors play a part in achieving the benefits of PST as a therapeutic intervention. The observed benefit of PST for patients experiencing anxiety may be due to problem resolution and consequent reduction in distress from anticipatory concern about the identified but unsolved problem.
It is important to note that, while in the clinical setting we may find ourselves attempting to solve problems for patients and to advise them on what we think they should do, 13 this is not PST. Essential to PST, as an evidence based therapeutic approach, is that the clinician helps the patient to become empowered to learn to solve problems for themselves. The GP's role is to work through the stages of PST in a structured, sequential way to determine and to implement the solution selected by the patient. These stages have been described previously. 14 Key features of PST are summarised in Table 1 .
Using PST in general practice
Using PST, like any other treatment approach, depends on identifying patients for whom it may be useful. Patients experiencing a symptom relating to life difficulties, including relationship, financial or employment problems, which are seen by the patient in a realistic way, may be suitable for PST. Frequently, such patients feel overwhelmed and at times confused by these difficulties. Encouraging the patient to clearly define the problem(s) and deal with one problem at a time can be helpful. To this end, a number of worksheets have been developed. A simple, single page worksheet is shown in Figure 1 . A typical case study in which PST may be useful is presented in Table 2 . By contrast, patients whose thinking is typically characterised by unhelpful negative thought patterns about themself or their world may more readily benefit from cognitive strategies that challenge unhelpful negative thought patterns (such as cognitive behaviour therapy [CBT]). 15 Some problems not associated with an identifiable implementable solution, including existential questions related to life meaning and purpose, may not be suitable for PST. Identification of supportive and coping strategies along with, if appropriate, work around reframing the question may be more suitable for such patients.
Problem solving therapy may be used with patients experiencing depression who are also on antidepressant medication. It may be initiated with medication or added to existing pharmacotherapy. Intuitively, we might expect enhanced outcomes from combined PST and pharmacotherapy. However, research suggests this does not occur, with PST alone, medication alone and a combination of PST and medication each resulting in a similar patient outcomes.8 In addition to GPs, PST may be provided by a range of health professionals, most commonly psychologists. General practitioners may find they have a role in reinforcing PST skills with patients who developed their skills with a psychologist, especially if all Better Access Initiative sessions with the psychologist have been utilised.
The intuitive nature of PST means its use in practice is often straightforward. However, this is not always the case. Common difficulties using PST with patients and potential solutions to these difficulties have previously been discussed by the author 14 and are summarised in Table 3 . Problem solving therapy may also have a role in supporting marginalised patients such as those experiencing major social disadvantage due to the postulated mechanism of action of empowerment of patients to address symptoms relating to life problems. 12 of action includes empowerment of patients to address symptom causing life problems. Social and cultural context should be considered when using PST with patients, including conceptualisation of a problem, its significance to the patient and potential solutions.
General practitioners may be concerned that consultations that include PST will take too much time. 13 However, Australian research suggests this fear may not be justified with many GPs being able to provide PST to a simulated patient with a typical presentation of depression in 20 minutes. 15 Therefore, the concern over consultation duration may be more linked to established patterns of practice than the use of PST. Problem solving therapy may add an increased degree of structure to complex consultations that may limit, rather than extend, consultation duration.
Figure 1. Problem solving therapy patient worksheet
PST skill development for GPs
Many experienced GPs have intuitively developed valuable problem solving skills. Learning about PST for such GPs often involves refining and focusing those skills rather than learning a new skill from scratch. 13 A number of practical journal articles 16 and textbooks 10 that focus on developing PST skills in primary care are available. In addition, PST has been included in some interactive mental health continuing medical education for GPs. 17 This form of learning has the advantage of developing skills alongside other GPs.
Problem solving therapy is one of the Medicare supported FPS available to GPs. It is an approach that has developed from a firm theoretical basis and includes principles that will be familiar to many GPs. It can be used within the constraints of routine general practice and has been shown, when provided by appropriately skilled GPs, to be as effective as antidepressant medication for major depression. It offers an additional therapeutic option to patients experiencing a number of the common mental health conditions seen in general practice, including depression 7–9 and anxiety. 10,11
Conflict of interest: none declared.
- Gask L. Problem-solving treatment for anxiety and depression: a practical guide. Br J Psychiatry 2006;189:287–8. Search PubMed
- Hickie I. An approach to managing depression in general practice. Med J Aust 2000;173:106–10. Search PubMed
- D'Zurilla T, Goldfried M. Problem solving and behaviour modification. J Abnorm Psychol 1971;78:107–26. Search PubMed
- Gotlib I, Asarnow R. Interpersonal and impersonal problem solving skills in mildly and clinically depressed university students. J Consult Clin Psychol 1979;47:86–95. Search PubMed
- D'Zurilla T, Nezu A. Social problem solving in adults. In: Kendall P, editor. Advances in cognitive-behavioural research and therapy. New York: Academic Press, 1982. p. 201–74. Search PubMed
- Hegel M, Barrett J, Oxman T. Training therapists in problem-solving treatment of depressive disorders in primary care: lessons learned from the: "Treatment Effectiveness Project". Fam Syst Health 2000;18:423–35. Search PubMed
- Mynors-Wallis LM, Gath DH, Lloyd-Thomas AR, Tomlinson D. Randomised control trial comparing problem solving treatment with Amitryptyline and placebo for major depression in primary care. BMJ 1995;310:441–5. Search PubMed
- Mynors-Wallis LM, Gath DH, Day A, Baker F. Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care. BMJ 2000;320:26–30. Search PubMed
- Bell A, D'Zurilla. Problem-solving therapy for depression: a meta-analysis. Clin Psychol Rev 2009;29:348–53. Search PubMed
- Mynors-Wallis L Problem solving treatment for anxiety and depression. Oxford: OUP, 2005. Search PubMed
- Seekles W, van Straten A, Beekman A, van Marwijk H, Cuijpers P. Effectiveness of guided self-help for depression and anxiety disorders in primary care: a pragmatic randomized controlled trial. Psychiatry Res 2011;187:113–20. Search PubMed
- Mynors- Wallis L. Does problem-solving treatment work through resolving problems? Psychol Med 2002;32:1315–9. Search PubMed
- Pierce D, Gunn J. GPs' use of problem solving therapy for depression: a qualitative study of barriers to and enablers of evidence based care. BMC Fam Pract 2007;8:24. Search PubMed
- Pierce D, Gunn J. Using problem solving therapy in general practice. Aust Fam Physician 2007;36:230–3. Search PubMed
- Pierce D, Gunn J. Depression in general practice, consultation duration and problem solving therapy. Aust Fam Physician 2011;40:334–6. Search PubMed
- Blashki G, Morgan H, Hickie I, Sumich H, Davenport T. Structured problem solving in general practice. Aust Fam Physician 2003;32:836–42. Search PubMed
- SPHERE a national mental health project. Available at www.spheregp.com.au [Accessed 17 April 2012]. Search PubMed
Also in this issue: Psychological strategies
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Problem-solving Treatment
E pst® offers computer-guided delivery of problem-solving treatment (pst)..
A form of cognitive-behavioral therapy, PST is one of the most widely studied therapies for depression. PST helps people learn skills for managing daily life problems rather than focusing on modifying thoughts and feelings directly.
Rationale and Research
The premise of PST is that taking an active role in problem-solving helps people suffering from depression feel more in control of their lives.
Decades of research on PST from across the globe has shown it to be effective for individuals of all ages and from various socio-economic and cultural backgrounds. Moreover, it has shown that PST can be effective treatment for suicide prevention.
Help people re-engage by
Focusing on the here and now rather than dwelling on the past, addressing concrete, observable problems in daily life, taking an active role to plan and implement solutions, building enjoyable activities into daily life.
Depression and Solving Problems
People with depression or stress often avoid dealing with their daily life problems. Hopelessness and low energy hinder active problem-solving. Instead, they passively rely on the actions of others or the passage of time to resolve issues. Problems build up and become more overwhelming, depression deepens, and they become more passive and withdrawn.
Types of Problems
Relationships, coping with health issues, adherence to medical regimens, employment or schoolwork, housework and daily routines.
PST teaches skills to manage daily life problems. The focus is on addressing concrete, observable problems rather than targeting thought processes and emotions.
In e PST (electronic problem-solving treatment) an on-screen expert clinician guides clients step-by-step through problem-solving, providing personalized feedback and life-like responses.
A virtual expert therapist helps users learn to:
- Identify problems
- Brainstorm possible solutions
- Plan and take actions to solve their own problems.
Taking action leads to a greater sense of control, improves mood and reduces depression.
Behavioral activation.
PST also includes behavioral activation — scheduling regular enjoyable activities — which is also known to positively affect mood. e PST also includes this important element.
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- Front Psychiatry
Problem Solving Therapy Improves Effortful Cognition in Major Depression
Chenguang jiang.
1 Wuxi Mental Health Center Affiliated to Nanjing Medical University, Wuxi, China
Hongliang Zhou
2 Nanjing Brain Hospital Affiliated to Nanjing Medical University, Nanjing, China
Zhenhe Zhou
Associated data.
The datasets generated for this study are available on request to the corresponding author.
Background: Effortful cognition processing is an intentionally initiated sequence of cognitive activities, which may supply top-down and goal-oriented reassessment of specific stimuli to regulate specific state-driven responses contextually, whereas automatic cognitive processing is a sequence of cognitive activities that is automatically initiated in response to an input configuration. The effortful–automatic perspective has implications for understanding the nature of the clinical features of major depressions. The aim of this study was to investigate the influence of problem solving therapy (PST) on effortful cognition in major depression (MD).
Methods: The participants included an antidepressant treatment (AT) group ( n = 31) or the combined antidepressant treatment and PST (CATP) group ( n = 32) and healthy controls (HCs) ( n = 30). Hamilton Depression Rating Scale (HAMD, 17-item version) and the face–vignette task (FVT) were measured for AT group and CATP group at baseline (before the first intervention) and after 12 weeks of interventions. The HC group was assessed with the FVT only once. At baseline, both patients and HCs were required to complete the basic facial emotion identification test (BFEIT).
Results: The emotion identification accuracy of the HC group was higher than that of the patient group when they performed BFEIT; patients with MD present poor FVT performances; compared to the antidepressant treatment, PST plus antidepressant treatment decreased HAMD scores and improved FVT performances in patients with MD.
Conclusions: Patients with MD present effortful cognition dysfunction, and PST can improve effortful cognitive dysfunction. These findings suggest that the measurement of effortful cognition might be one of the indexes for the therapeutic effect of PST in MD.
Introduction
Major depression (MD) is a common mental disorder with a higher disability rate, affecting 10–15% of the worldwide population every year. To date, some antidepressants, including several typical antidepressants and several atypical antidepressants, have been used to treat major depression; however, only 60–70% of patients respond to antidepressant treatment. Furthermore, 10–30% of these patients exhibit treatment-resistant symptoms such as suicidal thought, a low mood, a decline in interest, and a loss of happiness ( 1 ).
To improve the symptoms of MD, several treatment options have been developed, such as switching therapies, augmentation, combination, optimization, psychotherapies, modified electro-convulsive therapy (MECT), repetitive transcranial magnetic stimulation therapies, deep brain stimulation therapies, vagal nerve stimulation therapies, light-based therapies, acupuncture treatment, and yoga; these approaches have been considered and tailored for individual patients ( 2 – 4 ). Most important for the improvement of depressed patients' symptoms, many studies had reported that physical activity interventions are helpful to improve major depressive disorders because physical activity is associated with many mental health benefits ( 5 – 11 ). Assessments to determine symptom improvement for patients with MD often depend on decreased total Hamilton Depression Rating Scale (HAMD, 17 or 24 items) scores.
Problem solving therapy (PST) belongs to a type of cognitive behavioral therapy that mainly concentrates on training in appropriate problem-solving notions as well as skills. PST has been used for major depression ( 12 – 15 ). It has been confirmed that, in the depressed patient group, PST was equally effective as antidepressant treatments and more effective than no treatment and support or attention control patients ( 16 ). In clinical practice, the effective treatment program of PST in MD includes three aspects: [1] training in a positive problem orientation, [2] training in problem definition and formulation, the generation of alternatives, decision making, and solution implementation and verification, and [3] training in problem orientation plus problem definition and formulation, the generation of alternatives, decision making, and solution implementation and verification ( 16 ).
Cognitive function refers to mental processes involved in working memory, problem-solving, decision-making, the acquisition of knowledge, regulation of information, and reasoning. As a major symptom, cognitive function impairment is acknowledged as a clinical characteristic of major depression. Additionally, many studies of major depression have suggested a role for cognitive measures in predicting those at risk for poor outcomes ( 17 ). A previous study indicated that patients with major depression present negatively valanced emotional symptoms that are accompanied by cognitive deficits, and the emotional processing dysfunctions of the prefrontal cortex might lead to cognitive deficits in patients with MD ( 18 ). Adaptive emotional responding relies on both effortful cognition processing and automatic cognition processing. Effortful cognition processing is a controlled process and refers to an intentionally initiated sequence of cognitive activities, which may supply top-down as well as goal-oriented reassessment of emotional stimuli to regulate emotion-driven responses contextually ( 19 ). Effortful cognition was measured by the face–vignette task (FVT) ( 19 ). Relative to effortful cognitive processing, automatic cognitive processing is a sequence of cognitive activities that is automatically initiated in response to an input configuration ( 20 ). Automatic cognition processing requires near-zero attention for the task at hand and, in many instances, is executed in response to a specific stimulus.
Previous studies have shown that patients with MD present effortful cognitive dysfunction. For example, a previous study reported that, when patients with MD performed two contrasting cognitive tasks ( i.e ., one requiring sustained effort and information processing and the other requiring only superficial information processing that could be accomplished automatically), only the effort-demanding cognitive task was performed poorly ( 21 ). Additionally, two previous studies investigated the functions of automatic and effortful information processing in a visual search paradigm, and the results showed that the patients with MD exhibited longer reaction times on the tasks requiring more effortful information processing than the controls. However, there were no differences on tasks requiring automatic information processing ( 22 , 23 ).
Since cognitive function impairment plays a critical role in MD, the assessment of cognitive function is a better way to determine the treatment effect for MD. The effortful–automatic perspective has implications for understanding the nature of the clinical features of MD. Furthermore, the investigation of the influence of PST on effortful cognition in MD is helpful for improving the present understanding of the therapeutic mechanism and assess the therapeutic effect of PST. To date, no studies of PST on effortful cognition in MD have been reported. In this study, the participants included patients with MD and healthy controls (HCs). The MD group was treated with antidepressants or the combination of antidepressants with PST, and effortful cognition was rated by the FVT. The hypothesis of this study is that depressed patients display poor effortful cognition performance, and PST can improve effortful cognitive dysfunctions. The aim of this study was to investigate the effect of PST on effortful cognition in MD.
Materials and Methods
Time and setting.
This study was conducted in Wuxi Mental Health Center Affiliated to Nanjing Medical University, No. 156 Qianrong Road, Rongxiang Street, Binhu District, Wuxi City, P.R. China, from February 1, 2016 to February 27, 2020.
Diagnostic Approaches and Subjects
A total of 80 patients meeting the American Psychiatric Association's fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for major depression were recruited as the research group. The MD patients were randomly assigned to the antidepressant treatment (AT) group or the combined antidepressant treatment and PST (CATP) group. The allocation schedule was generated by using a list of random numbers. Thirty healthy persons were admitted to the HC group. All HCs had no personal history of mental disorders. Patients with MD were selected from Wuxi Mental Health Center Affiliated to Nanjing Medical University, No. 156 Qianrong Road, Rongxiang Street, Binhu District, Wuxi City, P.R. China; the normal controls were citizens of Wuxi City, Jiangsu Province, P.R. China, recruited by online and local community advertisements. Patients with MD and HC subjects were excluded from the study if they had been diagnosed with nicotine addiction or other psychoactive substance dependence, had suffered any systemic disease that may affect the central nervous system, or had received electroconvulsive therapy (including MECT) in the past 24 weeks. All patients and HC subjects were Chinese. All patients and HC subjects were paid 42.12 Euros plus travel costs.
Seven subjects in AT group and five subjects in CATP group were all diagnosed with bipolar disorder in the follow-up survey, and they were ultimately excluded from this study. Two subjects in AT group and three subjects in CATP group were also excluded from this study because they could not finish the follow-up assessment. Finally, the data from 31 subjects in AT group and 32 subjects in CATP group were used in the statistical analyses.
Measurements of Automatic and Effortful Cognition
Basic facial emotion identification test.
The basic facial emotion identification test (BFEIT) consists of eight examples of each of the seven basic facial emotions, e.g ., happy, angry, sad, fear, surprise, disgust, and calm, which were taken from the Chinese affective picture system ( 24 ). Male and female face pictures were balanced across each emotion category.
Face–Vignette Task
FVT was designed based on an effortful cognitive task that was used in the study on effortful vs . automatic emotional processing in patients with schizophrenia by Patrick et al. ( 19 ). E-Prime 2.0 software (Psychology software tools, INC, USA) was used to implement the experimental procedure. The face pictures were white and black photographs and included six emotional expressions, i.e ., happy, angry, sad, fear, surprise, and disgust, which were taken from the Chinese affective picture system ( 24 ). In each emotion, the male and female faces were equal. Within a given emotion category, the same identity was used only once. The situational vignettes communicated the six special emotions, i.e ., guilty, smug, hopeful, insulted, pain, and determined. Before the experiment, the intended emotion for each story (vignette) was verified by seven undergraduates, and the mean accuracy was 0.91 [standard deviation (SD) = 0.08], and the observed inter-rater reliability κ value was 0.75. The face–story pairs were matched such that each story was inconsistent with the facial expression according to the specially appointed emotional category ( e.g ., a happy facial expression paired with a smug story). Each specific emotion category depended on the situational context (see the listed example in Figure 1 ). The specially appointed face–story pairs included sad vs . guilty, happy vs . smug, fearful vs . painful, angry vs . determined, disgusted vs . insulted, and surprised vs . hopeful. During the FVT, the participants viewed a series of 24 face–story (vignette) pairs and were informed that each facial expression represented the subject of the vignette. The faces and vignettes were presented simultaneously. All participants were required to read the vignettes aloud. In each trial, all participants answered the question accompanied by face–vignette pairs through a specially appointed keypad in a multiple choice pattern. The 13 obtainable choices for each trial were as follows: angry, happy, sad, fearful, disgusted, surprised, smug, guilty, hopeful, determined, pain, insulted as well as no emotion.
Example of a trial on the face–vignette task. The situational vignettes in English are as follows: This is a story about a girl's birthday. The girl stayed in her room. She received a call from her beloved boyfriend: “You're waiting for me at home. I'll bring your favorite flowers to your birthday!” Several minutes later, she heard the knock of her boyfriend's arrival. The question was “What emotion is the person feeling?” Responding with “surprise” will be recorded as a face response and responding with “hopeful” will be recorded as a vignette response. Additionally, any other response will be recorded as a random response.
On the FVT, the responses of the participants were labeled as face responses, vignette responses, and random responses. The response data were converted to proportions, which were used for statistical analysis.
Problem Solving Therapy Procedure
The PST was performed as described in a previous study ( 25 ). All the patients with MD were scheduled for PST, which consists of six sessions administered every other week. The treatment sessions were conducted at the psychological therapy room of the Psychiatry Department. The PST was conducted by six psychotherapists, and visits were conducted by two psychiatric resident physicians. All the psychotherapists owned a therapy handbook and underwent training, including a short theoretical course, role playing in a clinical background as well as watching a training videotape. The PST includes three steps: [1] the patient's symptoms are linked with their problems in daily living, [2] the problems are defined and clarified, and [3] an attempt is made to solve the problems in a structured way. The sessions lasted 1 h for the first visit and half an hour for the subsequent visits.
Clinical Interventions and Clinical Assessment
Two psychiatric residents examined all the participants to confirm or exclude a major depression diagnosis based on DSM-5 criteria and to collect medication and sociodemographic data. A HAMD (17-item version) was applied to assess the depressive severity for patients. A decrease of more than 50% in HAMD (17-item version) scores from baseline to follow-up was defined as a treatment response, and HAMD (17-item version) scores <7 at follow-up were defined as clinical remission.
HAMD (17-item version) and the FVT data were measured for the AT group and CATP group at baseline (before the first intervention, time 1) and after 12 weeks of interventions (time 2). The HC group was assessed using the face–vignette task only once. At baseline, both patients and HCs were required to complete the BFEIT.
Statistical Analysis
Data are presented as mean (SD), and all data were analyzed with Statistical Product and Service Solution 18.0 statistical software (SPSS 18.0, International Business Machines Corporation). Comparisons of the demographic data, basic facial emotion identification test scores, face response proportions, vignette response proportions, and random response proportions at baseline among patients and healthy controls were conducted using the method of one-way analysis of variance (ANOVA) or the chi-square test. Comparisons of HAMD (17-item version) scores, face response proportions, vignette response proportions, and random response proportions between baseline (time 1) and after 12 weeks of interventions (time 2) in the patient group were performed using 2 × 2 repeated-measures ANOVA. In this study, all alpha values of 0.05 were considered as statistically significant throughout. Cohen's d effect sizes were used for t -tests. The cutoff values for Cohen's d 's were defined as trivial effect size when d < 0.19, small effect size when 0.2 < d < 0.49, medium effect size when 0.5 < d < 0.79, and large effect size when d > 0.8. Partial eta-square (η p 2 ) effect sizes were used for F -tests. Similarly, the cutoff values for η p 2 were set as trivial effect size when η p 2 < 0.019, small effect size when 0.02 < η p 2 < 0.059, medium effect size when 0.06 < η p 2 < 0.139, and large effect size when η p 2 > 0.14. Phi (ϕ) effect sizes were used for chi-square test. The cutoff values for ϕ were set as trivial effect size when ϕ < 0.09, small effect size when 0.10 < ϕ < 0.29, medium effect size when 0.30 < ϕ < 0.49, and large effect size when ϕ > 0.50.
The Demographic Data of All Participants
The demographic data of the participants are described in Table 1 . No significant differences were observed in sex ratio, mean age, age range, or mean education years among the AT group, CATP group, and HC group.
Demographic characteristics and clinical data of all participants.
AT, antidepressant treatment; CATP, the combination of antidepressant treatment and PST; HC, healthy control; SD, standard deviation; η p 2 , partial eta-square .
Antidepressant Treatments
In the AT group, 20 patients with MD were antidepressant-naïve, and 11 patients with MD were antidepressant-free (six for at least 24 weeks and five for at least 4 weeks); patients with MD received fluoxetine ( n = 8), paroxetine ( n = 7), fluvoxamine ( n = 7), sertraline ( n = 6), or escitalopram ( n = 3). The mean fluoxetine-equivalent dose was 30.5 (8.8) mg/day. In the CATP group, 19 patients with MD were antidepressant-naïve, and 13 patients with MD were antidepressant-free (eight for at least 24 weeks and five for at least 4 weeks); patients with MD received fluoxetine ( n = 9), paroxetine ( n = 8), fluvoxamine ( n = 8), sertraline ( n = 3), or escitalopram ( n = 4). According to a previous report ( 26 ), the mean fluoxetine-equivalent dose was 30.1 (7.9) mg/day. Neither of the patient groups used concomitant medications.
Comparisons of BFEIT Performance Among the AT Group, CATP Group, and HC Group
As shown in Figure 2 , one-way ANOVA revealed that there were significant differences in BFEIT performance (emotion identification accuracy) among the AT group, CATP group, and HC group ( F 2,90 = 27.729, df = 2, η p 2 = 0.33, p = 0.000). Least square difference tests were performed as post hoc analyses and showed significant differences between the HC group, AT group, and CATP group (all p = 0.000). The emotion identification accuracy of the HC group was higher than that of the AT group or CATP group. However, no significant difference was observed between the AT group and the CATP group ( p = 0.951).
Comparisons of BFEIT performance among the AT group, CATP group, and HC group. BFEIT, basic facial emotion identification test; ATG, antidepressant treatment group; CATPG, the combination of antidepressant treatment and PST group; HC, healthy control; SD, standard deviation.
Comparisons of HAMD (17-Item Version) Scores Before and After Clinical Interventions
As shown in Figure 3 , using HAMD (17-item version) scores as dependent variables, a 2 × 2 repeated-measures ANOVA with group (AT group vs . CATP group) as a between-subjects factor and time point (time 1 vs . time 2) as a within-subjects factor revealed that the interaction effect for group × time point was not significant ( F 1,61 = 1.697, η p 2 = 0.003, p = 0.198); however, the main effect for time point was significant ( F 1,61 = 206.419, η p 2 = 0.35, p = 0.000), and the main effect for group was significant ( F 1,61 = 170.914, η p 2 = 0.18, p = 0.038). The 12-week interventions decreased HAMD (17-item version) scores in the two patient groups.
Comparisons of HAMD scores before and after clinical interventions between the AT group and CATP group. HAMD, Hamilton Depression Rating Scale (17-item version); ATG, antidepressant treatment group; CATPG, the combination of antidepressant treatment and PST group; time 1, baseline; time 2, after 12 weeks of intervention; SD, standard deviation.
There were significant differences in the remission rate between the CATP group (19/32) and the AT group (14/31); the remission rate in the CATP group was higher than that of the AT group (χ 2 = 6.123, ϕ = 0.29, p = 0.028). There were significant differences in the treatment response rate between the CATP group (25/32) and AT group (18/31); the treatment response rate in the CATP group was higher than that of the AT group (χ 2 = 4.370, ϕ = 0.26, p = 0.035).
Comparisons of FVT Performance Among the AT Group, CATP Group, and HC Group
Baseline level.
As shown in Table 2 , one-way ANOVA revealed that there were significant differences in face response proportions and vignette response proportions among the AT group, CATP group, and HC group ( F 2,90 = 27.861, 18.234, all df = 2; η p 2 = 0.32, 0.36, all p = 0.000). Least square difference tests were performed as post hoc analyses and showed significant differences between the HC group and AT group or between the HC group and the CATP group (all p = 0.000). The face response proportions of the HC group were lower than those of the AT group and CATP group, and the vignette response proportions of the HC group were higher than those of the AT group and CATP group. For the above-mentioned two variables, no differences between the AT group and CATP group were observed ( p = 0.951, 0.913).
Face–vignette task performances (%, SD) among the AT group, CATP group, and healthy control group.
AT, antidepressant treatment; CATP, the combination of antidepressant treatment and PST; Time 1, baseline; Time 2, after 12 weeks of interventions; F, face response proportions; V, vignette response proportions; R, random response proportions .
However, there were no significant differences in random response proportions among the AT group, CATP group, and HC group ( F 2,90 = 0.979, df = 2, η p 2 = 0.006, p = 0.380).
Before and After Interventions
As shown in Table 2 , using face response proportions, vignette response proportions, and random response proportions as dependent variables, a 2 × 2 repeated-measures ANOVA with group (AT group vs . CATP group) as the between-subjects factor and time point (time 1 vs . time 2) as the within-subjects factor was performed.
Face Response Proportions
The interaction effect for group × time point was significant ( F 1,61 =25.174, df =1, η p 2 = 0.30, p = 0.000), the main effect for time point was significant ( F 1,61 = 138.086, df = 1, η p 2 = 0.32, p = 0.000), and the main effect for group was significant ( F 1,61 = 4.853, df = 1, η p 2 = 0.24, p = 0.031).
Vignette Response Proportions
The interaction effect for group × time point was significant ( F 1,61 = 29.450, df = 1, η p 2 = 0.31, p = 0.000), the main effect for time point was significant ( F 1,61 = 144.130, df = 1, η p 2 = 0.32, p = 0.000), and the main effect for group was significant ( F 1,61 = 3.083, df = 1, η p 2 = 0.18, p = 0.041).
Random Response Proportions
The interaction effect for group × time point was not significant ( F 1,61 = 1.003, df = 1, η p 2 = 0.001, p = 0.320), the main effect for time point was not significant ( F 1,61 = 1.519, df = 1, η p 2 = 0.001, p = 0.223), and the main effect for group was not significant ( F 1,61 = 0.017, df = 1, η p 2 = 0.000, p = 0.897).
This study is the first to survey the effect of problem-solving therapy on effortful cognition in MD using FVT; measurements of the basic facial emotion identification were also conducted. Our data showed that the emotion identification accuracy of HCs was higher than that of patients with MD; patients with MD exhibited poor FVT performance. Compared to antidepressant treatment, PST plus antidepressant treatment resulted in lower HAMD (17-item version) scores and better FVT performance.
This study also investigated the ability of patients with MD to employ contextual information when determining the intended or expressed or signified message of facial emotional expressions. In the FVT, target facial emotional expressions are preceded by stories describing situational messages which are discrepant in affective valence. What both patients with MD and HCs had judged reflects either the dominance of the emotional context or the facial emotional expression. Many studies on cognitive processing by patients with MD reported that depressive symptoms interfere with effortful processing, and the degree of interference is determined by the degree of effort required for the task, the severity of depression, and the valence of the stimulus material to be processed. However, depressive symptoms only interfere minimally with automatic processes ( 27 ).
Consistent with the findings of previous studies ( 21 – 23 ), our results showed that patients with MD could not utilize contextual information for specific face–vignette pairs. However, HCs more extensively made good judgments on emotion in line with contextual information, which indicates that patients with MD display poor effortful cognition performance. Cognition dysfunctions in MD include impairments of social cognition and neurocognition ( 28 , 29 ). Social cognition refers to a process or a function for an individual's mental operations underlying social behavior, while neurocognition refers to those basic information processing functions such as attention and executive processes. Effortful cognitive processing was involved in either social cognition or neurocognition. We verified our hypothesis, i.e ., patients with MD present effortful cognitive dysfunction.
In this study, we confirmed that PST plus antidepressant treatments leads to a greater reduction of depressive symptoms, a greater response rate, and a greater remission rate over a period of 12 weeks than antidepressant treatments only in patients with MD. We also indirectly verified our previous hypothesis, i.e ., PST can improve effortful cognitive dysfunction, namely, PST improved the severity of MD by improving effortful cognition. Our data provide supporting evidence for the conclusion that the facial affect processing ability could be a valuable predictor of successful social context integration in FVT in MD.
Conclusions
In conclusion, patients with MD present effortful cognitive dysfunction, and PST can improve effortful cognitive dysfunction. The measurement of effortful cognition might be one of the indexes for the therapeutic effect of PST in MD.
There are some limitations in the study. First, the findings must be considered preliminary due to the small sample size. Second, healthy controls were assessed with the FVT only once; therefore, the results of the FVT would be influenced by the practice effect in patients with MD. Future studies should augment the sample size and eliminate the practice effect to further confirm the relationship between effortful cognition and PST in MD. Finally, this study investigated the effect of PST plus antidepressant treatment on effortful cognition in MD. Therefore, no outcome of the pure PST effect on effortful cognition was obtained. The examination of the pure PST effect on effortful cognition in MD is necessary in a future study.
Data Availability Statement
Ethics statement.
The studies involving human participants were reviewed and approved by Affiliated Wuxi Mental Health Center of Nanjing Medical University. The patients/participants provided their written informed consent to participate in this study.
Author Contributions
CJ, HZ, and ZZ designed the study and wrote the paper. CJ, HZ, LC, and ZZ acquired and analyzed the data. All authors reviewed the content and approved the final version for publication.
Conflict of Interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
Acknowledgments
The authors would like to thank the Key Medical Talent Training Project of Jiangsu Province for providing support (project Grant No. ZDRCC2016019) for this research.
Funding. This research was supported by the Wuxi Taihu Talent Project (No. WXTTP2020008) and the Key Medical Talent Training Project of Jiangsu Province (No. ZDRCC2016019).
Cognitive Behavioral Therapy Los Angeles
Problem-solving therapy.
Problem-solving therapy is a treatment that helps people take action in their lives, helping them cope with difficulties, and teaching them to proactively solve their problems. Unlike traditional psychotherapy, problem-solving therapy makes use of cognitive and behavioral interventions, helping people directly work on life's challenges. Problem-solving therapy can help with achieving goals, finding purpose, reducing depression, managing anxiety, and solving relationship problems. Problem-solving therapy has been the subject of recent scientific research, showing it can be helpful not only with psychological problems, but with physical illness as well.
Problem-solving therapy works by teaching people skills to help them take a more active role in their lives, taking more initiative, and utilizing whatever influence they have to effectively make decisions and achieve their goals. By using this treatment approach with one specific problem, people learn to apply it to any other problem they may face, empowering them to face difficulties more independently. As these skills are repeatedly practice, clients often report an increased sense of confidence and agency in many aspects of their lives.
The core components of problem-solving therapy are described below:
Addressing problem orientation: Every person has learned to approach problems differently. Some people naturally take a more submissive approach, avoid the problem or associated conflict. Others take a compulsive approach, addressing the problem aggressively, but without much introspection or creativity. During treatment, thoughts, attitudes, and strategies for solving problems are assessed, and weaknesses are addressed through cognitive and behavioral techniques.
Clearly defining problems: Often people are hindered from solving the problems they face because they cannot clearly define what the actual problem is. For instance, if you identify that you are constantly stressed out at work, you might think that the anxiety is the problem to be solved. In reality, it may be that a lack of assertiveness with your boundaries is the actual problem, resulting in others delegating more work to you, and ultimately in you feeling increased stress.
Brainstorming and evaluating solutions: People who come to therapy often feel so overwhelmed by the magnitude of the things causing them distress, they feel it is a hopeless task to do anything to address their difficulties. By considering a multitude of potential solutions, problems increasingly feel more solvable. Thus people are more likely to take action to solve them.
Taking Action: Breaking down a problem into a series of achievable steps further helps people to actively address their problems. And rather than identifying a goal that feels overwhelming, in problem-solving therapy people learn to only plan what they are confident they can accomplish. Slowly and surely, by chipping away at large tasks, people solve their problems. While evidence-based research shows that problem solving treatment in Los Angeles is able to help people to face the conflicts in their lives head-on, a more effective result can sometimes be achieved when incorporated into a comprehensive CBT treatment. To learn more about CBT and problem-solving therapy, how it is used and what it can treat, use our menu at the top of the page to learn more or visit our CBT exercises pages. Cognitive Behavioral Therapy Los Angeles is a team of professional psychologists with extensive experience and training in providing CBT treatment options. Schedule a consultation today by clicking on the button below.
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Problem solving self-help guide
Work through a self-help guide for problem solving based on Cognitive Behavioural Therapy (CBT).
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Last updated: 04 March 2022
IMAGES
VIDEO
COMMENTS
If you’ve ever thought about receiving counseling or participating in therapy, you may wonder what options are available to you. Many different therapy styles can help you with anxiety, depression, substance use, and other mental health dis...
The six steps of problem solving involve problem definition, problem analysis, developing possible solutions, selecting a solution, implementing the solution and evaluating the outcome. Problem solving models are used to address issues that...
When multiplying or dividing different bases with the same exponent, combine the bases, and keep the exponent the same. For example, X raised to the third power times Y raised to the third power becomes the product of X times Y raised to th...
Problem-solving therapy is a cognitive–behavioral intervention geared to improve an individual's ability to cope with stressful life experiences. The underlying
Problem-solving therapy is all about training you to become adaptive in your life so that you will start to see problems as challenges to be
“Problem-solving therapy (PST) is a psychosocial intervention, generally considered to be under a cognitive-behavioral umbrella” (Nezu
Problem solving therapy, also called PST, is a type of therapy that uses both cognitive and behavioral patterns of the client better make
PST identifies strategies to support people to cope with difficulties in life and take the initiative to solve everyday problems. Using cognitive behavioral
Problem solving therapy involves patients learning or reactivating problem solving skills. These skills can then be applied to specific life problems associated
A form of CBT (cognitive-behavioral therapy), PST (problem-solving therapy), is one of the most widely studied therapies for depression. PST helps people
Problem-solving therapy refers to a psychological treatment that helps to teach you to effectively manage the negative effects of stressful events that can
Conclusions: Patients with MD present effortful cognition dysfunction, and PST can improve effortful cognitive dysfunction. These findings
Unlike traditional psychotherapy, problem-solving therapy makes use of cognitive and behavioral interventions, helping people directly work on life's
Work through a self-help guide for problem solving based on Cognitive Behavioural Therapy (CBT).