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What Is Problem-Solving Therapy?

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." She has a Master's degree in psychology.

social problem solving therapy definition

Daniel B. Block, MD, is an award-winning, board-certified psychiatrist who operates a private practice in Pennsylvania.

social problem solving therapy definition

Verywell / Madelyn Goodnight

Problem-Solving Therapy Techniques

How effective is problem-solving therapy, things to consider, how to get started.

Problem-solving therapy is a brief intervention that provides people with the tools they need to identify and solve problems that arise from big and small life stressors. It aims 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.

At a Glance

Problem-solving therapy is a short-term treatment used to help people who are experiencing depression, stress, PTSD, self-harm, suicidal ideation, and other mental health problems develop the tools they need to deal with challenges. This approach teaches people to identify problems, generate solutions, and implement those solutions. Let's take a closer look at how problem-solving therapy can help people be more resilient and adaptive in the face of stress.

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. 

Key Components

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.

Planful Problem-Solving

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

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 life stress issues and focuses on helping you find solutions to concrete issues. This approach can be applied to problems associated with various psychological and physiological symptoms.

Mental Health Issues

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

Specific Life Challenges

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 issues 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")

Problem-solving therapy can help people feel more empowered to deal with the problems they face in their lives. Rather than feeling overwhelmed when stressors begin to take a toll, this therapy introduces new coping skills that can boost self-efficacy and resilience .

Other Types of Therapy

Other similar types of therapy include cognitive-behavioral therapy (CBT) and solution-focused brief therapy (SFBT) . While these therapies work to change thinking and behaviors, they work a bit differently. Both CBT and SFBT are less structured than problem-solving therapy and may focus on broader issues. CBT focuses on identifying and changing maladaptive thoughts, and SFBT works to help people look for solutions and build self-efficacy based on strengths.

This form of therapy was initially developed to help people combat stress through effective problem-solving, and it was later adapted to address clinical depression specifically. 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 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 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 .

Keep In Mind

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.

Get Help Now

We've tried, tested, and written unbiased reviews of the best online therapy programs including Talkspace, BetterHelp, and ReGain. Find out which option is the best for you.

Shang P, Cao X, You S, Feng X, Li N, Jia Y. Problem-solving therapy for major depressive disorders in older adults: an updated systematic review and meta-analysis of randomized controlled trials .  Aging Clin Exp Res . 2021;33(6):1465-1475. doi:10.1007/s40520-020-01672-3

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

Owens D, Wright-Hughes A, Graham L, et al. Problem-solving therapy rather than treatment as usual for adults after self-harm: a pragmatic, feasibility, randomised controlled trial (the MIDSHIPS trial) .  Pilot Feasibility Stud . 2020;6:119. doi:10.1186/s40814-020-00668-0

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

Margolis SA, Osborne P, Gonzalez JS. Problem solving . In: Gellman MD, ed. Encyclopedia of Behavioral Medicine . Springer International Publishing; 2020:1745-1747. doi:10.1007/978-3-030-39903-0_208

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

Noyes K, Zapf AL, Depner RM, et al. Problem-solving skills training in adult cancer survivors: Bright IDEAS-AC pilot study .  Cancer Treat Res Commun . 2022;31:100552. doi:10.1016/j.ctarc.2022.100552

Albert SM, King J, Anderson S, et al. Depression agency-based collaborative: effect of problem-solving therapy on risk of common mental disorders in older adults with home care needs . The American Journal of Geriatric Psychiatry . 2019;27(6):619-624. doi:10.1016/j.jagp.2019.01.002

By Arlin Cuncic, MA 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." She has a Master's degree in psychology.

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Evidence-Based Treatment and Practice with Older Adults: Theory, Practice, and Research

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5 Problem-Solving Therapy: Theory and Practice

  • Published: May 2017
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Problem-solving therapy (PST) is a psychosocial intervention that teaches clients to cope with the stress of “here-and-now” problems in order to reduce negative health and mental health outcomes. In this chapter, the six stages of PST—problem orientation, problem definition, solution generation, decision-making, solution implementation, and outcome evaluation—are explained and exemplified via vignettes. Areas for which problem-solving therapy has been found useful are summarized, including depression, anxiety, relationship difficulties, and distress related to medical problems such as cancer and diabetes. The chapter describes contexts for practice, including primary care and home care, as well as adaptations for the use of PST with older adults. Finally, a case example of a problem-solving intervention with an unemployed depressed older man is presented to illustrate this approach.

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Problem-solving training as an active ingredient of treatment for youth depression: a scoping review and exploratory meta-analysis

  • Karolin R. Krause   ORCID: orcid.org/0000-0003-3914-7272 1 , 2 ,
  • Darren B. Courtney   ORCID: orcid.org/0000-0003-1491-0972 1 , 3 ,
  • Benjamin W. C. Chan 4 ,
  • Sarah Bonato   ORCID: orcid.org/0000-0002-5174-0047 1 ,
  • Madison Aitken   ORCID: orcid.org/0000-0002-4921-5462 1 , 3 ,
  • Jacqueline Relihan 1 ,
  • Matthew Prebeg 1 ,
  • Karleigh Darnay   ORCID: orcid.org/0000-0002-0395-8674 1 ,
  • Lisa D. Hawke   ORCID: orcid.org/0000-0003-1108-9453 1 , 3 ,
  • Priya Watson   ORCID: orcid.org/0000-0001-9753-6490 1 , 3 &
  • Peter Szatmari   ORCID: orcid.org/0000-0002-4535-115X 1 , 3 , 5  

BMC Psychiatry volume  21 , Article number:  397 ( 2021 ) Cite this article

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Metrics details

Problem-solving training is a common ingredient of evidence-based therapies for youth depression and has shown effectiveness as a versatile stand-alone intervention in adults. This scoping review provided a first overview of the evidence supporting problem solving as a mechanism for treating depression in youth aged 14 to 24 years.

Five bibliographic databases (APA PsycINFO, CINAHL, Embase, MEDLINE, Web of Science) and the grey literature were systematically searched for controlled trials of stand-alone problem-solving therapy; secondary analyses of trial data exploring problem-solving-related concepts as predictors, moderators, or mediators of treatment response within broader therapies; and clinical practice guidelines for youth depression. Following the scoping review, an exploratory meta-analysis examined the overall effectiveness of stand-alone problem-solving therapy.

Inclusion criteria were met by four randomized trials of problem-solving therapy (524 participants); four secondary analyses of problem-solving-related concepts as predictors, moderators, or mediators; and 23 practice guidelines. The only clinical trial rated as having a low risk of bias found problem-solving training helped youth solve personal problems but was not significantly more effective than the control at reducing emotional symptoms. An exploratory meta-analysis showed a small and non-significant effect on self-reported depression or emotional symptoms (Hedges’ g = − 0.34; 95% CI: − 0.92 to 0.23) with high heterogeneity. Removing one study at high risk of bias led to a decrease in effect size and heterogeneity (g = − 0.08; 95% CI: − 0.26 to 0.10). A GRADE appraisal suggested a low overall quality of the evidence. Tentative evidence from secondary analyses suggested problem-solving training might enhance outcomes in cognitive-behavioural therapy and family therapy, but dedicated dismantling studies are needed to corroborate these findings. Clinical practice guidelines did not recommend problem-solving training as a stand-alone treatment for youth depression, but five mentioned it as a treatment ingredient.

Conclusions

On its own, problem-solving training may be beneficial for helping youth solve personal challenges, but it may not measurably reduce depressive symptoms. Youth experiencing elevated depressive symptoms may require more comprehensive psychotherapeutic support alongside problem-solving training. High-quality studies are needed to examine the effectiveness of problem-solving training as a stand-alone approach and as a treatment ingredient.

Peer Review reports

Depressive disorders are a common mental health concern in adolescence [ 1 , 2 , 3 ] and associated with functional impairment [ 4 ] and an increased risk of adverse mental health, physical health, and socio-economic outcomes in adulthood [ 5 , 6 , 7 , 8 ]. Early and effective intervention is needed to reduce the burden arising from early-onset depression. Several psychotherapies have proven modestly effective at reducing youth depression, including cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT) [ 9 , 10 ]. Room for improvement remains; around half of youth do not show measurable symptom reduction after an average of 30 weeks of routine clinical care for depression or anxiety [ 11 ]. One barrier to greater impact is a lack of understanding of which treatment ingredients are most critical [ 12 , 13 ]. Identifying the “active ingredients” that underpin effective approaches, and understanding when and for whom they are most effective is an important avenue for enhancing impact [ 13 ]. Distilling interventions to their most effective ingredients while removing redundant content may also help reduce treatment length and cost, freeing up resources to expand service provision. Given that youth frequently drop out of treatment early [ 14 ], introducing the most effective ingredients at the start may also help improve outcomes.

One common ingredient in the treatment of youth depression is problem-solving (PS) training [ 15 ]. Problem solving in real-life contexts (also called social problem solving) describes “the self-directed process by which individuals attempt to identify [ …] adaptive coping solutions for problems, both acute and chronic, that they encounter in everyday living” (p.8) [ 16 ]. Within a relational/problem-solving model of stress and well-being, mental health difficulties are viewed as the result of maladaptive coping behaviours that cannot adequately safeguard an individual’s well-being against chronic or acute stressors [ 17 ]. According to a conceptual model developed by D’Zurilla and colleagues ([ 16 , 17 , 18 , 19 ]; see Fig.  1 ), effective PS requires a constructive and confident attitude towards problems (i.e., a positive problem orientation ), and the ability to approach problems rationally and systematically (i.e., rational PS style ). Defeatist or catastrophizing attitudes (i.e., a negative problem orientation ), passively waiting for problems to resolve (i.e., avoidant style ), or acting impulsively without thinking through possible consequences and alternative solutions (i.e., impulsive/careless style ) are considered maladaptive [ 16 , 18 , 20 ]. Empirical studies suggest maladaptive PS is associated with depressive symptoms in adolescents and young adults [ 21 , 22 , 23 , 24 , 25 ].

figure 1

Dimensions of Problem-Solving (PS) Ability

Problem-Solving Therapy (PST) is a therapeutic approach developed by D’Zurilla and Goldfried [ 26 ] in the 1970s, to alleviate mental health difficulties by improving PS ability. Conceptually rooted in Social Learning Theory [ 27 ], PST aims to promote adaptive PS by helping clients foster an optimistic and self-confident attitude towards problems (i.e., a positive problem orientation), and by helping them develop and internalize four core PS skills: (a) defining the problem; (b) brainstorming possible solutions; (c) appraising solutions and selecting the most promising one; (d) implementing the preferred solution and reflecting on the outcome ([ 16 , 17 , 18 , 19 ]; see Fig. 1 ). PST is distinct from Solution-Focused Brief Therapy (SFBT), which has different conceptual roots and emphasizes the construction of solutions over the in-depth formulation of problems [ 28 ].

PS training is also a common ingredient of other psychosocial depression treatments [ 15 , 20 ], such as CBT and Dialectical Behaviour Therapy (DBT) [ 15 , 29 , 30 , 31 , 32 ] that typically focus on strengthening PS skills rather than problem orientation [ 20 ]. In IPT, PS training focuses on helping youth understand and resolve relationship problems [ 29 , 30 , 33 , 34 ]. PS training is also a common component of family therapy [ 35 ], cognitive reminiscence therapy [ 36 ], and adventure therapy [ 37 ]. The extent to which PS training in these contexts follows the conceptual model by D’Zurilla and colleagues varies. Hereafter, we will use the term PST (“Problem-Solving Therapy”) where problem-solving training constitutes a stand-alone intervention; and we will use the term “PS training” where it is mentioned as a part of other therapies or discussed more broadly as an active ingredient of treatment for youth depression.

Meta-analyses considering over 30 randomized control trials (RCTs) of stand-alone PST for adult depression suggest it is as effective as CBT and IPT, and more effective than waitlist or attention controls [ 38 , 39 , 40 ]. PST has been applied with children, adolescents, and young adults [ 41 , 42 , 43 , 44 , 45 , 46 ], but dedicated manuals for different developmental stages are not readily available. In an assessment of fit between evidence-based therapy components and everyday coping skills used by school children, PS skills were the third most frequently endorsed skill set in terms of frequency of habitual use and perceived effectiveness, suggesting these skills are highly transferable and relevant to youth [ 47 ]. PS training can be brief (i.e., involve fewer than 10 sessions) [ 38 ], and has been delivered to youth by trained clinicians [ 45 ], lay counsellors [ 46 ], and via online platforms [ 44 ]. It can also be adapted for primary care [ 40 ]. In light of its versatility and of its effectiveness in adults, PS training is a prime candidate for a treatment ingredient that deserves greater scrutiny in the context of youth depression. However, no systematic evidence synthesis has yet examined its efficacy and effectiveness in this population.

This study had two sequential parts. First, we conducted a mixed-methods scoping review to map the available evidence relating to PS training as an active ingredient for treating youth depression. Youth were defined as aged 14 to 24 years, broadly aligning with United Nations definitions [ 48 ]. In a subsequent step, we conducted an exploratory meta-analysis to examine the overall efficacy of free-standing PST, based on clinical trials identified in the scoping review.

Scoping review

Scoping review methodology was used to provide an initial overview of the available evidence [ 49 ]. The review was pre-registered on the Open Science Framework [ 50 ] and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension for Scoping Reviews checklist [ 51 ] (Additional File  1 ). The review was designed to integrate four types of literature: (a) qualitative studies reporting on young people’s experiences with PS training; (b) controlled clinical trials testing the efficacy of stand-alone PST; (c) studies examining PS-related concepts as predictors, moderators, or mediators of treatment response within broader therapeutic interventions (e.g., CBT); and (d) clinical practice guidelines (CPGs) for youth depression. In addition, the search strategy included terms designed to identify relevant conceptual articles that are discussed here as part of the introduction [ 52 ].

Search strategy

Five bibliographic databases (APA PsycINFO, CINAHL, Embase, MEDLINE, Web of Science) and the grey literature were systematically searched for (a) empirical studies published from database inception through June 2020, and (b) CPGs published between 2005 and July 2020. Reference lists of key studies were searched manually, and records citing key studies were searched using Google Scholar’s “search within citing articles” function [ 52 ]. The search strategy was designed in collaboration with a research librarian (SB) and combined topic-specific terms defining the target population (e.g., “depression”; “adolescent?”) and intervention (e.g., “problem-solving”) with methodological search filters combining database-specific subject headings (e.g., “randomized controlled trial”) and recommended search terms. The search for CPGs built upon a previous systematic search [ 53 , 54 ], which was updated and expanded to cover additional languages and databases. A multi-pronged grey literature search retrieved records from common grey literature databases and CPG repositories, websites of relevant associations, charities, and government agencies. The search strategy is provided in Additional File  2 .

Inclusion and exclusion criteria

Empirical studies were included if the mean participant age fell within the eligible range of 14 to 24 years, and at least 50% of participants showed above-threshold depressive or emotional symptoms on a validated screening tool. Controlled clinical trials had to compare the efficacy or effectiveness of PST as a free-standing intervention with a control group or waitlist condition. Secondary analyses were considered for their assessment of PS ability as a predictor, moderator, or mediator of treatment response if they reported on data from controlled clinical trials of broader therapy packages. Records were included as CPGs if labelled as practice guidelines, practice parameters, or consensus or expert committee recommendations, or explicitly aimed to develop original clinical guidance [ 53 , 54 ]; and if focused on indicated psychosocial treatments for youth depression (rather than prevention, screening, or pharmacological treatment). Doctoral dissertations were included. Conference abstracts, non-controlled trials, and prevention studies were excluded. Language of publication was restricted to English, French, German, and Spanish.

All records identified were imported into the EPPI-Reviewer 4.0 review software [ 55 ], and underwent a two-stage screening process (Fig.  2 ). Title and abstract screening was conducted in duplicate for 10% of the identified records, yielding substantial inter-rater agreement ( kappa  = .75 and .86, for empirical studies and CPGs, respectively). Of studies retained for full text screening, 20% were screened in duplicate, yielding substantial agreement ( kappa  = .68 and .71, for empirical studies and CPGs, respectively). Disagreements were resolved through discussion.

figure 2

PRISMA Flow Chart of the Study Selection Process

Data extraction and synthesis

Data were extracted using templates tailored to each literature type (e.g., the Cochrane data collection form for RCTs). Information extracted included: citation details; study design; participant characteristics; and relevant qualitative or quantitative results. Additional information extracted from CPGs included the issuing authority, the target population, the treatment settings to which the guideline applied, and any recommendations in relation to PS training. Data from clinical trials and secondary analyses were extracted in duplicate, and any discrepancies were discussed and resolved. Data synthesis followed a five-step process of data reduction, display, comparison, conclusion drawing, and verification [ 56 ]. Scoping review findings were summarized in narrative format. In addition, effect sizes reported in PST trials for depression severity were entered into an exploratory meta-analysis (see below).

The Centre for Addiction and Mental Health (CAMH) implements a Youth Engagement Initiative that brings the voices of youth with lived experience of mental health difficulties into research and service design [ 57 , 58 , 59 ]. Two youth partners were co-investigators in this review and consulted with a panel of twelve CAMH youth advisors to inform the review process and help contextualize findings. Formal approval by a Research Ethics Board (REB) was not required, as youth were research partners rather than participants.

To incorporate a variety of perspectives, the review team convened for an inference workshop where emerging review findings and feedback from youth advisors were discussed and interpreted. The multidisciplinary team involved a methodologist; two child and adolescent psychiatrists with expertise in CBT, DBT, and IPT; a psychologist with expertise in parent-adolescent therapy; a research librarian; a family doctor; a biostatistician; a clinical epidemiologist; two youth research partners; and a youth engagement coordinator.

Exploratory Meta-analysis

Although meta-analyses are not typical components of scoping reviews [ 60 ], an exploratory meta-analysis was conducted following completion of the scoping review and narrative synthesis, to obtain an initial indication of the efficacy of stand-alone PST based on the clinical trials identified in the review. The PICO statement that guided the meta-analysis is shown in Table  1 .

Quality assessment

Risk of bias for included PST trials was appraised using the Cochrane Collaborations Risk of Bias (ROB) 2 tool [ 61 ]. Ratings were performed independently by two reviewers (KRK and MA), and consensus was formed through discussion. In addition, a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) appraisal was conducted (using the GRADEpro software; [ 62 ] to characterize the quality of the overall evidence. The evidence was graded for risk of bias, imprecision, indirectness, inconsistency, and publication bias [ 63 ]. A GRADE of “high quality” indicates a high level of confidence that the true effect lies close to the estimate; “moderate quality” indicates moderate confidence; “low quality” indicates limited confidence; and “very low quality” indicates very little confidence in the estimate. ROB ratings and GRADE appraisal results are provided in Additional File  6 .

Statistical analysis

The meta-analysis was conducted using the meta suite of commands in Stata 16.1. Effect sizes (Hedges’ g) and their confidence intervals were calculated based on the mean difference in depression severity scores between the PST and control conditions at the first post-treatment assessment [ 64 ]. Hedges’ g is calculated by subtracting the post-treatment mean score of the intervention group from the score of the control group, and by dividing the mean difference by the pooled standard deviation. Effect sizes between g = 0.2 and 0.5 indicate a small effect; g = 0.5 to 0.8 indicates a moderate effect; and g ≥ 0.8 indicates a large effect. Effect sizes were adjusted using the Hedges and Olkin small sample correction [ 64 ]. Pooled effect sizes were computed using a random effects model to account for heterogeneity in intervention settings, modes of delivery, and participant age and depression severity. The I 2 statistic was computed as an indicator of effect size heterogeneity. Higgins et al. [ 65 ] suggest that an I 2 below 30% represents low heterogeneity while an I 2 above 75% represents substantial heterogeneity. Investigations of heterogeneity are unlikely to generate valuable insights in small study samples, with at least ten studies recommended for meta-regression [ 65 ]. We conducted limited exploratory subgroup analysis by computing a separate effect size after excluding studies with high risk of bias. We inspected the funnel plot and considered conducting Egger’s test to examine the likelihood and extent of publication bias [ 66 ].

Selection and inclusion of studies

The search for empirical studies identified 563 unique records (Fig. 2 ), of which 148 were screened in full. Inclusion criteria were met by four RCTs of free-standing PST and four secondary analyses of clinical trials investigating PS-related concepts as predictors, mediators, or moderators of treatment response. No eligible qualitative studies that explicitly examined youth experiences of PS training were identified. The search for CPGs identified 9691 unique records, of which 41 were subject to full text screening, and 23 were included in the review. Below we present scoping review findings for all literature types, followed by the results from the meta-analysis for stand-alone PST trials.

Clinical trials of PST

Characteristics of the included PST trials are shown in Table  2 . Studies were published between 2008 and 2020 and included 524 participants (range: 45 to 251), with a mean age of 16.7 years (range: 12–25; 48% female). Participants had a diagnosis of major depressive disorder (MDD; k  = 1), elevated anxiety or depressive symptoms ( k  = 1), or various mild presenting problems including depression ( k  = 2). Treatment covered PS skills but not problem orientation (i.e., youth’s problem appraisals) and was delivered face to face ( k =  3) or online ( k  = 1) in five to six sessions. PST was compared with waitlist controls ( k  = 2), PS booklets ( k =  1), and supportive counselling ( k  = 1). Risk of bias was rated as medium for two [ 44 , 45 ], and high for one study [ 43 ] due to concerns about missing outcome data and the absence of a study protocol.

Eskin and colleagues [ 43 ] randomized 53 Turkish high school and university students with MDD to six sessions of PST or a waitlist. The study reports a significant treatment effect on self-reported depressive symptoms (d = − 1.20; F [1, 42] = 10.3, p  < .01.), clinician-reported depressive symptoms (d = − 2.12; F [1, 42] = 37.7, p  < .001), and recovery rates, but not on self-reported PS ability (d = − 0.46; F [1, 42] = 2.2, p  > .05). Risk of bias was rated as high due to 37% of missing outcome data in the control group and the absence of a published trial protocol.

Michelson and colleagues [ 46 ] compared PST delivered by lay counsellors in combination with booklets, to PS booklets alone in 251 high-school students with mild mental health difficulties (53% emotional problems) in low-income communities in New Delhi, India. At six weeks, the intervention group showed significantly greater progress towards overcoming idiographic priority problems identified at baseline (d = 0.36, p  = .002), but no significant difference in self-reported mental health difficulties (d = 0.16, p  = .18). Results were similar at 12 weeks, including no significant difference in self-reported emotional symptoms (d = 0.18, p  = .089). As there was no long-term follow-up, it is unknown whether reduced personal problems translated into reduced emotional symptoms in the longer term. Perceived stress at six weeks was found to mediate treatment effect on idiographic problems, accounting for 15% of the overall effect at 12 weeks.

Two trials found no significant effect of PST on primary or secondary outcomes: Hoek and colleagues [ 44 ] randomized 45 youth with elevated depression or anxiety symptoms to five sessions of online PST or a waitlist control; Parker and colleagues [ 45 ] randomized 176 youth with mixed presenting problems (54% depression) to either PST with physical activity or PST with psychoeducation, compared with supportive counselling with physical activity or psychoeducation [ 45 ]. Drop-out from PST was high in both studies, ranging from 41.4% [ 45 ] to 72.7% [ 44 ].

PS-related concepts as predictors, moderators, or mediators of treatment response

The review identified four secondary analyses of RCT data that examined PS-related concepts as predictors, moderators, or mediators of treatment response (see Table  3 , below). Studies were published between 2005 and 2014 and included data from 761 participants with MDD diagnoses, and a mean age of 15.2 years (range: 12–18; 61.2% female).

A secondary analysis of data from the Treatment for Adolescents with Depression Study (TADS, n  = 439) [ 79 ] explored whether baseline problem orientation and PS styles were significant predictors or moderators of treatment response to Fluoxetine, CBT, or a combination treatment at 12 weeks [ 70 ]. Negative problem orientation and avoidant PS style each predicted less improvement in depression symptom severity ( p  = .001 and p  = .003, respectively), while positive problem orientation predicted greater improvement ( p  = .002). There was no significant moderation effect. Neither rational PS style nor impulsive-careless PS style predicted or moderated change in depressive symptoms.

A secondary analysis of data from the Treatment of Resistant Depression in Adolescents (TORDIA) study [ 80 ] examined the impact of specific CBT components on treatment response at 12 weeks in youth treated with a selective serotonin reuptake inhibitor (SSRI) in combination with CBT ( n  = 166) [ 71 ]. Youth who received PS training were 2.3 times ( p  = .03) more likely to have a positive treatment response than those not receiving this component. A significant effect was also observed for social skills training (Odds Ratio [OR] = 2.6, p  = .04) but not for seven other CBT components. PS and social skills training had the most equal allocation ratios between youth who received them (52 and 54%, respectively) and youth who did not. Balanced allocation provides maximum power for a given sample size [ 81 ]. With allocation ratios between 1:3 and 1:5, analysis of the remaining seven components may have been underpowered. Of further note, CBT components were not randomly assigned but selected based on individual clinical needs. The authors did not correct for multiple comparisons as part of this exploratory analysis.

Dietz and colleagues [ 73 ] explored the impact of social problem solving on treatment outcome based on data from a trial comparing CBT and Systemic Behaviour Family Therapy (SBFT) with elements of PS training on the one hand, with Non-Directive Supportive Therapy on the other hand ( n  = 63). Both CBT and SBFT were associated with significant improvements in young people’s interpersonal PS behaviour (measured by coding videotaped interactions between youth and their mothers) over the course of treatment (CBT: b* = 0.41, p  = .006; SBFT: b* = 0.30, p  = .04), which in turn were associated with higher rates of remission (Wald z = 6.11, p  = .01). However, there was no significant indirect effect of treatment condition via youth PS behaviour, and hence, no definitive evidence of a formal mediation effect [ 82 ].

Kaufman and colleagues [ 72 ] examined data from a trial comparing an Adolescent Coping with Depression (CWD-A) group-based intervention with a life-skills control condition in 93 youth with comorbid depression and conduct disorder. The secondary analysis explored whether change in six CBT-specific factors, including the use of PS and conflict resolution skills, mediated the effectiveness of CWD-A. There was no significant improvement in PS ability in CWD-A, compared with the control, and hence no further mediation analysis was conducted.

PS training in clinical practice guidelines

We identified 23 CPGs from twelve countries relevant to youth depression (see Additional File  4 ), issued by governments ( k  = 6), specialty societies ( k  = 3), health care providers ( k  = 4), independent expert groups ( k  = 2), and others, or a combination of these. Of these 23 CPGs, 15 mentioned PS training in relation to depression treatment for youth, as a component of CBT ( k  = 7), IPT ( k  = 4), supportive therapy or counselling ( k  = 3), family therapy ( k  = 1), DBT ( k  = 1), and psychoeducation ( k  = 1).

None of the reviewed CPGs recommended free-standing PST as a first-line treatment for youth depression. However, five CPGs mentioned PS training as a treatment ingredient or adjunct component in the context of recommending broader therapeutic approaches. The World Health Organization’s updated Mental Health Gap Action Programme guidelines recommended PS training as an adjunct treatment (e.g., in combination with antidepressant medication) for older adolescents [ 83 ]. A guideline by Orygen (Australia) suggested that for “persistent sub-threshold depressive symptoms (including dysthymia) or mild to moderate depression”, options should include “6–8 sessions of individual guided self-help based on the principles of CBT, including behavioural activation and problem-solving techniques” [ 84 ]. The Chilean Ministry of Health recommended supportive clinical care with adjunctive psychoeducation and PS tools, or supportive counselling for individuals aged 15 and older with mild depression (p. 52) [ 85 ]. The Cincinnati Children’s Hospital Medical Centre recommended four to eight sessions of supportive therapy for mild or uncomplicated depression, highlighting “problem solving coping skills” as one element of supportive therapy (p. 1) [ 86 ]. Fifth, the American Academy of Child and Adolescent Psychiatry’s 2007 practice parameter suggested each phase of treatment for youth depression should include psychoeducation and supportive management, which might include PS training (p. 1510) [ 87 ]. CPGs did not specify whether PS training should incorporate specific modules, or whether the term was used loosely to describe unstructured PS support.

Meta-analysis

Each of the four RCTs of free-standing PST identified by the scoping review contributed one comparison to the exploratory meta-analysis of overall PST efficacy (see Fig.  3 ). Self-rated depression or emotional symptom severity scores were reported by all four studies and constituted the primary outcome for the meta-analysis. We conducted additional exploratory analysis for clinician-rated depression severity as reported in two studies [ 43 , 45 ]. The pooled effect size for self-reported depression severity was g = − 0.34 (95% CI: − 0.92 to 0.23). Heterogeneity was high ( I 2  = 88.37%; p  < .001). Due to the small number of studies included, analysis of publication bias via an examination of the funnel plot and tests of funnel plot asymmetry could not be meaningfully conducted [ 88 , 89 ]. The funnel plot is provided in Additional File  5 for reference (Fig. S3).

figure 3

Forest Plot: Random Effects Model with Self-Reported Depression or Emotional Symptoms as Primary Outcome (Continuous)

To achieve the best possible estimate of the true effect size and reduce heterogeneity we computed a second model excluding the one study with high risk of bias (i.e., [ 43 ]). The resulting effect size was g = − 0.08 (95% CI: − 0.26 to 0.10), with no significant heterogeneity ( I 2  = 0.00%; p  = 0.72; see Fig. S1 in Additional File 5 ). The pooled effect size for clinician-rated depression severity was g = − 1.39 with a wide confidence interval (95% CI: − 4.03 to 1.42) and very high heterogeneity ( I 2  = 97.41%, p  < 0.001; see Fig. S2 in Additional File 5 ).

Overall quality of the evidence

According to the GRADE assessment, the overall quality of the evidence was very low, with concerns related to risk of bias, the inconsistency of results across studies, the indirectness of the evidence with regards to the population of interest (i.e., only one trial focused exclusively on youth with depression), and imprecision in the effect estimate (Table S4 in Additional File 6 ).

This scoping review aimed to provide a first comprehensive overview of the evidence relating to PS training as an active ingredient for treating youth depression. The evidence base relating to the efficacy of PST as a stand-alone intervention was scarce and of low quality. Overall, data from four trials suggested no significant effect on depression symptoms. The scoping review identified some evidence suggesting PS training may enhance treatment response in CBT. However, this conclusion was drawn from secondary analyses where youth were not randomized to treatment with and without PS training, and where primary studies were not powered to test these differences. Disproportionate exposure to comparator CBT components also limits these findings. PST was not recommended as a stand-alone treatment for youth depression in any of the 23 reviewed CPGs; however, one guideline suggested it could be provided alongside other treatments for older adolescents, and four suggested PS training as a component of low-intensity psychosocial interventions for youth with mild to moderate depression.

Given the limited evidence base, only tentative suggestions can be made as to when and for whom PS training is effective. The one PST trial with a low risk of bias enrolled high-school students from low-income communities in New Delhi, and found that PST delivered by lay counselors in combination with PST booklets was more effective at reducing idiographic priority problems than booklets alone, but not at reducing mental health symptoms [ 46 ]. Within a needs-based framework of service delivery (e.g., [ 90 ]), PST may be offered as a low-intensity intervention to youth who experience challenges and struggle with PS—including in low-resource contexts. Future research could explore whether PS training might be particularly helpful for youth facing socioeconomic hardship and related chronic stressors by attenuating potentially harmful impacts on well-being [ 91 ]. If findings are promising, PS training may be considered for targeted prevention (e.g., [ 42 ]). However, at this time there is insufficient evidence to support PS training on its own as an intervention aimed at providing symptom relief for youth experiencing depression.

The PST manual suggests cognitive overload, emotional dysregulation, negative thinking and hopelessness can interfere with PS [ 16 ]. Youth whose depression hinders their ability to engage in PST may require additional support through more comprehensive therapy packages such as CBT or IPT with PS training. In the TORDIA study [ 80 ], where PS training was found to be one of the most effective components, it was generally taught alongside cognitive restructuring, behavioural activation, and emotion regulation, which may have facilitated youths’ ability to absorb PS training [ 71 ]. The focus of these other CBT components on changing negative cognitions and attributions may fulfil a similar function as problem orientation modules in stand-alone PST. Research that is powered to explore such mechanisms is needed. Future research should also apply methodologies designed to identify the most critical elements in a larger treatment package (e.g., dismantling studies; or sequential, multiple assignment, randomized trials) to examine the role of PS training when delivered alongside other components. While one trial focusing on CBT components is currently underway [ 92 ], similar research is needed for other therapies (e.g., IPT, DBT, family therapy).

The included PST trials provided between five and six sessions and covered PS skills but not problem orientation. Meta-analyses of PST for adult depression suggest treatment effectiveness may be enhanced by longer treatment duration (≥ 10 sessions) [ 38 ], and coverage of problem orientation alongside PS skills [ 39 ]. As per the PST treatment manual, strengthening problem orientation fosters motivation and self-efficacy and is an important precondition for enhancing skills [ 93 , 94 ]. In addition, only one youth PST trial assessed PS ability at baseline [ 43 ]. A meta-analysis of PST for adult depression [ 39 ] suggests that studies including such assessments show larger effect sizes, with therapists better able to tailor PST to individual needs. Future research should seek to replicate these findings specifically for youth depression.

Drop out from stand-alone PST was high in two out of four studies, ranging from 41.4% [ 45 ] to 72.7% [ 44 ]. Since its development in the 1970s, PST has undergone several revisions [ 16 , 93 , 95 , 96 , 97 ] but tailoring to youth has been limited. To contextualize the review findings, the review team consulted a panel of twelve youth advisors at the Centre for Addiction and Mental Health (without sharing emerging findings so as not to steer the conversation). Most had participated in PS training as part of other therapies, but none had received formal PST. A key challenge identified by youth advisors was how to provide PS training that is universally applicable and relevant to different youth without being too generic, rigid or schematic; and how to accommodate youth perspectives, complex problems, and individual situations and dispositions. Youth advisors suggested reviewing and reworking PS training with youth in mind, to ensure it is youth-driven, strengths-based, comprehensive, and personalized (see Fig. S4 in Additional File  7 for more detail). Youth advisors emphasized that PS training should identify the root causes underpinning superficial problems and address these through suitable complementary intervention approaches, if needed.

Solution-focused brief therapy (SFBT) has emerged as an antithesis to PST where more emphasis is given to envisaging and constructing solutions rather than analysing problems [ 28 ]. This may be more consistent with youth preferences for strengths-based approaches but may provide insufficiently comprehensive problem appraisals. Future research should compare the effectiveness and acceptability of PST and SFBT and consider possible benefits of combining the advantages of both approaches, to provide support that is strengths-based and targets root problems. More generally, given the effectiveness of PST in adults, future studies could examine whether there are developmental factors that might contribute to reduced effectiveness in youth and should be considered when adapting PST to this age group.

Strengths and limitations

This scoping review applied a broad and systematic approach to study identification and selection. We searched five bibliographic databases, and conducted an extensive grey literature search, considering records published in four languages. Nevertheless, our search may have missed relevant studies published in other languages. We found only a small number of eligible empirical studies, several of which were likely underpowered. As stated above, studies analysing PS-related concepts as predictors, moderators, or mediators of treatment response within broader therapies were heterogenous and limited by design and sample size constraints.

Similarly, there was heterogeneity in recruitment and intervention settings, age groups, and delivery formats across the four RCTs of stand-alone PST, and the overall quality of the evidence was very low. As reflected in our GRADE appraisal, one important limitation was the indirectness of the available evidence: Only one PST trial focused specifically on youth with an MDD diagnosis, while the remaining three included youth with a mix of mental health problems. Although outcomes were reported in terms of depression or emotional symptom severity, this was not based on a subgroup analysis focused specifically on youth with depression. Impact on this group may therefore have been underestimated. In addition, the only PST trial with a low risk of bias did not administer a dedicated depression symptom scale. Instead, our exploratory meta-analysis included scores from the 5-item SDQ emotional problems subscale, which assesses unhappiness, worries, clinginess, fears, and somatic symptoms—and may not have captured nuanced change in depression severity [ 98 , 99 ]. Other concerns that led us to downgrade the quality of the evidence related to considerable risk of bias, with only one out of four studies rated as having a low risk; and imprecision with several studies involving very small samples. Due to the small number of eligible studies, it was not possible to identify the factors driving treatment efficacy via meta-regression. The long-term effectiveness of PS training, or the conditions under which long-term benefits are likely to be realized also could not be examined [ 38 ].

PS training is a core component of several evidence-based therapies for youth depression. However, the evidence base supporting its efficacy as a stand-alone treatment is limited and of low quality. There is tentative evidence suggesting PS-training may drive positive outcomes when provided alongside other treatment components. On its own, PS training may be beneficial for youth who are not acutely distressed or impaired but require support with tackling personal problems. Youth experiencing moderate or severe depressive symptoms may require more comprehensive psychotherapeutic support alongside PS training, as there is currently no robust evidence for the ability of free-standing PST to effectively reduce depression symptoms.

High-quality trials are needed that assess PST efficacy in youth with mild, moderate, and severe depression, in relation to both symptom severity and idiographic treatment goals or priority problems. These studies should examine the influence of treatment length and module content on treatment impact. Dedicated studies are also needed to shed light on the role of PS training as an active ingredient of more comprehensive therapies such as CBT, DBT, IPT, and family therapy. Future studies should include assessments of adverse events and of cost effectiveness. Given high drop-out rates in several youth PST trials, it is important to adapt PS training approaches and therapy manuals as needed, following a youth-engaged research and service development approach [ 57 ], to ensure their relevance and acceptability to this age group.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Abbreviations

Avoidance style

Beck Depression Inventory

Centre for Addiction and Mental Health

Cognitive behavioural therapy

Children’s Depression Rating Scale—Revised

Center for Epidemiologic Studies Depression Scale

Clinical Global Impression Scale—Improvement

Cumulative Index to Nursing and Allied Health Literature

Clinical practice guideline

Adolescent Coping with Depression [intervention name]

Dialectical behaviour therapy

Grading of Recommendations Assessment, Development, and Evaluation

Impulsivity/Carelessness Style

Interpersonal psychotherapy

The Kiddie Schedule for Affective Disorders and Schizophrenia

Lifeskills training

Major depressive disorder

Medical Literature Analysis and Retrieval System Online

Negative problem orientation

Nondirective supportive therapy

Positive problem orientation

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

  • Problem solving

Problem-solving training

Problem-Solving Therapy

Randomized controlled trial

Research ethics board

Risk of bias

Rational problem-solving style

Systemic Behaviour Family Therapy

Strengths and Difficulties Questionnaire

Solution-Focused Brief Therapy

Social Problem-Solving Inventory Revised

Selective serotonin reuptake inhibitors

Treatment for Adolescents with Depression Study

Treatment of Resistant Depression in Adolescents

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Acknowledgments

We would like to thank the members of the Centre for Addiction and Mental Health (CAMH) youth advisory group for their valuable insights and suggestions. The systematic search for clinical practice guidelines presented in this review was based on a search strategy developed by Dr. Kathryn Bennett. We would like to thank Dr. Bennett for agreeing to the reuse of the strategy as part of this review. We would also like to thank the Cundill Centre for Child and Youth Depression for providing institutional support to this project.

This work was funded by a Wellcome Trust Mental Health Priority Area “Active Ingredients” commission awarded to KRK, DBC and PS, and the Centre for Addiction and Mental Health, Toronto, Canada.

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Karolin R. Krause, Darren B. Courtney, Sarah Bonato, Madison Aitken, Jacqueline Relihan, Matthew Prebeg, Karleigh Darnay, Lisa D. Hawke, Priya Watson & Peter Szatmari

Evidence Based Practice Unit, University College London and Anna Freud National Centre for Children and Families, London, UK

Karolin R. Krause

Department of Psychiatry, University of Toronto, Toronto, ON, Canada

Darren B. Courtney, Madison Aitken, Lisa D. Hawke, Priya Watson & Peter Szatmari

Independent Family Doctor, Toronto, ON, Canada

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Contributions

KRK, DBC and PS formulated the research questions and designed the study. SB conducted the systematic search for clinical practice guidelines and the grey literature search, and advised on the search for retrieving empirical studies, which was led by KRK. KRK, DBC and BWCC performed the screening of records for inclusion criteria. Data extraction was performed by KRK and BWCC. The risk of bias assessment for included randomized control trials was conducted by KRK and MA. The youth consultation was led by JR, MP and KD with input from LDH and KRK. Data analysis was led by KRK. All authors contributed to the interpretation of emerging findings through an internal findings workshop and through several rounds of feedback on the draft manuscript, which was drafted by KRK. All authors have reviewed and approved the final manuscript.

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Correspondence to Karolin R. Krause .

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Supplementary Information

Additional file 1..

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.

Additional file 2.

Search Strategy.

Additional file 3.

List of Studies Included in the Scoping Review.

Additional file 4.

Characteristics of Included Clinical Practice Guidelines.

Additional file 5.

Additional Data and Outputs from the Meta-Analysis.

Additional file 6.

Risk of Bias Assessment and GRADE Appraisal.

Additional file 7.

Illustration of Insights from the Consultation of Youth Advisors.

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Krause, K.R., Courtney, D.B., Chan, B.W.C. et al. Problem-solving training as an active ingredient of treatment for youth depression: a scoping review and exploratory meta-analysis. BMC Psychiatry 21 , 397 (2021). https://doi.org/10.1186/s12888-021-03260-9

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In This Article Expand or collapse the "in this article" section Brief Therapies in Social Work: Task-Centered Model and Solution-Focused Therapy

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Brief Therapies in Social Work: Task-Centered Model and Solution-Focused Therapy by Cynthia Franklin , Krystallynne Mikle LAST REVIEWED: 06 May 2015 LAST MODIFIED: 30 September 2013 DOI: 10.1093/obo/9780195389678-0188

Brief therapies serve as evidenced-based practices that place a strong emphasis on effective, time-limited treatments that aid in resolving clients’ presenting problems. The resources presented in this article summarize for professionals and educators the abundant literature evaluating brief therapies within social work practice. Brief therapies have appeared in many different schools of psychotherapy, and several approaches have also evolved within social work practice, but two approaches—the task-centered model and solution-focused brief therapy (SFBT)—stand out as being grounded in research and have also gained international acclaim as important interventions for implementation and further study. These two approaches are the focus of this bibliography. The task-centered model and SFBT were developed by social work practitioners and researchers for the purposes of making clinical practice more effective, and they share a common bond in hoping to improve the services delivered to clients. Since the development of the task-centered and solution-focused approaches, brief therapies have become essential to the work of all types of psychotherapists and clinicians, and many of the principles and practices of brief therapy that are a part of the task-centered and solution-focused approaches are now essential to psychotherapy training. Clinical social workers practicing from the perspective of the task-centered model and SFBT approaches work from several brief therapy assumptions. The first regards the client/therapist relationship. The best way to help clients is to work within a collaborative relationship to discover options for coping and new behavior that may also lead to specific tasks and solutions for change that are identified by the client. Second is the assumption that change can happen quickly and can be lasting. Third, focus on the past may not be as helpful to most clients as a focus on the present and the future. The fourth regards a pragmatic perspective about where the change occurs. The best approach to practice is pragmatic, and effective practitioners recognize that what happens in a client’s life is more important than what happens in a social worker’s office. The fifth assumption is that change can happen more quickly and be maintained when practitioners utilize the strengths and resources that exist within the client and his or her environment. The next assumption is that a small change made by clients may cause significant and major life changes. The seventh assumption is associated with creating goals. It is important to focus on small, concrete goal construction and helping the client move toward small steps to achieve those goals. The next regards change. Change is viewed as hard work and involves focused effort and commitment from the client and social worker. There will be homework assignments and following through on tasks. Also, it is assumed that it is important to establish and maintain a clear treatment focus (often considered the most important element in brief treatment). Parsimony is also considered to be a guiding principle (i.e., given two equally effective treatments, the one requiring less investment of time and energy is preferable). Last, it is assumed that without evidence to the contrary, the client’s stated problem is taken as the valid focus of treatment. The task-centered model and SFBT have developed a strong empirical base, and both approaches operate from a goal-oriented and strengths perspective. Both approaches have numerous applications and have successfully been used with many different types of clients and practice settings. Both approaches have also been expanded to applications in macro social work that focus on work within management- and community-based practices. For related Oxford Bibliographies entries, see Task-Centered Practice and Solution-Focused Therapy .

Task-Centered Model Literature

The task-centered model is an empirically grounded approach to social work practice that appeared in the mid-1960s at Columbia University and was developed in response to research reports that indicated social work was not effective with clients. William J. Reid was the chief researcher who helped develop this model, and he integrated many therapeutic perspectives to create the task-centered approach, including ideas from behavioral therapies. The task-centered model evolved out of the psychodynamic practice and uses a brief, problem-solving approach to help clients resolve presenting problems. The task-centered model is currently used in clinical social work and group work and may also be applied to other types of social work practice.

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10 Best Problem-Solving Therapy Worksheets & Activities

Problem solving therapy

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.

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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).

social problem solving therapy definition

  • 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).

Problem-solving therapy – Baycrest

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.

Worksheets for problem solving therapy

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

Problem-Solving Therapy

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

Emotion-Centered Problem-Solving Therapy

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

Handbook of Cognitive-Behavioral Therapies

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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Article contents

Cognitive behavioral therapy.

  • Addie Weaver , Addie Weaver Curtis Research Center, School of Social Work, University of Michigan
  • Joseph Himle , Joseph Himle School of Social Work, University of Michigan
  • Gail Steketee Gail Steketee School of Social Work, Boston University
  •  and  Jordana Muroff Jordana Muroff School of Social Work, Boston University
  • https://doi.org/10.1093/acrefore/9780199975839.013.874
  • Published online: 04 August 2014

This entry offers an overview of cognitive behavioral therapy (CBT). Cognitive behavioral therapy is introduced and its development as a psychosocial therapeutic approach is described. This entry outlines the central techniques and intervention strategies utilized in CBT and presents common disorder-specific applications of the treatment. The empirical evidence supporting CBT is summarized and reviewed. Finally, the impact of CBT on clinical social work practice and education is discussed, with attention to the treatment’s alignment with the profession’s values and mission.

  • cognitive behavioral therapy
  • evidence-based practice
  • clinical social work
  • mental health
  • psychosocial treatment

Definition/Description

Cognitive behavioral therapy (CBT) is a structured, time-limited approach to psychotherapy that aims to address clients’ current problems (Dobson & Dobson, 2009 ). CBT uses problem-focused cognitive and behavioral strategies guided by empirical science and derived from theories of learning and cognition (Craske, 2010 ). These interventions are delivered within a collaborative context where therapists and clients work together to identify problems, set goals, develop intervention strategies, and evaluate the effectiveness of those strategies.

CBT represents a broad approach to treatment that encompasses various theoretical models, including cognitive therapy (CT; Beck, 1976 ; Beck, Rush, Shaw, & Emery, 1979 ; Beck, 1995 ), rational-emotive behavioral therapy (REBT; Ellis, 1962 , 1979 ; 1994 ; Ellis & Dryden, 1997 ), problem-solving therapy (D’Zurilla & Nezu, 2007 ; Haley, 1987 ), stress inoculation training (SIT; Meichenbaum, 1993 ; Meichenbaum & Deffenbacher, 1988 ), schema-focused therapy (Young, 1994 ; Young, Klosko, & Weishaar, 2003 ), and dialectical behavioral therapy (DBT; Linehan, 1987 , 1993 ). Though individual cognitive behavioral treatment models may vary in their emphasis on behavioral and cognitive principles and methodologies, interventions under the CBT umbrella are unified by an empirical foundation, reliance on the theory and science of behavior and cognition, and a problem-focused orientation (Dobson & Dobson, 2009 ).

CBT can be defined by common features that cut across individual treatment models or variations.

Most notably, the cognitive behavioral approach emphasizes a person’s thinking as the prime determinant of emotional and behavioral responses to life events (Beck, 1976 ; Ellis, 1994 ; Meichenbaum, 1993 ). Dobson and Dozois ( 2001 ) offer three basic principles that are common to most CBT models:

The access hypothesis, which asserts that the content and process of our thinking is knowable and, with appropriate training and attention, persons can become aware of their own thinking

The mediation hypothesis, positing that there is cognitive mediation between events and persons’ typical responses to them. CBT maintains that the way people think about or interpret their experiences has a profound impact on how they feel about those experiences. Therefore, thoughts and beliefs strongly influence behavioral patterns. CBT suggests that thoughts and corresponding emotional and behavioral responses may become routine and automatic over time.

The change hypothesis asserts that, because cognitions are knowable and mediate the response to different situations, it is possible to intentionally modify how people respond to events. CBT maintains that an increased recognition and understanding of emotional and behavioral reactions, through the systematic use of cognitive strategies, leads to more functional and adaptive responses.

Additionally, CBT generally asserts that a more realistic, or accurate, appraisal of the world, and the ability to adapt to the real world, is one indication of good mental health. Conversely, maladaptive or dysfunctional assessments of reality lead to a distorted view of the world and more emotional and behavioral problems. As the mediation hypothesis suggests, CBT asserts that patterns of thinking, including general ideas, assumptions, and schemas (firmly held basic beliefs about the self, others, and the world), are derived over time based upon persons’ experiences interacting with their social environment (Dobson & Dobson, 2009 ). These assumptions and schemas affect how people view the world around them, potentially predisposing them to certain ways of thinking that become self-fulfilling prophesies (Beck, 1976 ). Once schemas became established, they not only affect memories of past experiences, but also influence future development by restricting the situations and activities people choose to engage in (Beck, 1976 ; Dobson & Dobson, 2009 ).

However, CBT contends that people do not just passively react to events and triggers in the world around them; rather, they have the potential to actively shape the course of their lives (i.e., change hypothesis). Therefore, CBT utilizes cognitive and behavioral strategies to help clients identify and replace maladaptive behaviors, emotions, and cognitions with more adaptive ones. Behavioral interventions, including behavioral activation, exposure, problem solving, social skills training, and relaxation training, focus on decreasing maladaptive behaviors and increasing adaptive ones by modifying their antecedents and consequences in ways that lead to new learning. Cognitive interventions, such as thought recording, reality testing, and reattribution or reappraisal, aim to restructure maladaptive or distorted thoughts and generate alternative, more evidence-based appraisals and beliefs.

Origins, Major Developers, and Contributors

CBT emerged as an approach to psychotherapy during the mid-20th century. The philosophical foundations of CBT were informed by Greek and Roman Stoicism, Buddhism, and Taoism, all of which emphasize reason, logic, and acceptance (Beck et al., 1979 ; Dryden, David, & Ellis, 2010 ). Influenced by the shift from psychodynamic theory to more scientific approaches to treatment (Beck, 1967 ; Ellis, 1979 ), CBT derived from advances in behavioral and cognitive theory and science (e.g., Eysenck, 1960 ; Lazarus, 1966 ). Behavioral approaches drew from the classical conditioning theory of Watson (Watson & Raynor, 1920 ; Watson, 1925 ) and Mowrer ( 1960 ) and the operant conditioning theory of Pavlov ( 1927 ) and B. F. Skinner ( 1938 , 1963 ), both of which focus on antecedents and reinforcers of behavior and advocate an empirical approach to evaluating behavior. In the 1950s and 1960s, pioneers in behavior therapy developed these theories further into models for intervening in various mental health problems, such as mood (depression, anxiety) and behavioral problems in children and adults (for review, see Clark & Fairburn, 1997 ). A few of these models and methods are noted below.

Early exposure methods for treating anxiety were derived from the animal models of reciprocal inhibition of Wolpe ( 1958 ), which he adapted for use in humans, developing and testing systematic desensitization, or brief exposures to feared cues offset by carefully trained relaxation responses (or other fear inhibitors). His methods were supported by Lang’s ( 1968 ) studies documenting the fear reducing effects of desensitization and further outlining the nature of fear. The two-stage model of fear and avoidance of Mowrer ( 1960 ) proposed that human fear was conditioned through the pairing of ordinary cues with actual fear and that avoidance persisted because it was negatively reinforced. This model was used extensively to develop interventions for anxiety and obsessive-compulsive disorders. Skinner’s operant conditioning models were further developed for application of reinforcement and contingencies applied to a variety of child and adult behaviors. Examples include Azrin’s token economy, time out, and habit reversal procedures for motor disorders (see Hersen, 2005 ), as well as Kazdin’s ( 1978 ) work on skills training and parent management for child behavior problems.

The social learning theory of Albert Bandura ( 1977 ) and social cognitive theory ( 1986 ), which focused on observational or vicarious learning, promoted both behavioral and cognitive models for understanding mental health. Albert Ellis ( 1962 ) and Aaron Beck ( 1976 ) developed early models of cognitive behavioral therapy that established the philosophical, theoretical, and practice foundations of this approach. While Ellis ( 1962 ) and Beck ( 1976 ; Beck et al., 1979 ) developed their models independently, both focused on the relationship between cognition and emotional disturbance, concluding that distorted and dysfunctional thinking is the primary determinant of mood and behavior (Craske, 2010 ). These early cognitive behavioral approaches also shared an emphasis on the importance of eliciting clients’ reports of situations and events occurring in daily life and assigning common sense meanings to clients’ problems (Dobson & Dobson, 2009 ).

Ellis’s rational emotive behavior therapy (REBT; Ellis, 1962 , 1979 , 1994 ; Ellis & Dryden, 1997 ) was built upon the ancient Greek and Roman Stoic philosophers, such as Epictetus, Epicurus, and Marcus Aurelius, and Asian philosophers, such as Confucius, Lao-Tsu, and Gautama Buddha, all of whom maintained that people are not disturbed by things but by their view of things (Ellis & Dryden, 1997 ). Ellis asserted that people’s beliefs, or how they think, strongly affect their emotional functioning. The REBT model maintained that emotional reactions were mediated by “internal sentences” or thoughts, and that holding certain irrational beliefs (e.g., absolutism, demand for love and approval, and demand for comfort) resulted in internal self-statements that were maladaptive responses to situations (Ellis, 1962 ). Ellis suggested that irrational beliefs lead to mislabeling of situations that ultimately create psychological problems and emotional distress. Ellis ( 1962 ) developed the ABC model to guide this process, wherein an activating event (A) happens in the environment around you; you hold a belief (B) about that event; and your belief elicits an emotional response or consequence (C). As a result, Ellis maintained that rational beliefs elicit appropriate emotional and behavioral response while irrational beliefs lead to inappropriate and dysfunctional response (Ellis & Dryden, 1997 ). Therefore, a goal of REBT is to help clients identify, challenge, and alter their irrational beliefs and negative thinking patterns to be more rational and realistic. REBT also focuses on targeting emotional responses that accompany irrational thoughts and encourages clients to change unwanted behaviors through meditation, journaling, and guided imagery.

Similarly, Beck based his cognitive therapy (CT) model ( 1976 ; Beck et al., 1979 ) on the idea that critical or negative automatic thoughts and unpleasant physical or emotional symptoms combine to form maladaptive cycles that maintain symptoms and result in emotional distress. Beck ( 1976 ) asserted that a person’s fundamental beliefs about themselves and the world predispose them to either psychological health or distress. CT suggests that a person’s way of organizing themselves and the world, or cognitive schema, results in automatic thoughts about situations and events (Dobson & Dobson, 2009 ). Beck identified common cognitive distortions (e.g., all-or-nothing thinking, overgeneralization, jumping to conclusions, should statements, labeling and mislabeling) that often operate as automatic thoughts (Beck, 1963 , 1976 ; Beck et al., 1979 ). He argued that cognitive distortions lead to faulty assumptions and misconceptions that inform both emotional and behavioral responses to an event or situation (Beck, 1963 ). CT aims to help clients identify automatic thoughts, understand how cognitive distortion or negative thinking influence feelings and behavior, develop a more realistic appraisal of situations and events, and modify dysfunctional beliefs and assumptions that predispose cognitive distortions (Beck, 1976 ; Beck et al., 1979 ).

Other popular therapeutic approaches under the CBT umbrella include Meichenbaum’s ( 1993 ; Meichenbaum & Deffenbacher, 1988 ) stress inoculation training (SIT), and problem-solving therapy (PST; D’Zurilla & Nezu, 2007 ; Haley, 1987 ). SIT helps persons develop skills, such as self-instruction, relaxation, behavioral rehearsal, and in vivo exposure, to protect themselves against the effects of anxiety and trauma and against future stressors. PST focuses on training individuals to effectively use problem-solving skills, which encourages and increases healthy coping and the ability to adapt.

It is also important to note the more recent development of third wave behavioral therapies. Since the 1990s a number of new interventions, referred to as the third wave of behavioral therapy, have emerged. Though rooted in CBT, third wave behavioral therapies emphasize the role of mindfulness and acceptance in the healing process. Dialectical behavior therapy (DBT; Linehan, 1987 , 1993 ), acceptance and commitment therapy (ACT; Hayes, 2004 ; Hayes et al., 2006 ), mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002 ), and mindfulness-based stress reduction (MBSR; Kabat-Zinn, 1990 ) are commonly considered part of the third wave. While still acknowledging the mediation between thoughts, behavior, and emotions, third wave interventions focus less on challenging clients’ irrational or negative thoughts and more on changing clients’ relationship to thoughts and feelings (Hayes, 2004 ; Singh, Lancioni, Wahler, Winton, & Singh, 2008 ). To this end, third wave behavioral therapies incorporate contextual and experiential change strategies such as mindfulness, acceptance, and cognitive defusion, and encourages a focus on relationships, values, emotional deepening, and contact with the present moment (Hayes, 2004 ), While proponents of third wave behavioral therapies assert that they maintain CBT’s commitment to an empirical, scientific approach to treatment (Hayes, 2004 ; Hayes, Masuda, Bissett, Luoma & Guerrero, 2004 ), some scholars have argued that third wave behavioral therapies may be getting ahead of the data (Corrigan, 2001 ) and do not yet meet established criteria to be considered empirically supported treatments (EST; Ost, 2008 ).

CBT Techniques

Cognitive behavioral therapists utilize a combination of cognitive and behavioral intervention strategies to address clients’ presenting problems. Clinicians select appropriate intervention strategies after conducting a thorough initial assessment to clarify how thoughts, emotions, and behaviors are interrelated. The intervention strategies employed may vary based upon clients’ presenting problem and skill level, as well as the treatment model. Behavioral interventions are often employed earlier in treatment as they are likely to address symptoms quickly, leaving clients better equipped to start focusing on cognitive aspects of problems (Dobson & Dobson, 2009 ); however, some approaches reverse this order. All CBT techniques are implemented within the context of therapist and client collaboration. Cognitive behavioral therapists emphasize and reward the clients’ effort when implementing intervention strategies, regardless of their outcome.

The central techniques and intervention strategies used in CBT are described below in the order they are generally implemented in treatment, beginning with psychoeducation, followed by behavioral interventions, and then cognitive restructuring. Finally, homework, a key aspect of CBT that is implemented across intervention strategies, is discussed.

Psychoeducation.

Psychoeducation is defined as teaching relevant psychological principles and knowledge to clients (Anderson, Hogarty, & Reiss, 1980 ). Helpful materials include information about the diagnosis, the treatment rationale, and research findings (Anderson et al., 1980 ), which can be presented in a variety of ways, depending on clients’ learning needs. Cognitive behavioral therapists often recommend a combination of didactic materials, including pamphlets, books, videos, and websites, that are tailored to a client’s education, language, literacy, skills, interests, resources, privacy needs, distress level, concentration ability, and quality of materials (Dobson & Dobson, 2009 ). Psychoeducation lets clients know that they are not alone and that their problems have been widely identified, researched, and discussed (Anderson et al., 1980 ). This can lead to feelings of support, hope, and validation, as well as a sense of control over problems that may begin to shift beliefs.

Behavioral Interventions: Reinforcement and response contingencies.

A variety of behavioral techniques are subsumed within this broad category of interventions that derive from operant (Skinnerian) models of human behavior. Following a careful behavioral analysis of the stimulus and responses in the problem context, therapists may apply direct reinforcements (rewards) for positive behaviors and costs (e.g., time out, loss of a privilege) for performance of problematic behaviors. In the case of child behaviors within a family context, parents are typically trained to observe the child’s behavior and apply appropriate positive and negative reinforcements.

Behavioral activation.

Behavioral activation encourages clients to engage in pleasurable or mastery (e.g., self-care, chores, paying bills) activities in a scheduled, monitored way. Originally developed by Ferster ( 1973 ) and Lewinsohn, Sullivan, & Grosscup ( 1980 ) as a depression treatment, behavioral activation has been implemented widely with clients experiencing decreased activity and reduced reinforcement across a range of diagnostic categories. Behavioral activation is used to help clients increase the quantity and quality of positively reinforced behavior and improve coping behaviors to deal more adaptively with negative life situations (Dobson & Dobson, 2009 ). Implementing behavioral activation early in therapy is likely to result in improved mood and higher levels of energy.

The first step in behavioral activation involves having clients create a simple, concrete list of their current activities, or, if they don’t engage in any current activities, a list of activities they enjoyed in the past or imagine would be helpful (Dobson & Dobson, 2009 ). Clients then identify an activity that they would like to increase (e.g., spending time with friends, cleaning the house) and choose small, incremental steps in support of their goal (e.g., call a friend; invite a friend to lunch). Throughout the intervention, clients are asked to complete an Activity Schedule, where activities are systematically recorded until they become more habitual. Clients’ efforts, rather than outcomes, are verbally reinforced, and clients are asked to make positive statements about their efforts as well (Dobson & Dobson, 2009 ).

Social skills training.

Social skills training, also referred to as communication skills training and assertiveness training, is a core component of behavior therapy and is used in CBT as needed (Dobson & Dobson, 2009 ). Social skills training includes the teaching and practice of basic communication and verbal skills (e.g., how to start conversations; how to make and respond to requests; pacing, rate of speech; loudness of voice; extraneous or habitual voice patterns, tone of voice), and nonverbal communication skills such as appropriate body language (e.g., physical proximity, facial expressiveness, hand gestures). More advanced skills such as assertive communication, dealing with conflict, and communicating in intimate relationships may also be addressed through social skills training (Dobson & Dobson, 2009 ). When providing this training, therapists must consider the variability in social expression (e.g., across culture and age groups) to ensure clients are able to communicate their needs and desires in an appropriate, acceptable manner (Dobson & Dobson, 2009 ).

Problem solving training.

CBT uses a general problem-solving format that is distinct from problem solving as a stand-alone treatment. In the problem-solving behavioral intervention strategy, clients identify a specific problem, generate strategies for addressing the problem, implement the strategy, and evaluate its effectiveness for addressing the identified problem (D’Zurilla & Goldfried, 1971 ).

The problem solving process begins with identifying and naming a specific problem (e.g., symptom of psychological disorder, psychosocial stressor) (D’Zurilla & Goldfried, 1971 ). The therapist and client determine the parameters of the problem, such as frequency, duration, triggers, and resolution, and develop an assessment strategy (Dobson & Dobson, 2009 ). During this process clients are encouraged to consider the idea of change and how to promote change. The therapist and client collectively generate a variety of possible strategies without initial evaluation of the approaches in order to think broadly and creatively about potential solutions. Then, they conduct cost-benefit analyses to evaluate each alternative and its likelihood of solving the original problem (D’Zurilla & Goldfried, 1971 ). The optimal strategy is selected and its implementation is discussed in detail (e.g., when it will begin, how it will be conducted, for how long) (Dobson & Dobson, 2009 ). The client then implements the selected strategy as homework. Finally, the client and therapist evaluate the outcome of the problem-solving strategy. If the problem was solved, they move to the next issue. If the problem was not solved, only partially solved, or changed, then the therapist and client circle back to reevaluate the problem and consider other alternative strategies (Dobson & Dobson, 2009 ).

Relaxation training.

CBT utilizes relaxation training to provide a personal self-care activity for clients, either as a strategy to decrease physical tension, calm down when agitated, or regulate internal sensations (Dobson & Dobson, 2009 ). Therapists can teach clients to use several different types of relaxation training, including progressive muscle relaxation, breathing retraining, autogenic relaxation, and visualization exercises (Jacobson, 1938 , 1970 ; Wolpe, 1969 ). It is often helpful to create personalized audio files for clients that include collaboratively planned relaxation strategies (Dobson & Dobson, 2009 ). CBT encourages frequent practice of relaxation strategies, and strategies are often tied to visual reminders or paired with regular daily activities to facilitate clients’ ability to call on these skills when needed.

Exposure-based interventions are among the most empirically tested and effective components of CBT (Barlow, 2002 ; Farmer & Chapman, 2008 ; Richard & Lauterbach, 2007 ). Exposure encourages clients to confront a feared stimulus (e.g., thoughts, emotional responses, activities, situations) in order to manage physiological anxiety and decrease fears. As exposure requires clients to take risks, cognitive behavioral therapists must ensure a good therapeutic alliance and communicate a solid rationale for the intervention strategy prior to its implementation (Dobson & Dobson, 2009 ).

The ultimate goal of exposure is to help clients recognize that a feared stimulus is not as scary, unpredictable, or out of control as they imagined and let them know that they can cope with previously avoided situations (Dobson & Dobson, 2009 ). Exposure-based interventions increase clients’ self-efficacy. Gradual and systematic exposure over time has been shown to diminish avoidance patterns, which indicates new learning (D’Zurrilla, Wilson, & Nelson, 1973 ; Watson, Gaind, & Marks, 1971 ). More recent, Craske, Kircanski, Zelikowsky, Mystkowski, Chowdhury, and Baker ( 2008 ), noting that fear levels at the time of exposure have not been shown to be reliable indicators of learning, have posited the evocation of inhibitory learning and fear toleration as shown at episodes of reexposure.

Exposure targets should be hierarchical, starting with a stimulus expected to trigger low levels of anxiety and gradually moving to stimuli likely to result in higher levels of anxiety (Dobson & Dobson, 2009 ). Effective exposure typically produces feelings of moderate anxiety intensity and should not produce extreme or overwhelming anxiety. Exposure is most effective when used frequently and continuously until anxiety is reduced; accordingly, exposure-based interventions may require longer and/or more frequent sessions (Foa, Jameson, Turner, & Payne, 1980 ). Though exposure interventions can occur in vivo or in imagery, in vivo exposure leads to greater benefits (Emmelkamp & Wessels, 1975 ). Clients are encouraged to practice exposure in a variety of situations and settings to promote generalization, with clients keeping a record of exposures and outcomes (Dobson & Dobson, 2009 ). Practice should occur both in-session and outside of sessions as part of homework.

Cognitive Restructuring

CBT clinicians use cognitive restructuring to help clients become aware of the connection between their thoughts, emotions, and behaviors. Cognitive restructuring consists of intervention strategies to help clients recognize, evaluate, and effectively respond to dysfunctional, negative, or distorted thoughts. The intervention strategies commonly employed during cognitive restructuring are described below.

Identification of problematic thoughts: Thought recording . Cognitive behavioral therapists must help clients develop an awareness of their dysfunctional or negative thoughts before they can employ interventions to change these thoughts. Thought recording helps increase clients’ awareness of dysfunctional or negative thoughts, while also providing a way for them to share and communicate experiences with their therapist (Dobson & Dobson, 2009 ). A daily dysfunctional thought record (DTR; Beck et al., 1979 ; Beck, 1995 ) is often used for this purpose. The DTR includes columns in which clients can record situations (e.g., date, time, event), as well as the automatic thoughts, emotions (e.g., type and intensity), and behaviors (e.g., actions and tendencies) the situations elicit. Later in treatment, clients are often given another version of the DTR that includes columns in which alternative (more adaptive) thoughts and behavioral outcomes are recorded as well.

Because identifying and recording dysfunctional and negative thoughts can be challenging for clients, their abilities and skill levels must be considered. Further, some clients may respond negatively to the term “dysfunctional” thought, so clinicians may need to modify their language to ensure that it is acceptable to clients (Dobson & Dobson, 2009 ). Therapists must be sure that clients clearly understand the linkage between their thoughts and responses before encouraging them to engage in thought recording.

Labeling cognitive distortions.

Once clients have identified and recorded their negative thoughts, clinicians can help clients identify cognitive distortions and discuss them. Driven by core beliefs, assumptions, or schemas, cognitive distortions interact with situational facts or circumstances, leading to automatic thoughts and situation-specific thinking (Beck, 1963 ). Cognitive behavioral therapists must recognize clients’ distorted thinking in order to plan effective intervention strategies (Dobson & Dobson, 2009 ). It is common for therapists and clients to review a list of cognitive distortions together. The dysfunctional thought record (DTR), described above, can be modified to include an additional column where clients name the cognitive distortions underlying their negative and dysfunctional thoughts.

Evaluating problematic thoughts: Reality testing and Socratic questioning . To counter cognitive distortions and negative or dysfunctional thoughts, CBT encourages clients to evaluate their thoughts through empirical hypothesis testing. Thoughts are viewed as hypotheses, rather than facts, and therefore can be questioned and challenged. Reality testing refers to intervention strategies that offer opportunities for clients to compare their thoughts to the actual evidence.

One of the most straightforward strategies for countering negative thoughts and distortions is simply asking clients to examine the evidence (e.g., type, quality, amount) that supports and refutes their original thought (Dobson & Dobson, 2009 ). Therapists use Socratic questioning (Beck et al., 1979 ) to help clients make guided discoveries and question their thoughts (Craske, 2010 ). Socratic questioning simply follows the client’s own logic, as if their assumption were true and corollaries to their reasoning would follow: “If what you say is true, then it seems like X would also be true. Do you think that’s correct?” This process often leads clients to realize that they do not have all of the information necessary to draw conclusions. It introduces data that does not fully support or is inconsistent with the original thought, and it may inform an alternative explanation for events (Beck et al., 1979 ). In addition to helping clients change their beliefs and assumptions, reality testing and Socratic questioning support clients’ ability to confront, rather than avoid, problem situations (Dobson & Dobson, 2009 ).

Reattribution.

Clients who have cognitive distortions or negative, dysfunctional thoughts often falsely attribute the cause of certain events or situations. It is common for clients to relate events and situations to themselves and to blame themselves for perceived negative outcomes associated with events or situations. Three well-recognized dimensions of attributions are locus (internal v. external), stability (single occurrence/unstable v. permanent/stable), and specificity (specific to one situation v. global) (Dobson & Dobson, 2009 ). For example, someone with depression may have the tendency to make internal, stable, and global attributions for failure (e.g., I am a failure), but external, unstable, and specific attributions for success (e.g., I was lucky that time) (Alloy, Abramson, Whitehouse, Hogan, Panzarella, & Rose, 2006 ).

CBT seeks to assist clients in recognizing and addressing attributional biases. Once clients are able to recognize attributional biases, they can compare their thoughts to factual evidence. Reattributional pie charts may be used to address attribution biases. First, the clinician and client construct a pie chart reflecting the factors that the client believes contributed to an event or situation (usually a negative one). Next, other potential causes of the event or situation are identified. The clinician asks the client whether any other factors may help to explain the situation or if any additional information may be important to consider. Finally, the pie chart is modified to reflect this reattribution. The exercise can be completed without pie charts using a percentage metaphor to attribute causes or by simply naming various causes of an outcome without determining the proportions for each causal factor (Dobson & Dobson, 2009 ).

De-catastrophizing/Identifying unrealistic expectations.

Clients with cognitive distortions and negative or dysfunctional thoughts may predict negative futures and create self-fulfilling prophecies. This is particularly common among clients with anxiety. CBT utilizes an evaluation process to facilitate clients’ ability to identify self-fulfilling prophecies and examine evidence related to their predictions (Dobson & Dobson, 2009 ). Results of the evaluation are used to challenge negative or unrealistic expectations.

The evaluation process involves hypothesis testing implemented through homework. Clients are first asked to clearly identify their predictions. Then clients establish what evidence will be necessary to either confirm or reject their prediction and develop a procedure for collecting relevant evidence (Dobson & Dobson, 2009 ). Next clients collect evidence as part of homework. At the next session, clients’ predictions are compared to the evidence and evidence-based outcomes. This evaluation-based cognitive intervention strategy may help clients realize that engaging in situations, rather than avoiding them, results in more accurate information and, therefore, may encourage them to collect and evaluate evidence when making predictions in the future (Dobson & Dobson, 2009 ).

Downward arrow.

The downward arrow is a common CBT strategy used to address implications of specific negative thoughts to help identify strongly held beliefs or catastrophic fears (Beck et al., 1979 ; Beck, 1995 ; Burns, 1989 ). The downward arrow technique helps clients think of their thoughts as hypotheses that can be evaluated rather than facts (Dobson & Dobson, 2009 ). Clinicians ask a series of questions about the meaning that clients attach to their thought until the client has no additional responses: “So if that happened, what would it mean?”; “What’s the worst part about that?”; “What would that mean about you?” The Downward Arrow method can serve as an initial assessment tool to identify problematic beliefs, and later in treatment as a way to examine and change intermediate and/or core beliefs when they occur during sessions.

Generating alternative thoughts.

Once clients have identified and evaluated dysfunctional, negative, or distorted thoughts, CBT employs cognitive strategies to generate, evaluate, and ultimately routinize more adaptive, alternative thoughts (Dobson & Dobson, 2009 ). Alternative thoughts can be introduced by the client, the therapist, or collaboratively. Clients may be asked to generate alternative thoughts after evaluating and reviewing evidence related to their original problematic thoughts. If clients have difficulty coming up with alternatives, therapists can offer suggestions for the client to consider. During this process, therapists must respect clients’ original problematic thoughts and acknowledge that generating alternative thoughts can be difficult.

After an alternative thought has been identified, the advantages of both the original and the alternative thought are evaluated. The evaluation process often includes an assessment of the negative thought and the alternative response (e.g., how useful, how helpful they are to clients), as well as cost-benefit analyses of the original thought and the alternative. Clinicians may also ask clients to consider how they would advise a friend with this type of thinking. Once acceptable alternative thoughts have been identified and evaluated, several strategies can be utilized to help clients respond to their original problematic thoughts with the more adaptive, alternative thoughts.

Point-counterpoint.

A point-counterpoint approach is used to help clients respond to negative thoughts. This technique utilizes cue cards with the original thought on one side and the alternative thought on the other side. Therapists then state or read the original thought while clients practice saying the alternative.

Rational role play.

Rational role play can be used to reinforce clients’ use of alternative thoughts and to increase clients’ confidence and ease in responding to negative, dysfunctional, or distorted thinking. This strategy calls for therapists and clients to engage in a role play between negative and more adaptive thinking, with the therapist articulating the problematic thoughts and the client verbalizing the alternative responses.

Task-interfering cognitions—task-orienting cognitions (TIC-TOC).

Another strategy used in CBT to encourage clients’ use of alternative thoughts is the task-interfering cognitions—task-orienting cognitions, or TIC-TOC intervention. The TIC-TOC approach, which refers to the sound of a clock’s pendulum, focuses on going back and forth between task-interfering cognitions (e.g., “I will never get this done”) and task-orienting cognitions (e.g., “If I just get started, it will likely get easier”). TIC-TOC helps clients develop an automatic, alternative response to negative thoughts. The TIC-TOC strategy is most appropriate for clients who experience repetitive thoughts that interfere with specific tasks (Dobson & Dobson, 2009 ).

Homework Assignments

Homework is an essential part of CBT. Goals for homework include learning and generalizing change beyond therapy sessions (Beck & Tompkins, 2007 ; Lambert, Harmon, & Slade, 2007 ). Homework assignments may consist of reading educational materials, completing activity schedules and dysfunctional thought records, conducting behavioral experiments, practicing communication skills, or evaluating problematic thoughts (Dobson & Dobson, 2009 ). Homework assignments are collaboratively developed by therapists and clients, increasing the likelihood of compliance and success. The meta-analytic review of Kazantzis, Whittington, and Dattilio ( 2010 ) suggests that extra-therapy assignments enhance treatment outcomes, although homework compliance has not been positively associated with outcome in all studies (Kazantzis & Dattilio, 2007 ).

Current Applications

Various models of CBT have been applied to a wide range of mental health problems, substance abuse disorders, and other problems. The most common, empirically supported applications of CBT are identified and described below.

Adult Disorders: Depression

Unipolar depression..

CBT treatments for depression have typically employed behavioral activation to increase natural reinforcers in the environment and cognitive restructuring to reduce negative automatic thoughts and increase positive ones, which in turn improve mood and behavior. Meta-analytic studies on treatment outcomes of such CBT methods for depression concluded that most studies show CBT to be superior to waitlist control and placebo treatments (e.g., Beltman, Oude Voshaar, & Speckens, 2010 ; Butler, Chapman, Forman, and Beck, 2006 ). When compared to pharmacological approaches, CBT and pharmacotherapy independently produced similar benefits for depression symptoms within the moderate to large range (Vos et al., 2004 ). Research also demonstrates that medications combined with CBT are associated with better outcomes than CBT as a standalone treatment (Chan, 2006 ), however, Butler, Chapman, Forman, and Beck ( 2006 ) concluded that CBT was moderately superior to medication treatment. Additionally, Hofmann, Asnaani, Vonk, Sawyer, and Fang ( 2012 ) suggest that CBT is as effective as other psychological treatments, such as psychodynamic psychotherapy, problem-solving therapy, and interpersonal psychotherapy, although CBT did not appear to improve upon behavioral treatments that lacked cognitive components. Similarly, findings for adolescents showed much larger effects for CBT than waitlist and other forms of treatment, including relaxation and supportive therapy. Hundt, Mignogna, Underhill, and Cully ( 2013 ) examined skill use as a component of CBT and found evidence that CBT skill practice has a mediating effect on depression.

Bipolar disorder.

CBT for bipolar disorder commonly includes psychoeducation of patients and families, monitoring manic and depressive symptoms, encouraging medication adherence, stress management strategies (e.g., control of the circadian rhythm, daily thought records, social skills training, problem solving), and reduction of stigma. CBT methods produced only moderate benefits for manic and depressive symptoms in meta-analyses of pre-post outcomes, and these effects tended to diminish during the follow-up period (Hofmann et al., 2012 ). While evidence that CBT works well as a stand-alone treatment unaccompanied by medications is limited (as psychopharmacotherapy is the most common form of treatment), CBT did appear to help delay or prevent relapse when compared to medications (Beynon, Soares-Weiser, Woolacott, Duffy, & Geddes, 2008 ). The analysis of da Costa et al. ( 2010 ) found that the majority of studies indicated better outcomes when CBT was combined with medication compared with medication alone. However, they caution that more studies are needed.

Adult Disorders: Anxiety Disorders

CBT methods have been especially well studied for anxiety disorders. Reviews on meta-analytic studies of psychotherapies for a range of anxiety disorders conclude that behavioral and cognitive treatments are efficacious whether delivered separately or combined (Deacon & Abramowitz, 2004 ; Hofmann et al., 2012 ). Hofmann and Smits ( 2008 ) conducted a meta-analysis of CBT versus placebo-controlled studies and found that CBT was effective for adult anxiety disorders, with the strongest effect among those with OCD and acute stress disorder. Norton and Price ( 2007 ) found similar results in another meta-analysis of CBT across the anxiety disorders.

Panic and agoraphobia.

Effective treatments for panic, with or without agoraphobia, have included the following elements: education about the nature and physiology of anxiety and panic, correction of misinterpretations of body sensations (for example, bodily signals of catastrophic outcomes like heart attack or suffocation), exposure to feared body sensations that trigger these misinterpretations, as well as coping skills to manage discomfort. These CBT methods show substantial advantages over waitlist and pill-form or psychological placebo conditions (Deacon & Abramowitz; 2004 ; Hofmann et al., 2012 ). In some studies, combined CBT showed advantages over behavioral methods alone (Gould, Otto, & Pollack, 1995 ), although Deacon and Abramowitz ( 2004 ) noted that cognitive and behavioral methods could not always be differentiated from each other.

Social phobia.

CBT for social anxiety typically includes exposure, cognitive restructuring, and social skills training that are delivered in either group or individual formats, or both. Meta-analytic findings indicated that CBT produced better outcomes than waitlist or placebo/attention control comparisons with evidence from follow-up measures demonstrating that medium-to-large effects were maintained or increased (Gould, Buckminster, Pollack, Otto, & Yap, 1997 ; Hofmann et al., 2012 ). Behavioral treatments using exposure were quite effective, and the addition of cognitive restructuring produced slightly higher effect sizes, but not significantly so; CT alone was less beneficial (Taylor, 1996 ). In reviewing the meta-analyses for CBT for social phobia, Deacon and Abramowitz ( 2004 ) concluded that behavioral elements were essential to effective treatment. In general, CBT methods showed more benefits over time than medication treatments (Hofmann et al., 2012 ).

Obsessive-compulsive disorder.

Similarly, early studies on OCD showed clear efficacy of behavioral treatments that included exposure to feared cues plus response prevention of rituals and avoidance behaviors, commonly abbreviated as ERP (e.g., Abramowitz, 1997 ; van Balkom et al., 1994 ). More recently, cognitive therapy models have applied cognitive restructuring to misinterpretations of intrusive thoughts, images, or impulses. A meta-analysis by Abramowitz, Foa, and Franklin ( 2002 ) indicated a stronger overall effect size from ERP versus CT, though the difference between these two methods was not significant. Practitioners often combine both methods for clients with OCD, especially in the form of behavior experiments that contain elements of both cognitive therapy and behavior therapy. Deacon and Abramowitz ( 2004 ) concluded that for both OCD and social phobia, behavioral methods without cognitive elements appeared to be the critical factor in therapy outcomes.

Generalized anxiety disorder.

Specific external triggers for GAD are more difficult to identify, and so it is challenging to apply standard exposure therapy used for other anxiety disorders. Thus, a wider variety of CBT methods have been studied. These include progressive muscle relaxation, self-monitoring and early cue detection, applied relaxation, self-control desensitization, and cognitive restructuring (Borkovec & Costello, 1993 ). Overall, meta-analyses strongly support the effectiveness of combined cognitive-behavioral interventions for GAD (Deacon & Abramowitz, 2004 ; Gould, Otto, Pollack, & Yap, 1997 ). A meta-analysis by Covin, Ouimet, Seeds, and Dozois ( 2008 ) found that combined cognitive and behavioral interventions were effective in treating pathological worry, a core component of GAD. Too few studies provide an adequate test of the benefits of strictly cognitive or strictly behavioral methods to indicate clearly that these are as effective as combined treatments.

Post-traumatic stress disorder.

Post-traumatic stress disorder (PTSD) is usually treated with a combination of behavioral and cognitive methods, including exposure to fear evoking memories and situational cues, cognitive restructuring, and anxiety-management skills. Other interventions include education, relaxation, and cognitive interventions to help manage anxiety symptoms and modify maladaptive beliefs. Eye-movement desensitization and reprocessing (EMDR; Shapiro, 1991 ) includes imagined exposure to traumatic memories plus coping statements during trauma recall, accompanied by therapist-guided saccadic eye movements. The review of Butler et al., ( 2006 ) indicated strong benefits of CBT over waitlist, EMDR, as well as stress management and other therapies. Other studies suggest that CBT methods produce similar effects to EMDR (Bisson et al., 2007 ), but agree that the actual benefit of the eye movement element is highly questionable. Deacon and Abramowitz ( 2004 ) concluded that the effectiveness of behavioral versus cognitive strategies could not be determined from meta-analyses, as most interventions for PTSD involved combinations of these two methods.

A number of meta-analyses have examined the efficacy of CBT for psychosis, also known as CBTp. CBTp includes cognitive and behavioral methods such as skills training, problem solving, Socratic questioning, exposure, and coping strategy enhancements (Lincoln et al., 2012 ). The largest of these meta-analyses reviewed 34 studies (Wykes, Steel, Everitt, & Tarrier, 2008 ). CBT showed a larger effect size for pre-post-treatment than treatment as usual (i.e., pharmacotherapy using anti-psychotic drugs) (Butler et al., 2006 ; Hofmann, Asmundson, & Beck, 2013 ; Hofmann et al., 2012 ). Beneficial effects were found for both positive and negative symptoms of schizophrenia, although the effects were larger overall for positive symptoms (Kingdon & Dimech, 2008 ). Wykes et al. ( 2008 ) meta-analytic review also showed improvement in functioning, mood, and social anxiety for CBTp interventions compared to medications. A recent community-based clinical study by Lincoln et al. ( 2012 ) found that CBTp for positive symptoms was effective for a variety of clients, treatment settings, and providers. Gould, Mueser, Bolton, Mays, & Goff ( 2001 ) reviewed studies in which cognitive therapy for psychotic symptoms in schizophrenia targeted recognition of, and distorted thinking about, positive symptoms of hallucinations and delusions. Five of seven studies showed a significant decrease in these symptoms and two showed non-significant decreases. Butler et al. ( 2006 ) noted that other methods of treatment, such as befriending clients and supportive therapy, had an intermediate degree of effect, falling between CBT and routine care. Interestingly, Hofmann et al. ( 2012 ) reported that early intervention services and family treatment had a greater impact in reducing hospital admission and relapse than did CBT.

Substance Abuse.

CBT for substance abuse integrates principles of harm reduction, motivation, and relapse prevention by applying a combination of skills training and operant conditioning, to manage cues and control urges, with cognitive therapy and motivational interviewing. CBT has been shown to be an effective intervention for alcohol and other drug use disorders (Dutra et al., 2008 ; Magill & Ray, 2009 ). A CBT study of substance abuse found that the quality of skills was more important than quantity, and that having even a few coping skills can often produce positive outcomes (Kiluk, Nich, Babuscio, & Carroll, 2010 ). Hofmann et al. ( 2012 ) summarized evidence that multiple sessions of CBT worked only moderately well for cannabis dependence and noted that other psychosocial interventions that are also associated with behavioral (i.e., contingency management) and cognitive strategies (i.e., relapse prevention, motivational interviewing) as well as medication treatments showed more benefit for dependence on opioids and alcohol (see Powers, Vedel, & Emmelkamp, 2008 ).

Eating Disorders.

CBT methods for treating eating disorders typically include developing a shared formulation of the problem, self-monitoring, weekly weighing, establishing regular eating patterns, involving others, and cognitive therapy to resolve the overvaluing of shape and weight and to reduce perfectionism and rigid dietary rules. Summaries of meta-analytic studies indicated that CBT showed strong effects for bulimia nervosa in pre-post trials (Butler et al., 2006 ) and medium effects compared to control therapies, such as interpersonal psychotherapy, dialectical behavioral therapy, hypno-behavioral therapy, supportive psychotherapy, weight loss strategies, and self-monitoring (Hay, Bacaltchuk, Stefano, & Kashyap, 2009 ; Hofmann et al., 2012 ). Behavioral treatments appeared to show more benefit than combined cognitive and behavioral methods (Thompson-Brenner, 2003 ). Binge eating disorder responded well to psychotherapy that typically included CBT methods as well as structured self-help with larger effect sizes than medications (Vocks et al., 2010 ). Combining these treatments did not improve binge eating specifically but appeared to increase weight loss somewhat (Reas & Grilo, 2008 ).

Chronic Pain.

Cognitive behavioral interventions for chronic pain and/or fibromyalgia typically involve a number of CBT-based interventions including but not limited to: progressive muscle or imagery-based relaxation, sleep hygiene techniques (e.g., consistent times in/out of bed; evening wind-down activities); cognitive interventions aimed at negative automatic thoughts related to sleep (e.g., “I will be a mess tomorrow if I don’t get to sleep”); pleasant activity scheduling; and activity pacing (e.g., limiting activities on days when feeling well and continuing some level of activity on higher pain days) (Williams, 2003 ). A recent meta-analysis of psychological treatment studies for fibromyalgia found modest effect sizes on short-term pain for a range of psychological interventions but found that CBT-based interventions were associated with the largest treatment effect sizes compared to other psychological approaches (Glombiewski et al., 2010 ).

Intimate Partner Violence (IPV) Perpetrators and Survivors.

Cognitive behavioral interventions for IPV perpetrators typically include cognitive approaches aimed at modifying attitudes and beliefs related to women, problem solving strategies, social skills training (e.g., assertiveness training) and anger management (e.g., timeout from anger-inducing situations, relaxation) approaches (Eckhardt et al., 2013 ). A single meta-analytic review involving psychosocial treatment for batterers found relatively small effects on a range of outcomes, including continued perpetration (Babcock, Green, & Robie, 2004 ). CBT-based approaches for batterers are typically delivered in small groups.

Studies of CBT-based approaches for IPV survivors are more limited in number but generally find positive impact on a range of targets including PTSD-related and depressive symptoms. In the largest of these studies, Kubany and colleagues (Kubany et al., 2004 ) compared immediate versus delayed cognitive trauma therapy for battered women (an approach that includes but is not limited to PTSD-related psychoeducation, prolonged exposure to abuse-related stimuli, cognitive approaches, assertiveness training and perpetrator identification training, and trauma history exploration) and found robust positive effects on PTSD symptoms, depression, guilt, and self-esteem in the immediate versus the delayed treatment group.

Smoking Cessation and Weight Loss.

CBT for smoking cessation often combines principles of motivational interviewing to address early stage ambivalence/barriers related to quitting with a range of CBT-informed interventions (Perkins, Conklin, & Levine, 2008 ). Core CBT strategies typically include analysis of smoking triggers, stimulus control-related strategies for avoiding smoking triggers, responding to smoking-related cognitions, and learning coping strategies for craving (e.g., observe craving changes, relaxation). A meta-analysis of the best-designed randomized controlled intervention trials for smoking cessation indicated that intensive behavioral interventions are associated with substantial increases in smoking abstinence compared to control (Mottillo et al., 2009 ). Finally, augmenting behavioral interventions with pharmacological interventions is likely more effective than behavioral interventions alone and sustained abstinence from smoking remains challenging even with best-practice treatment (Hall et al., 2002 ).

CBT-based strategies also dominate the literature on the psychosocial treatment of obesity. CBT techniques for weight control are in many ways similar to those used for smoking cessation and other addictive behaviors and include increasing motivation to control eating, increasing awareness of over-eating triggers, increasing active behaviors and exercise, identifying and challenging maladaptive cognitions related to eating, and self-monitoring (Cooper, Fairburn, & Hawker, 2003 ). A recent meta-analysis of randomized, controlled trials of psychosocial interventions (all but one involving either BT or CBT) found large and significant effect sizes for eating behavior and modest weight reductions post-treatment (Moldovan & David, 2011 ). Follow-up effect sizes are reduced for both eating and weight loss but remain significant.

Couples Therapy.

Cognitive behavioral couples therapy (CBCT) employs guided behavior change, social skills training emphasizing constructive communication, and cognitive restructuring interventions (e.g., guided discovery; reattribution, downward arrow) to address dysfunctional or distorted thoughts (Baucom, Epstein, Kirby, & LaTaillade, 2010 ). Socratic questioning should be used cautiously in CBCT, as the therapists’ questioning of one partner’s thoughts in the presence of the other partner may further contribute to negative outcomes (Baucom et al., 2010 ). Recent enhancements to CBCT, influenced by systems and ecological models of relationship functioning (e.g., Brofenbrenner, 1989 ) and a strengths-based perspective, place increased attention to macro-level interaction patterns as well as to personality, motives, and more stable individual characteristics (Epstein & Baucom, 2002 ). The meta-analytic review of Butler et al. ( 2006 ) found that cognitive behavioral marital therapy had a moderate effect on marital distress; however, their review included only one meta-analysis (Dunn & Schwebel, 1995 ) on cognitive behavioral therapy for couples.

Child Behavioral Management

The meta-analytic review of Hofmann et al. ( 2012 ) concluded that CBT was associated with large effects in treating internalizing symptoms in children and adolescents with anxiety disorders. This was especially true for children with OCD, as CBT improved these symptoms more than other forms of psychotherapy and serotonergic medications. Improvements in depressive symptoms were evident but not as strong, with medium effects. In the case of depression, CBT was as effective as interpersonal and family systems therapies but more effective than selective serotonin and other reuptake medications.

With regard to externalizing behaviors (e.g., disruptive classroom behaviors, aggressive/antisocial behaviors), CBT was as effective as other forms of psychosocial treatments and showed more benefit compared to treatment as usual, but not compared to pharmacotherapy. Very similar findings were also evident in meta-analyses of CBT for attention deficit hyperactivity disorder. Behavioral techniques such as motivational enhancement and application of contingencies showed modest benefits for adolescent smoking and substance use behaviors compared to no treatment, but not compared to other forms of psychotherapy.

Evidence-Based Practice

Given its scientific approach to treatment, it is not surprising that CBT is one of the most thoroughly researched forms of psychotherapy. The results of 120 clinical trials examining the effect of CBT were published between 1986 and 1993 (Hollon & Beck, 1994 ), by 2004 Butler et al. ( 2006 ) identified more than 325 published outcome studies on CBT’s efficacy (Butler et al., 2006 ), and Hofmann et al. ( 2012 ) found 269 meta-analytic studies of CBT published since 2000.

The extensive research suggests a strong empirical basis for CBT across a wide range of disorders (Butler et al., 2006 ; Hofmann et al., 2012 ). A review of 16 meta-analyses by Butler et al. ( 2006 ) found CBT effective for treating adult unipolar depression, generalized anxiety disorder, panic disorder with and without agoraphobia, social phobia, obsessive-compulsive disorder, PTSD, schizophrenia, marital distress, anger, bulimia nervosa, sexual offending, and chronic pain as well as adolescent unipolar depression, childhood depressive and anxiety disorders, and childhood somatic disorders. The meta-analytic review of Hofmann et al. ( 2012 ) suggests CBT has the strongest support for treating anxiety disorders, somatoform disorders, bulimia, anger control problems, and general stress. Results suggest that treatment gains are generally maintained over follow-up intervals ranging from 6 to 24 months (Butler et al., 2006 ; Norton & Price, 2007 ). It should be noted that comparisons were usually with control conditions receiving no treatment or nondirective supportive counseling as a placebo. Limited research has compared CBT to other active psychotherapies (Butler et al., 2006 ; Hofmann et al., 2012 ).

Evidence also suggests the versatility of CBT. CBT is effective when delivered in both individual and group formats (e.g., Butler et al., 2006 ; Hofmann et al., 2012 ) and findings indicate that frequency and duration of sessions are not related to outcomes (Norton & Price, 2007 ). Research demonstrates that CBT is effective among diverse populations, including participants of different racial and ethnic backgrounds, ages, and socioeconomic status (e.g., Ayers, Sorrell, Thorp, & Wetherell, 2007 ; Cartwright-Hatton, Roberts, Chitsabesan, Fothergill, & Harrinton, 2004 ; Compton et al., 2004 ; Hays, 2009 ; Horrell, 2008 ; Schraufnagel, Wagner, Miranda, & Roy-Bryne, 2006 ; Scogin, Welsh, Hanson, Stump, & Coates, 2005 ; Wilson & Cottone, 2013 ). Additionally, literature suggests that CBT is effective when implemented in non-mental health settings, such as primary care offices, schools, and vocational rehabilitation centers (e.g., Brown & Schulberg, 1995 ; Hoagwood & Erwin, 1997 ; Rose & Perz, 2005 ; Roy-Byrne et al., 2005 ). Further, evidence is growing indicating that CBT can be effectively delivered with technology, with computerized CBT (cCBT) and CBT delivered via videoconferencing garnering empirical support (e.g., Andrews et al., 2010 ; Antonacci, Bloch, Saeed, Yildirim, & Talley, 2008 ; Kaltenthaler et al., 2006 ; Simpson, 2009 ).

CBT and Social Work

Enhancing human well-being and helping to meet basic human needs of all people, with particular attention to vulnerable populations, is the primary mission of the social work profession (NASW, 1996 ). Additionally, the NASW Code of Ethics ( 1996 ) states that social workers should advance the professional mission by working toward the maintenance and promotion of high standards of practice. Therefore, it is not surprising that social work has long emphasized the need for a scientific foundation to inform and guide practice (Cheney, 1926 ; Reynolds, 1942 ). The movement toward evidence-based practice (EBP), or “the integration of best research evidence with clinical expertise and client values” has further influenced the social work profession (Sackett, Straus, Richardson, Rosenberg, & Haynes, 2000 , p.1).

Eileen Gambrill, one of the earliest most influential scholars to introduce and advocate the use of EBP within the social work profession (Thyer, 2002 ), was also instrumental in studying and encouraging the implementation of behavioral approaches in social work (e.g., Gambrill, 1977 ; Gambrill, Thomas, & Carter, 1971 ). In the late 1960s and early 1970s, scholars at the University of Michigan School of Social Work, including Edwin Thomas, Richard Stuart, and Gambrill, began applying behavioral approaches to social work practice (Gambrill, 1995 ). Gambrill ( 1995 ) notes the expansion of behavioral methods, including CBT, within social work, and she attributes this to their compatibility with professional interests as well as their commitment to a scientific approach, including the use of empirical research, to guide practice.

CBT has arguably the best evidence for effectiveness of mental and behavioral health problems among all psychotherapies (Hollon & Beck, 1994 ; Dobson, 2010 ; Butler et al., 2006 ; Hofmann et al., 2012 ), and has become one of the most frequently used psychosocial interventions. Given the increasing emphasis on EBP, CBT has had a distinct impact on social work practice. Social workers make up the largest group of behavioral health providers in the United States (NASW, 2005 ) and deliver more than 60% of mental health treatment (NASW, 2006 ). An increasing number of social workers report using CBT as their preferred model of practice (Granvold, 2011 ; Thyer & Myers, 2011 ). Between 1987 and 2007, the percentage of social workers practicing from a CBT-perspective more than tripled (Bike, Norcross, & Schatz, 2009 ; Norcross, Garofalo, & Koocher, 2006 ). Evidence suggests that between 30% and 43% of social workers practicing in the United States report using CBT (Pignotti & Thyer, 2009 ; Prochaska & Norcross, 2010 ). The need for clinical social workers in the fields of mental health and substance abuse is expected to rise by 20% between 2008 and 2018 (Bureau of Labor Statistics, 2010 ), and expert forecasts indicate that CBT will be increasingly in demand and used among social workers (Prochaska & Norcross, 2010 ). However, an acute shortage of qualified CBT therapists exists in many countries relative to demand and the treatment’s potential value to society (Chambless & Ollendick, 2001 ).

Though social workers indicate CBT is a preferred method of practice, a large gap remains between the availability of EBPs and their use in clinical practice (Weissman & Sanderson, 2002 ; New Freedom Commission, 2003). One proposed reason for this persistent gap is mental health professionals’ lack of training in EBPs, such as CBT. While the combination of didactic content and supervised clinical work is considered the gold standard for learning a new treatment, a survey of randomly selected CSWE-accredited MSW programs suggests that 62% did not require both didactic training and clinical supervision for any EBP (Weissman et al., 2006 ). Didactic content related to CBT was offered and required at substantially higher rates than other evidence-based psychotherapies (e.g., interpersonal psychotherapy, multisystemic therapy), with 93% of MSW programs offering didactic training in CBT and 80% requiring didactic training in CBT. Though 66% of MSW programs reported offering clinical supervision for CBT, only 21% of programs required it (Weissman et al., 2006 ). Restructuring the organizational framework of social work curriculum to provide students with intensive training seminars and practicum devoted to EBPs and the systematic monitoring of clinical outcomes may help to address this gap within social work education (Thyer & Myers, 2011 ).

The widespread use of CBT among social workers and its inclusion in social work curriculum has led to attention to the fit between CBT as a therapeutic approach and social work’s professional mission and values. The critical analysis of CBT and social work values undertaken by Gonzalez-Prendes and Brisebois ( 2012 ) suggests that CBT promotes equality within the therapeutic relationship, aims to understand the context that has shaped a person’s reality, and promotes a healthy level of social interest (e.g., protecting the rights of others and addressing unfair or unjust treatment that diminishes the quality of a person’s social environment). Therefore, the analysis concludes that CBT, grounded in a non-judgmental, strength-based, empowering philosophy and focused on promoting unconditional acceptance and respect of self and others, aligns with the social work profession’s mission of social justice (Gonzalez-Prendes & Brisebois, 2012 ).

CBT refers to a family of short-term, problem-focused interventions rooted in behavioral and cognitive traditions that acknowledge the primary role thoughts have in shaping behaviors and emotions. CBT employs behavioral and cognitive intervention strategies aimed at identifying and challenging maladaptive or dysfunctional thoughts, behaviors, and emotions with more adaptive alternatives. Evidence supporting the effectiveness of CBT has grown substantially since the 1980s and, as such, the treatment has been increasingly used by mental health professionals, including social workers. Social workers provide a large proportion of mental health services and most commonly endorse CBT as their preferred model of practice. However, a documented shortage of providers qualified to deliver CBT has been registered, and social workers could be better prepared to provide CBT if more schools of social work offered both didactic and supervised clinical training. CBT aligns with social work’s guiding values and mission, and it has been found to effectively treat mental disorders across diverse populations and settings, further supporting its relevance to the social work profession.

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Further Reading

  • Academy of Cognitive Therapy : http://www.academyofct.org
  • Anxiety Disorders Association of America : http://www.adaa.org/
  • Association for Behavioral and Cognitive Therapies : http://www.abct.org/home/
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  • Behavior Therapy Training Institute : http://www.ocfoundation.org/btti.aspx
  • International OCD Foundation : http://www.ocfoundation.org/

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Improving Our Understanding of Impaired Social Problem-Solving in Children and Adolescents with Conduct Problems: Implications for Cognitive Behavioral Therapy

  • Published: 14 February 2022
  • Volume 25 , pages 552–572, ( 2022 )

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  • Walter Matthys   ORCID: orcid.org/0000-0002-8887-0785 1 &
  • Dennis J. L. G. Schutter   ORCID: orcid.org/0000-0003-0738-1865 2  

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In cognitive behavioral therapy (CBT) children and adolescents with conduct problems learn social problem-solving skills that enable them to behave in more independent and situation appropriate ways. Empirical studies on psychological functions show that the effectiveness of CBT may be further improved by putting more emphasis on (1) recognition of the type of social situations that are problematic, (2) recognition of facial expressions in view of initiating social problem-solving, (3) effortful emotion regulation and emotion awareness, (4) behavioral inhibition and working memory, (5) interpretation of the social problem, (6) affective empathy, (7) generation of appropriate solutions, (8) outcome expectations and moral beliefs, and (9) decision-making. To improve effectiveness, CBT could be tailored to the individual child’s or adolescent’s impairments of these psychological functions which may depend on the type of conduct problems and their associated problems.

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This work was supported by an NWO (Dutch Research Foundation) Innovational Research Grant VI.C.181.005 (D.S).

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Matthys, W., Schutter, D.J.L.G. Improving Our Understanding of Impaired Social Problem-Solving in Children and Adolescents with Conduct Problems: Implications for Cognitive Behavioral Therapy. Clin Child Fam Psychol Rev 25 , 552–572 (2022). https://doi.org/10.1007/s10567-021-00376-y

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  • Problem-solving is one technique used on the behavioral side of cognitive-behavioral therapy.
  • The problem-solving technique is an iterative, five-step process that requires one to identify the problem and test different solutions.
  • The technique differs from ad-hoc problem-solving in its suspension of judgment and evaluation of each solution.

As I have mentioned in previous posts, cognitive behavioral therapy is more than challenging negative, automatic thoughts. There is a whole behavioral piece of this therapy that focuses on what people do and how to change their actions to support their mental health. In this post, I’ll talk about the problem-solving technique from cognitive behavioral therapy and what makes it unique.

The problem-solving technique

While there are many different variations of this technique, I am going to describe the version I typically use, and which includes the main components of the technique:

The first step is to clearly define the problem. Sometimes, this includes answering a series of questions to make sure the problem is described in detail. Sometimes, the client is able to define the problem pretty clearly on their own. Sometimes, a discussion is needed to clearly outline the problem.

The next step is generating solutions without judgment. The "without judgment" part is crucial: Often when people are solving problems on their own, they will reject each potential solution as soon as they or someone else suggests it. This can lead to feeling helpless and also discarding solutions that would work.

The third step is evaluating the advantages and disadvantages of each solution. This is the step where judgment comes back.

Fourth, the client picks the most feasible solution that is most likely to work and they try it out.

The fifth step is evaluating whether the chosen solution worked, and if not, going back to step two or three to find another option. For step five, enough time has to pass for the solution to have made a difference.

This process is iterative, meaning the client and therapist always go back to the beginning to make sure the problem is resolved and if not, identify what needs to change.

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Advantages of the problem-solving technique

The problem-solving technique might differ from ad hoc problem-solving in several ways. The most obvious is the suspension of judgment when coming up with solutions. We sometimes need to withhold judgment and see the solution (or problem) from a different perspective. Deliberately deciding not to judge solutions until later can help trigger that mindset change.

Another difference is the explicit evaluation of whether the solution worked. When people usually try to solve problems, they don’t go back and check whether the solution worked. It’s only if something goes very wrong that they try again. The problem-solving technique specifically includes evaluating the solution.

Lastly, the problem-solving technique starts with a specific definition of the problem instead of just jumping to solutions. To figure out where you are going, you have to know where you are.

One benefit of the cognitive behavioral therapy approach is the behavioral side. The behavioral part of therapy is a wide umbrella that includes problem-solving techniques among other techniques. Accessing multiple techniques means one is more likely to address the client’s main concern.

Salene M. W. Jones Ph.D.

Salene M. W. Jones, Ph.D., is a clinical psychologist in Washington State.

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Evidence-Based Treatment

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Evidence-Based Therapy

Therapy at va.

Evidence-based therapies (EBTs) have been shown to improve a variety of mental health conditions and overall well-being. These treatments are tailored to each Veteran’s needs, priorities, values, preferences, and goals for therapy. EBTs often work quickly and effectively, sometimes within a few weeks or months, depending on the nature or severity of your symptoms. Work with your VA provider to choose the treatment options that work best for you. To learn more about EBTs offered at VA and the mental health conditions they are used to treat, explore the information below.

Acceptance and Commitment Therapy for Depression (ACT-D)

ACT-D is a therapy that can help transform and improve the lives of people experiencing depression . ACT-D aims to help you live in a way that’s more closely aligned with your values, improving your relationships with yourself, others, and the world.

Through this therapy, you’ll learn to accept your thoughts and emotions, choose and commit to actions that align with your values, and take action to achieve what matters most to you. ACT-D typically requires 10 to 16 individual sessions, but it can be tailored to your treatment preferences and priorities. This therapy can lead to:

  • A decrease in negative thoughts and feelings.
  • Increased awareness and focus that helps you to fully connect with others and live in the moment.
  • The ability to clarify your values and take action to achieve what means the most to you in life.

If you choose ACT-D, you may be asked to:

  • Commit to attending sessions regularly.
  • Set treatment goals with your provider at the onset of therapy.
  • Speak openly about your depression, the challenges you’re facing, and your values.

To determine whether ACT-D may be right for you, speak with your mental health provider about your symptoms so you can work together to create the most effective treatment plan.

Behavioral Activation (BA)

BA is a therapy that has been shown to relieve or resolve symptoms of depression . This therapy will help you become more engaged with activities that can improve your mood.

BA will teach you ways to build personally rewarding daily activities, and ways to identify and achieve the things you value and enjoy in life. Sessions of BA are action-oriented, focused on problem-solving, and typically provided in 20 to 24 individual sessions. After participating in this treatment, you may experience:

  • An increase in healthy behaviors and positive experiences, thoughts, and mood.
  • The ability to turn overwhelming tasks into attainable achievements.
  • Increased participation in hobbies and social events, including some that you may have enjoyed before your depression.

If you choose BA, you may be asked to:

  • Develop a personalized plan to help you reconnect with the experiences you find rewarding.
  • Engage with activities that may feel uncomfortable at first but will help you become more socially active.

To learn more about this therapy, speak with your mental health provider about your symptoms and treatment goals. Together, you can determine the treatment that best fits your needs.

Behavioral Family Therapy (BFT)

BFT is a family therapy for Veterans who have complex, long-term mental health conditions, such as schizophrenia and bipolar disorder , or frequently experience psychosis.

Typically lasting from 20 to 25 sessions of 50 minutes each, BFT emphasizes the importance of a strong family support system, and it can help motivate your loved ones to participate in this journey with you. BFT has five components: engagement, assessment, illness education, communication skills training, and problem-solving instruction. These components may be presented through:

  • Role-playing and skill practice in an out-of-session setting.
  • Review of written materials.
  • Family education about mental health and your specific condition.
  • Development of communication and problem-solving skills to help you and your family cope with mental health stressors together.

If you choose this therapy, you may be asked to:

  • Commit to attending regular weekly sessions.
  • Practice role-playing and skill development in and out of therapy sessions.

Cognitive Behavioral Conjoint Therapy (CBCT)

CBCT is a therapy that is shown to help treat PTSD in Veterans. This treatment is delivered together with a Veteran’s family member or another loved one. Some Veterans desire family involvement in their treatment because of the impact that PTSD has had on the quality of their relationships and social life.

CBCT typically consists of a 15-session treatment plan over three phases, which can be tailored to each couple. After engaging with this therapy, you may experience:

  • A decrease in PTSD symptoms and their severity.
  • Improved relationships with your family members and others in your life.
  • A decrease in comorbid symptoms that may be linked to your PTSD and their severity.
  • An increase in your partner’s mood and engagement.

If you choose CBCT, you may be asked to:

  • Learn about PTSD and its impact on how relationships function.
  • Practice new communication skills with your partner, both in and outside of sessions.
  • Develop skills to help you and your partner overcome avoidance.
  • Change problematic beliefs about trust, power, and emotional and physical intimacy.

To learn more about CBCT, speak with your mental health provider about how you’re feeling and discuss your goals and preferences for treatment.

Cognitive Behavioral Therapy

CBT is a recommended treatment for Veterans struggling with stimulant use disorder. This therapy focuses on relationships between thoughts, feelings, behaviors and situations and helps Veterans build skills to change their unwanted behaviors and achieve their goals. CBT is considered a short-term therapy and typically involves six to 14 sessions. Through this therapy, you learn to:

  • Cope with triggers for using stimulants, such as cravings and social pressures.
  • Manage high-risk situations.
  • Reinforce behaviors that align with your recovery goals.
  • Challenge thoughts that lead to and follow stimulant use.

If you choose CBT, you will be asked to:

  • Commit to attending regular sessions.
  • Work with your provider to set treatment goals.
  • Identify triggers for using stimulants.
  • Practice — outside therapy sessions — the skills you learn in therapy.

To learn more about CBT, speak with your mental health provider or ask your primary care provider for a referral to a therapist.

Cognitive Behavioral Therapy for Depression (CBT-D)

CBT-D is a type of therapy that is shown to be an effective treatment for depression. CBT-D treatments often focus on identifying and altering unhelpful thought patterns and behaviors that contribute to or worsen symptoms of depression.

Typically lasting from 12 to 16 sessions, CBT-D can help you reach your treatment goals. Through this therapy, you may:

  • Develop more balanced and helpful thoughts about yourself, others, and the future.
  • Spend more time engaging in pleasurable or productive activities.
  • Learn new skills to help achieve personal goals and solve problems, improving your quality of life and overall level of functioning.

If you choose CBT-D, you will be asked to:

  • Address important personal issues during each session.
  • Practice the new skills you learn outside of therapy sessions.

No matter what is causing your mental health condition, proven treatments and resources are available. To learn more about CBT-D, speak openly with your mental health provider about your symptoms so you can work together to determine the best treatment plan for you.

Cognitive Behavioral Therapy for Insomnia (CBT-I)

CBT-I is a talk therapy that research has shown to be the best way to treat insomnia disorder. Veterans with insomnia disorder experience frequent sleep disruption, usually over more than three months, which may include trouble getting to sleep or staying asleep as well as waking up too early.

CBT-I therapy typically involves about four to seven weekly sessions of 30 to 60 minutes each. During CBT-I talk therapy, you may:

  • Learn how much sleep you need to feel rested and how to achieve it.
  • Spend less time in bed trying to sleep.
  • Learn how to turn your bed back into a place for sleep, not wakefulness.
  • Learn strategies that help your mind and body relax and prepare for sleep.
  • Adjust thoughts that get in the way of sleep.

If you choose CBT-I treatment, you will be asked to:

  • Commit to attending weekly sessions.
  • Maintain a daily sleep diary so that you and your therapist can track your sleep challenges and improvements.
  • Practice new skills, such as relaxation strategies or wind-down routines.

No matter what caused your insomnia or how long you have experienced it, CBT-I is a treatment with the proven ability to help, even if you have other medical or mental health conditions. To learn more about CBT-I, speak with your mental health provider or ask your primary care provider for a screening for insomnia disorder and referral to care.

Cognitive Behavioral Therapy for Substance Use Disorders (CBT-SUD)

CBT-SUD is being disseminated as part of the ongoing, national VA Evidence-Based Psychotherapy (EBP) Training Initiative. CBT-SUD is an evidence-based, time-limited intervention that teaches Veterans how to make and maintain changes in substance use and improve their quality of life. CBT-SUD encourages Veterans to adopt an active, problem-solving approach to cope with the many challenges associated with substance use conditions.

Contingency Management (CM)

CM is an evidence-based treatment for substance use disorder (SUD); and, it is particularly helpful for those patients who misuse stimulants (like cocaine or methamphetamine) or marijuana.  In CM, the patient receives incentives for completing recovery behaviors such as abstinence verified by urine drug screens (UDS). The incentives increase in size with consistent performance of the recovery behavior, i.e. for consecutive negative UDS results. Extensive research on CM has shown that is a very effective treatment for helping a wide array of patients with SUD, including Veterans, achieve and maintain abstinence and retention in treatment. 

Cognitive Processing Therapy (CPT)

CPT is a therapy shown to treat PTSD that teaches Veterans to identify, evaluate, and ultimately modify the unpleasant thoughts following a traumatic experience. Trauma can change the way you think about yourself, others, and the world, and it may leave you feeling stuck. Through CPT, you can learn skills that help you recognize more helpful ways to think about your trauma and create a new perspective on the world.

CPT typically lasts from seven to 15 weekly sessions, either in an individual or a group setting, depending on your preference. Through this therapy, you may:

  • Develop healthier, balanced beliefs about yourself and others.
  • Relieve feelings of distress related to memories of the trauma.
  • Return to the activities you enjoy in life.
  • Practice new skills that provide more helpful ways to think about your trauma.

If you choose CPT, you will be asked to:

  • Speak and write about the impact of the trauma you’ve experienced.
  • Learn to identify and challenge unhelpful thoughts.
  • Complete take-home practice assignments between sessions to apply the skills you are learning in therapy.

Speak openly with your mental health provider about your symptoms and priorities so you can work together to determine whether this therapy is best for you.

Dialectical Behavioral Therapy (DBT)

DBT teaches skills to help control harmful and impulsive behaviors such as self-harming, substance misuse, and binge eating; reduce suicidal thoughts and behaviors; and improve symptoms of PTSD, depression, and borderline personality disorder. This treatment can also help patients build and maintain healthy relationships and may be particularly well-suited for people who experience a lot of conflict in relationships with frequent ups and downs. DBT uses a combination of acceptance and change strategies to help you learn new problem-solving and coping skills to improve your overall quality of life.

DBT lasts longer than some other EBTs, typically taking at least six months to provide full benefits. There are four main components to this treatment: individual therapy, skills training classes, one-on-one “in-the-moment” telephone consultation, and weekly consultation with a therapist. DBT can be personalized for each individual, depending on the nature and extent of your mental health challenges and their impact on your quality of life. Through this therapy, you may:

  • Develop a more balanced view of your experiences and opportunities for experiencing safety and growth.
  • Find increased motivation to participate in activities and hobbies.
  • Develop new ways to understand and address painful emotions and ask for the support you may need.
  • Learn to build and maintain satisfying relationships.
  • Practice mindfulness to help you stay in the here and now.
  • Develop effective coping skills to reduce impulsive behaviors.

If you choose DBT, you may be asked to:

  • Attend weekly sessions with your provider to discuss therapy goals, progress, and any challenges encountered since your last check-in.
  • Participate in a weekly skills group to learn and practice ways of coping with problems and emotions, and apply new skills to specific events and challenges in your life.
  • Complete homework between sessions to practice new skills, track your progress, and then review your efforts with your providers.

No matter what brings you into care, proven treatments and resources are available. To learn more about DBT, speak openly with your mental health provider about your symptoms so you can work together to determine the best treatment plan for you.

Eye Movement Desensitization Reprocessing for PTSD (EMDR-PTSD)

EMDR has been shown to reduce symptoms of posttraumatic stress disorder (PTSD). This treatment pairs patients’ eye movements with their processing of traumatic memories. A patient pays attention to a back-and-forth movement or sound while they recall a traumatic memory until the distress associated with that memory decreases. Eventually, they focus on a positive belief or feeling while they hold the memory in their mind. EMDR typically consists of six to 12 sessions. Through this therapy, you:

  • Learn emotional management techniques, such as relaxation techniques.
  • Follow emotional management with in-depth processing of traumatic memories and the beliefs and physical symptoms attached to those memories.

To determine whether EMDR is right for you, talk with your mental health provider about your symptoms so you can work together to create the most effective treatment plan.

Integrative Behavioral Couples Therapy (IBCT)

IBCT is a therapy for couples that focuses on reducing marital distress and improving relationship satisfaction. This therapy develops increased emotional understanding, effective communication strategies, and improved behavioral responses between loved ones. By accepting your differences and understanding your partner’s sensitivities and stressors, you can work together to overcome the challenges you’re facing.

IBCT typically ranges from 11 to 26 sessions, but your treatment plan will be tailored to your needs and has no fixed number of sessions. The therapy may teach you how to negotiate and set goals together with your partner, friend, or family member in two phases: evaluation and treatment.

  • The evaluation phase usually consists of a joint session, an individual session with each partner, and a feedback session for the therapist to explain their understanding of the couple’s problems and outline next steps for treatment.
  • The treatment phase consists of the therapist’s work with the couple to alter and improve the way they interact with and understand each other.

Through this therapy, you may:

  • Experience increasing relationship satisfaction.
  • See an improvement in your communication skills and emotional closeness with your partner.
  • Recognize and change problematic patterns of interaction.
  • Increase your positive interactions and connection.

To learn more about IBCT, speak with your mental health provider about how you’re feeling and discuss your goals and preferences for treatment.

Interpersonal Therapy (IPT)

IPT is a therapy that focuses on healing relationship problems that may be the cause or result of depression . By understanding the connection between interpersonal issues and your depression, you can create social skills to help deal with these problems and improve the way you feel.

IPT typically involves 12 to 16 weekly sessions of 50 minutes each over three phases:

  • Initial sessions provide information about depression and how it may be affecting your daily life.
  • Intermediate sessions focus on one or two specific areas that are most concerning to you and that you believe contribute to your depression. In these sessions, you will also begin developing new skills to improve your response to certain life stressors.
  • In the termination phase, your mental health provider will review your progress with you, explore your possible stressors, discuss the new skills you’ve learned, and evaluate whether further treatment is needed. After this phase, many Veterans notice an increase in overall life satisfaction.

If you choose IPT, you will be asked to:

  • Set treatment goals with your therapist.
  • Discuss personal issues that you’re experiencing in each session.
  • Practice new skills inside and outside of the sessions.

To learn more about this therapy and its treatment phases, speak with your mental health provider about your symptoms and treatment goals.

Motivational Enhancement Therapy (MET)

MET is a therapy that is mainly for Veterans who are thinking about changing their use of alcohol or drugs. This brief intervention focuses on exploring your reasons and motivations for changing your substance use.

Lasting from three to four sessions, MET can be used alone or as a step toward other treatments, depending on your individual needs. Through this therapy, you may:

  • Experience an increased awareness of your reasons for and commitment to changing your alcohol or drug use.
  • Develop healthier substance use habits and health-related behaviors.
  • Reduce your engagement in risky activities, such as having unprotected sex, gambling, or taking drugs with unsafe needles.
  • Commit to attending weekly sessions for up to four weeks.
  • Complete an assessment to explore your reasons for changing substance use.
  • Review the assessment results with your therapist to identify your motivations for change and, when it makes sense, to formulate a treatment plan that works for you.

By speaking openly with your mental health provider about your substance use, you can collaborate to find the treatment that is best for you.

Motivational Interviewing (MI)

MI is a therapy that can help you develop healthier habits related to substance use , smoking, nutrition, exercise, chronic health problems, and risky behaviors. An MI therapist will work with you to explore your values and goals for treatment and your reasons for change. This is accomplished in a therapy environment that is based on collaboration, respect for your right to self-determination, and compassion.

Typically lasting from one to four sessions, MI focuses on exploring your reasons for changing a behavior that affects your health. This therapy can work alone or in combination with other treatments. Through this therapy, you may:

  • Experience an increased awareness of your reasons for and commitment to changing the target behavior you discuss with your therapist.
  • Commit to healthier choices related to substance use, nutrition, exercise, and addressing chronic health problems.
  • Choose to engage in follow-up care, if needed, to support your treatment goals.

If you choose MI, you may be asked to:

  • Commit to attending weekly sessions lasting one to three weeks.
  • Work with your therapist to identify the focus or target of the behavior change.
  • Speak about your experiences in changing your behavior and your reasons for making that change.

By speaking openly and honestly with your mental health provider about mixed feelings you may have about a change you are considering, you can work together to explore and use your motivation for change.

Problem-Solving Therapy (PST)

PST is a therapy for Veterans who are experiencing depression or suicidal thoughts . PST can help you recover from the effects of experiencing difficult situations and learn skills for coping with challenging life circumstances and chronic daily stressors.

PST is a goal-oriented treatment that can teach you to identify, understand, and evaluate problems. Then you may learn to find creative solutions to those problems and pursue the best course of action to overcome them. The number of sessions varies depending on your needs. Through this treatment, you may:

  • Strengthen your ability to address negative feelings associated with suicide and depression.
  • Increase your confidence in confronting situations in a deliberate way.
  • Heighten your feelings of optimism and motivation.
  • Increase your ability to think things through when you feel overwhelmed.
  • Learn to address difficult challenges such as finding a job or working through a serious health issue.

If you choose PST, you may be asked to:

  • Complete written assignments in and outside of sessions, sometimes as homework.
  • Learn new problem-solving skills to overcome obstacles and address challenges.
  • Identify a problem and practice your new skills to find a solution.
  • Learn new skills to address negative emotions, brain overload, and low motivation.
  • Meet regularly with your therapist to discuss and establish goals for treatment.

Prolonged Exposure Therapy (PE)

PE is a highly effective therapy for PTSD that helps patients gradually address their symptoms and get their lives back. PE works by having you approach and address traumatic memories, feelings, and situations that you may be avoiding because of the traumatic event(s) you experienced. By talking about these difficult moments, you can begin to overcome these challenges and decrease symptoms of PTSD so that you can start living your life more fully again.

PE typically lasts from eight to 15 sessions. Your provider will work with you to ensure that therapy progresses at a rate that works best for you and is tailored to your treatment preferences, values, and priorities. Through this therapy, you may:

  • Learn new breathing techniques to help relieve your distress.
  • Engage with and feel more comfortable in safe situations that you have been avoiding due to trauma.
  • Process and work through the traumatic event, which will ultimately decrease unwanted memories and thoughts.
  • Change negative, unwanted beliefs by working through the memory and engaging in activities you have been avoiding.
  • Talk about the details of your trauma.
  • Make a list and gradually revisit the people, places, or activities that you’ve avoided since your trauma.
  • Complete homework and practice new skills outside of the sessions.

Speak openly with your provider about your mental health symptoms so that you can work together to determine the treatment plan that is best for you.

Safety Planning (SP)

SP is an intervention to help Veterans experiencing suicidal thoughts and behaviors. By working together with your provider, you will create a safety plan that includes a list of prioritized coping strategies and sources of support to use in preventing or responding to a suicidal crisis. The plan can help you discover healthy ways to cope with suicidal thoughts, curb harmful behaviors, and improve your quality of life.

SP can be a single session or incorporated into ongoing treatment with your provider. Creating the SP may take about an hour. After creating a safety plan, you may:

  • Experience a heightened sense of self-control.
  • Have a more optimistic attitude when it comes to addressing suicidal thoughts and crises.

If you choose SP, you may be asked to:

  • Work with your provider to create a list of coping strategies and resources to use during a suicidal episode.
  • Identify warning signs that signal when to use your coping strategies.
  • Discuss how to use the safety plan and how to overcome barriers or obstacles to using the plan.
  • Review the plan periodically with your provider when your circumstances or needs change.

Speak openly with your provider about your feelings and mental health symptoms so that you can work together to develop a safety plan that best meets your needs and situation.

Social Skills Training (SST)

SST is an intervention that was developed to treat individuals with schizophrenia. SST is also commonly effective in helping people diagnosed with schizoaffective disorder, bipolar disorder, or treatment-refractory depression. Typically, SST is provided in a group setting to teach you ways to better express yourself and respond to others’ thoughts, feelings, and needs. SST can help you learn to communicate and get along better with others in group sessions designed to be very supportive (and even fun!).

Before joining the first group session, you will attend an individual session to learn more about the intervention and set a personal goal or goals for the social skills group. The length and frequency of an SST group’s sessions depend on the setting, as well as the needs of the group members. SST groups usually meet once or twice a week for up to six months. A group leader can provide more specific information about SST groups available at your VA.

SST strives to improve your social skills and increase your ability to function in everyday settings. Through this group intervention, you may:

  • Improve social skills that help you make progress toward your goals.
  • Learn to start and maintain better conversations.
  • Become more skillful in asking for help from others.
  • More effectively express your feelings, resolve conflicts, make friends, and assert yourself when necessary.
  • Learn to improve and maintain social relationships.
  • Become more independent.

If you choose SST, you may be asked to:

  • Learn about the importance of various social skills.
  • Demonstrate your ability to use various social skills in role-plays.
  • Accept constructive feedback and notes for improvement from group facilitators and peers.
  • Practice new social skills in the community between SST group sessions.

To learn more about SST, speak with your mental health provider about your goals and preferences for treatment.

Written Exposure Therapy

Written exposure therapy can help Veterans relieve symptoms of posttraumatic stress disorder (PTSD). With this therapy, you learn to lessen the distress caused by traumatic memories.

Written exposure therapy typically consists of five sessions. Through the therapy, you learn that:

  • Traumatic memories do not have to cause significant distress.
  • Any distress you feel is temporary.
  • It is possible to develop new ways of thinking about the trauma and its meaning.

If you choose written exposure therapy, you will be asked to:

  • Write in detail about the trauma you experienced.
  • Reframe the way you think about your trauma.

To learn whether written exposure therapy is right for you, speak with your mental health provider about your mental health symptoms and discuss your goals and preferences for treatment.

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  • J Psychother Pract Res
  • v.9(4); Fall 2000

Basic Strategies of Dynamic Supportive Therapy

Supportive therapy is the psychotherapeutic approach employed with the majority of mentally ill individuals. Nevertheless, most mental health professional training programs dedicate little time and effort to the teaching and learning of supportive therapy, and many mental health professionals are unable to clearly and concisely articulate the nature or process of supportive work. Although supportive therapy incorporates many specific techniques from a wide variety of psychotherapy schools, it can be conceptualized as consisting of a more limited number of underlying strategies. The fundamental strategies that underpin effective supportive therapy with mentally ill individuals are described.

Amidst the many psychotherapeutic schools, approaches, and techniques, it is easy to lose sight of the reality that the paradigm employed for work with the majority of mentally ill patients represents some form of “supportive therapy.” 1 – 10 Indeed, Hellerstein et al. 11 have argued that supportive therapy should be viewed as the treatment model of choice, or default therapy, for most patients. Nonetheless, confronted with a confusing amalgam of psychotherapeutic theories and techniques—cognitive-behavioral therapy, 12 – 16 interpersonal psychotherapy, 17 , 18 psychodynamic psychotherapy, 1 , 19 ego psychology, 20 , 21 object relations, 22 – 29 self psychology, 30 – 33 eye movement desensitization and reprocessing, 34 to name just a few— beginning therapists often find it difficult to arrive at a set of consistent principles on which to base their supportive interventions. The problem is exacerbated by the mismatch between the frequent use of supportive therapy and the typically small portion of training program time and effort dedicated to teaching and learning in this domain. The result is that many mental health professionals are unable to clearly and concisely articulate the finite number of basic strategies on which effective supportive therapy is founded. 35

The goal of this paper is to present a concise and coherent description of the fundamental strategies underlying supportive psychotherapy. Novalis et al. 6 note that supportive therapy may be conceived as an overarching therapeutic “matrix in which more specific techniques of therapy can be embedded” (p. 20). Thus, insofar as supportive therapy employs techniques from a wide variety of psychotherapeutic schools or disciplines, the nomenclature and terms presented here will derive from myriad sources and schools; no attempt will be made to restrict the elaboration of key principles to a single psychotherapeutic paradigm. In addition, the classification system used here to categorize the various supportive therapy strategies is but one such arrangement. Many of the identified strategies could easily be placed in different categories, or even in multiple categories.

THE BASIC STRATEGIES OF DYNAMICSUPPORTIVE THERAPY

Strategy #1:formulate the case.

The mere mention of the word formulation often unsettles psychotherapists, neophytes and veterans alike, calling forth fantasies of having to construct a lengthy and exhaustively detailed psychoanalytic understanding of every nuance of the patient's mental life, beginning from birth (or perhaps even prenatally) and continuing to the present time. Insofar as the term formulation has a psychodynamic connotation resulting from its historical origins, some therapists prefer the term case conceptualization as one that is more neutral, suggesting a whole range of biopsychosocial etiologies. Whichever term is used, this not uncommon sense of dread and incompetence with respect to case formulation or conceptualization is unfortunate, not just because constructing one need not be a crushing burden, but also because a case formulation or conceptualization is vital to the success of the psychotherapeutic enterprise. It is the therapist's “theory of the case,” his or her understanding of what is “wrong” with the patient, and, as such, it serves as a roadmap for future therapeutic interventions. 36 – 42

Whether explicitly or implicitly, every good therapist bases his or her interventions on an understanding of “Why?” and “Why now?” Why is this particular patient presenting with these particular difficulties at this particular time? Indeed, a perhaps incongruous but apt analogy may be made with the auto mechanic. Without some theoretical understanding of how cars work, as well as some notion of “what's broken,” an auto mechanic is unlikely to fix an automobile. The mechanic's interventions will be, at best, random, shotgun attempts to alter something that, with luck, will occasionally result in a better-running automobile. So too for the psychotherapist: without some theoretical understanding (from whatever paradigm or combination of paradigms) of what it is that makes people tick, without some notion of “what's broken” with this particular person at this particular time, the therapist can only guess at appropriate and useful interventions.

The case formulation serves other important purposes as well for the supportive therapist. It allows the therapist to keep an eye on the horizon, to make sure that, overall, therapist and patient are moving in the right direction, even if they have to tack left and right to get there. Furthermore, it serves to organize in the therapist's mind the key problems and interventions. It also suggests hypotheses for further testing: “I need more information,” or, “Maybe this is why the patient is having trouble in this area.” It is through the testing of such hypotheses that the therapist comes to a useful understanding of the patient on which he or she can base beneficial psychotherapeutic interventions.

Another point with respect to case conceptualization: human beings—all individuals—are enormously complex in their thinking, feeling, and behavior. To come to a true and deep understanding of another person does not happen immediately or easily; it takes time and patience, effort, trial-and-error and hypothesis testing, an open and inquisitive mind. And just as one comes to have a deeper appreciation of friends and colleagues over time, so too does the supportive therapist become more knowledgeable about the patient over time. This means that the case formulation or conceptualization is never truly finished; it is, by definition, a work in progress, a fluid conceptualization that is altered as new information becomes available, old hypotheses prove unhelpful or untenable, and new aspects of the patient emerge. The good therapist is always updating, amending, and refining his or her understanding of the patient and of “what's broken.”

The supportive therapist need not necessarily share this case conceptualization with the patient, nor is the patient required to have the same understanding of key issues as does the therapist. The important point is that the therapist has a case formulation or conceptualization and that he or she uses it and updates it regularly.

In order to illustrate an appropriate case formulation and how it might be employed in the implementation of dynamic supportive psychotherapy, an extensive clinical vignette, “Amy,” follows the discussion of supportive strategies.

Strategy #2:Be a Good Parent

Perhaps the single most helpful concept in guiding the therapeutic interventions of the supportive therapist is to view the therapist–patient relationship in analogy to the parent–child relationship. Such an analogy does not imply that the patient in supportive therapy is a child or should be infantilized by the therapist. Rather, the analogy underscores the empirical observation that psychiatric patients, at least in some spheres of function, often think, feel, or behave like children, rather than as adults. Indeed, if the patient were functioning at a mature, adult level in most significant areas of life, he or she would likely not need a supportive therapist. The supportive therapy patient typically is operating ineffectively, that is, at a nonadult or childlike level, in one or more psychological domains such as reality testing, problem solving, affect modulation, impulse control, or interpersonal relations. Thus, to the extent that a patient is functioning at a childlike level in significant domains of life, the supportive therapist assumes a parental role with respect to the patient.

What does it mean to “be a good parent” in this context? The supportive therapist constantly assesses the patient developmentally with respect to the latter's strengths and deficits. The current context and stressors confronting the patient are considered. When appropriate, the patient is comforted and soothed by the therapist; at other times, the therapist serves as a cheerleader, encouraging, nurturing, validating, praising, or congratulating the patient. On still other occasions, however, the patient must be confronted with respect to self-destructive behaviors. Appropriate protection, containment, and limit-setting are balanced with promotion of autonomy and independence. Similarly, the supportive therapist offers whatever help is needed, but at the same time encourages the patient's growth and self-sufficiency. Suggestions, advice, and teaching are used to guide the patient's thinking and behavior; but, like a good parent, the therapist's intent is to help the patient reach his or her own goals rather than to substitute the therapist's life plan or wishes for those of the patient. In contrast to the reserved stance of the psychoanalyst, the supportive therapist may use significant self-disclosure, sharing thoughts, feelings, or experiences that will help the patient manage similar issues in his or her own life. Overall, the supportive therapist attempts to help the patient develop into an individual who is mature, in control, effective, and satisfied, just as a parent does with a child. In the language of self psychology, 33 the supportive therapist is a good selfobject, providing needed mirroring, idealizing, and twinship experiences that allow the patient to internalize important psychological functions that are currently deficient.

A key question that is often helpful in guiding therapeutic decisions in supportive therapy is: “What would a good parent do in this situation with this person?” Other questions logically follow from this starting point: “Am I pushing too hard, or am I not asking enough of the patient?” “Will the particular experience under discussion be a good learning or growth promoting experience, or will it be an overwhelming, traumatic experience?” “Am I acting in the patient's best interests, or do I have another agenda?” “How can I help this particular person at this particular time in this particular situation accomplish his or her goals?”

The analogy between the therapist–patient and parent–child relationships is so important in guiding the supportive therapist's stance toward, and interventions with, the patient that it will be reemphasized throughout this article.

Strategy #3:Foster and Protect the Therapeutic Alliance

Although there is some disagreement, in general the failure to foster and maintain a good working or therapeutic alliance 43 between patient and therapist is a predictor of poor psychotherapy outcome. 44 – 49 Indeed, this may be especially true in supportive therapy with poorly functioning patients, who may enter the therapeutic relationship with little trust, unrealistic expectations, and poor frustration tolerance. For some such patients, real and perceived mistakes, miscommunications, or disrespect on the part of the therapist do not merit a second chance, and such patients may terminate the therapy immediately thereafter.

Thus, the supportive therapist's first goal, and one to which he or she must attend throughout the therapy, is the facilitation and maintenance of a good therapeutic alliance with the patient. Not surprisingly, a positive therapeutic alliance in supportive therapy often casts the therapist in the role of a good parent. The supportive therapist need not love the patient (indeed, it may be a matter of concern if he or she does love a particular patient), nor must he or she agree with or endorse all of the patient's thoughts, beliefs, feelings, or behaviors. What the therapist must do, however, is respect the patient as a person (though not necessarily respecting that person's behavior)—a person who, at least at some level, is struggling with the same life issues as is everyone else, mentally healthy and unhealthy alike. The supportive therapist must couple this respect with compassion, empathy, and commitment.

There are other important elements of a good therapeutic alliance. Even with the most disordered of patients, the therapist tries to ally with those parts of the patient that are the healthiest: a borderline patient's concern that his or her children not suffer the same childhood as did the patient, a schizophrenic's desire to become part of an appropriate social milieu, an alcoholic's wish to retain a good job and be a good provider for his or her family. Few indeed are the patients, no matter how psychologically or mentally disordered, that do not retain areas of higher, and appropriate, mental functioning. The therapist's task is to locate and identify these healthy parts of the patient and ally with them or enlist them in the service of the best interests of the patient.

A common strategy in this regard is the attempt by the therapist to use the patient's observing ego as an ally. The term observing ego 43 refers to an individual's ability to step back, get some distance or perspective, and observe himself as he would a friend or family member. This requires a patient to step outside of the moment and honestly critique his or her thoughts, feelings, and behaviors. Another example of a therapist's attempt to ally with the healthy parts of the patient: the supportive therapist and patient attempt to work collaboratively in the development of shared goals and strategies for the attainment of those goals. When a therapist and a patient share common goals, they become allies and find it easier to work together; in contrast, when the therapist's goals and the patient's goals differ, tension arises and the therapy often fails.

With respect to personal characteristics, the supportive therapist does not try to emulate the reserved interpersonal stance of the psychoanalyst. He or she is friendly (although not necessarily a friend), parental (but not paternalistic), flexible, creative, and, above all, human. Humor, when used appropriately, is a powerful tool in the hands of a good supportive therapist and a robust coping mechanism for the patient. The supportive therapist is down-to-earth and practical, attempting to address everyday but important problems or difficulties in patients' lives. The supportive therapist does what the patient needs without fanfare or struggle; it is not a venue for long theoretical explanations or intellectual athletics. Unlike more psychodynamically and psychoanalytically oriented therapists, the supportive therapist is often very interpersonally active, asking questions, making suggestions, praising, suggesting, guiding, and so forth. Finally, a good supportive therapist believes in, and demonstrates, common sense, common courtesy, and the Golden Rule (i.e., the patient is treated as the therapist would want to be treated).

Strategy #4:Manage the Transference

Patients invariably have feelings about their therapists. When some of these feelings are “transferred” from early, important, childhood figures (e.g., the parents), to whom they were originally directed, onto the therapist, they are called “transference.” 43 , 50 Transference, by definition, results in a distortion of the patient's perception of the therapist; the patient cannot accurately perceive who the therapist truly is because the latter is viewed through the colored lens of previous experiences with significant others. Although most beginning therapists tend to think of transference as consisting of negative feelings toward the therapist (e.g., “You're mean, just like my father”), transference may consist of positive feelings as well. In the latter instance, the therapist may be seen as more intelligent, more powerful, or more loving than he or she really is.

In the classical psychoanalytic tradition, transference is “interpreted.” 43 The psychoanalyst does not rush to explain or correct the patient's misperceptions of him or her; rather, the patient's feelings about the therapist are explored and related to previous important experiences with significant others. In contrast, supportive therapists typically do not interpret the transference; they “manage” it.

There are two key principles in the management of transference. First, positive transference is not interpreted; it is used. This means that insofar as a patient may view the therapist as omnipotent, omniscient, purely loving, and the like, the therapist does not correct or interpret such distortions; instead, the therapist uses the patient's faith in him or her to further the aims of the supportive psychotherapy. Thus, the supportive therapist allows the patient's belief in his or her superior knowledge and experience to foster the likelihood that the patient will follow suggestions or advice put forth by the therapist. (A psychoanalyst, in contradistinction, might interpret the patient's overvaluation of his or her abilities as a reaction formation against deep-seated, but repressed, anger toward the therapist).

The second element of the management of transference relates to negative transference. Here, again, the transference is not interpreted (e.g., “You are angry at me for not returning your phone call soon enough because you see me as a selfish and withholding person like your father, who never gave you what you needed”); no attempt is made to explore the childhood roots or early interpersonal experiences that may underlie the negative transference feelings. Nor, however, is negative transference used (unlike positive transference). Indeed, negative transference in supportive therapy must be aggressively confronted and corrected; failure to do so often results in rapid and premature termination of therapy. Thus, in the example above, the supportive therapist might manage the patient's negative transference by saying, “I'm sorry I didn't return your telephone call earlier, but I was already on the phone with a very agitated and suicidal patient.” Rapid and vigorous correction of negative transference (“Yes, I spoke with your employer about your medications, but please remember that I did so at your request”) is essential, especially with paranoid patients for whom perceived nefarious motives or misbehavior on the part of the therapist often represents sufficient cause to immediately discontinue therapy. More generally, management of negative transference often requires the therapist to openly, explicitly, and nondefensively discuss what he or she is doing and why such actions are being taken.

Strategy #5:Hold and Contain the Patient

The concepts of holding and containing refer to a therapist's attempts to be a good parent by providing empathy, understanding, and verbal soothing; modulating affect; restricting self-defeating impulsivity or acting out; and generally setting appropriate limits. 51 – 54 Holding and containing may also include allowing the patient to ventilate, emote, or otherwise express his or her thoughts, fantasies, or feelings. At what point should a supportive therapist intervene? The answer, once again, is to think like a parent. When a very young child is frightened by a thunderstorm, a good parent comforts the child and makes him feel safe: “It's okay, it's just a thunderstorm and it will pass; we'll be safe inside at home.” Similarly: “It's scary going for a job interview, but we've practiced repeatedly and I think you can do it; the worst that happens is that you don't get this job, but there are plenty of others.”

Containing the patient may require more aggressive interventions as well, including the use of psychotropic medications and psychiatric hospitalization. Both of these interventions should be used when appropriate, with forthright explanations as to why the therapist thinks they are necessary and beneficial at this time. Similarly, a therapist may need to call a parent, friend, spouse, co-worker, employer, social service agencies, or even the police in order to prevent physically dangerous or seriously future-foreclosing behavior on the part of the patient. The courts may need to be involved. As is the case with a good parent, however, these decisions should not be countertransferentially determined punitive actions, but calmly instituted interventions for the good of the patient.

Even when containing the patient, it is important to protect his or her autonomy as much as possible. As soon as the patient is able to regain control, make appropriate decisions, and take appropriate actions, the therapist should relinquish control in those domains. Often the degree of containment will vary with the patient's condition and the stressors to which he or she is exposed, as would occur with a child.

Strategy #6:Lend Psychic Structure

The notion of “lending ego” derives from the psychoanalytic tradition; and broadly conceived, it refers to a therapist's functioning as an “auxiliary ego” for the patient. 8 The patient is allowed to use or “borrow” the therapist's presumably well-working mind and psychological capacities in order to enhance his or her own, relatively deficient, psychic functioning in particular domains. In effect, the patient is encouraged to think like the therapist, who presumably represents a good role model for mental health.

What sort of ego functions are “lent” in supportive therapy? They may include any or all, in various combinations, of the important mental or psychological functions. Often of key importance is reality testing, since it is difficult to negotiate one's environment successfully if one cannot distinguish between reality and fantasy. Other important ego functions that may be lent include problem analysis and solving, affect modulation, impulse control (“think before you act”), and, perhaps, the functions subsumed under the recently popular term of “emotional intelligence,” 55 which include interpersonal awareness, empathy, and social skills.

The concept of lending psychic structure may be enlarged to include the lending of superego or, simply put, conscience. Some patients need to be encouraged to relax the self-imposed restrictions of conscience; they need to “lighten up,” take chances, and have some fun. Conversely, other patients may require a bolstering of their superego insofar as they do not have, or do not sufficiently act upon, reasonable notions of right and wrong. In either case, the therapist may present his or her own superego as a model for appropriate use by the patient.

One final comment is in order regarding the “lending” of psychic structure. The supportive therapist is, indeed, making a “loan,” rather than a permanent gift, to most patients. Although it is true that some patients (typically those with chronic, severe mental illnesses) may need an auxiliary ego or superego for the foreseeable future, many patients will borrow the supportive therapist's psychological functions for more circumscribed periods of time. The therapist lends the patient what psychic structure is needed at the time it is needed, but, concomitantly, the therapist tries to promote the patient's growth, independence, and autonomy.

Strategy #7:Maximize Adaptive Coping Mechanisms

In all psychotherapy, including supportive therapy, an important goal is to increase a patient's coping skills and use of adaptive defense mechanisms. 56 – 59 Adaptive defense mechanisms include intellectualization, rationalization, humor, anticipation, altruism, and sublimation; in contrast, the more maladaptive defense mechanisms include denial, splitting, projection, and acting out. The supportive therapist's goal is not only to increase the use of the former but also to decrease use of the latter. Whether one uses the term coping mechanisms or defense mechanisms , the process involved is one of healthy adjustment by the patient to current stressors. Examples might include going for a walk, calling a friend, immersing oneself in work, applying relaxation techniques, speaking with a therapist, and so forth.

The supportive therapist can enhance a patient's coping skills through education about, and repeated practice of, specific mechanisms for dealing with stressful situations. The literature is replete with concrete suggestions and training programs in this regard. Two of the most useful approaches are the “skills training” aspect of dialectical behavior therapy 60 (e.g., core mindfulness, interpersonal effectiveness, emotion regulation, and distress tolerance skills), and the use of “coping cards” as described by Beck. 16 Whatever training paradigm is used, it is crucial that the patient begin well ahead of time to prepare to use specific coping skills in particular circumstances. Patient coping skills may also be enhanced in supportive therapy through the therapist's lending of ego as well as role modeling.

Strategy #8:Provide a Role Model for Identification

A corollary of the therapist's strategy of lending psychic structure to the patient might appear obvious, but it is worth underscoring because of its importance in supportive therapy: the supportive therapist should willingly provide him- or herself as a healthy role model with which the patient can identify. The patient is not encouraged to live a life identical to that of the therapist (e.g., to adopt the therapist's political views or take up the same hobbies). Rather, the patient is offered the opportunity to identify with the healthy psychological structure and function of the therapist, especially with respect to reality testing, affect modulation, impulse control, problem solving, and interpersonal interactions.

To this end, and in contradistinction to the classic psychoanalytic approach, therapist self-disclosure can play an important role in supportive therapy. Such self- disclosure should be judiciously employed with the best interests of the patient in mind; the therapist need not, and should not, reveal every personal detail. Nevertheless, to the extent that a supportive therapy patient can benefit from concrete examples of how others have handled specific situations, the therapist may offer him- or herself as an illustrative instance. In so doing, the therapist may not only provide an opportunity for valuable vicarious learning on the part of the patient, but may also foster the therapeutic alliance.

The supportive therapist as role model cannot, and more importantly should not, present herself as a perfect human being. Not only is the therapist far from perfect, but there is much the patient can learn from the therapist's mistakes and failures as well as successes, from trials and tribulations as well as triumphs, from the therapist's “bad days” as well as “good days.” Indeed, it is often of great benefit to the patient to learn (either through therapist self-disclosure of past events or through direct observation of the therapist in the office) how the therapist handles anger, irritation, confusion, disappointment, embarrassment, and failure—the vicissitudes of life that confront everyone, whether mentally ill or psychologically healthy. To the extent that the patient sees the therapist struggle to deal with such issues, the patient's thoughts, feelings, and behavior gain some measure of normalization (“Everyone gets mad sometimes; it's not just me”). This realization in itself may be an important vehicle by which the patient can experience an elevation in self-esteem. Thus, the supportive therapist does not hold him- or herself up as an impeccable role model with whom the patient should identify, but rather presents as a decent, mature human being.

Strategy #9:Decrease Alexithymia

The concept of alexithymia has generated considerable controversy. 61 – 67 Indeed, the very term alexithymia —literally, “no words for mood”—has been used in multiple ways in the psychotherapeutic literature. For some authors, the term refers to the inability to become aware of, or recognize, what one is feeling; for others, the term indicates an individual's inability to verbally label what he or she is feeling. Whatever definition one accepts, and in fact both deficits may be present in a given person, alexithymia is more than a simple cognitive deficit.

Indeed, the lack of awareness that one is experiencing feelings, the inability to recognize those feelings, and/or the lack of capacity to name those feelings is highly disabling. The very act of naming a feeling gives an individual a sense of understanding of and control over the emotion, analogous to finally learning the specific diagnosis of the medical illness from which one has been suffering. (This is true even if the illness is one for which there is no cure.) It is considerably more frightening to feel under assault by something unknown than known, and for many psychologically impaired patients the onrush of unidentifiable affects feels very much like an overwhelming assault or intrusion from the outside. In addition, the ability to identify and name feelings makes it easier to reflect on those feelings as well as discuss them with others. Finally, significant alexithymia makes it very difficult to engage in the next basic strategy outlined below: one cannot make connections between feelings and thoughts, behaviors, or events if one is unable to recognize and label those feelings. Thus, alexithymia is an appropriate target for supportive psychotherapy intervention. The goal is to help the patient recognize, acknowledge, identify, and label emotions.

Some patients benefit from a written list of feelings (available in many texts) so that they can review the list in a specific situation and attempt to find the word or words that best describe their affect. Many patients begin to recognize and label their feelings by concentrating on somatic sensations associated with particular affects: “It felt like my stomach was coming into my throat” for “fear,” or “My head felt like it was going to explode” for “anger.” In a related way, some patients find it helpful to describe their emotions in terms of metaphors relevant to their life experience or interests, whether in music, art, sports, or other areas: “I felt like a linebacker run amok,” or “I felt like a winter night with a soft snow falling.” Such metaphorical descriptions can then be given a specific label for convenient reference and communication. “I felt like a linebacker run amok” becomes “enraged,” while “I felt like a winter night with a soft snow falling” becomes “serene.”

Strategy #10:Make Connections

It is easy to underestimate the difficulty that psychologically impaired individuals may have in making the connections that otherwise healthy people make in everyday life. And these connections—between thoughts and feelings, between events and subsequent thoughts or feelings, and between an individual's behavior and the response of others—are crucial to the ability to negotiate and function in the real world. A therapist's ability to enhance a patient's competence in making these connections will often result in substantial benefits in the patient's overall functioning and life satisfaction.

There are many patients, more severely impaired, who are unable to make the association between an event or situation in the real world and their subsequent feelings. For these individuals, feelings often seem to come out of nowhere. Inundated by affects they cannot understand or locate in a particular context, they feel affectively helpless and out of control. The realization that “I am feeling sad because my friend did not call me today as I expected” or “I am anxious because my therapist will be leaving on vacation” helps the patient to recognize the source of affects and to specifically target areas for intervention (e.g., “Perhaps you could call your friend,” or “Maybe we should talk about how you're going to handle yourself while I'm on vacation”).

Similarly, the basic notion, now enshrined in cognitive therapy, that thoughts and feelings are connected, is often alien to the more severely psychologically impaired. This relationship works both ways in the sense that either a thought or a feeling may be identified by the patient first. Nevertheless, a straightforward cognitive approach 16 in which the patient is shown how to identify the underlying automatic thoughts and core beliefs that lead to unpleasant affects not only gives the patient a greater sense of control, but also allows for targeted cognitive interventions that can be made in conjunction with a therapist or on the patient's own.

Finally, a fundamental connection that is often deficient in personality-disordered and other severely psychologically impaired individuals is that between their behavior and the way in which others (particular people, the world in general) respond to them. In such cases the therapist might say, for instance, “Perhaps so many people are angry with you because you provoke them in some way,” or “Maybe one of the reasons you so frequently feel abandoned by your friends has to do with how much you ask of them.” Such confrontations must be done sensitively, empathically, and tactfully. The ultimate result is a change in locus of control from external to internal, a heightened sense of personal responsibility, and, not infrequently, relief on the part of the patient at actually having some control over the way in which the world responds to him or her.

Strategy #11:Raise Self-Esteem

Foster competency:.

All psychotherapies attempt to raise patients' self-esteem, although many different approaches (e.g., self-talk, correction of cognitive distortions, unraveling of unconscious guilt) may be taken in order to accomplish this goal. Nevertheless, perhaps the most direct and often the most robust means of raising self-esteem is by fostering an individual's competency in real skills. Indeed, there is nothing more effective in helping a patient feel better about him- or herself than the actual demonstration to self and others that he or she is truly competent. In this respect, talk may be beneficial in elevating self-esteem; but proof, and true belief, require competent performance in real-life situations.

What tactics are useful in promoting an individual's competence or mastery? Perhaps the most important are taking one step at a time and working to set a patient up for success rather than failure. In other words, the therapist guides the patient through individual steps of appropriate size and manipulates the variables to increase the likelihood of success at each step.

For example, a female patient has been unable to obtain a job for several years. Rather than simply send her on a job interview with the hope that she will be successful, the therapist may engage in behavioral rehearsal with the patient. Through role play, the patient may alleviate some of her anxiety, and together she and the therapist can problem solve potential difficulties (e.g., “How do I respond if I'm asked why I haven't been working for the past two years?”). The patient and therapist may agree to engage in “practice interviews” with employers in which the patient is not especially interested, using the experiences to prepare for future interviews for desirable jobs. At each step it is important for the therapist and patient to pay attention to key details. The therapist may specifically advise the patient with respect to her clothing, placement of hands, use of language in general, or phrasing of certain responses. The therapist attempts to optimize the likelihood that the patient will succeed at this particular task. At the same time, however, the therapist is ready to support and comfort the patient if she is unsuccessful; again, like a good parent, the therapist serves as a cheerleader and encourages the patient to try again.

The ultimate goal is to enhance the patient's functional, healthy, adaptive behaviors through the mastery of key skills, especially interpersonal and social skills, problem-solving, and coping strategies. The therapist attempts to provide the patient with specific, concrete tools consistent with the latter's innate abilities and current functioning. It may be difficult for the supportive therapist to determine where the line is between appropriate encouragement and pushing too hard or giving up on the patient too early. Like a good parent, the therapist should not settle for too little from the patient, but must also beware not to not push the patient beyond his or her capabilities so that a learning, self-esteem- enhancing activity becomes a traumatic one instead.

Encourage Employment:

Although this is not true for all psychologically disturbed or mentally ill individuals, the great majority of psychiatric patients will benefit from having a job, even if it is an unpaid, volunteer position. For psychiatric patients especially, work serves other important functions besides providing an income. It structures an individual's time, provides a sense of identity, increases self-esteem, and furnishes a sense of belonging to a larger community. For patients with interpersonally barren lives, work provides a ready-made socialization experience that allows them to observe and incorporate the social skills of others and practice those skills in a real-world setting. Thus, as a general rule the supportive therapist encourages a patient to work in whatever capacity or setting is consistent with the patient's overall level of functioning.

Normalize Thoughts, Feelings, and Behaviors:

Perhaps with the exception of severely personality-disordered patients, most mentally ill individuals believe that they are “not normal.” Whether it be particular thoughts, certain feelings, or specific behaviors, such patients suspect that they are in some fundamental way different from healthy, effective, and happy people. Often at some level they recognize that they are not functioning as well as those around them.

One does not successfully allay such anxieties by giving false assurances. On the other hand, it can be very helpful for patients to recognize that they are not alone. The realization that everyone struggles with the fundamental human issues (work, love, play, illness, loss, death) can provide solace, just as can the realization that simply “being angry” may be normal rather than a sign of mania or personality disorder. Even the narcissistic injury engendered by the realization that one is engaging in highly maladaptive behaviors can be reduced and normalized by noting that such behaviors, while currently destructive, may have been highly appropriate, perhaps even life-saving, in an earlier time or context. 68 The therapist might note, for example, “One of the reasons that it's hard for you to assert yourself at work is that when you were growing up your alcoholic father would physically assault you if you spoke up. Being more assertive would be helpful to you now, but had you been so as a child, it might literally have been fatal.” Patients are often greatly relieved, sometimes even proud, to learn that current counterproductive behavior is mistimed or misplaced but is the result of highly adaptive attempts to cope with very difficult earlier life situations.

Strategy #12:Ameliorate Hopelessness

Hopelessness in mentally ill individuals is often related to cognitive constriction, the patient's sense of having few options at his or her disposal. In that respect, removing the blinders, if you will, often greatly increases a patient's hope for the future; the patient needs to learn that there are more options available than he or she imagined. A useful approach to this problem is that of cognitive-behavioral therapy, 16 with specific discussion of negative cognitive distortions that lead to hopelessness, as well as behavioral practice to reinforce a new way of thinking.

In a similar way, the use of reframing as a psychotherapeutic tactic can combat feelings of hopelessness. The patient is helped to see the “silver lining” in his or her circumstances. One instance of the reframing technique has been described above in connection with the normalization of destructive behaviors. Likewise, a supportive therapist might reframe a 25-year-old patient's bitter struggle with her parents as an attempt, perhaps misguided in its tactics, to obtain the entirely legitimate goal of adult autonomy: “I think what you're trying to do, to take responsibility and to control your own life, is very appropriate; perhaps together we can discover some ways to do this that don't cause such anger between you and your parents.”

In supportive therapy the therapist may take active steps to combat hopelessness through direct environmental manipulation. Helping a patient obtain disability status, get a new apartment, keep a job, find transportation—all of these everyday specifics can be of crucial importance to the patient, and their successful negotiation leads to increased optimism about the future. Hopelessness can also be ameliorated by elevation of the patient's self-esteem; as previously discussed, the most effective way to do this is through the development of true competence or mastery of specific skills.

Strategy #13:Focus on the Here and Now

Supportive psychotherapy is not a classical “depth psychology” in which the therapist attempts to explore the patient's childhood experiences in order to understand the effect of those experiences on present-day thoughts, feelings, and behaviors. This is not to say that such exploration may not be appropriate and useful in supportive therapy, only that the primary focus should be on the “here and now” rather than the “there and then.”

The here-and-now issues that should be the primary focus of supportive therapy are those concerning everyday functioning. How is the patient feeling? How is the patient getting along at work, with family, with friends? Is the patient able to pay the rent? Does he or she have difficulty finding transportation to and from work? Is group therapy beneficial? Is the patient taking his or her medication, and have there been any side effects? It is through these everyday details that the therapist has sufficient data to judge how the patient is doing and what should be the focus of their work together. Once current mood and symptoms as well as logistical issues concerning rent, transportation, medication, and the like have been satisfactorily reviewed or addressed, the here-and-now focus should concentrate on a crucial area for most psychologically impaired patients: interpersonal relations and social skills. The more the therapist can help a patient increase his or her interpersonal awareness and reality testing as well as develop appropriate social skills, the better the patient will function in everyday existence. Hence, social skills training, whether part of a formal program or simply integrated into the fabric of the supportive therapist's general work with the patient, is of prime importance to the patient's overall functioning and life satisfaction.

The supportive therapist should work collaboratively with the patient to set an appropriate agenda for each session. Nevertheless, it is the therapist's ultimate responsibility to ensure that the most important issues confronting the patient or therapy are addressed in a timely fashion. Thus, it is often helpful for the therapist to have in mind a “hierarchy of thematic priority” 29 or a “hierarchy of primary targets” 69 with which to rank the significance of the various issues to be addressed in a given session. As a general rule, at the top of such lists are the following:

  • Threats to physical safety of the patient or others, such as suicidal or homicidal thoughts or behaviors.
  • Therapy-interfering behaviors, such as requests to decrease session frequency or to terminate the therapy, plans to leave the geographic area, failure to pay for therapy, destruction of office property, boundary intrusions involving the therapist.
  • Future-foreclosing events or plans, 54 such as precipitously leaving a job or moving out of one's house without alternative living arrangements.
  • Treatment noncompliance, such as failure to take necessary medications or to see an auxiliary therapist or psychiatrist.
  • Negative transference.

Strategy #14:Encourage Patient Activity

It is crucial that the supportive therapist help the patient to become active, to “do” rather than simply “say” or “talk about.” Whether in the office with the therapist or in the everyday world, the patient is encouraged to experiment with new ways of thinking, feeling, and behaving. Talking about issues is often very beneficial in supportive therapy, but in the long run, discussion alone is no substitute for action. Only through the successful testing of new interpersonal behaviors or skills, the conquest of specific fears, or the mastery of feelings of inadequacy will the patient truly be convinced that he or she is capable in various domains. It is one thing to talk to a 10-year-old boy about his feelings of failure; it is quite another to teach him to hit a home run when playing baseball with his friends; it is the latter experience that is most likely to serve as an antidote to his feelings of inadequacy.

It is also helpful to have the patient set concrete, achievable behavioral goals. “I want to be happy” or “I want to be a better person” are legitimate goals, but they are so broad as to be difficult to operationalize; in addition, such general goals make assessment of progress difficult, often resulting in the patient experiencing a sense of “going nowhere.” Thus, “I want to be a better person” might be concretized into specific behavioral objectives as follows: “I want to apologize to my family when I become unreasonably angry with them, and I want to return telephone calls from friends within 24 hours.”

The setting of specific, concrete, achievable behavioral goals serves another important function: it enables employment of the behavioral principle of “shaping.” Patients, like psychologically healthy persons, may not perform complex behaviors well on the first attempt. Often they must first practice and master part-behaviors or components of the overall skill. Subsequently, these component behaviors are integrated with one another in increasingly sophisticated ways that ultimately lead to competence in the application of the entire, complex skill.

Returning to a previous example, a patient needs to get a job in order to support herself. The supportive therapist may work sequentially with the patient on each of the steps involved in the process of obtaining a job: selecting the right job, constructing a resume, choosing the right clothes, practicing appropriate manners, coherently describing occupational goals, responding to difficult questions, and following up on the interview. By setting specific, concrete behavioral goals, it is possible to break large accomplishments into smaller ones, transform seemingly overwhelming tasks into manageable lesser tasks, and set the patient up for success rather than failure.

The supportive therapist, like a good parent, should assess the patient's current psychological state and capacities, the overall context, and the specific task under consideration, pondering if, when, and how the patient should venture forth into a new or difficult experience. Thereafter, the therapist should work with the patient to devise a specific plan of action, using whatever techniques may be most beneficial in dealing with a particular issue or problem for this particular patient.

With the typical supportive therapy patient, behavioral approaches—behavioral rehearsal, role playing, relaxation, graded exposure, visualization and imagery, and so forth—are often the most useful in helping the patient to reach his or her goals. Many of these techniques are enumerated and detailed by J. S. Beck 16 and by Linehan. 60 , 69 The patient may also be encouraged to become active through the assignment of homework to be completed between sessions. J. S. Beck 16 provides sensible guidelines in this regard, stressing the importance of working collaboratively with the patient to set homework; starting assignments in the office; reviewing homework at the next session; anticipating and troubleshooting potential difficulties; and, more generally, attending to activity monitoring and scheduling.

In terms of encouraging the patient to be active and experiment with new ways of thinking, feeling, or behaving, it is helpful to emphasize patience (“Everything in its time and place” or “Rome wasn't built in a day”), persistence (“Winners never quit and quitters never win”), and practice (“Practice makes perfect”). Here, again, the supportive therapist serves as a cheerleader for the patient's efforts, even if such efforts are initially unsuccessful or even disastrous.

Strategy #15:Educate the Patient (and Family)

Education is invariably a large and important part of the supportive therapist's work. Using understandable, nontechnical language and employing sensitivity to what the patient can and cannot tolerate hearing at a given time, the therapist tries to help the patient learn about his or her illness (e.g., depression). The illness's symptoms, course, and prognosis are discussed. Special attention should be directed toward precipitants of decompensation (e.g., particular situations, times of year, stressful circumstances, alcohol or drug use) as well as premonitory symptoms (e.g., decreased sleep, change in appetite) that presage impending decompensation. Armed with knowledge of precipitants and warning symptoms specific for a particular illness in his or her particular case, the patient can take steps to prevent, or at least ameliorate, psychological breakdown. If the patient is prescribed psychotropic medications, he or she should be educated with respect to indications for the pharmacologic intervention, expected time course and benefits, and risks and side effects. Throughout the continuing process of such education, it is important that the supportive therapist preserve hope in the patient, balancing the reality of the patient's circumstances with appropriate optimism for the future.

Especially with the more severely or chronically mentally ill, there may be great benefit to similarly educating the patient's family, significant others, key friends, employer, or various social agencies. Such persons can serve, if they are willing and able, as additional “observing egos” and “auxiliary egos” for the patient. At the same time, however, the patient's wishes, autonomy, and confidentiality must be respected. Except in cases of emergency (e.g., imminent risk of physical danger to self or others), the therapist should ask the patient's explicit permission to speak with others about his or her case.

A second educational role of the supportive therapist has already been mentioned above. That is, the therapist may also educate the patient with respect to reality testing, modulating affect, controlling impulses, making connections, developing social skills, obtaining a job, preparing a budget, using public transportation, applying for social security disability, and any other specific tasks or functions that the patient is unable to enact without help.

In each of the above instances, knowledge empowers the patient, leading to actual competency and elevated self-esteem.

Strategy #16:Manipulate the Environment

Some of the differences between supportive therapy and psychodynamic, psychoanalytic, or insight-oriented psychotherapies 8 have already been highlighted. A final consideration in this regard relates to the therapist's willingness to manipulate the environment around the patient.

The supportive therapist, unlike the typical psychoanalyst, may intervene with other persons or agencies to help the patient, again with due regard for the patient's independence and privacy. Hence, the supportive therapist may attempt to maximize family support by working with key family members. The therapist may enlist the aid of various social service agencies, speak with an employer to explain the patient's condition, communicate with the court system, perhaps even accompany the patient to the Social Security office if necessary. The supportive therapist's role is once more akin to that of a good parent. He or she provides the help that is needed (i.e., the accomplishment of important tasks of which the patient is currently incapable) while simultaneously promoting the patient's growth and ultimate independence.

Although it is the most common psychotherapeutic treatment paradigm for mentally ill patients, supportive therapy receives relatively little time in the typical mental health professional training curriculum. This, in conjunction with the employment of diverse techniques from different psychotherapy paradigms, has left many mental health professionals confused as to the fundamental nature and process of supportive therapy. The basic strategies that provide the foundation for effective supportive therapy have been described so that the supportive therapist can focus his or her interventions to maximize benefit to the patient.

CLINICAL VIGNETTE: AMY

Amy is a 22-year-old college senior who presents to the Student Health Service Counseling Center on her own initiative with a 2-month history of depressive symptoms accompanied by faltering grades and intermittent alcohol abuse. There is no history of psychiatric hospitalization, suicide gesture or attempt, or previous contact with a mental health professional other than the school counselor. Early in her junior year at college, Amy's primary care physician had prescribed fluoxetine 20 mg daily because of dysphoria, impaired sleep and concentration, and decreased appetite with a 5-pound weight loss over the preceding 3 months. Four months later, however, Amy discontinued the medication on her own, feeling that it had provided no significant relief. Up until her senior year Amy had been a very good student, maintaining a B+ grade point average while majoring in history. Over the course of the last semester, however, her grades have fallen markedly. Even more worrisome for Amy herself has been the new onset of excessive drinking, a behavior very unlike Amy.

Amy has a number of pressing concerns. As the end of her senior year in college approaches, she is still unsure about a future career. Her father wants her to enter law school, but she is more inclined to become a writer, an occupation that he views as frivolous and risky. A second concern for Amy is that she has become increasingly estranged from her two female roommates, feeling over the past semester that she has less and less in common with them. Indeed, while her roommates are planning for, and looking forward to, successful careers, Amy feels “stuck” and confused about her future occupation. Finally, Amy is unhappy with her relationship with her “intermittent boyfriend” and unsure of their future. He is a bright but rigid and demanding premedical student who is very critical of others. Often the boyfriend tells Amy that her thoughts and feelings are “just plain wrong.” More generally, although intelligent, attractive, athletic, and possessing a good sense of humor, Amy has always felt insecure in relationships with men.

Amy is the youngest of three sisters. Her father, an attorney at law, is a hard-driving, perfectionistic, and demanding senior partner of a prestigious law firm in a large city. Amy's father has high expectations of everyone in the family; he requires each family member to be intelligent, attractive, physically fit, and successful. In contrast, Amy's mother, formerly a nurse but now a full-time homemaker, is much less assertive than Amy's father. Indeed, she too seems intimidated by her husband's demands for excellence. All of the women in the family—mother and daughters—have felt his pressure to remain trim and attractive, attain top grades, and be occupationally successful. Amy's eldest sister has completed law school and is now clerking for a prominent federal judge. The middle sister is in her final year of law school, planning to specialize in international finance. Amy, in contrast, not only is uninterested in a legal career, but also has maintained “only” a 3.4 grade point average (her sisters are both straight-A students, like their father). There is no history of mental illness within the family.

Amy has no history of significant medical illnesses or surgery. Her only regular medication consists of a multivitamin tablet daily. Amy has briefly experimented with marijuana and cocaine, but currently she acknowledges only the use of alcohol. Although abstaining from alcohol consumption during the week, on a typical weekend evening over the past 2 months Amy has consumed several cans of beer followed by three to five mixed drinks. These drinking binges typically occur in a local bar with acquaintances from class. The next morning Amy feels very guilty, remorseful, and angry with herself for her “irresponsible” behavior.

Formulation. (#1)  The most important psychological issues for Amy are low self-esteem and difficulties in establishing her own identity, especially one different from that expected of her by her father. These concerns have intensified during Amy's senior year in college as she is forced to confront the question of what she will do after graduation. In spite of her many strengths (intelligence, humor, athletic prowess, and physical beauty), Amy feels fundamentally unlovable, unattractive, and incompetent.

Amy's feelings of low self-esteem are related to her unsuccessful lifelong attempts to be a “good enough” daughter in her father's eyes. Amy is well aware that her father is greatly disappointed in her insofar as she is unwilling or unable to follow in the footsteps of her older sisters, who are both straight-A students well on the path to becoming powerful and successful lawyers as well as beautiful women. In this respect Amy identifies with her mother, a passive and depressed woman who analogously feels that she can never do, or be, enough for her husband. Not only does Amy share with her mother a deep-seated sense of unworthiness, but also in her relationships with men Amy demonstrates her mother's passivity, masochism, and fears of criticism and rejection. Like her mother, Amy is reluctant to become emotionally intimate with a man, believing that such a relationship ultimately places her in a vulnerable position from which she is likely to experience more pain and disappointment than gratification. In contrast, Amy's recent estrangement from her female roommates and her generally limited relationships with other women her age reflect long-standing conscious and unconscious competition with her older sisters. Amy views other women, especially aggressive and successful women, as competitors in relation to whom she always appears to be inferior.

Over the years Amy has developed coping/defense mechanisms that reflect her biological temperament and innate abilities, modeling by her parents, and environmental reinforcement. Isolation of affect and turning anger against the self, both modeled by Amy's mother, serve to contain Amy's feelings and prevent angry retaliation on the part of her aggressive father; the latter defense, however, results in feelings of guilt, shame, and depression. Through the defense mechanism of displacement, Amy is able to channel her aggressive and competitive impulses into athletic activities that avoid direct conflict with her family. Intellectualization serves a similar purpose, allowing Amy to compete with her father and sisters in the cognitive domain (although in areas other than law), which they most highly value. The process of intellectualization also reinforces the containment of feelings that Amy is fearful of releasing. The recent onset of excessive drinking and perhaps falling grades may reflect Amy's underlying depression, but they also serve to act out some of her unconscious conflicts. Thus, alcohol abuse and poor grades represent an indirect means by which Amy can express her anger toward her father (by behaving in ways that embarrass him and sabotage his goals for her) and also punish herself for not being “good enough” as well as for having hostile feelings toward her father. Amy's increasing depression and recent acting out have been precipitated by the pressure of her impending graduation from college, forcing her to confront issues about herself and her family that she has tried to suppress. Finally, Amy's choice of boyfriend suggests a transference reenactment and/or a neurotic self- fulfilling prophecy: she has chosen to become involved with a man very much like her father. Although unconsciously Amy symbolically seeks her father's approval and acceptance within her relationship with her boyfriend, instead she experiences criticism and rejection that recapitulate her relationship with her father.

In addition to her intelligence, humor, athletic prowess, and physical attractiveness, Amy has other strengths. Her interpersonal anxieties notwithstanding, Amy is socially appropriate and adept and has good empathy for others. In general she is an unselfish and kind person. In many areas of functioning she has demonstrated creativity, persistence, and courage. Her current lack of impulse control with respect to alcohol consumption is the exception rather than the norm. Finally, although currently feeling overwhelmed and confused, Amy generally possesses good introspective capacities, including the ability to view herself and her behavior objectively.

Supportive Interventions.  Amy easily falls within the inclusion criteria for a variety of psychotherapeutic approaches, including, at the very least, supportive psychotherapy and psychodynamic psychotherapy. The therapist's decision to employ supportive therapy as the primary approach in Amy's treatment reflects his assessment of the realities of patient choice, resource limitations, and college life. Although Amy could certainly benefit from psychodynamic psychotherapy, she is, in fact, a soon-to-be-graduating senior in college who will likely move to a different area of the country. Even more immediately, however, Amy, like many patients, seeks rapid amelioration of her symptoms and concrete guidance in moving forward in her life. At this particular moment she is less interested in a deeper understanding of her difficulties—“insight”—than in a speedy “cure.” And, to this end, she welcomes a more active, here-and-now approach. As noted earlier, and consistent with changing patient expectations, needs, and resources, Hellerstein et al. 11 have argued that the treatment model of choice, or default therapy, for most patients should be supportive therapy.

For Amy, the supportive therapist as a good parent (#2) requires appropriate containment of her self-destructive behavior balanced with validation of her strengths, dreams, and goals. The therapist's objective is not to impose a particular occupational choice or life plan on Amy, but rather to help her make her own choices as well as to find, and accept, herself.

The focus of supportive work with Amy will be less on the psychodynamics of her family and peer relationships than on the present (the here and now (#13) ) and the future: controlling her acting out and fulfilling her academic requirements for graduation; defining a career choice and pursuing the necessary steps to enact her aspirations; dealing with her father's domination, disappointment, and rejection; and forging satisfying and appropriate relationships with men and women her age. Such therapeutic work may involve exploration of the past in order to understand Amy's present situation, thoughts, feelings, and behavior; the goal, however, is not to recapitulate the past in the present (e.g., in the transference) but to rapidly construct a better future.

The most immediate goals for Amy's therapy are to ameliorate her depressive symptoms, contain or limit her self-destructive acting out through the abuse of alcohol, and prevent serious damage to her future career by academic failure in her senior year at college. Because Amy already knows full well, and feels guilty about, the destructive nature of her behavior (her current conduct notwithstanding, she possesses a strong sense of right and wrong), and has demonstrated good impulse control throughout most of her life, it is likely that the supportive therapist will not need to aggressively set limits (i.e., hold and contain (#5) ) on her use of alcohol except to ensure that Amy is not drinking and driving or otherwise engaging in life-threatening conduct. Indeed, the very fact of addressing her problems with a mental health professional may be sufficient to allow Amy to regain her usual appropriate control of her behavior. Amy's depression will require supportive therapeutic techniques that focus on both short-term and long-term issues, perhaps in conjunction with antidepressant medication if her symptoms are sufficiently severe.

Amy is struggling with the definition and consolidation of her identity as an individual, an identity distinct from that dictated by her father. In this struggle Amy is neither alone nor abnormal, for a key developmental task of late adolescence and early adulthood is to forge such a new sense of self. Similarly, it is not uncommon for this healthy consolidation of identity to result in family conflict, especially in families that implicitly or explicitly demand that children follow their parents' dictates and aspirations rather than their own. Amy may benefit from a reframing (#12) of her difficulties with her father as a strength, rather than a failure, on her part—a sign of her struggle for autonomy and an authentic self. Indeed, she might even be portrayed as more independent and courageous than her more highly acclaimed sisters for daring to go her own way. Thus, by normalizing (#11) and reframing (#12) Amy's depression and recent abuse of alcohol as a struggle for individuation from her family, the supportive therapist will concomitantly begin to raise Amy's self-esteem (#11) as well as decrease her hopelessness (#12) about the future (“I know it's hard now, but this is just one of the many things everyone has to deal with as he or she grows up and begins to move away from the family. Ultimately, you'll get through this just like other people your age.”). To this end, the therapist may disclose (#8) some of his own difficulties in defining himself and breaking away from his family of origin (i.e, provide a role model for identification (#8) ).

Although Amy is currently feeling overwhelmed, her life history suggests that she is generally capable of functioning at a mature psychological level. Thus, the supportive therapist's lending of psychic structure (#6) is likely to be temporary and situation-based. Reality testing (#6,#8) might focus on the recognition and acknowledgment of Amy's real strengths (e.g., intelligence, creativity, humor, athleticism), helping to elevate her currently impaired self-esteem. (#11) Problem-solving skills, perhaps role-modeled (#8) by the therapist, would initially emphasize here-and-now issues such as preventing academic failure in Amy's senior year and taking concrete steps to investigate and pursue a career as a writer. The therapist would do well to encourage activity. (#14) He could encourage Amy to actively explore taking the GREs in order to apply to graduate school in journalism, or to investigate potential job opportunities in journalism for recently graduated collegians, as well as consider the practical concerns of where she might live and how she would support herself. By breaking down the seemingly overwhelming task of deciding on a career and finding a job into smaller, definable, stepwise goals, the therapist sets her up for success rather than failure (#11) and, concomitantly, ameliorates hopelessness. (#12)

Amy would also benefit from borrowing the supportive therapist's superego, (#6) but not because she lacks sufficient feelings of guilt or shame regarding her recent alcohol-related acting out and academic decline. Quite to the contrary, the therapist might want to help Amy stop castigating herself for not being exactly what her father wants her to be, to learn to accept herself for who she is and what she wants to do in life. Thus, it is a less harsh, more forgiving superego that the therapist might provide for Amy's use and internalization. As previously noted, control of Amy's acting out requires more ego than superego; she already feels guilty and ashamed of her behavior, but she does not understand why it is happening and how to stop it. With sufficient clarification and support, Amy will likely regain control over her self-destructive actions.

The supportive therapist is required less to foster competency (#11) in Amy than to help her recognize and accept the many competencies already in her possession, even if they are not the same skills valued by her father. In this respect a cognitive therapeutic approach may be helpful in allowing Amy to have a more balanced perspective on her strengths and weaknesses. Nevertheless, in comparison to her other talents, Amy is considerably less capable and competent in her interpersonal relationships with men and, more recently, with women her age. A combination of an exploratory approach (e.g., making connections (#10) between her sisters and her roommates as well as between her father and her choice of boyfriend) and a supportive approach might be helpful, again accompanied by appropriate therapist self-disclosure (#8) and role modeling. (#8) A specific, longer-term goal in this regard might consist, for example, of developing a nonabusive, intimate relationship with a man; specific steps (through the provision by the therapist of an auxiliary ego (#6) ) might include finding the right man (where, how, when) and learning to tolerate intimate feelings as well as feelings of rejection. As above, the development and pursuit of smaller, stepwise, definable goals (rather than “I want to get along with everybody”) assists the therapist in setting Amy up for success rather than failure. (#11)

Amy needs only a modicum of education (#15) about mental illness per se (e.g., depression); more important is education about how she manages her feelings of failure, rejection, competition, and anger. The supportive therapist may help Amy to make connections (#10) between her feelings and both her depressive symptoms and her acting out. Making these connections can help with maximization of her adaptive coping mechanisms (#7) (e.g., intellect, humor, sports), which are currently overwhelmed. Thus, for example, as Amy becomes more aware of her anger at her father, the therapist may work with her to replace destructive coping strategies (e.g., turning anger against the self and acting out) with ones that are more appropriate (e.g., direct expression of her frustration with her father, humor). Similarly, the therapist might elect to use another of Amy's strengths, her wordsmithing abilities as a future writer, to help her identify, acknowledge, and appropriately express her feelings (#9) about her family.

Amy's therapist needs to be aware of and to manage transference difficulties (#4) that may impinge on the therapeutic relationship. In particular, Amy may react to a male therapist with feelings transferred from her relationship with her father, misinterpreting the therapist's comments as dominating, critical, and rejecting. She may then respond to these feelings by becoming passive or defensive or by increased acting out. In contrast, Amy might view a female therapist, especially one closer to her age than to her mother's, as a competitive sibling to be regarded coldly, suspiciously, and enviously. In either case, the supportive therapist should foster the therapeutic alliance (#3) by attempting to ally with Amy's healthy ego—those parts of her that are appropriately concerned with her falling grades, alcohol abuse, career dilemma, and interpersonal difficulties.

The supportive therapist would need to enact relatively few environmental manipulations (#16) on Amy's behalf. For example, because she is 22 years of age, many therapists would be reluctant to speak directly with her family, feeling that Amy's age-appropriate developmental task is to increase her autonomy and learn to negotiate issues with her family on an adult-to-adult basis. On the other hand, a supportive therapist might help Amy to obtain the application materials for the GREs, make specific contacts for a job after graduation, or refer her to an appropriate group therapy experience with similar high-functioning individuals.

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  1. Problem-Solving Therapy: Definition, Techniques, and Efficacy

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  6. What Conditions Does Problem Solving Therapy Treat?

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  1. Problem solving 😂🤣 Daily life of a couple #couple #shorts

COMMENTS

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    Problem-solving therapy is a brief intervention that provides people with the tools they need to identify and solve problems that arise from big and small life stressors. It aims 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 ...

  2. Problem-Solving Therapy

    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.

  3. Social Problem Solving

    Definition Social problem solving is the process by which individuals identify and enact solutions to social life situations in an effort to alter the problematic nature of the situation, their relation to the situation, or both [ 7 ]. Description

  4. Problem-Solving Therapy: How It Works & What to Expect

    Problem-solving therapy (PST) is an intervention with cognitive and behavioral influences used to assist individuals in managing life problems. Therapists help clients learn effective skills to address their issues directly and make positive changes.

  5. Social problem-solving

    Social problem-solving, in its most basic form, is defined as problem solving as it occurs in the natural environment. [1] More specifically it refers to the cognitive-behavioral process in which one works to find adaptive ways of coping with everyday situations that are considered problematic.

  6. Problem-Solving Therapy: Theory and Practice

    Problem-solving therapy (PST) is a psychosocial intervention that teaches clients to cope with the stress of "here-and-now" problems in order to reduce negative health and mental health outcomes.

  7. Social Problem Solving and Health

    Specifically, it was argued that successful problem-solving consists of identifying a problem, defining the characteristics and important aspects of the problem, generating possible solutions and alternatives for the problem, choosing a viable solution and implementing it, and then monitoring and evaluating the progress of the solution.

  8. Social problem solving: Theory, research, and training.

    Abstract We put together a book that would offer readers multiple perspectives, insights, and directions in understanding social problem solving as an important theory that has driven wide-ranging scientific research and as an important means of training to empower and elevate the lives of individuals.

  9. Problem Solving

    Definition Problem-solving therapy (PST) is a brief, empirically supported, cognitive-behavioral intervention aimed at training clients to identify, evaluate, and resolve everyday problems through the methodical application of problem-solving skills.

  10. Problem-solving training as an active ingredient of treatment for youth

    Problem-Solving Therapy (PST) is a therapeutic approach developed by D'Zurilla and Goldfried [] in the 1970s, to alleviate mental health difficulties by improving PS ability.Conceptually rooted in Social Learning Theory [], PST aims to promote adaptive PS by helping clients foster an optimistic and self-confident attitude towards problems (i.e., a positive problem orientation), and by ...

  11. PDF Social Problem Solving Therapy For Depression and Executive Dysfunction

    al., 1993) is Social Problem Solving Therapy (SPST). SPST offers older adults an empirically supported treatment geared towards treatment of depression by teaching problem solving skills to patients so that they can address their negative perceptions and cognitions while in therapy and upon completion of treatment, be able to continue to do

  12. Social Problem Solving Ability Predicts Mental Health Among

    Most of the researches about social problem- solving are influenced by the social problem solving model. The problem solving therapy (PST) approach, based on this model,[ 9 ] has been utilized as an intervention modality in depression, suicide,[ 10 ] reduction of problems related to mental and physical health,[ 11 ] and anxiety.[ 12 ]

  13. Problem-Solving Therapy

    Definition. Problem-solving therapy (PST), developed by Nezu and colleagues, is a non-pharmacological, empirically supported cognitive-behavioral treatment (D'Zurilla and Nezu 2006; Nezu et al. 1989 ). The problem-solving framework draws from a stress-diathesis model, namely, that life stress interacts with an individual's predisposition ...

  14. Brief Therapies in Social Work: Task-Centered Model and Solution

    Introduction Brief therapies serve as evidenced-based practices that place a strong emphasis on effective, time-limited treatments that aid in resolving clients' presenting problems. The resources presented in this article summarize for professionals and educators the abundant literature evaluating brief therapies within social work practice.

  15. Problem Solving Therapy Improves Effortful Cognition in Major

    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. ... training in problem definition and formulation, the generation of alternatives, decision making, and solution implementation and verification, ... Social cognition ...

  16. 10 Best Problem-Solving Therapy Worksheets & Activities

    "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.

  17. Design Guidelines for Social Problem-Solving Interventions

    Abstract. Two or more social actors-individuals, groups, and organizations-engage in social problem solving when resolving or managing a shared problem. Social problem solving poses significant conceptual and control difficulties that make it highly episodic and prone to setbacks. This paper proposes a framework for understanding social problem ...

  18. Cognitive Behavioral Therapy

    Definition/Description Cognitive behavioral therapy (CBT) is a structured, time-limited approach to psychotherapy that aims to address clients' current problems (Dobson & Dobson, 2009 ). CBT uses problem-focused cognitive and behavioral strategies guided by empirical science and derived from theories of learning and cognition (Craske, 2010 ).

  19. Improving Our Understanding of Impaired Social Problem-Solving in

    In cognitive behavioral therapy (CBT) children and adolescents with conduct problems learn social problem-solving skills that enable them to behave in more independent and situation appropriate ways. Empirical studies on psychological functions show that the effectiveness of CBT may be further improved by putting more emphasis on (1) recognition of the type of social situations that are ...

  20. Solving Problems the Cognitive-Behavioral Way

    Problem-solving is one technique used on the behavioral side of cognitive-behavioral therapy. The problem-solving technique is an iterative, five-step process that requires one to...

  21. Evidence-Based Treatment

    BA is a therapy that has been shown to relieve or resolve symptoms of depression. This therapy will help you become more engaged with activities that can improve your mood. BA will teach you ways to build personally rewarding daily activities, and ways to identify and achieve the things you value and enjoy in life.

  22. Problem-solving therapy : a social competence approach to clinical

    Problem-solving therapy : a social competence approach to clinical intervention. T. D'Zurilla, A. Nezu. Published 1986. Psychology. An introduction and guide for therapists and counselors in the mental health professions to the approach as a reliable clinical treatment, health maintenance strategy, and prevention program.…. Expand.

  23. Basic Strategies of Dynamic Supportive Therapy

    The ultimate goal is to enhance the patient's functional, healthy, adaptive behaviors through the mastery of key skills, especially interpersonal and social skills, problem-solving, and coping strategies. The therapist attempts to provide the patient with specific, concrete tools consistent with the latter's innate abilities and current ...