problem solving therapy means

Cognitive Behavioral Therapy

Solving problems the cognitive-behavioral way, problem solving is another part of behavioral therapy..

Posted February 2, 2022 | Reviewed by Ekua Hagan

• What Is Cognitive Behavioral Therapy?
• Find a therapist who practices CBT
• 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.

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., is a clinical psychologist in Washington State.

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What is Solution-Focused Therapy: 3 Essential Techniques

You’re at an important business meeting, and you’re there to discuss some problems your company is having with its production.

At the meeting, you explain what’s causing the problems: The widget-producing machine your company uses is getting old and slowing down. The machine is made up of hundreds of small parts that work in concert, and it would be much more expensive to replace each of these old, worn-down parts than to buy a new widget-producing machine.

You are hoping to convey to the other meeting attendees the impact of the problem, and the importance of buying a new widget-producing machine. You give a comprehensive overview of the problem and how it is impacting production.

One meeting attendee asks, “So which part of the machine, exactly, is getting worn down?” Another says, “Please explain in detail how our widget-producing machine works.” Yet another asks, “How does the new machine improve upon each of the components of the machine?” A fourth attendee asks, “Why is it getting worn down? We should discuss how the machine was made in order to fully understand why it is wearing down now.”

You are probably starting to feel frustrated that your colleagues’ questions don’t address the real issue. You might be thinking, “What does it matter how the machine got worn down when buying a new one would fix the problem?” In this scenario, it is much more important to buy a new widget-producing machine than it is to understand why machinery wears down over time.

When we’re seeking solutions, it’s not always helpful to get bogged down in the details. We want results, not a narrative about how or why things became the way they are.

This is the idea behind solution-focused therapy . For many people, it is often more important to find solutions than it is to analyze the problem in great detail. This article will cover what solution-focused therapy is, how it’s applied, and what its limitations are.

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This Article Contains:

What is solution-focused therapy, theory behind the solution-focused approach, solution-focused model, popular techniques and interventions, sfbt treatment plan: an example, technologies to execute an sfbt treatment plan (incl. quenza), limitations of sfbt counseling, what does sfbt have to do with positive psychology, a take-home message.

Solution-focused therapy, also called solution-focused brief therapy (SFBT), is a type of therapy that places far more importance on discussing solutions than problems (Berg, n.d.). Of course, you must discuss the problem to find a solution, but beyond understanding what the problem is and deciding how to address it, solution-focused therapy will not dwell on every detail of the problem you are experiencing.

Solution-focused brief therapy doesn’t require a deep dive into your childhood and the ways in which your past has influenced your present. Instead, it will root your sessions firmly in the present while working toward a future in which your current problems have less of an impact on your life (Iveson, 2002).

This solution-centric form of therapy grew out of the field of family therapy in the 1980s. Creators Steve de Shazer and Insoo Kim Berg noticed that most therapy sessions were spent discussing symptoms, issues, and problems.

De Shazer and Berg saw an opportunity for quicker relief from negative symptoms in a new form of therapy that emphasized quick, specific problem-solving rather than an ongoing discussion of the problem itself.

The word “brief” in solution-focused brief therapy is key. The goal of SFBT is to find and implement a solution to the problem or problems as soon as possible to minimize time spent in therapy and, more importantly, time spent struggling or suffering (Antin, 2018).

SFBT is committed to finding realistic, workable solutions for clients as quickly as possible, and the efficacy of this treatment has influenced its spread around the world and use in multiple contexts.

SFBT has been successfully applied in individual, couples, and family therapy. The problems it can address are wide-ranging, from the normal stressors of life to high-impact life events.

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The solution-focused approach of SFBT is founded in de Shazer and Berg’s idea that the solutions to one’s problems are typically found in the “exceptions” to the problem, meaning the times when the problem is not actively affecting the individual (Iveson, 2002).

This approach is a logical one—to find a lasting solution to a problem, it is rational to look first at those times in which the problem lacks its usual potency.

For example, if a client is struggling with excruciating shyness, but typically has no trouble speaking to his or her coworkers, a solution-focused therapist would target the client’s interactions at work as an exception to the client’s usual shyness. Once the client and therapist have discovered an exception, they will work as a team to find out how the exception is different from the client’s usual experiences with the problem.

The therapist will help the client formulate a solution based on what sets the exception scenario apart, and aid the client in setting goals and implementing the solution.

You may have noticed that this type of therapy relies heavily on the therapist and client working together. Indeed, SFBT works on the assumption that every individual has at least some level of motivation to address their problem or problems and to find solutions that improve their quality of life .

This motivation on the part of the client is an essential piece of the model that drives SFBT (Miller & Rollnick, 2013).

Solution-focused theorists and therapists believe that generally, people develop default problem patterns based on their experiences, as well as default solution patterns.

These patterns dictate an individual’s usual way of experiencing a problem and his or her usual way of coping with problems (Focus on Solutions, 2013).

The solution-focused model holds that focusing only on problems is not an effective way of solving them. Instead, SFBT targets clients’ default solution patterns, evaluates them for efficacy, and modifies or replaces them with problem-solving approaches that work (Focus on Solutions, 2013).

In addition to this foundational belief, the SFBT model is based on the following assumptions:

• Change is constant and certain;
• Emphasis should be on what is changeable and possible;
• Clients must want to change;
• Clients are the experts in therapy and must develop their own goals;
• Clients already have the resources and strengths to solve their problems;
• Therapy is short-term;
• The focus must be on the future—a client’s history is not a key part of this type of therapy (Counselling Directory, 2017).

Based on these assumptions, the model instructs therapists to do the following in their sessions with clients:

• Ask questions rather than “selling” answers;
• Notice and reinforce evidence of the client’s positive qualities, strengths, resources, and general competence to solve their own problems;
• Work with what people can do rather than focusing on what they can’t do;
• Pinpoint the behaviors a client is already engaging in that are helpful and effective and find new ways to facilitate problem-solving through these behaviors;
• Focus on the details of the solution instead of the problem;
• Develop action plans that work for the client (Focus on Solutions, 2013).

SFBT therapists aim to bring out the skills, strengths, and abilities that clients already possess rather than attempting to build new competencies from scratch. This assumption of a client’s competence is one of the reasons this therapy can be administered in a short timeframe—it is much quicker to harness the resources clients already have than to create and nurture new resources.

Beyond these basic activities, there are many techniques and exercises used in SFBT to promote problem-solving and enhance clients’ ability to work through their own problems.

Working with a therapist is generally recommended when you are facing overwhelming or particularly difficult problems, but not all problems require a licensed professional to solve.

For each technique listed below, it will be noted if it can be used as a standalone technique.

Asking good questions is vital in any form of therapy, but SFBT formalized this practice into a technique that specifies a certain set of questions intended to provoke thinking and discussion about goal-setting and problem-solving.

One such question is the “coping question.” This question is intended to help clients recognize their own resiliency and identify some of the ways in which they already cope with their problems effectively.

There are many ways to phrase this sort of question, but generally, a coping question is worded something like, “How do you manage, in the face of such difficulty, to fulfill your daily obligations?” (Antin, 2018).

Another type of question common in SFBT is the “miracle question.” The miracle question encourages clients to imagine a future in which their problems are no longer affecting their lives. Imagining this desired future will help clients see a path forward, both allowing them to believe in the possibility of this future and helping them to identify concrete steps they can take to make it happen.

This question is generally asked in the following manner: “Imagine that a miracle has occurred. This problem you are struggling with is suddenly absent from your life. What does your life look like without this problem?” (Antin, 2018).

If the miracle question is unlikely to work, or if the client is having trouble imagining this miracle future, the SFBT therapist can use “best hopes” questions instead. The client’s answers to these questions will help establish what the client is hoping to achieve and help him or her set realistic and achievable goals.

The “best hopes” questions can include the following:

• What are your best hopes for today’s session?
• What needs to happen in this session to enable you to leave thinking it was worthwhile?
• How will you know things are “good enough” for our sessions to end?
• What needs to happen in these sessions so that your relatives/friends/coworkers can say, “I’m really glad you went to see [the therapist]”? (Vinnicombe, n.d.).

To identify the exceptions to the problems plaguing clients, therapists will ask “exception questions.” These are questions that ask about clients’ experiences both with and without their problems. This helps to distinguish between circumstances in which the problems are most active and the circumstances in which the problems either hold no power or have diminished power over clients’ moods or thoughts.

Exception questions can include:

• Tell me about the times when you felt the happiest;
• What was it about that day that made it a better day?
• Can you think of times when the problem was not present in your life? (Counselling Directory, 2017).

Another question frequently used by SFBT practitioners is the “scaling question.”

It asks clients to rate their experiences (such as how their problems are currently affecting them, how confident they are in their treatment, and how they think the treatment is progressing) on a scale from 0 (lowest) to 10 (highest). This helps the therapist to gauge progress and learn more about clients’ motivation and confidence in finding a solution.

For example, an SFBT therapist may ask, “On a scale from 0 to 10, how would you rate your progress in finding and implementing a solution to your problem?” (Antin, 2018).

Do One Thing Different

This exercise can be completed individually, but the handout may need to be modified for adult or adolescent users.

This exercise is intended to help the client or individual to learn how to break his or her problem patterns and build strategies to simply make things go better.

The handout breaks the exercise into the following steps (Coffen, n.d.):

• Think about the things you do in a problem situation. Change any part you can. Choose to change one thing, such as the timing, your body patterns (what you do with your body), what you say, the location, or the order in which you do things;
• Think of a time that things did not go well for you. When does that happen? What part of that problem situation will you do differently now?
• Think of something done by somebody else does that makes the problem better. Try doing what they do the next time the problem comes up. Or, think of something that you have done in the past that made things go better. Try doing that the next time the problem comes up;
• Think of something that somebody else does that works to make things go better. What is the person’s name and what do they do that you will try?
• Think of something that you have done in the past that helped make things go better. What did you do that you will do next time?
• Feelings tell you that you need to do something. Your brain tells you what to do. Understand what your feelings are but do not let them determine your actions. Let your brain determine the actions;
• Feelings are great advisors but poor masters (advisors give information and help you know what you could do; masters don’t give you choices);
• Think of a feeling that used to get you into trouble. What feeling do you want to stop getting you into trouble?
• Think of what information that feeling is telling you. What does the feeling suggest you should do that would help things go better?
• Change what you focus on. What you pay attention to will become bigger in your life and you will notice it more and more. To solve a problem, try changing your focus or your perspective.
• Think of something that you are focusing on too much. What gets you into trouble when you focus on it?
• Think of something that you will focus on instead. What will you focus on that will not get you into trouble?
• Imagine a time in the future when you aren’t having the problem you are having right now. Work backward to figure out what you could do now to make that future come true;
• Think of what will be different for you in the future when things are going better;
• Think of one thing that you would be doing differently before things could go better in the future. What one thing will you do differently?
• Sometimes people with problems talk about how other people cause those problems and why it’s impossible to do better. Change your story. Talk about times when the problem was not happening and what you were doing at that time. Control what you can control. You can’t control other people, but you can change your actions, and that might change what other people do;
• Think of a time when you were not having the problem that is bothering you. Talk about that time.
• If you believe in a god or a higher power, focus on God to get things to go better. When you are focused on God or you are asking God to help you, things might go better for you.
• Do you believe in a god or a higher power? Talk about how you will seek help from your god to make things go better.
• Use action talk to get things to go better. Action talk sticks to the facts, addresses only the things you can see, and doesn’t address what you believe another person was thinking or feeling—we have no way of knowing that for sure. When you make a complaint, talk about the action that you do not like. When you make a request, talk about what action you want the person to do. When you praise someone, talk about what action you liked;
• Make a complaint about someone cheating at a game using action talk;
• Make a request for someone to play fairly using action talk;
• Thank someone for doing what you asked using action talk.

Following these eight steps and answering the questions thoughtfully will help people recognize their strengths and resources, identify ways in which they can overcome problems, plan and set goals to address problems, and practice useful skills.

While this handout can be extremely effective for SFBT, it can also be used in other therapies or circumstances.

To see this handout and download it for you or your clients, click here .

Presupposing Change

The “presupposing change” technique has great potential in SFBT, in part because when people are experiencing problems, they have a tendency to focus on the problems and ignore the positive changes in their life.

It can be difficult to recognize the good things happening in your life when you are struggling with a painful or particularly troublesome problem.

This technique is intended to help clients be attentive to the positive things in their lives, no matter how small or seemingly insignificant. Any positive change or tiny step of progress should be noted, so clients can both celebrate their wins and draw from past wins to facilitate future wins.

Presupposing change is a strikingly simple technique to use: Ask questions that assume positive changes. This can include questions like, “What’s different or better since I saw you last time?”

If clients are struggling to come up with evidence of positive change or are convinced that there has been no positive change, the therapist can ask questions that encourage clients to think about their abilities to effectively cope with problems, like, How come things aren’t worse for you? What stopped total disaster from occurring? How did you avoid falling apart? (Australian Institute of Professional Counsellors, 2009).

The most powerful word in the Solution Focused Brief Therapy vocabulary – The Solution Focused Universe

A typical treatment plan in SFBT will include several factors relevant to the treatment, including:

• The reason for referral, or the problem the client is experiencing that brought him or her to treatment;
• A diagnosis (if any);
• List of medications taken (if any);
• Current symptoms;
• Support for the client (family, friends, other mental health professionals, etc.);
• Modality or treatment type;
• Frequency of treatment;
• Goals and objectives;
• Measurement criteria for progress on goals;
• Client strengths ;
• Barriers to progress.

All of these are common and important components of a successful treatment plan. Some of these components (e.g., diagnosis and medications) may be unaddressed or acknowledged only as a formality in SFBT due to its usual focus on less severe mental health issues. Others are vital to treatment progress and potential success in SFBT, including goals, objectives, measurement criteria, and client strengths.

To this end, therapists are increasingly leveraging the benefits of technology to help develop, execute, and evaluate the outcomes of treatment plans efficiently.

Among these technologies are many digital platforms that therapists can use to carry out some steps in clients’ treatment plans outside of face-to-face sessions.

For example, by adopting a versatile blended care platform such as Quenza , an SFBT practitioner may carry out some of the initial steps in the assessment/diagnosis phase of a treatment plan, such as by inviting the client to complete a digital diagnostic questionnaire.

Likewise, the therapist may use the platform to send digital activities to the client’s smartphone, such as an end-of-day reflection inviting the client to recount their application of the ‘Do One Thing Different’ technique to overcome a problem.

These are just a few ideas for how you might use a customizable blended care tool such as Quenza to help carry out several of the steps in an SFBT treatment plan.

Some of the potential disadvantages for therapists include (George, 2010):

• The potential for clients to focus on problems that the therapist believes are secondary problems. For example, the client may focus on a current relationship problem rather than the underlying self-esteem problem that is causing the relationship woes. SFBT dictates that the client is the expert, and the therapist must take what the client says at face value;
• The client may decide that the treatment is successful or complete before the therapist is ready to make the same decision. This focus on taking what the client says at face value may mean the therapist must end treatment before they are convinced that the client is truly ready;
• The hard work of the therapist may be ignored. When conducted successfully, it may seem that clients solved their problems by themselves, and didn’t need the help of a therapist at all. An SFBT therapist may rarely get credit for the work they do but must take all the blame when sessions end unsuccessfully.

Some of the potential limitations for clients include (Antin, 2018):

• The focus on quick solutions may miss some important underlying issues;
• The quick, goal-oriented nature of SFBT may not allow for an emotional, empathetic connection between therapist and client.
• If the client wants to discuss factors outside of their immediate ability to effect change, SFBT may be frustrating in its assumption that clients are always able to fix or address their problems.

Generally, SFBT can be an excellent treatment for many of the common stressors people experience in their lives, but it may be inappropriate if clients want to concentrate more on their symptoms and how they got to where they are today. As noted earlier, it is also generally not appropriate for clients with major mental health disorders.

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First, both SFBT and positive psychology share a focus on the positive—on what people already have going for them and on what actions they can take. While problems are discussed and considered in SFBT, most of the time and energy is spent on discussing, thinking about, and researching what is already good, effective, and successful.

Second, both SFBT and positive psychology consider the individual to be his or her own best advocate, the source of information on his or her problems and potential solutions, and the architect of his or her own treatment and life success. The individual is considered competent, able, and “enough” in both SFBT and positive psychology.

This assumption of the inherent competence of individuals has run both subfields into murky waters and provoked criticism, particularly when systemic and societal factors are considered. While no respectable psychologist would disagree that an individual is generally in control of his or her own actions and, therefore, future, there is considerable debate about what level of influence other factors have on an individual’s life.

While many of these criticisms are valid and bring up important points for discussion, we won’t dive too deep into them in this piece. Suffice it to say that both SFBT and positive psychology have important places in the field of psychology and, like any subfield, may not apply to everyone and to all circumstances.

However, when they do apply, they are both capable of producing positive, lasting, and life-changing results.

Solution-focused therapy puts problem-solving at the forefront of the conversation and can be particularly useful for clients who aren’t suffering from major mental health issues and need help solving a particular problem (or problems). Rather than spending years in therapy, SFBT allows such clients to find solutions and get results quickly.

Have you ever tried Solution-Focused Brief Therapy, as a therapist or as a client? What did you think of the focus on solutions? Do you think SFBT misses anything important by taking the spotlight off the client’s problem(s)? Let us know in the comments section.

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

Antin, L. (2018). Solution-focused brief therapy (SFBT). Good Therapy. Retrieved from https://www.goodtherapy.org/learn-about-therapy/types/solution-focused-therapy

• Australian Institute of Professional Counsellors. (2009, March 30). Solution-focused techniques. Counseling Connection. Retrieved from http://www.counsellingconnection.com/index.php/2009/03/30/solution-focused-techniques/
• Berg, I. K. (n.d.). About solution-focused brief therapy. SFBTA . Retrieved from http://www.sfbta.org/about_sfbt.html
• Coffen, R. (n.d.). Do one thing different [Handout]. Retrieved from https://www.andrews.edu/~coffen/Do%20one%20thing%20different.pdf
• Focus on Solutions. (2013, October 28). The brief solution-focused model. Focus on solutions: Leaders in solution-focused training. Retrieved from http://www.focusonsolutions.co.uk/solutionfocused/
• George, E. (2010). Disadvantages of solution focus? BRIEF. Retrieved from https://www.brief.org.uk/resources/faq/disadvantages-of-solution-focus
• Iveson, C. (2002). Solution-focused brief therapy. Advances in Psychiatric Treatment, 8 (2), 149-156.
• Miller, W. R., & Rollnick, S. (2013). Motivational interviewing: Helping people change (3rd ed.). New York, NY: Guilford Press.
• Vinnicombe, G. (n.d.). Greg’s SFBT handout. Useful Conversations. Retrieved from http://www.usefulconversations.com/downloads

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What our readers think.

Thank you. I’m about to start an MMFT internship, and SFBT is the model I prefer. You put everything in perspective.

Great insights. I have a client who has become a bit disengaged with our work together. This gives me a really helpful new approach for our upcoming sessions. He’s very focused on the problem and wanting a “quick fix.” This might at least get us on that path. Thank you!

Hi Courtney, great paper! I will like to know more about the limitations to SFT and noticed that you provided an intext citation to Antin 2016. Would you be able to provide the full reference? Thank you!

Thank you for bringing this to our attention. The reference has now been updated in the reference list — this should be Antin (2018):

– Nicole | Community Manager

The only thing tat was revealed to me while reading this article is the client being able to recognize the downfall of what got them into their problem in the first place. I felt that maybe a person should understand the problem to the extent that they may understand how to recognize what led to the problem in the first place. Understanding the process of how something broke down would give one knowledge and wisdom that may be able to be applied in future instances when something may go wrong again. Even if the thing is new (machine or person) having the wisdom and understanding of the cause that led to the effect may help prevent and or overcome an arising problem in the future. Not being able to recognize the process that brought down the machine and or human may be like adhering to ignorance, although they say ignorance is bliss in case of an emergency it would be better to be informed rather then blindly ignorant, as the knowledge of how the problem surfaced in the first place may alleviate unwarranted suffering sooner rather than later. But then again looking at it this way I may work myself out of a job if my clients never came back to see me. However is it about me or them or the greater societal structural good that we can induce through our education, skills, training, experience, and good will good faith effort to instill social justice coupled with lasting change for the betterment of human society and the world as a whole.

Very very helpful, thank you for writing. Just one point “While no respectable psychologist would disagree that an individual is generally in control of his or her own actions and, therefore, future, there is considerable debate about what level of influence other factors have on an individual’s life.” I think any psychologist that has worked in neurological dysfunction would probably acknowledge consciousness and ‘voluntary control’ are not that straight-forward. Generally though, I suppose there’s that whole debate of if we are ever in control of our actions or even our thoughts. It may well boil down to what we mean by ‘we’, as in what are we? A bundle of fibres acting on memories and impulses? A unique body of energy guided by intangible forces? Maybe I am not a respectable psychologist 🙂

This article provided me with insight on how to proceed with a role-play session in my CBT graduate course. Thank you!

Hi Derrick, That’s fantastic that you were able to find some guidance in this post. Best of luck with your grad students! – Nicole | Community Manager

Thank You…Great input and clarity . I now have light…

I was looking everywhere for a simple explanation for my essay and this is it!! thank you so much for this is was very useful and I learned a lot.

Very well done. Thank you for the multitude of insights.

Thank you for such a good passage discussed. I really have a great time understanding it.

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Problem-Solving Therapy

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• First Online: 01 January 2017
• pp 1874–1883
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• Sherry A. Beaudreau 2 , 3 , 4 ,
• Christine E. Gould 2 , 5 ,
• Erin Sakai 6 &
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Behavioral intervention; Skills-based therapy; Treatment

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 toward developing a psychiatric disorder. The driving model behind PST posits that individuals who experience difficulty solving life’s problems or coping with stressors of everyday living struggle with psychiatric symptoms more often than individuals considered as good problem solvers. This psychological treatment teaches a step-by-step approach to the process of identifying and implementing adaptive solutions for daily problems. By teaching individuals to solve their problems more effectively and efficiently, this model assumes that their stress and related psychiatric symptoms will...

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Beaudreau, S.A., Gould, C.E., Sakai, E., Huh, J.W.T. (2017). Problem-Solving Therapy. In: Pachana, N.A. (eds) Encyclopedia of Geropsychology. Springer, Singapore. https://doi.org/10.1007/978-981-287-082-7_90

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What is Problem-Solving Therapy? (The Pros and Cons)

When you’re navigating a difficult situation, it can feel like problems keep piling up. It’s easy to feel overwhelmed and discouraged when you can’t seem to find a solution to any of them.

Fortunately, problem-solving therapy can be a short-term, effective way to find the answers you need.

Here at KMA Therapy, we know that choosing a type of therapy should be the least of your problems. We’re passionate about educating our clients and community about the different types of therapy available, and how to know which ones could be a great choice for them.

After reading this article, you’ll know what problem-solving therapy is, what happens during problem-solving therapy, and its pros and cons.

What is Problem-Solving Therapy?

Problem-solving therapy is a short-form treatment that usually lasts between four and twelve sessions.

It is most frequently used to treat depression, with a primary focus on helping you build the tools needed to identify and solve problems.

The main goal of problem-solving therapy is to improve your overall quality of life by helping you reduce the impact of stressors and problems you’re facing.

Problem-solving therapy is used to treat:

• Suicidal ideation
• Self-harm behaviours

If you’re experiencing suicidal ideation or are having thoughts of harming yourself, you can connect with Talk Suicide Canada for immediate support.

What Happens During Problem-Solving Therapy?

During problem-solving therapy, your therapist will focus on two main components.

1. Positive problem-solving framework

Positive problem-solving involves creating a framework that allows you to view things in a positive way by allowing yourself to feel confident and capable when handling your problems.

This means figuring out how to accept that you’ll still face problems in your life, while feeling more sure about your ability to face, address, and overcome them.

2. Planful problem-solving

Planful problem-solving involves four steps that help you learn how to solve problems in a healthy way:

• Defining the problem that you need to solve in a way where potential solutions can be created
• Exploring alternative solutions to the problem you’re facing by listing as many creative solutions to your problem as you can
• Discussing decision-making strategies to help you know which solution to choose and how to adapt to overcome obstacles
• Implementing your solution for your problem and assessing whether it was the right choice

What are the Pros of Problem-Solving Therapy?

Problem-solving therapy is an effective and helpful form of therapy that can help you see meaningful changes in your life in a short amount of time.

Problem-solving therapy may be a great choice for you if:

• You want a short-term form of therapy
• You’re facing specific issues that you want to build solutions for
• You’re looking for clear solutions to problems without unpacking the cause

In general, problem-solving therapy is a great choice if there’s something specific in your life that’s causing additional problems.

For example, if you’re struggling with depression that makes you unable to keep in touch with loved ones or stay on top of your bills, problem-solving therapy can be a great choice to help you find solutions that work for these specific issues.

However, if you’re struggling to find the motivation to get out of bed in the morning because you want a deeper sense of purpose in your life, another form of therapy might be a better choice.

What are the Cons of Problem-Solving Therapy?

While problem-solving therapy can be quick, effective, and empowering, it’s not always the best choice if you’re interested in more in-depth conversations in therapy.

Problem-solving therapy may not be the right fit if you:

• Are looking to unpack or reprocess past experiences
• Want to explore complex or existential questions in therapy
• Are interested in changing general behavioural patterns (rather than specific problems)

Alternatives to Problem-Solving Therapy

After learning about the pros and cons of problem-solving therapy, you may be interested in some alternative forms of therapy to explore.

Alternatives to problem-solving therapy include:

• Existential therapy , which allows you to explore your sense of purpose and meaning in life
• Cognitive behavioural therapy , which focuses on helping you restructure your thought and behaviour patterns
• Dialectical behaviour therapy, which helps you build skills to change and solve problems, with an additional focus on mindfulness and relationships

Next Steps for Beginning Therapy

After reading this article, you know what problem-solving therapy is and how to know if it’s the right choice for you.

Here at KMA Therapy, our passionate team of therapists has been supporting our clients with tailored therapy plans for over 15 years.

You don’t have to know exactly what type of therapy you want to pursue when you meet a therapist for the first time, so don’t worry if you’re feeling overwhelmed.

It’s helpful to have a sense of what you like and dislike, and what types of therapy sound interesting to you - but your therapist will help you choose what will work best and create a treatment plan customized to you.

Register online for more information or download our free Therapy 101 Guide to learn more.

If you’d prefer to keep reading, explore these articles we’ve chosen for you:

• What is Psychodynamic Therapy? (The Pros and Cons)
• Therapy 101: The Ultimate Guide to Beginning Therapy
• What is a Therapy Introductory Session?

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What Is Cognitive Behavioral Therapy (CBT)?

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Cognitive behavioral therapy (CBT) is a type of psychotherapeutic treatment that helps people learn how to identify and change the destructive or disturbing thought patterns that have a negative influence on their behavior and emotions.

Cognitive behavioral therapy combines cognitive therapy with behavior therapy by identifying maladaptive patterns of thinking, emotional responses, or behaviors and replacing them with more desirable patterns.

Cognitive behavioral therapy focuses on changing the automatic negative thoughts that can contribute to and worsen our emotional difficulties, depression , and anxiety . These spontaneous negative thoughts also have a detrimental influence on our mood.

Through CBT, faulty thoughts are identified, challenged, and replaced with more objective, realistic thoughts.

Everything You Need to Know About CBT

This video has been medically reviewed by Steven Gans, MD .

Types of Cognitive Behavioral Therapy

CBT encompasses a range of techniques and approaches that address our thoughts, emotions, and behaviors. These can range from structured psychotherapies to self-help practices. Some of the specific types of therapeutic approaches that involve cognitive behavioral therapy include:

• Cognitive therapy centers on identifying and changing inaccurate or distorted thought patterns, emotional responses, and behaviors.
• Dialectical behavior therapy (DBT)  addresses destructive or disturbing thoughts and behaviors while incorporating treatment strategies such as emotional regulation and mindfulness.
• Multimodal therapy suggests that psychological issues must be treated by addressing seven different but interconnected modalities: behavior, affect, sensation, imagery, cognition, interpersonal factors, and drug/biological considerations.
• Rational emotive behavior therapy (REBT) involves identifying irrational beliefs, actively challenging these beliefs, and finally learning to recognize and change these thought patterns.

While each type of cognitive behavioral therapy takes a different approach, all work to address the underlying thought patterns that contribute to psychological distress.

Cognitive Behavioral Therapy Techniques

CBT is about more than identifying thought patterns. It uses a wide range of strategies to help people overcome these patterns. Here are just a few examples of techniques used in cognitive behavioral therapy. 

Identifying Negative Thoughts

It is important to learn what thoughts, feelings, and situations are contributing to maladaptive behaviors. This process can be difficult, however, especially for people who struggle with introspection . But taking the time to identify these thoughts can also lead to self-discovery and provide insights that are essential to the treatment process.

Practicing New Skills

In cognitive behavioral therapy, people are often taught new skills that can be used in real-world situations. For example, someone with a substance use disorder might practice new coping skills and rehearse ways to avoid or deal with social situations that could potentially trigger a relapse.

Goal-Setting

Goal setting can be an important step in recovery from mental illness, helping you to make changes to improve your health and life. During cognitive behavioral therapy, a therapist can help you build and strengthen your goal-setting skills .

This might involve teaching you how to identify your goal or how to distinguish between short- and long-term goals. It may also include helping you set SMART goals (specific, measurable, attainable, relevant, and time-based), with a focus on the process as much as the end outcome.

Problem-Solving

Learning problem-solving skills during cognitive behavioral therapy can help you learn how to identify and solve problems that may arise from life stressors, both big and small. It can also help reduce the negative impact of psychological and physical illness.

Problem-solving in CBT often involves five steps:

• Identify the problem
• Generate a list of potential solutions
• Evaluate the strengths and weaknesses of each potential solution
• Choose a solution to implement
• Implement the solution

Self-Monitoring

Also known as diary work, self-monitoring is an important cognitive behavioral therapy technique. It involves tracking behaviors, symptoms, or experiences over time and sharing them with your therapist.

Self-monitoring can provide your therapist with the information they need to provide the best treatment. For example, for people with eating disorders, self-monitoring may involve keeping track of eating habits, as well as any thoughts or feelings that went along with consuming a meal or snack.

Additional cognitive behavioral therapy techniques may include journaling , role-playing , engaging in relaxation strategies , and using mental distractions .

What Cognitive Behavioral Therapy Can Help With

Cognitive behavioral therapy can be used as a short-term treatment to help individuals learn to focus on present thoughts and beliefs.

CBT is used to treat a wide range of conditions, including:

• Anger issues
• Bipolar disorder
• Eating disorders
• Panic attacks
• Personality disorders

In addition to mental health conditions, cognitive behavioral therapy has also been found to help people cope with:

• Chronic pain or serious illnesses
• Divorce or break-ups
• Grief or loss
• Low self-esteem
• Relationship problems
• Stress management

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Benefits of Cognitive Behavioral Therapy

The underlying concept behind CBT is that thoughts and feelings play a fundamental role in behavior. For example, a person who spends a lot of time thinking about plane crashes, runway accidents, and other air disasters may avoid air travel as a result.

The goal of cognitive behavioral therapy is to teach people that while they cannot control every aspect of the world around them, they can take control of how they interpret and deal with things in their environment.

CBT is known for providing the following key benefits:

• It helps you develop healthier thought patterns by becoming aware of the negative and often unrealistic thoughts that dampen your feelings and moods.
• It is an effective short-term treatment option as improvements can often be seen in five to 20 sessions.
• It is effective for a wide variety of maladaptive behaviors.
• It is often more affordable than some other types of therapy .
• It is effective whether therapy occurs online or face-to-face.
• It can be used for those who don't require psychotropic medication .

One of the greatest benefits of cognitive behavioral therapy is that it helps clients develop coping skills that can be useful both now and in the future.

Effectiveness of Cognitive Behavioral Therapy

CBT emerged during the 1960s and originated in the work of psychiatrist Aaron Beck , who noted that certain types of thinking contributed to emotional problems. Beck labeled these "automatic negative thoughts" and developed the process of cognitive therapy. 

Where earlier behavior therapies had focused almost exclusively on associations, reinforcements , and punishments to modify behavior, the cognitive approach addresses how thoughts and feelings affect behaviors.

Today, cognitive behavioral therapy is one of the most well-studied forms of treatment. It has been shown to be effective in the treatment of a range of mental conditions, including anxiety, depression, eating disorders, insomnia, obsessive-compulsive disorder , panic disorder, post-traumatic stress disorder , and substance use disorder.

• Research indicates that cognitive behavioral therapy is the leading evidence-based treatment for eating disorders .
• CBT has been proven helpful in those with insomnia, as well as those who have a medical condition that interferes with sleep, including those with pain or mood disorders such as depression.
• Cognitive behavioral therapy has been scientifically proven to be effective in treating symptoms of depression and anxiety in children and adolescents.
• A 2018 meta-analysis of 41 studies found that CBT helped improve symptoms in people with anxiety and anxiety-related disorders, including obsessive-compulsive disorder and post-traumatic stress disorder.
• Cognitive behavioral therapy has a high level of empirical support for the treatment of substance use disorders, helping people with these disorders improve self-control , avoid triggers, and develop coping mechanisms for daily stressors.

CBT is one of the most researched types of therapy, in part, because treatment is focused on very specific goals and results can be measured relatively easily.

Verywell Mind's Cost of Therapy Survey , which sought to learn more about how Americans deal with the financial burdens associated with therapy, found that Americans overwhelmingly feel the benefits of therapy:

• 80% say therapy is a good investment
• 91% are satisfied with the quality of therapy they receive
• 84% are satisfied with their progress toward mental health goals

Things to Consider With Cognitive Behavioral Therapy

There are several challenges that people may face when engaging in cognitive behavioral therapy. Here are a few to consider.

Change Can Be Difficult

Initially, some patients suggest that while they recognize that certain thoughts are not rational or healthy, simply becoming aware of these thoughts does not make it easy to alter them.

CBT Is Very Structured

Cognitive behavioral therapy doesn't focus on underlying, unconscious resistance to change as much as other approaches such as  psychoanalytic psychotherapy . Instead, it tends to be more structured, so it may not be suitable for people who may find structure difficult.

You Must Be Willing to Change

For cognitive behavioral therapy to be effective, you must be ready and willing to spend time and effort analyzing your thoughts and feelings. This self-analysis can be difficult, but it is a great way to learn more about how our internal states impact our outward behavior.

Progress Is Often Gradual

In most cases, CBT is a gradual process that helps you take incremental steps toward behavior change . For example, someone with social anxiety might start by simply imagining anxiety-provoking social situations. Next, they may practice conversations with friends, family, and acquaintances. By progressively working toward a larger goal, the process seems less daunting and the goals easier to achieve.

How to Get Started With Cognitive Behavioral Therapy

Cognitive behavioral therapy can be an effective treatment choice for a range of psychological issues. If you or someone you love might benefit from this form of therapy, consider the following steps:

• Consult with your physician and/or check out the directory of certified therapists offered by the National Association of Cognitive-Behavioral Therapists to locate a licensed professional in your area. You can also do a search for "cognitive behavioral therapy near me" to find local therapists who specialize in this type of therapy.
• Consider your personal preferences , including whether face-to-face or online therapy will work best for you.
• Contact your health insurance to see if it covers cognitive behavioral therapy and, if so, how many sessions are covered per year.
• Make an appointment with the therapist you've chosen, noting it on your calendar so you don't forget it or accidentally schedule something else during that time.
• Show up to your first session with an open mind and positive attitude. Be ready to begin to identify the thoughts and behaviors that may be holding you back, and commit to learning the strategies that can propel you forward instead.

What to Expect With Cognitive Behavioral Therapy

If you're new to cognitive behavioral therapy, you may have uncertainties or fears of what to expect. In many ways, the first session begins much like your first appointment with any new healthcare provider.

During the first session, you'll likely spend some time filling out paperwork such as HIPAA forms (privacy forms), insurance information, medical history, current medications, and a therapist-patient service agreement. If you're participating in online therapy, you'll likely fill out these forms online.

Also be prepared to answer questions about what brought you to therapy, your symptoms , and your history—including your childhood, education, career, relationships (family, romantic, friends), and current living situation.

Once the therapist has a better idea of who you are, the challenges you face, and your goals for cognitive behavioral therapy, they can help you increase your awareness of the thoughts and beliefs you have that are unhelpful or unrealistic. Next, strategies are implemented to help you develop healthier thoughts and behavior patterns.

During later sessions, you will discuss how your strategies are working and change the ones that aren't. Your therapist may also suggest cognitive behavioral therapy techniques you can do yourself between sessions, such as journaling to identify negative thoughts or practicing new skills to overcome your anxiety .

If you are having suicidal thoughts, contact the  National Suicide Prevention Lifeline  at  988 for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911.

For more mental health resources, see our  National Helpline Database .

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By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

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Problem solving therapy Use and effectiveness in general practice

Problem solving therapy has been described as pragmatic, effective and easy to learn. It is an approach that makes sense to patients and professionals, does not require years of training and is effective in primary care settings. 1 It has been described as well suited to general practice and may be undertaken during 15–30 minute consultations. 2

Problem solving therapy takes its theoretical base from social problem solving theory which identifies three distinct sequential phases for addressing problems: 3

• discovery (finding a solution)
• performance (implementing the solution)
• verification (assessing the outcome).

Initially, the techniques of social problem solving emerged in response to empirical observations including that people experiencing depression exhibit a reduced capacity to resolve personal and social problems. 4,5 Problem solving therapy specifically for use in primary care was then developed. 6

Problem solving therapy has been shown to be effective for many common mental health conditions seen by GPs, including depression 7–9 and anxiety. 10,11 Most research has focused on depression. In randomised controlled trials, when delivered by appropriately trained GPs to patients experiencing major depression, PST has been shown to be more effective than placebo and equally as effective as antidepressant medication (both tricyclics and selective serotonin reuptake inhibitors [SSRIs]). 7,8 A recent meta-analysis of 22 studies reported that for depression, PST was as effective as medication and other psychosocial therapies, and more effective than no treatment. 9 For patients experiencing anxiety, benefit from PST is less well established. It has been suggested it is most effective with selected patients experiencing more severe symptoms who have not benefited from usual GP care. 10 Problem solving therapy may also assist a group of patients often seen by GPs: those who feel overwhelmed by multiple problems but who have not yet developed a specific diagnosis.

Although PST has been shown to be beneficial for many patients experiencing depression, debate continues about the mechanism(s) through which the observed positive impact of PST on patient affect is achieved. Two mechanisms have been proposed: the patient improves because they achieve problem resolution, or they improve because of a sense of empowerment gained from PST skill development. 12 Perhaps both factors play a part in achieving the benefits of PST as a therapeutic intervention. The observed benefit of PST for patients experiencing anxiety may be due to problem resolution and consequent reduction in distress from anticipatory concern about the identified but unsolved problem.

It is important to note that, while in the clinical setting we may find ourselves attempting to solve problems for patients and to advise them on what we think they should do, 13 this is not PST. Essential to PST, as an evidence based therapeutic approach, is that the clinician helps the patient to become empowered to learn to solve problems for themselves. The GP's role is to work through the stages of PST in a structured, sequential way to determine and to implement the solution selected by the patient. These stages have been described previously. 14 Key features of PST are summarised in Table 1 .

Using PST in general practice

Using PST, like any other treatment approach, depends on identifying patients for whom it may be useful. Patients experiencing a symptom relating to life difficulties, including relationship, financial or employment problems, which are seen by the patient in a realistic way, may be suitable for PST. Frequently, such patients feel overwhelmed and at times confused by these difficulties. Encouraging the patient to clearly define the problem(s) and deal with one problem at a time can be helpful. To this end, a number of worksheets have been developed. A simple, single page worksheet is shown in Figure 1 . A typical case study in which PST may be useful is presented in Table 2 . By contrast, patients whose thinking is typically characterised by unhelpful negative thought patterns about themself or their world may more readily benefit from cognitive strategies that challenge unhelpful negative thought patterns (such as cognitive behaviour therapy [CBT]). 15 Some problems not associated with an identifiable implementable solution, including existential questions related to life meaning and purpose, may not be suitable for PST. Identification of supportive and coping strategies along with, if appropriate, work around reframing the question may be more suitable for such patients.

Problem solving therapy may be used with patients experiencing depression who are also on antidepressant medication. It may be initiated with medication or added to existing pharmacotherapy. Intuitively, we might expect enhanced outcomes from combined PST and pharmacotherapy. However, research suggests this does not occur, with PST alone, medication alone and a combination of PST and medication each resulting in a similar patient outcomes.8 In addition to GPs, PST may be provided by a range of health professionals, most commonly psychologists. General practitioners may find they have a role in reinforcing PST skills with patients who developed their skills with a psychologist, especially if all Better Access Initiative sessions with the psychologist have been utilised.

The intuitive nature of PST means its use in practice is often straightforward. However, this is not always the case. Common difficulties using PST with patients and potential solutions to these difficulties have previously been discussed by the author 14 and are summarised in Table 3 . Problem solving therapy may also have a role in supporting marginalised patients such as those experiencing major social disadvantage due to the postulated mechanism of action of empowerment of patients to address symptoms relating to life problems. 12 of action includes empowerment of patients to address symptom causing life problems. Social and cultural context should be considered when using PST with patients, including conceptualisation of a problem, its significance to the patient and potential solutions.

General practitioners may be concerned that consultations that include PST will take too much time. 13 However, Australian research suggests this fear may not be justified with many GPs being able to provide PST to a simulated patient with a typical presentation of depression in 20 minutes. 15 Therefore, the concern over consultation duration may be more linked to established patterns of practice than the use of PST. Problem solving therapy may add an increased degree of structure to complex consultations that may limit, rather than extend, consultation duration.

Figure 1. Problem solving therapy patient worksheet

PST skill development for GPs

Many experienced GPs have intuitively developed valuable problem solving skills. Learning about PST for such GPs often involves refining and focusing those skills rather than learning a new skill from scratch. 13 A number of practical journal articles 16 and textbooks 10 that focus on developing PST skills in primary care are available. In addition, PST has been included in some interactive mental health continuing medical education for GPs. 17 This form of learning has the advantage of developing skills alongside other GPs.

Problem solving therapy is one of the Medicare supported FPS available to GPs. It is an approach that has developed from a firm theoretical basis and includes principles that will be familiar to many GPs. It can be used within the constraints of routine general practice and has been shown, when provided by appropriately skilled GPs, to be as effective as antidepressant medication for major depression. It offers an additional therapeutic option to patients experiencing a number of the common mental health conditions seen in general practice, including depression 7–9 and anxiety. 10,11

Conflict of interest: none declared.

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• Hickie I. An approach to managing depression in general practice. Med J Aust 2000;173:106–10. Search PubMed
• D'Zurilla T, Goldfried M. Problem solving and behaviour modification. J Abnorm Psychol 1971;78:107–26. Search PubMed
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• Hegel M, Barrett J, Oxman T. Training therapists in problem-solving treatment of depressive disorders in primary care: lessons learned from the: "Treatment Effectiveness Project". Fam Syst Health 2000;18:423–35. Search PubMed
• Mynors-Wallis LM, Gath DH, Lloyd-Thomas AR, Tomlinson D. Randomised control trial comparing problem solving treatment with Amitryptyline and placebo for major depression in primary care. BMJ 1995;310:441–5. Search PubMed
• Mynors-Wallis LM, Gath DH, Day A, Baker F. Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care. BMJ 2000;320:26–30. Search PubMed
• Bell A, D'Zurilla. Problem-solving therapy for depression: a meta-analysis. Clin Psychol Rev 2009;29:348–53. Search PubMed
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Problem Solving Therapy Improves Effortful Cognition in Major Depression

Chenguang jiang.

1 Wuxi Mental Health Center Affiliated to Nanjing Medical University, Wuxi, China

Hongliang Zhou

2 Nanjing Brain Hospital Affiliated to Nanjing Medical University, Nanjing, China

Zhenhe Zhou

Associated data.

The datasets generated for this study are available on request to the corresponding author.

Background: Effortful cognition processing is an intentionally initiated sequence of cognitive activities, which may supply top-down and goal-oriented reassessment of specific stimuli to regulate specific state-driven responses contextually, whereas automatic cognitive processing is a sequence of cognitive activities that is automatically initiated in response to an input configuration. The effortful–automatic perspective has implications for understanding the nature of the clinical features of major depressions. The aim of this study was to investigate the influence of problem solving therapy (PST) on effortful cognition in major depression (MD).

Methods: The participants included an antidepressant treatment (AT) group ( n = 31) or the combined antidepressant treatment and PST (CATP) group ( n = 32) and healthy controls (HCs) ( n = 30). Hamilton Depression Rating Scale (HAMD, 17-item version) and the face–vignette task (FVT) were measured for AT group and CATP group at baseline (before the first intervention) and after 12 weeks of interventions. The HC group was assessed with the FVT only once. At baseline, both patients and HCs were required to complete the basic facial emotion identification test (BFEIT).

Results: The emotion identification accuracy of the HC group was higher than that of the patient group when they performed BFEIT; patients with MD present poor FVT performances; compared to the antidepressant treatment, PST plus antidepressant treatment decreased HAMD scores and improved FVT performances in patients with MD.

Conclusions: Patients with MD present effortful cognition dysfunction, and PST can improve effortful cognitive dysfunction. These findings suggest that the measurement of effortful cognition might be one of the indexes for the therapeutic effect of PST in MD.

Introduction

Major depression (MD) is a common mental disorder with a higher disability rate, affecting 10–15% of the worldwide population every year. To date, some antidepressants, including several typical antidepressants and several atypical antidepressants, have been used to treat major depression; however, only 60–70% of patients respond to antidepressant treatment. Furthermore, 10–30% of these patients exhibit treatment-resistant symptoms such as suicidal thought, a low mood, a decline in interest, and a loss of happiness ( 1 ).

To improve the symptoms of MD, several treatment options have been developed, such as switching therapies, augmentation, combination, optimization, psychotherapies, modified electro-convulsive therapy (MECT), repetitive transcranial magnetic stimulation therapies, deep brain stimulation therapies, vagal nerve stimulation therapies, light-based therapies, acupuncture treatment, and yoga; these approaches have been considered and tailored for individual patients ( 2 – 4 ). Most important for the improvement of depressed patients' symptoms, many studies had reported that physical activity interventions are helpful to improve major depressive disorders because physical activity is associated with many mental health benefits ( 5 – 11 ). Assessments to determine symptom improvement for patients with MD often depend on decreased total Hamilton Depression Rating Scale (HAMD, 17 or 24 items) scores.

Problem solving therapy (PST) belongs to a type of cognitive behavioral therapy that mainly concentrates on training in appropriate problem-solving notions as well as skills. PST has been used for major depression ( 12 – 15 ). It has been confirmed that, in the depressed patient group, PST was equally effective as antidepressant treatments and more effective than no treatment and support or attention control patients ( 16 ). In clinical practice, the effective treatment program of PST in MD includes three aspects: [1] training in a positive problem orientation, [2] training in problem definition and formulation, the generation of alternatives, decision making, and solution implementation and verification, and [3] training in problem orientation plus problem definition and formulation, the generation of alternatives, decision making, and solution implementation and verification ( 16 ).

Cognitive function refers to mental processes involved in working memory, problem-solving, decision-making, the acquisition of knowledge, regulation of information, and reasoning. As a major symptom, cognitive function impairment is acknowledged as a clinical characteristic of major depression. Additionally, many studies of major depression have suggested a role for cognitive measures in predicting those at risk for poor outcomes ( 17 ). A previous study indicated that patients with major depression present negatively valanced emotional symptoms that are accompanied by cognitive deficits, and the emotional processing dysfunctions of the prefrontal cortex might lead to cognitive deficits in patients with MD ( 18 ). Adaptive emotional responding relies on both effortful cognition processing and automatic cognition processing. Effortful cognition processing is a controlled process and refers to an intentionally initiated sequence of cognitive activities, which may supply top-down as well as goal-oriented reassessment of emotional stimuli to regulate emotion-driven responses contextually ( 19 ). Effortful cognition was measured by the face–vignette task (FVT) ( 19 ). Relative to effortful cognitive processing, automatic cognitive processing is a sequence of cognitive activities that is automatically initiated in response to an input configuration ( 20 ). Automatic cognition processing requires near-zero attention for the task at hand and, in many instances, is executed in response to a specific stimulus.

Previous studies have shown that patients with MD present effortful cognitive dysfunction. For example, a previous study reported that, when patients with MD performed two contrasting cognitive tasks ( i.e ., one requiring sustained effort and information processing and the other requiring only superficial information processing that could be accomplished automatically), only the effort-demanding cognitive task was performed poorly ( 21 ). Additionally, two previous studies investigated the functions of automatic and effortful information processing in a visual search paradigm, and the results showed that the patients with MD exhibited longer reaction times on the tasks requiring more effortful information processing than the controls. However, there were no differences on tasks requiring automatic information processing ( 22 , 23 ).

Since cognitive function impairment plays a critical role in MD, the assessment of cognitive function is a better way to determine the treatment effect for MD. The effortful–automatic perspective has implications for understanding the nature of the clinical features of MD. Furthermore, the investigation of the influence of PST on effortful cognition in MD is helpful for improving the present understanding of the therapeutic mechanism and assess the therapeutic effect of PST. To date, no studies of PST on effortful cognition in MD have been reported. In this study, the participants included patients with MD and healthy controls (HCs). The MD group was treated with antidepressants or the combination of antidepressants with PST, and effortful cognition was rated by the FVT. The hypothesis of this study is that depressed patients display poor effortful cognition performance, and PST can improve effortful cognitive dysfunctions. The aim of this study was to investigate the effect of PST on effortful cognition in MD.

Materials and Methods

Time and setting.

This study was conducted in Wuxi Mental Health Center Affiliated to Nanjing Medical University, No. 156 Qianrong Road, Rongxiang Street, Binhu District, Wuxi City, P.R. China, from February 1, 2016 to February 27, 2020.

Diagnostic Approaches and Subjects

A total of 80 patients meeting the American Psychiatric Association's fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for major depression were recruited as the research group. The MD patients were randomly assigned to the antidepressant treatment (AT) group or the combined antidepressant treatment and PST (CATP) group. The allocation schedule was generated by using a list of random numbers. Thirty healthy persons were admitted to the HC group. All HCs had no personal history of mental disorders. Patients with MD were selected from Wuxi Mental Health Center Affiliated to Nanjing Medical University, No. 156 Qianrong Road, Rongxiang Street, Binhu District, Wuxi City, P.R. China; the normal controls were citizens of Wuxi City, Jiangsu Province, P.R. China, recruited by online and local community advertisements. Patients with MD and HC subjects were excluded from the study if they had been diagnosed with nicotine addiction or other psychoactive substance dependence, had suffered any systemic disease that may affect the central nervous system, or had received electroconvulsive therapy (including MECT) in the past 24 weeks. All patients and HC subjects were Chinese. All patients and HC subjects were paid 42.12 Euros plus travel costs.

Seven subjects in AT group and five subjects in CATP group were all diagnosed with bipolar disorder in the follow-up survey, and they were ultimately excluded from this study. Two subjects in AT group and three subjects in CATP group were also excluded from this study because they could not finish the follow-up assessment. Finally, the data from 31 subjects in AT group and 32 subjects in CATP group were used in the statistical analyses.

Measurements of Automatic and Effortful Cognition

Basic facial emotion identification test.

The basic facial emotion identification test (BFEIT) consists of eight examples of each of the seven basic facial emotions, e.g ., happy, angry, sad, fear, surprise, disgust, and calm, which were taken from the Chinese affective picture system ( 24 ). Male and female face pictures were balanced across each emotion category.

Face–Vignette Task

FVT was designed based on an effortful cognitive task that was used in the study on effortful vs . automatic emotional processing in patients with schizophrenia by Patrick et al. ( 19 ). E-Prime 2.0 software (Psychology software tools, INC, USA) was used to implement the experimental procedure. The face pictures were white and black photographs and included six emotional expressions, i.e ., happy, angry, sad, fear, surprise, and disgust, which were taken from the Chinese affective picture system ( 24 ). In each emotion, the male and female faces were equal. Within a given emotion category, the same identity was used only once. The situational vignettes communicated the six special emotions, i.e ., guilty, smug, hopeful, insulted, pain, and determined. Before the experiment, the intended emotion for each story (vignette) was verified by seven undergraduates, and the mean accuracy was 0.91 [standard deviation (SD) = 0.08], and the observed inter-rater reliability κ value was 0.75. The face–story pairs were matched such that each story was inconsistent with the facial expression according to the specially appointed emotional category ( e.g ., a happy facial expression paired with a smug story). Each specific emotion category depended on the situational context (see the listed example in Figure 1 ). The specially appointed face–story pairs included sad vs . guilty, happy vs . smug, fearful vs . painful, angry vs . determined, disgusted vs . insulted, and surprised vs . hopeful. During the FVT, the participants viewed a series of 24 face–story (vignette) pairs and were informed that each facial expression represented the subject of the vignette. The faces and vignettes were presented simultaneously. All participants were required to read the vignettes aloud. In each trial, all participants answered the question accompanied by face–vignette pairs through a specially appointed keypad in a multiple choice pattern. The 13 obtainable choices for each trial were as follows: angry, happy, sad, fearful, disgusted, surprised, smug, guilty, hopeful, determined, pain, insulted as well as no emotion.

Example of a trial on the face–vignette task. The situational vignettes in English are as follows: This is a story about a girl's birthday. The girl stayed in her room. She received a call from her beloved boyfriend: “You're waiting for me at home. I'll bring your favorite flowers to your birthday!” Several minutes later, she heard the knock of her boyfriend's arrival. The question was “What emotion is the person feeling?” Responding with “surprise” will be recorded as a face response and responding with “hopeful” will be recorded as a vignette response. Additionally, any other response will be recorded as a random response.

On the FVT, the responses of the participants were labeled as face responses, vignette responses, and random responses. The response data were converted to proportions, which were used for statistical analysis.

Problem Solving Therapy Procedure

The PST was performed as described in a previous study ( 25 ). All the patients with MD were scheduled for PST, which consists of six sessions administered every other week. The treatment sessions were conducted at the psychological therapy room of the Psychiatry Department. The PST was conducted by six psychotherapists, and visits were conducted by two psychiatric resident physicians. All the psychotherapists owned a therapy handbook and underwent training, including a short theoretical course, role playing in a clinical background as well as watching a training videotape. The PST includes three steps: [1] the patient's symptoms are linked with their problems in daily living, [2] the problems are defined and clarified, and [3] an attempt is made to solve the problems in a structured way. The sessions lasted 1 h for the first visit and half an hour for the subsequent visits.

Clinical Interventions and Clinical Assessment

Two psychiatric residents examined all the participants to confirm or exclude a major depression diagnosis based on DSM-5 criteria and to collect medication and sociodemographic data. A HAMD (17-item version) was applied to assess the depressive severity for patients. A decrease of more than 50% in HAMD (17-item version) scores from baseline to follow-up was defined as a treatment response, and HAMD (17-item version) scores <7 at follow-up were defined as clinical remission.

HAMD (17-item version) and the FVT data were measured for the AT group and CATP group at baseline (before the first intervention, time 1) and after 12 weeks of interventions (time 2). The HC group was assessed using the face–vignette task only once. At baseline, both patients and HCs were required to complete the BFEIT.

Statistical Analysis

Data are presented as mean (SD), and all data were analyzed with Statistical Product and Service Solution 18.0 statistical software (SPSS 18.0, International Business Machines Corporation). Comparisons of the demographic data, basic facial emotion identification test scores, face response proportions, vignette response proportions, and random response proportions at baseline among patients and healthy controls were conducted using the method of one-way analysis of variance (ANOVA) or the chi-square test. Comparisons of HAMD (17-item version) scores, face response proportions, vignette response proportions, and random response proportions between baseline (time 1) and after 12 weeks of interventions (time 2) in the patient group were performed using 2 × 2 repeated-measures ANOVA. In this study, all alpha values of 0.05 were considered as statistically significant throughout. Cohen's d effect sizes were used for t -tests. The cutoff values for Cohen's d 's were defined as trivial effect size when d < 0.19, small effect size when 0.2 < d < 0.49, medium effect size when 0.5 < d < 0.79, and large effect size when d > 0.8. Partial eta-square (η p 2 ) effect sizes were used for F -tests. Similarly, the cutoff values for η p 2 were set as trivial effect size when η p 2 < 0.019, small effect size when 0.02 < η p 2 < 0.059, medium effect size when 0.06 < η p 2 < 0.139, and large effect size when η p 2 > 0.14. Phi (ϕ) effect sizes were used for chi-square test. The cutoff values for ϕ were set as trivial effect size when ϕ < 0.09, small effect size when 0.10 < ϕ < 0.29, medium effect size when 0.30 < ϕ < 0.49, and large effect size when ϕ > 0.50.

The Demographic Data of All Participants

The demographic data of the participants are described in Table 1 . No significant differences were observed in sex ratio, mean age, age range, or mean education years among the AT group, CATP group, and HC group.

Demographic characteristics and clinical data of all participants.

AT, antidepressant treatment; CATP, the combination of antidepressant treatment and PST; HC, healthy control; SD, standard deviation; η p 2 , partial eta-square .

Antidepressant Treatments

In the AT group, 20 patients with MD were antidepressant-naïve, and 11 patients with MD were antidepressant-free (six for at least 24 weeks and five for at least 4 weeks); patients with MD received fluoxetine ( n = 8), paroxetine ( n = 7), fluvoxamine ( n = 7), sertraline ( n = 6), or escitalopram ( n = 3). The mean fluoxetine-equivalent dose was 30.5 (8.8) mg/day. In the CATP group, 19 patients with MD were antidepressant-naïve, and 13 patients with MD were antidepressant-free (eight for at least 24 weeks and five for at least 4 weeks); patients with MD received fluoxetine ( n = 9), paroxetine ( n = 8), fluvoxamine ( n = 8), sertraline ( n = 3), or escitalopram ( n = 4). According to a previous report ( 26 ), the mean fluoxetine-equivalent dose was 30.1 (7.9) mg/day. Neither of the patient groups used concomitant medications.

Comparisons of BFEIT Performance Among the AT Group, CATP Group, and HC Group

As shown in Figure 2 , one-way ANOVA revealed that there were significant differences in BFEIT performance (emotion identification accuracy) among the AT group, CATP group, and HC group ( F 2,90 = 27.729, df = 2, η p 2 = 0.33, p = 0.000). Least square difference tests were performed as post hoc analyses and showed significant differences between the HC group, AT group, and CATP group (all p = 0.000). The emotion identification accuracy of the HC group was higher than that of the AT group or CATP group. However, no significant difference was observed between the AT group and the CATP group ( p = 0.951).

Comparisons of BFEIT performance among the AT group, CATP group, and HC group. BFEIT, basic facial emotion identification test; ATG, antidepressant treatment group; CATPG, the combination of antidepressant treatment and PST group; HC, healthy control; SD, standard deviation.

Comparisons of HAMD (17-Item Version) Scores Before and After Clinical Interventions

As shown in Figure 3 , using HAMD (17-item version) scores as dependent variables, a 2 × 2 repeated-measures ANOVA with group (AT group vs . CATP group) as a between-subjects factor and time point (time 1 vs . time 2) as a within-subjects factor revealed that the interaction effect for group × time point was not significant ( F 1,61 = 1.697, η p 2 = 0.003, p = 0.198); however, the main effect for time point was significant ( F 1,61 = 206.419, η p 2 = 0.35, p = 0.000), and the main effect for group was significant ( F 1,61 = 170.914, η p 2 = 0.18, p = 0.038). The 12-week interventions decreased HAMD (17-item version) scores in the two patient groups.

Comparisons of HAMD scores before and after clinical interventions between the AT group and CATP group. HAMD, Hamilton Depression Rating Scale (17-item version); ATG, antidepressant treatment group; CATPG, the combination of antidepressant treatment and PST group; time 1, baseline; time 2, after 12 weeks of intervention; SD, standard deviation.

There were significant differences in the remission rate between the CATP group (19/32) and the AT group (14/31); the remission rate in the CATP group was higher than that of the AT group (χ 2 = 6.123, ϕ = 0.29, p = 0.028). There were significant differences in the treatment response rate between the CATP group (25/32) and AT group (18/31); the treatment response rate in the CATP group was higher than that of the AT group (χ 2 = 4.370, ϕ = 0.26, p = 0.035).

Comparisons of FVT Performance Among the AT Group, CATP Group, and HC Group

Baseline level.

As shown in Table 2 , one-way ANOVA revealed that there were significant differences in face response proportions and vignette response proportions among the AT group, CATP group, and HC group ( F 2,90 = 27.861, 18.234, all df = 2; η p 2 = 0.32, 0.36, all p = 0.000). Least square difference tests were performed as post hoc analyses and showed significant differences between the HC group and AT group or between the HC group and the CATP group (all p = 0.000). The face response proportions of the HC group were lower than those of the AT group and CATP group, and the vignette response proportions of the HC group were higher than those of the AT group and CATP group. For the above-mentioned two variables, no differences between the AT group and CATP group were observed ( p = 0.951, 0.913).

Face–vignette task performances (%, SD) among the AT group, CATP group, and healthy control group.

AT, antidepressant treatment; CATP, the combination of antidepressant treatment and PST; Time 1, baseline; Time 2, after 12 weeks of interventions; F, face response proportions; V, vignette response proportions; R, random response proportions .

However, there were no significant differences in random response proportions among the AT group, CATP group, and HC group ( F 2,90 = 0.979, df = 2, η p 2 = 0.006, p = 0.380).

Before and After Interventions

As shown in Table 2 , using face response proportions, vignette response proportions, and random response proportions as dependent variables, a 2 × 2 repeated-measures ANOVA with group (AT group vs . CATP group) as the between-subjects factor and time point (time 1 vs . time 2) as the within-subjects factor was performed.

Face Response Proportions

The interaction effect for group × time point was significant ( F 1,61 =25.174, df =1, η p 2 = 0.30, p = 0.000), the main effect for time point was significant ( F 1,61 = 138.086, df = 1, η p 2 = 0.32, p = 0.000), and the main effect for group was significant ( F 1,61 = 4.853, df = 1, η p 2 = 0.24, p = 0.031).

Vignette Response Proportions

The interaction effect for group × time point was significant ( F 1,61 = 29.450, df = 1, η p 2 = 0.31, p = 0.000), the main effect for time point was significant ( F 1,61 = 144.130, df = 1, η p 2 = 0.32, p = 0.000), and the main effect for group was significant ( F 1,61 = 3.083, df = 1, η p 2 = 0.18, p = 0.041).

Random Response Proportions

The interaction effect for group × time point was not significant ( F 1,61 = 1.003, df = 1, η p 2 = 0.001, p = 0.320), the main effect for time point was not significant ( F 1,61 = 1.519, df = 1, η p 2 = 0.001, p = 0.223), and the main effect for group was not significant ( F 1,61 = 0.017, df = 1, η p 2 = 0.000, p = 0.897).

This study is the first to survey the effect of problem-solving therapy on effortful cognition in MD using FVT; measurements of the basic facial emotion identification were also conducted. Our data showed that the emotion identification accuracy of HCs was higher than that of patients with MD; patients with MD exhibited poor FVT performance. Compared to antidepressant treatment, PST plus antidepressant treatment resulted in lower HAMD (17-item version) scores and better FVT performance.

This study also investigated the ability of patients with MD to employ contextual information when determining the intended or expressed or signified message of facial emotional expressions. In the FVT, target facial emotional expressions are preceded by stories describing situational messages which are discrepant in affective valence. What both patients with MD and HCs had judged reflects either the dominance of the emotional context or the facial emotional expression. Many studies on cognitive processing by patients with MD reported that depressive symptoms interfere with effortful processing, and the degree of interference is determined by the degree of effort required for the task, the severity of depression, and the valence of the stimulus material to be processed. However, depressive symptoms only interfere minimally with automatic processes ( 27 ).

Consistent with the findings of previous studies ( 21 – 23 ), our results showed that patients with MD could not utilize contextual information for specific face–vignette pairs. However, HCs more extensively made good judgments on emotion in line with contextual information, which indicates that patients with MD display poor effortful cognition performance. Cognition dysfunctions in MD include impairments of social cognition and neurocognition ( 28 , 29 ). Social cognition refers to a process or a function for an individual's mental operations underlying social behavior, while neurocognition refers to those basic information processing functions such as attention and executive processes. Effortful cognitive processing was involved in either social cognition or neurocognition. We verified our hypothesis, i.e ., patients with MD present effortful cognitive dysfunction.

In this study, we confirmed that PST plus antidepressant treatments leads to a greater reduction of depressive symptoms, a greater response rate, and a greater remission rate over a period of 12 weeks than antidepressant treatments only in patients with MD. We also indirectly verified our previous hypothesis, i.e ., PST can improve effortful cognitive dysfunction, namely, PST improved the severity of MD by improving effortful cognition. Our data provide supporting evidence for the conclusion that the facial affect processing ability could be a valuable predictor of successful social context integration in FVT in MD.

Conclusions

In conclusion, patients with MD present effortful cognitive dysfunction, and PST can improve effortful cognitive dysfunction. The measurement of effortful cognition might be one of the indexes for the therapeutic effect of PST in MD.

There are some limitations in the study. First, the findings must be considered preliminary due to the small sample size. Second, healthy controls were assessed with the FVT only once; therefore, the results of the FVT would be influenced by the practice effect in patients with MD. Future studies should augment the sample size and eliminate the practice effect to further confirm the relationship between effortful cognition and PST in MD. Finally, this study investigated the effect of PST plus antidepressant treatment on effortful cognition in MD. Therefore, no outcome of the pure PST effect on effortful cognition was obtained. The examination of the pure PST effect on effortful cognition in MD is necessary in a future study.

Data Availability Statement

Ethics statement.

The studies involving human participants were reviewed and approved by Affiliated Wuxi Mental Health Center of Nanjing Medical University. The patients/participants provided their written informed consent to participate in this study.

Author Contributions

CJ, HZ, and ZZ designed the study and wrote the paper. CJ, HZ, LC, and ZZ acquired and analyzed the data. All authors reviewed the content and approved the final version for publication.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Acknowledgments

The authors would like to thank the Key Medical Talent Training Project of Jiangsu Province for providing support (project Grant No. ZDRCC2016019) for this research.

Funding. This research was supported by the Wuxi Taihu Talent Project (No. WXTTP2020008) and the Key Medical Talent Training Project of Jiangsu Province (No. ZDRCC2016019).