problem solving model can be used for short term treatment

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.

Before you continue, we thought you might like to download our three Positive Psychology Exercises for free . These science-based exercises will explore fundamental aspects of positive psychology including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

This Article Contains:

What is 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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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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What Is Cognitive Behavioral Therapy (CBT)?

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

Rachel Goldman, PhD FTOS, is a licensed psychologist, clinical assistant professor, speaker, wellness expert specializing in eating behaviors, stress management, and health behavior change.

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• Getting Started

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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Lazarus AA, Abramovitz A. A multimodal behavioral approach to performance anxiety . J Clin Psychol. 2004;60(8):831-40. doi:10.1002/jclp.20041

Lincoln TM, Riehle M, Pillny M, et al. Using functional analysis as a framework to guide individualized treatment for negative symptoms . Front Psychol. 2017;8:2108. doi:10.3389/fpsyg.2017.02108

Ugueto AM, Santucci LC, Krumholz LS, Weisz JR. Problem-solving skills training . Evidence-Based CBT for Anxiety and Depression in Children and Adolescents: A Competencies-Based Approach . 2014. doi:10.1002/9781118500576.ch17

Lindgreen P, Lomborg K, Clausen L.  Patient experiences using a self-monitoring app in eating disorder treatment: Qualitative study .  JMIR Mhealth Uhealth.  2018;6(6):e10253. doi:10.2196/10253

Tsitsas GD, Paschali AA. A cognitive-behavior therapy applied to a social anxiety disorder and a specific phobia, case study . Health Psychol Res. 2014;2(3):1603. doi:10.4081/hpr.2014.1603

Kumar V, Sattar Y, Bseiso A, Khan S, Rutkofsky IH.  The effectiveness of internet-based cognitive behavioral therapy in treatment of psychiatric disorders .  Cureus . 2017;9(8):e1626.

Trauer JM, Qian MY, Doyle JS, Rajaratnam SMW, Cunnington D. Cognitive behavioral therapy for chronic insomnia: A systematic review and meta-analysis .  Ann Intern Med . 2015;163(3):191. doi:10.7326/M14-2841

Agras WS, Fitzsimmons-craft EE, Wilfley DE.  Evolution of cognitive-behavioral therapy for eating disorders .  Behav Res Ther . 2017;88:26-36. doi:10.1016/j.brat.2016.09.004

Oud M, De winter L, Vermeulen-smit E, et al.  Effectiveness of CBT for children and adolescents with depression: A systematic review and meta-regression analysis . Eur Psychiatry . 2019;57:33-45. doi:10.1016/j.eurpsy.2018.12.008

Carpenter J, Andrews L, Witcraft S, Powers M, Smits J, Hofmann S. Cognitive behavioral therapy for anxiety and related disorders: A meta‐analysis of randomized placebo‐controlled trials .  Depress Anxiety . 2018;35(6):502–14. doi:10.1002/da.22728

National Institute on Drug Abuse (NIDA).  Cognitive-behavioral therapy (alcohol, marijuana, cocaine, methamphetamine, nicotine) .

Gaudiano BA. Cognitive-behavioural therapies: Achievements and challenges . Evid Based Ment Health . 2008;11(1):5-7. doi:10.1136/ebmh.11.1.5

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Coull G, Morris PG. The clinical effectiveness of CBT-based guided self-help interventions for anxiety and depressive disorders: A systematic review . Psycholog Med . 2011;41(11):2239-2252. doi:10.1017/S0033291711000900

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

Problem Solving Treatment (PST)

Problem-Solving Treatment (PST) is a brief form of evidence-based treatment that was originally developed in Great Britain for use by medical professionals in primary care. It is also known as Problem-Solving Treatment – Primary Care (PST-PC). PST has been studied extensively in a wide range of settings and with a variety of providers and patient populations.

PST teaches and empowers patients to solve the here-and-now problems contributing to their depression and helps increase self-efficacy. It typically involves six to ten sessions, depending on the patient’s needs. The first appointment is approximately one hour long because, in addition to the first PST session, it includes an introduction to PST techniques. Subsequent appointments are 30 minutes long.

PST is not indicated as a primary treatment for: substance abuse/dependence, acute primary post-traumatic stress disorder, panic disorder, new onset bipolar disorder, new onset psychosis.

Learn more about how to get trained in PST on this page .

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10 Contemporary Problem-Solving Therapy: A Transdiagnostic Intervention

Arthur M. Nezu, Department of Psychology, Drexel University

Alexandra P. Greenfield, Drexel University

Christine Maguth Nezu, Department of Psychology, Drexel University

• Published: 09 June 2015
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This chapter describes problem-solving therapy, a cognitive-behavioral intervention that teaches individuals a set of adaptive problem-solving activities geared to foster their ability to cope effectively with stressful life circumstances in order to reduce negative physical and psychological symptoms. This approach is based on the notion that what is often conceptualized as psychopathology and behavioral difficulties is a function of ineffective coping with life stress. Research addressing differences between effective and ineffective problem solving and the role of social problem solving as a moderator of the stress–distress relationship is presented. In addition, studies that support the efficacy of problem-solving therapy interventions are provided. A brief overview of the clinical components of problem-solving therapy is described that address problems of cognitive overload, emotional dysregulation, negative thinking, poor motivation, and ineffective problemsolving. Future directions for clinical practice, training, and research are included.

Problem solving has traditionally been conceptualized as a major component of executive functioning that involves higher order mental or cognitive processes. In this context, research in experimental psychology has predominantly addressed the question of how humans solve problems of a cognitive or intellectual nature, such as a mathematical calculation or logic puzzle. However, these do not generally reflect the complexity of problems that people face in the real world, which are different than such cognitive problems in that they are (a) often stressful, (b) caused by or engender emotional difficulties, and (c) frequently involve other individuals. It was not until the second half of the twentieth century that research began to focus on those factors that impact one’s ability to solve the types of problems that are typically encountered in everyday life ( D’Zurilla & Nezu, 2007 ). This also led to the question of whether individuals can be trained to become better problem solvers as a means of decreasing emotional difficulties and improve their overall quality of life. It was from this context that problem-solving therapy was developed.

Problem-solving therapy (PST) is a psychosocial intervention developed within a social learning framework and based on a biopsychosocial, diathesis-stress model of psychopathology. In general, this intervention involves training individuals in a set of skills aimed to enhance their ability to cope effectively with a variety of life stressors that have the potential to generate negative health and mental health outcomes, such as chronic medical conditions, depression, and anxiety. Life stressors can include both major negative life events (e.g., death of a loved one, diagnosis and treatment of a chronic illness, loss of a job, incarceration, military combat) and chronic daily problems (e.g., continuous tension with coworkers, reduced financial resources, discrimination, marital difficulties).

PST assumes that much of what is conceptualized as psychopathology and behavioral difficulties, including significant emotional problems, is a function of continuous ineffective coping with life stressors. As a result, it is hypothesized that teaching individuals to become better problem solvers can serve to reduce extant physical and mental health difficulties. The overarching goal of PST is to promote the successful adoption of adaptive problem-solving attitudes (i.e., optimism, enhanced self-efficacy) and the effective implementation of certain behaviors (i.e., adaptive emotional regulation, planful problem solving) as a means of coping with life stressors and thereby attenuating the negative effects of stress on physical and mental well-being.

The origins of PST from a social learning perspective can be traced back to the seminal article by D’Zurilla and Goldfried (1971) , who developed a prescriptive model of training for individuals to enhance their ability to cope effectively with problems encountered in daily living. Early research applying this model to clinical populations focused on PST as a treatment for adults with major depressive disorder (e.g., Nezu, 1986 ). Subsequently, researchers and clinicians all over the world have successfully applied variations of this model to a wide range of psychological disorders, medical problems, and clinical populations (see D’Zurilla & Nezu, 2007 ). In addition, PST has been effective across different modes of implementation (e.g., individual, group, telephone, Internet) and has been applied as a means of enhancing one’s adherence to other medical or psychosocial interventions ( Nezu, Nezu, & Perri, 2006 ).

As new research improves our understanding of problem solving and stress, we have continuously revised and updated the basic PST model to incorporate findings from the outcome literature, as well as basic research from the fields of affective neuroscience, cognitive psychology, and clinical psychology. As such, we refer to the current model of treatment as “contemporary PST.” This chapter will provide a broad overview of the conceptual and empirical underpinnings of this cognitive-behavioral intervention, as well as a brief description of clinical guidelines.

Problem, Solution, and Social Problem Solving

We begin by defining the constructs of problems, solutions, and social problem solving, the latter term used to describe the type of problem solving that occurs in real-life settings rather than problems of a more intellectual or academic nature.

We define a problem as a life situation, present or anticipated, that requires an adaptive response in order to prevent negative consequences from occurring but where an effective response or solution is not immediately obvious or available to the individual experiencing the situation due to the existence of various obstacles. The problem can arise from a person’s social or physical environment (e.g., conflict with a family member, poor living conditions). It can also originate internally or intrapersonally (e.g., desire to make more money, confusion about life goals).

The barriers that make the situation a problem for a given individual or set of individuals can involve a variety of factors. These can include (a) novelty (e.g., beginning a new romantic relationship); (b) ambiguity (e.g., uncertainty about how one is perceived by his or her coworkers); (c) unpredictability (e.g., lack of control over one’s job stability); (d) conflicting goals (e.g., difference between spouses/partners with regard to child-rearing philosophies); (e) performance skills deficits (e.g., difficulties with communication); (f) lack of resources (e.g., limited finances); and (g) significant emotional arousal (e.g., prolonged grief over the loss of a loved one).

An individual may recognize that a problem exists almost immediately based on one’s overall reactions (e.g., physical symptoms, negative thoughts, urge to aggress) or only after repeated attempts to cope with the situation have failed. A problem can be a single, time-limited event (e.g., misplacing one’s keys; forgetting to set one’s alarm clock), a series of similar or related events (e.g., repeated disagreements between friends; not having a job that pays well), or a chronic, ongoing situation (e.g., a serious medical illness; persistent depressive symptoms).

According to this view, a problem is not a product of either the environment or the person alone. Rather, it is best understood as a person–environment relationship represented by a real or perceived discrepancy between the demands of the situation and one’s coping ability and reactions. Problems are therefore idiographic and can be expected to change in difficulty or significance over time, depending on changes in the person, environment, or both. In other words, what a problem is for one person may not be a problem for someone else. In addition, what serves as a problem for a given person at one time may not be a problem for this same person at another point in time.

We define a solution as a situation-specific coping response that is the outcome of the problem-solving process when it is applied to a specific situation. An effective solution achieves the problem-solving goal while simultaneously maximizing positive consequences and minimizing negative consequences. The potential outcomes to consider may include possible impacts on the self and others, as well as short-term and long-term effects. Different individuals across different environments may vary in their evaluation of solutions based on the particular norms, values, and goals of the problem solver.

Social Problem Solving

Social problem solving (SPS) is the process by which individuals attempt to identify, discover, or create adaptive means of coping with a wide variety of stressful problems, both acute and chronic, encountered during the course of living ( D’Zurilla & Nezu, 2007 ). It reflects the process whereby people direct their coping efforts at altering the problematic nature of a given situation, their reactions to such problems, or both. Rather than representing a singular type of coping behavior or activity, SPS represents the multidimensional metaprocess of ideographically identifying and selecting various coping responses to implement in order to match adequately the unique features of a given stressful situation at a given time ( Nezu, 2004 ).

The construct of social problem solving should be differentiated from that of problem-focused coping. The term coping generally refers to the cognitive and behavioral activities that an individual uses to manage stressful situational demands, as well as the emotions they generate. Two major types of coping have been described in the literature: problem-focused coping and emotion-focused coping ( Lazarus & Folkman, 1984 ). Problem-focused coping includes those activities that are directed at changing the stressful situation for the better (i.e., meeting, changing, or controlling situational demands). On the other hand, emotion-focused coping includes those activities aimed at managing the negative emotions generated by a stressful situation.

Within this context, SPS has, at times, been misrepresented as being equivalent to a form of problem-focused coping, suggesting that SPS goals include only mastery goals or attempts to control the environment (e.g., change another’s behavior). However, we define SPS as a broader, more versatile coping strategy that often includes both problem-focused and emotion-focused objectives. Regardless of whether the objective is articulated as problem focused or emotion focused, the ultimate goal is to minimize the negative effects of stressful life events on well-being. It is likely that particularly stressful problems require both problem-focused and emotion-focused objectives to be successfully resolved.

A Multidimensional Model of Social Problem Solving

According to contemporary SPS theory, problem-solving outcomes are largely determined by two general, but partially independent, dimensions: (a) problem orientation and (b) problem-solving style ( D’Zurilla, Nezu, & Maydeu-Olivares, 2004 ). Problem orientation (PO) represents the set of cognitive-affective schemas regarding individuals’ generalized beliefs, attitudes, and emotional reactions about real-life problems, as well as their ability to cope successfully with such difficulties. Whereas the original model suggested that the two types of problem orientations represented opposite ends of the same continuum (e.g., D’Zurilla & Nezu, 1999 ), subsequent research suggests that they operate somewhat independent of each other ( Nezu, 2004 ). These two orthogonal orientation components are positive problem orientation and negative problem orientation.

A positive problem orientation involves the tendency for individuals to (a) perceive problems as challenges rather than major threats to one’s well-being, (b) be optimistic in believing that problems are solvable, (c) have a strong sense of self-efficacy regarding their ability to handle difficult problems, (d) believe that successful problem solving usually involves time and effort, and (e) view negative emotions as important sources of information necessary for effective problem solving.

A negative problem orientation refers to the tendency of individuals to (a) view problems as major threats to one’s well-being, (b) generally perceive problems to be unsolvable, (c) maintain doubts about their ability to cope with problems successfully, and (d) become particularly frustrated and upset when faced with problems or when they experience negative emotions.

An individual’s problem orientation can have a strong influence on his or her motivation and ability to engage in focused attempts to solve problems. As such, the importance of assessing and addressing one’s dominant orientation is considered a key component of the overall PST approach. For this reason, it is very important to include a specific and comprehensive focus on orientation variables when conducting PST. Unfortunately, some researchers have equated PST solely with “rational or logical” problem-solving skills and have de-emphasized or ignored problem-orientation variables. Because PST aims to help people cope effectively with real-life stressful problems, we firmly believe that attention must be paid to individuals’ general beliefs, attitudes, and emotional reactions to real-world problems.

In support of this point, two recent meta-analytic reviews of the extant literature of PST, in addition to a randomized, controlled trial that directly posed this question ( Nezu & Perri, 1989 ), support the notion that excluding a specific focus on problem-orientation variables consistently leads to significantly less efficacious outcome as compared to protocols that do include such training ( Bell & D’Zurilla, 2009 ; Malouff, Thorsteinsson, & Schutte, 2007 ).

The second major dimension of SPS, problem- solving style , refers to the core cognitive-behavioral activities that people engage in when attempting to solve stressful problems. Three styles have been identified ( D’Zurilla, Nezu, & Maydeu-Olivares, 2002 ; D’Zurilla et al., 2004 ): planful or rational problem solving, avoidant problem solving, and impulsive-careless problem solving.

Planful problem solving is the constructive approach that involves the systematic and planful application of the following set of specific skills: (a) problem definition and formulation (i.e., clarifying the nature of a problem, delineating a realistic set of problem-solving goals and objectives, and identifying those obstacles that prevent one from reaching such goals); (b) generation of alternatives (i.e., brainstorming a range of possible solution strategies geared to overcome the identified obstacles); (c) decision making (i.e., predicting the likely consequences of these various alternatives, conducting a cost-benefit analysis based on these identified outcomes, and developing a solution plan that is geared to achieve the problem-solving goal); and (d) solution implementation and verification (i.e., carrying out the solution plan, monitoring and evaluating the consequences of the plan, and determining whether one’s problem-solving efforts have been successful or need to continue).

In addition to planful problem solving, two problem-solving styles have been further identified, both of which, in contrast, are frequently ineffective in nature ( D’Zurilla et al., 2002 , 2004 ). An impulsive/careless style is the problem-solving approach whereby an individual tends to engage in impulsive, hurried, and careless attempts at problem resolution. Avoidant problem solving is the problem-solving style characterized by procrastination, passivity, and overdependence on others to provide solutions. In general, both styles are associated with ineffective or unsuccessful coping. Moreover, people who typically engage in these styles tend to worsen existing problems and even create new ones.

It should be noted that this model does not suggest that individuals should be characterized exclusively by either type of orientation or problem-solving style across all situations. Rather, each represents a strong tendency to either view or react toward problems from a particular perspective based on one’s learning experiences. For example, it is possible for individuals to be characterized as having a positive orientation when dealing with one type of problem (e.g., work-related difficulties), while simultaneously having a negative orientation when addressing other types of problems (e.g., relationship difficulties).

In addition, it should be noted that this five-component model of SPS (i.e., positive orientation, negative orientation, planful problem-solving style, impulsive/careless style, and avoidant style) has been cross-validated numerous times across various populations, ethnic minority cultures, and age groups ( D’Zurilla & Nezu, 2007 ).

Social Problem Solving and Psychopathology

A large assumption underlying the relevance of PST as a psychosocial intervention is the notion that SPS represents a set of strategies that fosters effective coping with various forms of life stress. In support of this theory, research over the past several decades has consistently identified many pathology-related differences between individuals characterized as “effective” versus “ineffective” problem solvers across a range of age groups, populations, and cultures, and using differing measures of SPS (see D’Zurilla & Nezu, 2007 ; Nezu, Wilkins, & Nezu, 2004 , for overviews of this literature). In general, when compared to their effective counterparts, ineffective problem solvers report a greater number of life problems, more health and physical symptoms, more anxiety, more depression, and more psychological maladjustment. Moreover, a negative problem orientation has been found to be associated with negative moods under routine and stressful conditions in general, as well as significantly related to pessimism, negative emotional experiences, and clinical depression ( Nezu, 2004 ). Persons with a negative orientation also tend to worry and complain more about their health ( Elliott, Grant, & Miller, 2004 ).

In addition, problem-solving deficits have been found to be significantly related to poor self-esteem, hopelessness, suicidal risk, self-injury, anger proneness, increased alcohol intake and substance risk taking, personality difficulties, criminal behavior, alcohol dependence, physical health problems, and diminished life satisfaction ( D’Zurilla & Nezu, 2007 ).

A Problem-Solving/Stress Model of Psychopathology

Elsewhere, we have described in detail a diathesis-stress model of psychopathology that posits how SPS interacts with various biological, psychological, and social variables to influence how a given individual will respond to various life stressors and, consequently, what the outcome of this process might be (see Nezu, Nezu, & D’Zurilla, 2013 for a more detailed description of this model, particularly the distal, proximal, and immediate roles that various neurobiological, immune, and brain chemistry factors play in this process).

According to this model, certain distal factors, in the form of genetic predispositions and early life stress, have been found to produce both biological (e.g., increased stress sensitivity leading to lowered thresholds for triggering depressive reactions later in life; Nugent, Tyrka, Carpenter, & Price, 2011 ) and psychosocial (e.g., lack of opportunity to develop effective problem-solving skills due to stress-related overtaxed efforts to cope; Wilhelm et al., 2007 ) vulnerabilities that can further make one more susceptible to negative health and mental health outcomes during adolescence, adulthood, and older adulthood.

Focusing on more proximal variables, substantial research has documented the causal role of stress (in the form of major negative life events and chronic daily problems) in causing the initial onset and/or exacerbating preexisting psychopathology (e.g., depression) and certain medical disorders (e.g., heart disease, diabetes) ( Pandey, Quick, Rossi, Nelson, & Martin, 2011 ). In addition to the presence of stress as a contributor to psychopathology, there may be important biological, developmental, sociodemographic, and psychological factors that play a role in how individuals respond to stressors. Experiencing stress in the absence of effective coping can lead to increased levels of stress and distress (termed “stress generation”) and a cyclical pattern of negative symptoms. Individuals who have experienced larger amounts of early life stress and/or possess a genetic vulnerability, in the face of this stress generation process, are then especially vulnerable to negative health outcomes (e.g., Monroe et al., 2006 ).

SPS is considered to be a key component of successful coping and is therefore hypothesized to serve as an important moderator of the overall stress–distress relationship. In other words, the manner in which people cope with extant stressful events via effective SPS may affect the degree to which they will experience both acute and/or long-term psychological distress. In general, studies directly exploring this question provide evidence that SPS, in fact, is a significant moderator of the stress–distress relationship. For example, under similar levels of high stress, individuals with ineffective or poor SPS have been found to experience significantly higher levels of psychological distress as compared to individuals characterized by effective SPS ( Londahl, Tverskoy, & D’Zurilla, 2005 ; Nezu & Ronan, 1988 ; Ranjbar, Bayani, & Bayani, 2014 ).

The model further suggests that if one’s problem-solving ability is unable to adequately cope with life stress, not only is it likely that he or she will experience negative health outcomes and psychological distress, but such outcomes can also subsequently produce further life stress, as well as continuously undermine one’s problem-solving attempts. We suggest that this reciprocal “downward spiral” of stress-distress generation can lead to long-term clinical disorders.

Efficacy of Problem-Solving Therapy

PST has been applied, both as the sole intervention strategy and as part of a larger treatment package, to a wide variety of patient populations and clinical problems. In the past several years, three major meta-analyses of PST randomized, controlled trials have been published and provide support for the overall efficacy of this approach. For example, Malouff et al. (2007) conducted a meta-analysis of 32 studies, including close to 3,000 participants, that evaluated the efficacy of PST across a variety of mental and physical health problems. These authors found that PST was (a) equally as effective as other psychosocial treatments, and (b) significantly more effective than both no-treatment and attention-placebo control conditions. In addition, the inclusion of training in problem orientation and the assignment of homework led to larger effect sizes in treatment outcome.

A second meta-analysis published in the same year was conducted by Cuijpers, van Straten, and Warmerdam (2007) . This investigation focused exclusively on trials of PST for the treatment of depression. Specifically, they focused on 13 randomized, controlled trials that collectively included over 1,100 participants. Based on their results, they concluded that although additional research is needed due to an identified variability in outcomes across studies, “there is no doubt that PST can be an effective treatment for depression” (p. 9). Note that one possible explanation for such variability involves the lack of a focus on problem-orientation variables in some of the studies characterized by lower effect sizes.

A third meta-analysis that also focused exclusively on PST for depression was conducted by Bell and D’Zurilla (2009) and included seven additional studies beyond those in the Cuijpers et al. (2007) meta-analysis. These authors came to similar conclusions when looking at both post-treatment and follow-up results across investigations. Specifically, PST was found to be equally effective for the treatment of depression as compared to both alternative psychosocial therapies and psychiatric medication, and more efficacious as compared to supportive therapy and attention-control conditions. In addition, Bell and D’Zurilla found that significant moderators of treatment effectiveness included whether the PST protocol included problem-orientation training and whether all four planful problem-solving skills were included.

Although not focusing exclusively on PST, three additional meta-analyses provide further support for PST as an evidenced-based treatment. One investigation involved both a meta-analysis and metaregression of randomized, controlled trials of brief psychological therapies for adult patients with anxiety, depression, or mixed common mental health problems treated in primary care ( Cape, Whittington, Buszewicz, Wallace, & Underwood, 2010 ). Across 34 studies, involving close to 4,000 patients, it was concluded that PST for depression and mixed anxiety/depression was an effective treatment. Controlling for diagnosis, a metaregression analysis found no difference in efficacy between cognitive-behavioral therapy and PST. Another systematic review and meta-analysis evaluated the relative efficacy of various brief psychotherapy approaches (eight or fewer sessions) for depression and again found PST to be an efficacious intervention ( Nieuwsma et al., 2012 ). A more recent meta-analysis focused on different types of psychotherapy for adult depression and similarly found PST to be characterized by robust effects ( Barth et al., 2013 ). These systematic reviews provide for substantial evidence in support of the efficacy of PST-based interventions for treating a wide range of mental disorders, particularly depression.

PST as a Transdiagnostic Intervention

Because PST has been found to be an effective treatment for a wide variety of populations and clinical problems, it can be viewed as a transdiagnostic approach. Conceptually, because stress plays a significant role, either as an etiological and/or maintaining variable, regarding many forms of psychopathology and patient problems, it stands to reason why this would be the case. A brief listing of problems and populations for which PST has been found to be effective include the following: adults with major depressive disorder ( Nezu, 1986 ); medical patients also diagnosed with depression ( Harpole et al., 2005 ); adults attempting suicide ( Hatcher et al., 2011 ); adults with intellectual disabilities and comorbid psychiatric diagnoses ( C. M. Nezu, Nezu, & Arean, 1991 ); young offenders with intellectual disabilities ( Langdon et al., 2013 ); caregivers of patients with dementia ( Garand et al., 2013 ), traumatic brain injury ( Rivera et al., 2008 ), and stroke ( Grant et al., 2002 ); adolescents with conduct disorder and substance abuse problems ( Azrin et al., 2001 ); older adults with major depression and executive dysfunction ( Alexopoulos et al., 2011 ); cancer patients and their significant others ( Nezu, Nezu, Felgoise, McClure, & Houts, 2003 ); adults with hypertension ( García-Vera, Labrador, & Sanz, 1997 ); patients with lower back pain ( van den Hout, Vlaeyen, Heuts, Zijlema, & Wijen, 2003 ); low-income, Latino adults diagnosed with cancer ( Ell et al., 2008 ); and adults with type 2 diabetes ( Katon et al., 2004 ).

PST has also been used as an adjunct approach to foster the effectiveness of other behavioral intervention strategies ( Nezu et al., 2006 ). It has been found to be effective if provided individually ( Nezu et al., 2003 ), in a group format ( Nezu & Perri, 1989 ), over the telephone ( Allen et al., 2002 ), via the Internet ( Choi et al., 2014 ), and as part of a collaborative care model of health care delivery ( Unűtzer et al., 2002 ). More recently, PST has been applied to a US veteran population as a means of fostering their resilience in order to prevent future psychopathology ( Tenhula et al., 2014 ).

Problem-Solving Therapy: Overview of Clinical Guidelines

In this next section, we provide a brief overview of the clinical components of contemporary PST. According to the model, we suggest that several major obstacles can potentially exist for a given individual when attempting to resolve real-life stressful problems successfully. These include the following:

The ubiquitous human presence of “brain overload,” especially under stressful circumstances

Limited or deficient ability to engage in effective emotional regulation

Biased cognitive processing of various emotion-related information (e.g., negative automatic thoughts, poor self-efficacy beliefs, difficulties in disengaging from negative mood-congruent autobiographical memories)

Poor motivation due to feelings of hopelessness

Ineffective problem-solving strategies

PST focuses on training individuals in four major problem-solving “toolkits” that address each of the aforementioned general barriers. These toolkits include (a) problem-solving multitasking; (b) the “stop, slow down, think, and act” (SSTA) method of approaching problems while under stress; (c) healthy thinking and positive imagery; and (d) planful problem solving.

Note that a client’s specific problem-solving strengths and weaknesses should determine whether all strategies in all toolkits are taught and emphasized. In addition, when choosing which training activities to engage in, the therapist should use clinical judgment regarding the relevance of other related factors, such as the anticipated length of treatment, the severity of negative symptoms, and the subsequent progress (or lack of) being made by the individual. In other words, not all materials across all four toolkits are mandatory to employ during treatment. Rather, the therapist should use assessment and outcome data to inform the inclusion and subsequent emphasis of particular PST activities.

Problem-Solving Multitasking: Overcoming Brain Overload

This set of tools is geared to help an individual overcome the ubiquitous human limitation when attempting to cope with stressful situations in real life: “brain or cognitive overload” ( Rogers & Monsell, 1995 ). Due to basic human limitations in our ability to manipulate large amounts of information in our working memory simultaneously while attempting to solve complex problems or make effective decisions, especially when under stress, individuals are taught to use three “multitasking enhancement” skills: externalization, visualization, and simplification. These skills are considered foundational to effective problem solving, similar to those skills that may be taught as basic to effective aerobic exercise, such as stretching, breathing, and maintaining a healthy diet.

Externalization involves displaying information “externally” as often as possible. More specifically, clients are taught to write ideas down, draw diagrams or charts to determine relationships, draw maps, make lists, and audiotape ideas. In this manner, one’s working memory is not overly taxed and can allow one to concentrate more on other activities, such as creatively thinking of various solutions. The visualization tool is presented as using one’s “mind’s eye” or visual imagery to help (a) better clarify the nature of a problem, (b) practice carrying out a solution (imaginal rehearsal), and (c) reduce high levels of negative arousal (i.e., a form of guided imagery whereby one is directed imaginally to go on a peaceful vacation). Simplification involves “breaking down” or simplifying problems in order to make them more manageable. Clients are taught to break down complex problems into more manageable smaller problems, and to translate complex, vague, and abstract concepts into more simple, specific, and concrete language.

“Stop, Slow Down, Think, and Act” (SSTA): Overcoming Emotional Dysregulation and Ineffective Problem Solving under Stress

This toolkit becomes especially important to emphasize in situations where the primary goal of PST for a particular individual involves the decrease of clinically significant emotional distress (e.g., depression, suicidal ideation, generalized anxiety). It is also useful for training individuals as a means of preventing extant emotional concerns from becoming particularly problematic. In essence, clients are taught a series of steps to enhance their ability to modulate (as opposed to “eradicate”) negative emotional arousal in order to more effectively apply a systematic approach to solving problems (i.e., to be able to optimally use the various planful problem-solving skills). It is also presented to individuals as the overarching “map” to follow when attempting to cope with stressful problems that engender strong emotional reactions and is included as the major treatment strategy geared to foster adaptive emotional regulation skills. It is also included in PST as a means of minimizing impulsive/careless attempts at problem solving, as well as avoidance of the problem.

According to the SSTA method, clients are first taught to become “emotionally mindful” by being more aware of, and specifically focusing on, when and how they experience negative emotional arousal. Specifically, they are taught to notice changes in physical (e.g., headache, fatigue, pain), mood (e.g., sadness, anger, tension), cognitive (e.g., worry, thoughts of negative outcomes), and/or behavioral (e.g., urge to run away, yelling, crying) indicators. For certain individuals, additional training may be necessary to increase the accuracy by which they attempt to identify and label emotional phenomena. Next, they are taught to “Stop” and focus on what is happening in order to become more aware of what is engendering this arousal. More specifically, they are directed to engage in behaviors (e.g., shouting out loud, raising one’s hands, holding up a stop sign) that help them to “put on the brakes” in order to better modulate their emotional arousal (i.e., prevent the initial arousal from evoking a more intense form of the emotion together with its “full-blown” concomitant negative thinking, state-dependent negative memories, negative affect, and maladaptive behaviors).

Next, in order to meaningfully be able to “Stop,” clients are further taught to “Slow Down”; that is, to decrease the accelerated rate at which one’s negative emotionality can occur. Various specific techniques are provided and practiced with clients in order to offer them a choice among a pool of potentially effective “slowing-down tools.” These include counting down from 10 to 1, diaphragmatic breathing, guided imagery or visualization, “fake smiling” (in keeping with the potential positive impact related to the facial feedback hypothesis; Havas, Glenberg, Gutowski, Lucarelli, & Davidson, 2010 ), “fake yawning” (in keeping with recent neuroscience research demonstrating the efficacy of directed yawning as both a stress management strategy and a means to enhance cognitive awareness; Newberg & Waldman, 2009 ), meditation, exercise, talking to others, and prayer (if relevant to a particular individual). Individuals are also encouraged to use strategies that have been helpful to them in the past.

The “Thinking” and “Acting” steps in SSTA refer to applying the four specific planful problem-solving tasks (i.e., defining the problem and setting realistic goals, generating alternative solutions, decision making, solution implementation and verification) once one is “slowed down,” in attempting to resolve or cope with the stressful problem situation that initially evoked the negative emotional stress reaction.

Healthy Thinking and Positive Imagery: Overcoming Negative Thinking and Reduced Motivation

This toolkit is included to specifically address additional problem orientation issues if relevant to a particular individual, that is, negative thinking and feelings of hopelessness. Similar to cognitive restructuring strategies, clients are taught that “how one thinks can affect how one feels.” In essence, this toolkit entails a variety of cognitive change techniques geared to enhance optimism and enhanced self-efficacy. For example, clients are taught to use the “ABC Model of Thinking” (where “A” = the a ctivating or triggering event, “B” = a given b elief, attitude, or viewpoint, and “C” = the emotional c onsequence that is based on that belief, as compared to “reality”) in order to determine whether one needs to change such negative beliefs. They are provided with a series of “healthy thinking” rules (e.g., “Nothing is 100% perfect … problems are a normal part of life … everyone makes mistakes … every minute I spend thinking negatively takes away from enjoying my life”), as well as a list of “realistically optimistic self-statements” (e.g., “I can solve this problem;” “I’m okay—feeling sad under these circumstances is normal;” “I can’t direct the wind, but I can adjust the sails;” “Difficult and painful does not equal hopeless!”), as more optimistic examples of ways to think in order to readjust their orientation.

In addition, if a given individual has particular difficulty with changing his or her negative thinking, we also advocate having the PST therapist conduct a “reverse advocacy role play” exercise surrounding a given individual’s unique negative thinking patterns. In this exercise, a given maladaptive attitude is temporarily “adopted” by the therapist using a role-play format. The individual, who now has to adopt the role of “counselor,” has to provide reasons or arguments for why such an attitude is incorrect, maladaptive, or dysfunctional. In this manner, the client is influenced to begin verbalizing those aspects of a positive problem orientation. The process of identifying a more appropriate set of beliefs toward problems and providing justification for the validity of these attitudes helps the individual to begin to personally adopt such an orientation.

The second tool in this toolkit focuses on using visualization to enhance motivation and to decrease feelings of hopelessness. The use of visualization here, which is different than that described within the multitasking toolkit, is to help the client to sensorially experience what it “feels” like to successfully solve a difficult problem; in other words, to “see the light at the end of the tunnel or the crossing ribbon at the finishing line.” With this strategy, the therapist’s goal is to help patients create the experience of success in their “mind’s eye” and vicariously experience the potential reinforcement to be gained. Clients are specifically taught to not focus on “how” the problem got solved; rather, to focus on the feelings associated with having already solved it. The central goal of this strategy is to have individuals create their own positive consequences (in the form of affect, thoughts, physical sensations, and behavior) associated with solving a difficult problem as a major motivational step toward overcoming low motivation and feelings of hopelessness, as well as minimizing the tendency to engage in avoidant problem solving.

Planful Problem Solving: Fostering Effective Problem Solving

This last toolkit provides training in the four planful problem-solving tasks, the first being problem definition. This activity involves having clients separate facts from assumptions when describing a problem, delineate a realistic and attainable set of problem-solving goals and objectives, and identify those obstacles that prevent one from reaching such goals. Note that this model advocates delineating both problem-focused goals , which include objectives that entail changing the nature of the situation so that it no longer represents a problem, as well as emotion-focused goals , which include those objectives that involve moderating one’s cognitive-emotional reactions to those situations that cannot be changed. Strategies that might be effective in reaching such emotion-focused goals might include stress management, forgiveness of others, and acceptance that the situation cannot be changed.

The second task, generating alternatives , involves creatively brainstorming a range of possible solution strategies geared to overcome the identified obstacles to their goals using various brainstorming techniques. Decision making , the third planful problem-solving task, involves predicting the likely consequences of the various alternatives previously generated, conducting a cost-benefit analysis based on these identified outcomes, and developing a solution plan geared to achieve the articulated problem-solving goal. The last activity, solution implementation and verification , entails having the person optimally carry out the solution plan, monitor and evaluate the consequences of the plan, and determine whether his or her problem-solving efforts have been successful or need to continue.

Guided Practice

A major part of the PST intervention involves providing feedback and additional training to individuals in the four toolkits as they continue to apply the model to current problems they are experiencing. In addition, PST encourages individuals to “forecast” future stressful situations, whether positive (e.g., getting a promotion and moving to a new city) or negative (e.g., the break-up of a relationship) in order to anticipate how such tools can be used in the future to minimize potential negative consequences.

Future Directions

The need to address problems effectively is a fundamental part of the human experience across time and environments. Therefore, the importance of problem solving as a construct in psychology and psychotherapy is significant. In this last section, we outline several ideas about potential future directions across clinical practice, training, and research arenas.

Clinical Practice

Patients’ self-management of chronic illnesses, such as diabetes, cancer, and heart disease, has received increasing attention as a means of enhancing one’s sense of self-efficacy and the ability to deal with the difficult exigencies associated with ongoing medical illness ( Bodenheimer, Lorig, Holman, & Grumbach, 2002 ). Within this context, teaching patients to become better problem solvers as a means of improving their self-management skills can be a potentially valuable approach.

Because ineffective problem solving has continuously been associated with mental health problems and poor adjustment to stressful events, focusing on the enhancement of problem solving prior to the experience of a stressful event can serve an important prevention role. Providing training in effective problem solving to individuals about to engage in a potentially stressful role, job, or activity may prevent them from experiencing consequent distress. For example, similar to the rationale for teaching critical thinking skills to college students as a basis for general learning, becoming a more effective problem solver may represent an important preventive approach provided to students at various educational levels as a means of enhancing overall adjustment. Additional examples can include training military personnel, firefighters, and police officers as a way to prevent burnout and ineffective adjustment to traumatic events. This concept can also apply to helping family members to become more effective caregivers when a loved one suffers from a chronic illness or dementia. All such situations represent ongoing difficult problems that can potentially be better handled through a more planful approach.

Further, it would be worthwhile for problem-solving-based approaches to be disseminated and integrated more effectively into standard health and behavioral health care delivery systems. For example, an initial evaluation of a national rollout of a PST-based intervention by the Department of Veterans Affairs, entitled Moving Forward ( Nezu & Nezu, 2014 ), has shown promising results regarding its impact on decreasing depression, enhancing problem solving, and fostering resilience among veterans ( Tenhula et al., 2014 ).

Problem-solving and causal reasoning skills are core competencies in the scientific practice of professional psychology ( Layne, Steinberg, & Steinberg, 2014 ; C. M. Nezu & Nezu, 1995 ). Effective problem solving, within a therapy context, is represented by a clinician’s ability to define the problem validly (i.e., assessment, diagnosis, and case conceptualization), identify potentially effective means of reaching treatment goals (i.e., intervention strategies), make multiple decisions about conducting therapy (e.g., which intervention to carry out and when, when to terminate therapy), and evaluate the outcomes of the treatment subsequent to its implementation.

Problem solving, in this context, can be viewed as important skills to learn as part of an overall approach to competency-based training in applied psychology ( Beck et al., 2014 ). Students at various levels of training and education in applied psychology fields can be taught problem-solving skills to apply in relation to a wide range of professional activities, including assessment, intervention, consultation, interpersonal relationships, ethical dilemmas, and research.

Possible future research directions regarding PST involve testing the validity of the previously suggested applications of problem solving in clinical practice and training via rigorous research protocols. In addition, future studies could evaluate the value of adding PST to other forms of medical and psychotherapy interventions to enhance adherence to such treatments by overcoming various barriers (e.g., poor motivation, stress). Investigating possible moderators, such as personality characteristics, age, comorbid disorders, and intellectual functioning, of the effects of PST represents another major area of needed research in the future. Another research priority should be the continued determination of whether the established association between SPS and distress, as well as the efficacy of PST, is valid among other cultures. Last, similar to other psychotherapy research endeavors, it would be important to identify mediators of PST (i.e., mechanisms of action) in order to strengthen further the effectiveness of this intervention approach.

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Nezu, A. M. , Nezu, C. M. , & D’Zurilla, T. J. ( 2013 ). Problem-solving therapy: A treatment manual . New York: Springer.

Nezu, A. M. , Nezu, C. M. , Felgoise, S. H. , McClure, K. S. , & Houts, P. S. ( 2003 ). Project Genesis: Assessing the efficacy of problem-solving therapy for distressed adult cancer patients.   Journal of Consulting and Clinical Psychology , 71 , 1036–1048.

Nezu, A. M. , Nezu, C. M. , & Perri, M. G. ( 2006 ). Problem solving to promote treatment adherence. In W. T. O’Donohue & E. R. Levensky (Eds.), Promoting treatment adherence: A practical handbook for health care providers (pp. 135–148). New York: Sage Publications.

Nezu, A. M. , & Perri, M. G. ( 1989 ). Social problem solving therapy for unipolar depression: An initial dismantling investigation. Journal of Consulting and Clinical Psychology , 57 , 408–413.

Nezu, A. M. , & Ronan, G. F. ( 1988 ). Stressful life events, problem solving, and depressive symptoms among university students: A prospective analysis.   Journal of Counseling Psychology , 35 , 134–138.

Nezu, A. M. , Wilkins, V. M. , & Nezu, C. M. ( 2004 ). Social problem solving, stress, and negative affective conditions. In E. C. Chang , T. J. D’Zurilla , & L. J. Sanna (Eds.), Social problem solving: Theory, research, and training (pp. 49–65). Washington, DC: American Psychological Association.

Nezu, C. M. , Greenberg, J. , & Nezu, A. M. ( 2006 ). Project STOP: Cognitive-behavioral assessment and treatment for sex offenders with intellectual disability.   Journal of Forensic Psychology Practice , 6 , 87–103.

Nezu, C. M. , & Nezu, A. M. ( 1995 ). Clinical decision making in everyday practice: The science in the art.   Cognitive and Behavioral Practice , 2 , 5–25.

Nezu, C. M. , Nezu, A. M. , & Arean, P. A. ( 1991 ). Assertiveness and problem-solving training for mildly mentally retarded persons with dual diagnosis.   Research in Developmental Disabilities , 12 , 371–386.

Nieuwsma, J. A. , Trivedi, R. B. , McDuffie, J. , Kronish, I. , Benjamin, D. , & Williams, J. W. ( 2012 ). Brief psychotherapy for depression: A systematic review and meta-analysis.   International Journal of Psychiatry and Medicine , 43 , 129–151.

Nugent, N. R. , Tyrka, A. R. , Carpenter, L. L. , & Price, L. N. ( 2011 ). Gene-environment interactions: Early life stress and risk for depressive and anxiety disorders.   Psychopharmacology , 214 , 175–196.

Pandey, A. , Quick, J. C. , Rossi, A. M. , Nelson, D. L. , & Martin, W. ( 2011 ). Stress and the workplace: 10 years of science, 1997-2007. In R. J. Contrada & A. Baum (Eds.), The handbook of stress science: Biology, psychology, and health (pp. 137–149). New York: Springer.

Ranjbar, M. , Bayani, A. A. , & Bayani, A. ( 2014 ). Social problem solving ability predicts mental health among undergraduate students.   International Journal of Preventive Medicine , 4 , 1337–1341.

Rivera, P. A. , Elliott, T. R. , Berry, J. W. , & Grant, J. S. ( 2008 ). Problem-solving training for family caregivers of persons with traumatic brain injuries: A randomized controlled trial.   Archives of Physical and Medical Rehabilitation , 89 , 931–941.

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Cognitive Behavioral Therapy

Reviewed by Psychology Today Staff

Cognitive behavioral therapy (CBT) is a short-term form of psychotherapy based on the idea that the way someone thinks and feels affects the way he or she behaves. CBT aims to help clients resolve present-day challenges like depression or anxiety , relationship problems, anger issues, stress , or other common concerns that negatively affect mental health and quality of life. The goal of treatment is to help clients identify, challenge, and change maladaptive thought patterns in order to change their responses to difficult situations.

Originally called simply “cognitive therapy,” what is now CBT was developed in the 1960s and 1970s by psychiatrist Aaron Beck, who found that helping depressed patients recognize and challenge their automatic negative thoughts had a positive impact on their symptoms. Beck drew on theories developed by psychologist Albert Ellis, the creator of rational emotive behavior therapy (REBT), among others, to develop an approach that was short-term and goal-oriented, in contrast to the dominant modalities of the time. Though it was originally designed to treat depression, since its inception CBT has been found to be effective for a wide range of mental health conditions and day-to-day psychological challenges, and is recommended as the first-line treatment for disorders including depression, anxiety, and insomnia .

• When It's Used
• What to Expect
• How It Works
• What to Look for in a Cognitive Behavioral Therapist

CBT is appropriate for children, adolescents, and adults and for individuals, families, and couples. A large body of research has found it to be either highly or moderately effective in the treatment of depression , generalized anxiety disorder, post- traumatic stress disorder, general stress, anger issues, panic disorders, agoraphobia, social phobia , eating disorders, marital difficulties , obsessive-compulsive disorder, and childhood anxiety and depressive disorders. CBT may also be effective as an intervention for chronic pain conditions and associated distress. CBT can be used alone or in conjunction with psychiatric medication . Some studies have found that CBT and medication are equally effective in treating depression.

Specialized forms of CBT may also be used to treat specific conditions. For example, cognitive behavioral therapy for insomnia , or CBT-I, has been found to be a highly effective short-term treatment for chronic insomnia; it is now the recommended first-line treatment for individuals struggling with insomnia. Another example is enhanced cognitive behavioral therapy, or CBT-E , a form of CBT specifically designed to treat eating disorders. Brief cognitive behavioral therapy, or BCBT, is a shortened form of CBT used in situations where the client is not able to undergo a longer course of therapy.

CBT is a structured form of psychotherapy that can occur in a relatively short period of time—often between 5 and 20 weekly sessions, generally around 45 to 50 minutes each. CBT usually starts with one or two sessions focused on assessment, during which the therapist will help the client identify the symptoms or behavior patterns that are causing them the most problems and set goals for treatment. In subsequent sessions, the client will identify the negative or maladaptive thoughts they have about their current problems and determine whether or not these thoughts are realistic. If these thoughts are deemed unrealistic, the client will learn skills that help them challenge and ultimately change their thinking patterns so they are more accurate with respect to a given situation. Once the client’s perspective is more realistic, the therapist can help them determine an appropriate course of action.

CBT usually concludes with a session or two of recapping, reassessing, and reinforcing what was learned. If necessary, someone may return to therapy for periodic maintenance sessions. Along the way, clients will most likely be given “homework” to do between sessions. That work will typically include exercises that will help them learn to apply the skills and solutions they came up with in therapy to real-world situations in their day-to-day life.

While cognitive behavioral therapy may sound simple—CBT therapist Seth Gillihan writes that he tells clients that the things he’ll ask them to do are “stupidly obvious” —it can be quite challenging in practice. Our patterns of thinking are often deeply entrenched and habitual—and as with any long-standing habit, it can be an arduous process to replace one thought pattern with a new, healthier one. And while clients undergoing CBT will likely not spend a large amount of time exploring their childhood or past, they may still be asked to examine thoughts and behavior patterns that they may find embarrassing or shameful. As in all types of therapy, it is important to work with a therapist with whom one can be open and candid.

CBT integrates behavioral theories and cognitive theories to conclude that the way people perceive a situation determines their reaction more than the actual reality of the situation does. When a person is distressed or discouraged, his or her view of an experience may not be realistic. Changing the way clients think and see the world can change their responses to circumstances.

CBT often targets cognitive distortions , or irrational patterns of thought that can negatively affect behavior. Common cognitive distortions include all-or-nothing thinking (seeing everything in black-and-white terms and ignoring nuance), catastrophizing (always assuming the worst will happen), and personalization (believing that the individual is responsible for everything that happens around them, whether good or bad).

For example, someone who is prone to catastrophizing may assume that a friend who doesn't text them back right away is angry at them, potentially leading them to withdraw socially, lash out at the friend, ruminate, or otherwise behave in a non-productive way. Using CBT, they may learn to recognize their tendency to jump to the worst possible conclusion—and the next time their friend does not return their text, they can remind themselves that the friend has always returned texts in the past and may simply be busy. Such reframing can help someone refrain from engaging in counterproductive behavior.

CBT is rooted in the present, so the therapist will initially ask clients to identify life situations, thoughts, and feelings that cause acute or chronic distress. The therapist will then explore whether or not these thoughts and feelings are productive or even valid. The goal of CBT is to get clients actively involved in their own treatment plan so that they understand that the way to improve their lives is to adjust their thinking and their approach to everyday situations.

CBT is among the most widely-utilized therapeutic approaches, so many people are able to locate a therapist in their area who practices it, but CBT has also been found to be effective when delivered online. There is no particular certification or license required to practice CBT, but clients are advised to look for a credentialed mental health professional with specialized training and experience in cognitive behavioral therapy. In addition to confirming these credentials, it is important to find a therapist with whom one feels comfortable, as CBT is a collaborative process and a strong therapeutic alliance is critical to its success.

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Volume 41, Issue 9, September 2012

Problem solving therapy Use and effectiveness in general practice

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

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

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

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

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

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

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

Using PST in general practice

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

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

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

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

Figure 1. Problem solving therapy patient worksheet

PST skill development for GPs

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

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

Conflict of interest: none declared.

• Gask L. Problem-solving treatment for anxiety and depression: a practical guide. Br J Psychiatry 2006;189:287–8. Search PubMed
• Hickie I. An approach to managing depression in general practice. Med J Aust 2000;173:106–10. Search PubMed
• D'Zurilla T, Goldfried M. Problem solving and behaviour modification. J Abnorm Psychol 1971;78:107–26. Search PubMed
• Gotlib I, Asarnow R. Interpersonal and impersonal problem solving skills in mildly and clinically depressed university students. J Consult Clin Psychol 1979;47:86–95. Search PubMed
• D'Zurilla T, Nezu A. Social problem solving in adults. In: Kendall P, editor. Advances in cognitive-behavioural research and therapy. New York: Academic Press, 1982. p. 201–74. Search PubMed
• Hegel M, Barrett J, Oxman T. Training therapists in problem-solving treatment of depressive disorders in primary care: lessons learned from the: "Treatment Effectiveness Project". Fam Syst Health 2000;18:423–35. Search PubMed
• Mynors-Wallis LM, Gath DH, Lloyd-Thomas AR, Tomlinson D. Randomised control trial comparing problem solving treatment with Amitryptyline and placebo for major depression in primary care. BMJ 1995;310:441–5. Search PubMed
• Mynors-Wallis LM, Gath DH, Day A, Baker F. Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care. BMJ 2000;320:26–30. Search PubMed
• Bell A, D'Zurilla. Problem-solving therapy for depression: a meta-analysis. Clin Psychol Rev 2009;29:348–53. Search PubMed
• Mynors-Wallis L Problem solving treatment for anxiety and depression. Oxford: OUP, 2005. Search PubMed
• Seekles W, van Straten A, Beekman A, van Marwijk H, Cuijpers P. Effectiveness of guided self-help for depression and anxiety disorders in primary care: a pragmatic randomized controlled trial. Psychiatry Res 2011;187:113–20. Search PubMed
• Mynors- Wallis L. Does problem-solving treatment work through resolving problems? Psychol Med 2002;32:1315–9. Search PubMed
• Pierce D, Gunn J. GPs' use of problem solving therapy for depression: a qualitative study of barriers to and enablers of evidence based care. BMC Fam Pract 2007;8:24. Search PubMed
• Pierce D, Gunn J. Using problem solving therapy in general practice. Aust Fam Physician 2007;36:230–3. Search PubMed
• Pierce D, Gunn J. Depression in general practice, consultation duration and problem solving therapy. Aust Fam Physician 2011;40:334–6. Search PubMed
• Blashki G, Morgan H, Hickie I, Sumich H, Davenport T. Structured problem solving in general practice. Aust Fam Physician 2003;32:836–42. Search PubMed
• SPHERE a national mental health project. Available at www.spheregp.com.au [Accessed 17 April 2012]. Search PubMed

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• v.62(Suppl 2); 2020 Jan

Family Interventions: Basic Principles and Techniques

Mathew varghese.

Department of Psychiatry, National Institute of Mental Health and Neuro Sciences (NIMHANS), Bangalore, Karnataka, India

Vivek Kirpekar

1 N.K.P. Salve Institute of Medical Sciences, Nagpur, Maharashtra, India

Santosh Loganathan

Introduction.

Mental health professionals in India have always involved families in therapy. However, formal involvement of families occurred about one to two decades after this therapeutic modality was started in the West by Ackerman.[ 1 ] In India, families form an important part of the social fabric and support system, and as a result, they are integral in being part of the treatment and therapeutic process involving an individual with mental illness. Mental illnesses afflict individuals and their families too. When an individual is affected, the stigma of being mentally ill is not restricted to the individual alone, but to family members/caregivers also. This type of stigma is known as “Courtesy Stigma” (Goffman). Families are generally unaware and lack information about mental illnesses and how to deal with them and in turn, may end up maintaining or perpetuating the illness too. Vidyasagar is credited to be the father of Family Therapy in India though he wrote sparingly of his work involving families at the Amritsar Mental Hospital.[ 2 ] This chapter provides salient features of broad principles for providing family interventions for the treating psychiatrist.

TYPES AND GRADES FOR FAMILY INTERVENTIONS

Working with families involves education, counseling, and coping skills with families of different psychiatric disorders. Various interventions exist for different disorders such as depression, psychoses, child, and adolescent related problems and alcohol use disorders. Such families require psychoeducation about the illness in question, and in addition, will require information about how to deal with the index person with the psychiatric illness. Psychoeducation involves giving basic information about the illness, its course, causes, treatment, and prognosis. These basic informative sessions can last from two to six sessions depending on the time available with clients and their families. Simple interventions may include dealing with parent-adolescent conflict at home, where brief counseling to both parties about the expectations of each other and facilitating direct and open communication is required.

Additional family interventions may cover specific aspects such as future plans, job prospects, medication supervision, marriage and pregnancy (in women), behavioral management, improving communication, and so on. These family interventions offering specific information may also last anywhere between 2 and 6 sessions depending on the client's time. For example, explaining the family about the marriage prospects of an individual with a psychiatric illness can be considered a part of psychoeducation too, but specific information about marriage and related concerns require separate handling. At any given time, families may require specific focus and feedback about issues such issues.

Family therapy is a structured form of psychotherapy that seeks to reduce distress and conflict by improving the systems of interactions between family members. It is an ideal counseling method for helping family members adjust to an immediate family member struggling with an addiction, medical issue, or mental health diagnosis. Specifically, family therapists are relational therapists: They are generally more interested in what goes on between the individuals rather than within one or more individuals. Depending on the conflicts at issue and the progress of therapy to date, a therapist may focus on analyzing specific previous instances of conflict, as by reviewing a past incident and suggesting alternative ways family members might have responded to one another during it, or instead proceed directly to addressing the sources of conflict at a more abstract level, as by pointing out patterns of interaction that the family might not have noticed.

Family therapists tend to be more interested in the maintenance and/or solving of problems rather than in trying to identify a single cause. Some families may perceive cause-effect analyses as attempts to allocate blame to one or more individuals, with the effect that for many families, a focus on causation is of little or no clinical utility. It is important to note that a circular way of problem evaluation is used, especially in systemic therapies, as opposed to a linear route. Using this method, families can be helped by finding patterns of behavior, what the causes are, and what can be done to better their situation. Family therapy offers families a way to develop or maintain a healthy and functional family. Patients and families with more difficult and intractable problems such as poor prognosis schizophrenia, conduct and personality disorder, chronic neurotic conditions require family interventions and therapy. The systemic framework approach offers advanced family therapy for such families. This type of advanced therapy requires training that very few centers, such as the Family Psychiatry Center at the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru, Karnataka, India offer to trainees and residents. These sessions may last anywhere from eight sessions up to 20 or more on occasions [ Table 1 ].

Types and grades of family interventions

Goals of family therapy

Usual goals of family therapy are improving the communication, solving family problems, understanding and handling special family situations, and creating a better functioning home environment. In addition, it also involves:

• Exploring the interactional dynamics of the family and its relationship to psychopathology
• Mobilizing the family's internal strength and functional resources
• Restructuring the maladaptive interactional family styles (including improving communication)
• Strengthening the family's problem-solving behavior.

Reasons for family interventions

The usual reasons for referral are mentioned below. However, it may be possible that sometimes the reasons identified initially may be just a pointer to many other lurking problems within the family that may get discovered eventually during later assessments.

• Marital problems
• Parent–child conflict
• Problems between siblings
• The effects of illness on the family
• Adjustment problems among family members
• Inconsistency parenting skills
• Psychoeducation for family members about an index patient's illness
• Handling expresses emotions.

CHALLENGES FACED BY THE NOVICE THERAPIST

Whether one is a young student, or a seasoned individual therapist, dealing with families can be intimidating at times but also very rewarding if one knows how to deal with them. We have outlined certain challenges that one faces while dealing with families, especially when one is beginning.

Being overeager to help

This can happen with beginner therapists as they are overeager and keen to help and offer suggestions straight away. If the therapist starts dominating the interaction by talking, advising, suggesting, commenting, questioning, and interpreting at the beginning itself, the family falls silent. It is advisable to probe with open-ended questions initially to understand the family.

Poor leadership

It is advisable for the therapist to have control over the sessions. Sometimes, there may be other individuals/family members who maybe authoritative and take control. Especially in crisis situations, when the family fails to function as a unit, the therapist should take control of the session and set certain conditions which in his professional judgment, maximize the chances for success.

Not immersing or engaging/fear or involving

A common problem for the beginning therapist is to become overly involved with the family. However, he may realize this and try to panic and withdraw when he can become distant and cold. Rather, one should gently try to join in with the family earning their true respect and trust before heading to build rapport.

Focusing only on index patient

Many families believe that their problem is because of the index patient, whereas it may seem a tactical error to focus on this person initially. In doing so, it may essentially agree to the family's hypothesis that their problem is arising out of this person. It is preferable, at the outset to inform the family that the problem may lie with the family (especially when referrals are made for family therapies involving multiple members), and not necessarily with any one individual.

Not including all members for sessions

Many therapeutic efforts fail because important family members are not included in the sessions. It is advisable to find out initially who are the key members involved and who should be attending the sessions. Sometimes, involving all members initially and then advising them to return to therapy as and when the need arises is recommended.

Not involving members during sessions

Even though one has involved all members of the family in the sessions, not all of them may be engaged during the sessions. Sometimes, the therapist's own transference may hold back a member of the family in the sessions. Rather, it is recommended that the therapist makes it clear that he/she is open to their presence and interactions, either verbally or nonverbally.

Taking sides with any member of the family

It may be easy to fall into the trap of taking one member's side during sessions leaving the other party doubting the fairness and judgment of the therapist. For example, after meeting one marital partner for a few sessions, the therapist, when entering the couple, discussions may be heavily biased in his views due to his/her prior interaction. Therapists should be aware of this effect and try to be neutral as possible yet take into confidence each member attending the sessions. Therapist's countertransference can easily influence him/her to take sides, especially in families that are overtly blaming from the start, or with one member who may be aggressive in the sessions, or very submissive during the sessions can influence the therapist's sides; and one needs to be aware of this early in the sessions.

Guarded families

Some families put on a guarded façade and refuse to challenge each other in the session. By being neutral and nonjudgmental, sometimes, the therapist can perpetuate this guarded façade put forth by families. Hence, therapists must be able to read this and try to challenge them, listen to microchallenges within the family, must be ready to move in and out from one family member to another, without fixing to one member.

Communicating with the therapist outside sessions

Many families attempt to reduce tension by communicating with therapist outside the session, and beginning therapist are particularly susceptible for such ploys. The family or a member/s may want to meet the therapist outside the sessions by trying to influence the therapist to their views and opinions. Therapists must refrain from such encounters and suggest discussing these issues openly during the sessions. Of course, rarely, there may be sensitive or very personal information that one may want to discuss in person that may be permissible.

Ignoring previous work done by other therapists

It is easy for family therapists to ignore previous therapists. The family therapist's ignorance of the effects of previous therapy can serious hamper the work. By discussing the previous therapist helps the new therapist to understand the problem easily and could save time also.

Getting sucked to the family's affective state/mood

If transference involves the therapist in family structure, the therapist's dependency can overinvolved him in the family's style and tone of interaction. A depressed family causes both: Therapist to relate seriously and sadly. A hostile family may cause the therapist to relate in an attacking manner. The most serious problem can occur when a family is in a state of anxiety, induces the therapist to become anxious and make his/her comments to seem accusatory and blaming. It is very difficult for the beginning therapist to “feel” where the family is affectively, to be empathic, yet to be able to relate at times on a different affective level-to respond according to situations. It is important to be aware of the affective state/mood of the family but slips in and out of that state [ Table 2 ].

Guidelines for conducting interventions with families

FUNCTIONS OF A FAMILY THERAPIST

• The family therapist establishes a useful rapport: Empathy and communication among the family members and between them and himself
• The therapist clarifies conflict by dissolving barriers, confusions, and misunderstandings
• Gradually, the therapist attempts to bring to the family to a mutual and more accurate understanding of what is wrong
• Counteracting inappropriate denials, conflicts
• Lifting hidden intrapersonal conflict to the level of interpersonal interaction.
• The therapist fulfills in part the role of true parent figure, a controller of danger, and a source of emotional support and satisfaction-supplying elements that the family needs but lacks. He introduces more appropriate attitudes, emotions, and images of family relations than the family has ever had
• The therapist works toward penetrating (entering into) and undermining resistances and reducing the intensity of shared currents of conflict, guilt, and fear. He accomplishes these aims mainly using confrontation and interpretation
• The therapist serves as a personal instrument of reality testing for the family.

In carrying out these functions, the family therapist plays a wide range of roles, as:

• An activator
• Interpreter
• Re-integrator

BASIC STEPS FOR FAMILY INTERVENTIONS

The initial phase of therapy, the referral intake.

• Family assessment
• Family formulation and treatment plan
• Formal contract.

Patients and their families are usually referred to as some family problem has been identified. The therapist may be accustomed to the usual one-on-one therapeutic situation involving a patient but may be puzzled in his approach by the presence of many family members and with a lot of information. A few guidelines are similar to the approaches followed while conducting individual therapy. The guidelines for conducting family interventions are given in Table 2 . At the time of the intake, the therapist reviews all the available information in the family from the case file and the referring clinicians. This intake session lasts for 20–30 min and is held with all the available family members. The aim of the intake session is to briefly understand the family's perception of their problem, their motivation and need to undergo family intervention and the therapist assessments of suitability for family therapy. Once this is determined the nature and modality of the therapy is explained to the family and an informal contract is made about modalities and roles of therapist and the family members. The do's and don’ts of the family interventions are laid down to the family at the outset of the process of the interventions.

The family assessment and hypothesis

The assessment of different aspects of family functioning and interactions must typically take about 3–5 sessions with the whole family, each session must last approximately 45 min to an hour. Different therapists may want to take assessments in different ways depending on their style. Mentioned below are a few tasks which are recommended for the therapist to perform. Usually, it is recommended that the naïve therapist starts with a three-generation genogram and then follows-up with the different life cycle stages and family functions as outlined below.

• The three-generation genogram is constructed diagrammatically listing out the index patient's generation and two more related generations, for example, patients and grandparents in an adolescent client or parents and children in a middle-aged client. The ages and composition of the members are recorded, and the transgenerational family patterns and interactions are looked at to understand the family from a longitudinal and epigenetic perspective. The therapist also familiarizes himself with any family dynamics prior to consultation. This gives a broad background to understand the situation the family is dealing with now
• The life cycle of the index family is explored next. The functions of the family and specific roles of different members are delineated in each of the stages of the family life cycle.[ 3 ] The index family is seen from a developmental perspective, and the therapist gets a longitudinal and temporal perspective of the family. Care is taken to see how the family has coped with problems and the process of transition from one stage to another. If children are also part of the family, their discipline and parenting styles are explored (e.g., whether there is inconsistent parenting)
• Problem Solving: Many therapists look at this aspect of the family to see how cohesive or adaptable the family has been. Usually, the family members are asked to describe some stress that the family has faced, i.e., some life events, environmental stressors, or illness in a family member. The therapist then proceeds to get a description of how the family coped with this problem. Here, “circular questions” are employed and therapist focuses on antecedent events. The crisis and the consequent events are examined closely to look for patterns that emerge. The family function (or dysfunction) is heightened when there is a crisis situation and the therapist look at patterns rather than the content described. Thus, the therapist gets an “as if I was there” view of the family. The same inquiry is possible using the technique of enactment[ 4 ]
• The Structural Map: Once the inquiry is over, the therapist draws the structural map, which is a diagrammatic representation of the family system, showing the different subsystems, its boundaries, power structure and relationships between people. Diagrammatic notions used in structural therapy or Bowenian therapy are used to denote relationships (normal, conflictual, or distant) and subsystem boundaries, in different triadic relationships. This can also be done on a timeline to show changes in relationships in different life cycle stages and influences from different life events
• What the client is trying to convey through his/her symptoms?
• What is the role of the family in maintaining these symptoms?
• Why has the family come now?

This circular hypothesis can be confirmed on further inquiry with the family to see how the “dysfunctional equilibrium” is maintained. At this stage, we suggest that a family formulation is generated, hypothesized and analyzed. This leads to a comprehensive systemic formulation involving three generations. This formulation will determine which family members we need to see in a therapy, what interventional techniques we should use and what changes in relationships we should effect. The team will also discuss the minimum, most effective treatment plan which emerges considering the most feasible changes the family can make

• Formal Contract: A brief understanding of the family homeostasis is presented to the family. Sometimes, the full hypothesis may be fed to the family in a noncritical and positive way (“Positive Connotation”), appreciating the way in which the system is functioning the therapist presents the treatment plat to the family and negotiates with the members the plan and action they would like to take up at the present time. The time frame and modality of therapy is contracted with the family, and the therapy is put into force. The frequency and intensity of sessions are determined by the degree of distress felt by the family and the geographical distance from the therapy center, i.e., families may be seen as inpatients at the center if they are in crisis or if they live far away.

The Family Psychiatry Center at The NIMHANS, Bengaluru, Karnataka, India, is one of the centers where formal training in therapy is regularly conducted. An outline of the Family Assessment Proforma[ 5 ] used at this center is given in Figure 1 . Several other structured family assessment instruments are available [ Figure 1 ].

Family assessment proforma (Obtained with permission from the Family Psychiatry Center, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India)

Middle phase of therapy

This phase of therapy forms the major work that is carried out with the family. Depending on the school of therapy, that is used, these sessions may number from a few (strategic) to many sessions lasting many months (psychodynamic). The techniques employed depend on the understanding of the family during the assessment as much as the family – therapist fit. For example, the degree of psychological sophistication of the clients will determine the use of psychodynamic and behavioral techniques. Similarly, a therapist who is comfortable with structural/strategic methods would put these therapies to maximum use. The nature of the disorder and the degree of pathology may also determine the choice of therapy, i.e., behavioral techniques may be used more in chronic psychotic conditions while the more difficult or resistant families may get brief strategic therapies. We will now describe some of the important techniques used with different kinds of problems.

Psychodynamic therapy

This school was one of the first to be described by people like Ackerman and Bowen.[ 1 , 6 ] This method has been made more contextual and briefer by therapists like Boszormenyi-Nasgy and Framo.[ 7 , 8 ] Essentially, the therapist understands the dynamics employed by different members of the family and the interrelationships of these members. These family ego defenses are interpreted to the members and the goal of therapy is to effects emotional insight and working through of new defense patterns. Family transferences may become evident and may need interpretation. Therapy usually lasts from 15 to 30 sessions and this method may be employed in persons who are psychologically sophisticated, and able to understand dynamics and interpretations. Sustained and high motivation is necessary for such a therapy. This method is found useful in couples with marital discord from upper middle-class backgrounds. Time required is a major constraint.

Behavioral methods

Behavioral techniques find use in many types of therapies and conditions. It has been extensively used in chronic psychotic illnesses by workers such as Fallon et al. , (1986) and Anderson et al. [ 9 , 10 ] Psychoeducation and skills training in communication and problem-solving are found very useful among families which do not have very serious dysfunction. Techniques such as modeling or role-plays are useful in improving communication styles and to teach parenting skills with disturbed children. Obviously, motivation for therapy is a major requisite and hence techniques such as contracting, homework assignments are used in couples with marital discord. Behavioral techniques used in sexual dysfunction are also possible when adapted according to clients’ needs.

Structural family therapy

Described by Minuchin; Fishman and Unbarger[ 4 , 11 , 12 ] has become quite popular over the past few years among therapists in India. This is possibly because of many reasons. Our families are available with their manifold subsystems of parents, children, grandparents and structure is easily discerned and changed. In addition, in recent years most clients present with conduct and personality disorders in adolescence and early adulthood. Hence, techniques like unbalancing, boundary-making are quite useful as the common problems involve adolescents who are wielding power with poor marital adjustments between parents. These techniques are useful for many of our clients.

Strategic technique

We have found that these brief techniques can be very powerfully used with families which are difficult and highly resistant to change. We usually employ them when other methods have failed, and we need to take a U-turn in therapy. Techniques employed by the Milan school[ 13 , 14 ] reframing, positive connotation, paradoxical (symptom) prescription have been used effectively. So also have techniques like prescription in brief methods advocated by Erikson, Watzlawick et al. ,[ 15 , 16 ] been useful. Familiarity and competence with these techniques is a must and therapy is usually brief and quickly terminated with prescriptions [ Table 3 ].

Summaries of the different schools of therapies

SES – Socioeconomic status

FAMILY INTERVENTIONS IN SPECIFIC DISORDERS

Techniques to promote family adaptation to illness.

• Heighten awareness of shifting family roles – pragmatic and emotional
• Facilitate major family lifestyle changes
• Increase communication within and outside the family regarding the illness
• Help family to accept what they cannot control, focus energies on what they can
• Find meaning in the illness. Help families move beyond “Why us?”
• Facilitate them grieving inevitable losses–of function, of dreams, of life
• Increase productive collaboration among patients, families, and the health-care team
• Trace prior family experience with the illness through constructing a genogram
• Set individual and family goals related to illness and to nonillness developmental events.

Schizophrenia

Family EE and communication deviance (or lack of clarity and structure in communication) are well-established risk factors for the onset of schizophrenia.

Psychoeducational interventions aim to increase family members’ understanding of the disorder and their ability to manage the positive and negative symptoms of psychosis.

Simple strategies would include reduction of adverse family atmosphere by reducing stress and burden on relatives, reduction of expressions of anger and guilt by the family, helping relatives to anticipate and solve problems, maintenance of reasonable expectations for patient performance, to set appropriate limits whilst maintaining some degree of separation when needed; and changing relatives’ behavior and belief systems.

Programs emphasize family resilience. Address families’ need for education, crisis intervention, skills training, and emotional support.

Bipolar mood disorder

To recognize the early signs and symptoms of bipolar disorder.

Develop strategies for intervening early with new episodes and assure consistency with medication regimens.

Manage moodiness and swings of the patient, anger management, feelings of frustration.

Family conflict and rejection, low family support, ineffective communication, poor expression of affect, abuse, and insecure attachment bonds are primary focus of family therapy associated with depression cognitive-behavioral and interpersonal interventions for depression.

Family-based treatment for anxiety combines family therapy with cognitive-behavioral interventions.

Targets the characteristics of the family environment that support anxiogenic beliefs and avoidant behaviors.

The goal is to disrupt the interactional patterns that reinforce the disorder.

To assist family members in using exposure, reward, relaxation, and response prevention techniques to reduce the patients’ anxieties.

Eating disorders

Target the dysfunctional family processes, namely, enmeshment and overprotectiveness.

To help parents build effective and developmentally appropriate strategies for promoting and monitoring their child's eating behaviors.

Childhood disorders

The primary focus is the development of effective parenting and contingency management strategies that will disrupt the problematic family interactions associated with ADHD and ODD.

Family-based interventions for autism spectrum disorder

Parents taught to use communication and social training tools that are adapted to the needs of their children and apply these techniques to their family interactions at home.

Substance misuse

Enhance the coping ability of family members and reduce the negative consequences of alcohol and drug abuse on concerned relatives; eliminate the family factors that constitute barriers to treatment; use family support to engage and retain the drug and/or alcohol user in therapy; change the characteristics of the family environment that contribute to relapse Al-Anon, AL-teen.

Termination phase

This last phase of therapy is finished in a couple of sessions. The initial goals of therapy are reviewed with the family. The family and the therapist review together the goals which were achieved, and the therapist reminds the family the new patterns/changes which have emerged. The need to continue these new patterns is emphasized. At the same time, the family is cautioned that these new patterns will occur when all members make a concerted effort to see this happen. Family members are reminded that it is easy to fall back to the old patterns of functioning which had produced the unstable equilibrium necessitating consultation.

At termination, the therapist usually negotiates new goals, new tasks or new interactions with the family that they will carry out for the next few months in the follow up period. The family is told that they need to review these new patterns after a couple of months so as to determine how things have gone and how conflicts have been addressed by the family. This way the family has a better chance of sustaining the change created. Sometimes booster sessions are also advised after 6–12 months especially for outstation families who cannot come regularly for follow-ups. These booster sessions will review the progress and negotiate further changes with the family over a couple of sessions. This follow-up period, after therapy is terminated is crucial for working through process and ensures that the client-therapist bond is not severed too quickly. It is easy to deal with the clients’ and therapist’ anxieties if this transition phase is smooth.

SPECIAL SOCIOCULTURAL ISSUES IN THERAPY SPECIFIC TO INDIA

Most Indian families are functionally joint families though they may have a nuclear family structure. Furthermore, unlike the Western world more than two generations readily come for therapy. Hence, it becomes necessary to deal with two to three generations in therapy and also with transgenerational issues. Our families also foster dependency and interdependency rather than autonomy. This issue must also be kept in mind when dealing with parent–child issues. Indians have a varied cultural and religious diversity depending on the region from which the family comes. The therapist has to be familiar with the regional customs, practices, beliefs, and rituals. The Indian family therapist has to also be wary of being too directive in therapy as our families may give the mantle of omnipotence to the therapist and it may be more difficult for us to adopt at one-down or nondirective approach. Hence, while systemic family therapy is eminently possible in India one must keep in mind these sociocultural factors so as to get a good “family-therapist fit.”

Constraint factors in therapy

The economic backwardness of most out families makes therapy feasible and affordable, in terms of time and money spent, only to the middle and upper classes of our society. The poorer families usually drop out of therapy as they have other more pressing priorities. The lack of tertiary social support and welfare or social security makes it less possible to network with other systems. We are also woefully inadequate in terms of trained family therapists to cater to our large population. In our country, distances seem rather daunting and modes of transport and communication are poor for families to readily seek out a therapist. We work with these constraint factors and so the “family-therapy” fit is an important factor for families that are seeking and staying in family therapy. 17

CONCLUSIONS

Over the last few years, a systemic model has evolved for service and for training. The model uses a predominantly systematic framework for understanding families and the techniques for therapy are drawn from different schools namely the structural, strategic, and behavioral psychodynamic therapies.

Appendix: Glossary of terms

The repetitive patterns of interaction that organize the way in which family members relate and interact with each other.

Boundaries are the rules defining who participates in the system and how, i.e., the degree of access outsiders have to the system.

It may comprise of a single person, or several persons joined together by common membership criteria, for example, age, gender, or shared purpose.

When alignments stand in opposition to another part of the system (i.e., when several family members are against another member/s.

The joining together of two or more members. It popularly designates appositive affinity between two units of a system.

Channels of communication are a mechanism that defines “who speaks to whom.” When channels of communication are blocked, needs cannot be fulfilled, problems cannot be solved, and goals cannot be achieved.

Enmeshed families

In which, there is extreme sensitivity among the individual members to each other and their primary subsystem.

Financial support and sponsorship

Conflicts of interest.

There are no conflicts of interest.

Long-Term vs. Short-Term Psychotherapy Treatments

Mental Health Education » Long-Term vs. Short-Term Psychotherapy Treatments

These days, psychotherapy treatment options abound, with various forms of therapy offering different advantages and drawbacks. When deciding between short-term vs. long-term types of treatment, there are several key aspects one should consider when deciding on a treatment length, as well as the type of treatment itself.

Psychotherapy: Definition

The American Psychiatry Association (APA) defines psychotherapy as a way to assist individuals contending with various types of mental health difficulties. It is also known as talk therapy. By communicating with one another (mainly through talking, though some forms of therapy also incorporate physical activity), patient and therapist are able to gain a better understanding of the condition afflicting the patient. Over time, the patient is hopefully able to contemplate their own perspectives, defense mechanisms, scenarios, relationships, hopes and fears in their lives, both past and present, and consider how they wish to approach them moving forward. While most forms of therapy include the patient and therapist, others can include the patient and a loved one, group therapy, or animal-assisted therapy, to name a few.

Psychotherapy has been repeatedly proven to offer significant benefits to patients, with roughly 75% reporting an improvement in their well-being following therapy.

The APA goes on to state that psychotherapy can be long or short-term, spanning individual sessions or, in some cases, throughout one’s life. Psychotherapy can be offered as a standalone treatment, or in addition to other forms of treatment, such as medication or medical device treatments. As with other forms of treatment, it is strongly encouraged to consult with a licensed professional when deciding on a therapeutic treatment option.

The APA also stresses the importance of setting: psychotherapy treatments should begin by understanding the patient’s needs from the treatment and why they decided to seek it out. It should also set parameters for the frequency of the treatment’s sessions, its costs, cancellation fees and limits—with the APA particularly underscoring the importance of refraining from intimate contact between patient and therapist.

Long-term Psychotherapy Options

Historically, psychotherapy was offered as a long-term form of mental health support, and an intense one at that, with patients coming in for a session several times a week, for years.

The benefits of long-therapy include allowing the patient and therapist to take their time unpacking troubling, and at times traumatic issues, whose ramifications may have plagued the patient for a great deal of their lives. Though patients often feel an urgency to relieve themselves of adverse symptoms, some can take years to eradicate, just as some patterns of behavior can take years to replace. For these cases, there is long-term therapy.

Long-term psychotherapy options include the following:

• Psychoanalysis . One of the earliest forms of psychotherapy, psychoanalysis was invented by Dr. Sigmund Freud, who sought to uncover the mechanisms behind patients’ seemingly illogical responses. Psychoanalysis is one of the more intense forms of therapy and is typically composed of three-to-five sessions each week. Psychoanalysis can go on for years, or even indefinitely, as it attempts to make sense of the patient’s psyche and adapt their reactions and defense mechanisms to more beneficial ones, allowing them, as Freud put it, to “love and work.” The exhaustive nature of psychoanalysis can be experienced as too adverse for certain patients and may even cause an unraveling effect when they reach a traumatic event in their past. For this reason, patients with active psychosis are usually not referred to psychoanalysis. On the other hand, its in-depth approach has been found to be effective with more expansive mental health disorders, particularly personality disorders . Psychoanalysis can also help in cases of depression or anxiety , when the patient has the time and financial ability to deep-dive into their symptoms, in an effort to gain clarity as to what is causing them.
• Psychodynamics . Less intense than psychoanalysis but still offering long-term support, psychodynamic therapy usually involves weekly or bi-weekly sessions between patient and therapist. It typically goes on for at least a few months, as the therapist and patient learn to build a bond of trust, and an environment conducive to finding out new truths about oneself that have lain hidden and affecting the patient’s life from within. Like psychoanalysis, long-term psychodynamic therapy has been shown to be particularly beneficial with depression and personality disorders.
• Rehabilitative Psychotherapy. Focused not just on the mind, but on the connection between mind and body, rehabilitative psychology offers mental health support to individuals who have experienced a severe disruption to their well-being, and sometimes trauma, due to an accident, injury or illness. It often deals with the ways in which the patient’s ideas of self-worth, role in society, body image and other aspects of their life have changed due to the even or ongoing situation they are facing. Rehabilitative therapy runs the gamut between offering short-term support immediately after an accident, to continuing with the patient throughout their lives, particularly in cases of chronic illness.

Short-Term Psychotherapy Options

Short-term types of treatment are typically more goal-oriented than long-term therapy and tend to focus on specific challenges that are causing patients the greatest amount of adversity at present. One of its main advantages over long-term psychotherapy is that short-term therapy helps the patient face any avoidance tendencies they might have: whereas a long-term setting could allow them to put off dealing with a distressing aspect of their life, the more limited time frame of short-term therapy can push patients toward acknowledging and dealing with their most pressing issues.

Short-term therapy normally lasts up to 10-20 sessions, or three-to-five months. Short-term treatments initially gained recognition in the 1950s, following the rise of behavioral and family therapies, which offered a more direct approach to mental health disorders than psychodynamics. Its popularity grew further during the 1980s, when reports on the benefits of short-term treatments began being published.

Short-term treatment types include the following:

• Cognitive Behavioral Treatment (CBT). Relies on acknowledging distress and gradually exposing the patient to triggering stimuli, in an effort to build up their tolerance to them. CBT has been found to be particularly effective with obsessive-compulsive disorder (OCD).
• Short-Term Psychodynamics . As opposed to classic psychodynamics , which seeks to offer a fuller, contemplative approach to the patient’s life, short-term psychodynamics delves into more specific aspects of their experiences, such as their defense mechanisms and relationships. By turning their attention to certain areas of their life, short-term psychodynamics wishes to help the patient recognize which of their patterns of behavior are no longer adaptive, and where they might benefit from trying out new ways to react to their internal world and external environment. Emotional phobias, where the patient is overwhelmed with anxiety due to a particular emotional context, respond well to short-term psychodynamic.
• Gestalt Therapy . A more humanistic approach, gestalt psychotherapy views each individual’s perspective on their experiences as unique. Gestalt is a very validating form of therapy and aims to create consistency between the patient’s responses and their emotions, so they can feel the different aspects of their lives are integrated with one another. Gestalt has been shown to offer symptom relief in cases of anxiety and relationship-centered difficulties.

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An Integrative Model for Short-Term Treatment

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• William J. Reid 5  

Part of the book series: Applied Clinical Psychology ((NSSB))

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Approaches to interpersonal helping continue to proliferate with literally hundreds of overlapping and competing models currently on the clinical scene. Although therapists, researchers, and clinicians have striven diligently to identify which models may be best suited for which clients, problems, and so forth, these efforts have as yet produced little that is definitive, at least little that is backed by persuasive evidence. These developments have sparked a continuing movement toward eclecticism in practice as well as the rise of “integrative” practice models. The essential function of integrative models is to provide ways of synthesizing this diversity for purposes of practice, training, and research. Although the syntheses they offer are inevitably partial and selective, they can present theoretical horizons and technical combinations not found in single models.

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Reid, W.J. (1990). An Integrative Model for Short-Term Treatment. In: Wells, R.A., Giannetti, V.J. (eds) Handbook of the Brief Psychotherapies. Applied Clinical Psychology. Springer, Boston, MA. https://doi.org/10.1007/978-1-4899-2127-7_3

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Using the problem solving model and systems theory: Identify the...

Using the problem solving model and systems theory:

• Identify the theoretical orientation you have selected to use.
• Describe how you would assess the problem orientation of the client in your selected case study (i.e., how the client perceives the problem). Remember to keep the theoretical orientation in mind in this assessment stage.
• Discuss the problem definition and formulation based on the theoretical orientation you have selected.
• Identify and describe two solutions from all the solutions possible. Remember, some of these solutions should stem from the theoretical orientation you are utilizing.
• Describe how you would implement the solution. Remember to keep the theoretical orientation in mind.
• Describe the extent to which the client is able to mobilize the solutions for change.
• Discuss how you would evaluate whether the outcome is achieved or not. Remember to keep the theoretical orientation in mind.
• Explain how well the problem-solving model can be used for short-term treatment of this client.
• Describe one merit and one limitation of using the problem-solving model for this case.

The problem-solving model was first laid out by Helen Perlman. Her seminal 1957 book, Social Casework: A Problem-Solving Process , described the problem-solving model and the 4Ps. Since then, other scholars and practitioners have expanded the problem-solving model and problem-solving therapy. At the heart of problem-solving model and problem-solving therapy is helping clients identify the problem and the goal, generating options, evaluating the options, and then implementing the plan.

Because models are blueprints and are not necessarily theories, it is common to use a model and then identify a theory to drive the conceptualization of the client's problem, assessment, and interventions. Take, for example, the article by Westefeld and Heckman-Stone (2003). Note how the authors use a problem-solving model as the blueprint in identifying the steps when working with clients who have experienced sexual assault. On top of the problem-solving model, the authors employed crisis theory, as this theory applies to the trauma of going through sexual assault. Observe how, starting on page 229, the authors incorporated crisis theory to their problem-solving model.

Identifying Data Ella Schultz is a 16-year-old White female of German decent. She was raised in Ohio. Ella's family consists of her father, Robert (44 years old), and her mother, Rose (39 years old). Ella currently resides in a residential group home, where she has been since she ran away from home. Ella has been provided room and board in the residential treatment facility for the past 3 months. Ella describes herself as bi-sexual. Presenting Problem Ella has been living homeless for 13 months. She has been arrested on two occasions for shoplifting and once for loitering (as a teen in need of supervision) in the last 7 months. Ella has recently been court ordered to reside in a group home with counseling. She refuses to return home due to the abuse she experienced. After 3 months at Teens First, Ella said she is thinking about reinitiating contact with her mother. She has not seen either parent in 6 months and missed the stability of the way her family "used to be," although she is also conflicted due to recognizing the instability of her family. Ella is confused about the path to follow. Family Dynamics Ella indicates that her family worked well until her father began drinking heavily about 3 years ago. She remembers her parents being social and going out or having friends over for drinks, but she never remembered them becoming drunk. Then, her father lost his job as an information technology (IT) support professional and was unable to find meaningful work. He took on part-time jobs at electronics stores, but they left him demoralized. Her parents stopped socializing, and then her father was fired from his last job because he arrived drunk. Ella's father would regularly be drunk by the time she arrived home from school. When Ella started having trouble in school, her father would berate her when she came home if she didn't study immediately. Then, he would interrupt her studies by following her around and verbally abusing her. Soon after, he began hitting her or throwing objects at her. Once she went to the emergency room for stitches on her brow when she was struck by a drinking glass her father threw. She was able to convince the emergency room (ER) staff, however, that it was a bike accident, as she was known as an avid biker around her community, often riding to and from school and elsewhere. Ella's mother did not witness these events, as they often occurred before she returned from work, and her father might be passed out by this time. Ella reports that her mother was in denial about her father, often pretending there was no issue. When Ella tried to report the abuse, her mother took her father's side. Finally, after the stitches, Ella confronted her mom with her father present. Her father denied it, flew into a rage, and then physically abused both Ella and her mom. The next day, Ella's mom acted as if nothing happened. After the abuse quickly escalated in the next week, to the point where she could no longer hide it or cover it up,

Ella fled home and has been homeless since. She left a note before leaving for school one morning and did not return home. Educational History Ella attends school at the group home, taking general education classes for her general education development (GED) credential. Shortly after her father lost his job, Ella began experiencing learning disabilities. Her difficulties began in math, where she had difficulty sorting and making sense of numbers. Then she began to fall behind in her reading. Her grades went from a B average to consistent D's. Some of Ella's Instructors began to raise the issue of a possible learning disability. A counselor made an appointment to discuss possible causes, but Ella left school and home just prior to that meeting, and did not attend. Employment History Ella reports that her father was employed as an IT support professional at a bank. When the bank downsized and closed many branches, her father was laid off. He was unable to secure another IT support position, as many companies had begun outsourcing this work to contractors or overseas. He began to work part-time retail jobs at consumer electronics stores but quickly became demoralized and lost a series of those jobs. Her mother works as a full-time home health aide. Social History Ella reports that the homeless encampment (where she wound up for a long stretch) had a group of teens that stuck together for protection and to shield themselves and each other from certain bad choices. It was at this time that Ella reports she became bisexual, seeking out and bonding to a group of women who were able to avoid being exploited for human trafficking. The encampment group did still engage in risky behavior, however, including frequent shoplifting and other theft to secure food, supplies, etc. Likewise, although Ella reports that she did not engage in prostitution, she did engage in unprotected sex with one woman whose sexual history may have included prostitution or intravenous drug use. Thus Ella contracted a sexually transmitted infection (STI) in one instance. Ella reports she might consider trying to go home if she knew her father was no longer there, despite feeling betrayed by her mother. She would also be willing to reconcile and attend therapy with her. However, Ella feels that her mother, who comes from a very religious family (though does not practice much now), would ultimately reject her due to her bisexual identification. Ella also feels a strong bond to the group of teens and women with whom she stayed in the homeless encampment. She reports that she misses them and wishes she could see them—especially one teen in particular named Marisol. She says she considers these women to be as much, if not more, her family as her biological family.

Mental Health History Ella began counseling to address the abuse in her history. In her initial reports, as detailed above, she cites mostly verbal and psychological abuse with only two instances of physical abuse. She denies any sexual abuse. When Ella recounts the physical abuse specifically, however, she shows added signs of acute distress and trauma. The physical harm caused by the event that triggered her leaving was reportedly significant—bruising on both arms, a split lip, a bloody nose, and a bump on the head—all from punches—as well as bruises on her leg from being kicked. She did not seek medical help and avoided as much social contact as possible the day she ran away, so as not to encourage inquiries about her home situation. Ella does have positive memories of what she calls "the before time," and she shows a desire to return to that time. She worries for her mom, despite feeling betrayed by her. The last time she did have contact with her mom, she promised to leave her dad, but Ella does not know if this ever occurred. Legal History Ella has been arrested three times, twice for shoplifting and once for vagrancy. Citing the abuse she reported at home and the fears she felt, Ella was mandated to services at the Teens First agency, unlike her prior arrests when she was sent to detention. Alcohol and Drug Use History Ella denies any alcohol or drug use while living homeless. She reports the homeless encampment (where she wound up for a long stretch) had a group of teens that stuck together and were able to shield themselves from certain bad choices. Medical History During intake, it was noted that Ella showed signs of living homeless, including carrying all her possessions in one bag, signs of malnourishment, feet with heavy callouses, and clothing in disrepair. She did not show signs of drug use or self-harm. The STI she contracted was diagnosed upon intake, and she received antibiotics for treatment. Strengths Ella is resilient in learning how to survive in a difficult situation. She was able to avoid the more severe negative outcomes, such as human trafficking and drug use. She is able to form beneficial bonds for protection and support. Father: Robert Schultz (44 years old) Mother: Rose Schultz (39 years old) Daughter: Ella Schultz (16 years old)

Answer & Explanation

1. The ecological systems theory has been chosen as the theoretical framework for this situation. This theory highlights the significance of comprehending the person in relation to their several systems, such as their family, microsystem, mesosystem, exosystem, and macrosystem (interactions between systems) (sociocultural effects).

2. It's critical to comprehend Ella's perception of the issue with her existing circumstances in order to evaluate the client's problem orientation. This would include investigating her ideas, sentiments, and convictions on her family dynamics, abuse, and homelessness. Evaluating her comprehension of how these things affect her relationships, mental health, and general well-being would also be crucial.

3. The issue description and formulation for Ella would include identifying the connections between the several systems she is a member of and her unique experiences, in accordance with the ecological systems theory. This would include admitting how her father's drunkenness and abuse affected the dynamics of her family, her choice to leave her family and become homeless, and her participation in the group of women and teenagers living in the homeless encampment. The formulation would also take into account how cultural circumstances, such her mother's religious convictions and her father's restricted employment options, contributed to the issue.

4. Individual and systemic treatments might be two possible approaches to Ella's problems.

Offering trauma-informed therapy to Ella on an individual basis might be one way to support her in processing and recovering from the harm she endured. This could include methods like Eye Movement Desensitization and Reprocessing (EMDR) to treat any symptoms of trauma she might be feeling, as well as Cognitive Behavioral Therapy (CBT) to confront her negative ideas and attitudes.

Working with Ella's parents and the residential group home to enable family therapy sessions might be another systemic option. This might aid in addressing the fundamental problems with the family structure, such the effects of her father's alcoholism, her mother's enabling actions, and the need for better boundaries and communication. It could also include offering her father tools and support while he pursues therapy for his alcoholism.

5. The therapist would need to build a solid therapeutic connection with Ella and provide a secure space for her to examine her feelings in order to put the individual-level solution into practice. To assist Ella in processing and recovering from her traumatic experiences, the therapist might use trauma-focused therapies. The ecological systems theory's theoretical stance would stress how crucial it is to take into account how a person interacts with their numerous systems. Therefore, in order to guarantee a coordinated and comprehensive approach to Ella's assistance, the therapist might also work in conjunction with other professionals engaged, such as the personnel of the residential group home.

6. A number of variables, including Ella's desire to participate in the healing process, her degree of support and resources, and her willingness and preparedness for treatment, will determine how much she is able to mobilize the solutions for change. Additionally, she may not be able to completely activate the solutions if she has any underlying mental health conditions or persistent trauma symptoms. Therefore, to address any obstacles or difficulties that may occur, continual evaluation and modification of the treatments may be required.

7. The therapist may use both qualitative and quantitative metrics to assess whether or not the desired result was attained. Ella's enhanced coping mechanisms and interpersonal connections, together with her subjective experience and impression of change, could all be evaluated qualitatively by the therapist. The therapist could quantify changes in symptoms related to trauma using the Trauma Symptom Inventory-2 (TSI-2), measure changes in depressive symptoms using the Beck Depression Inventory (BDI), and examine changes in behavioral and emotional functioning using the Child Behavior Checklist (CBCL).

8. The problem-solving model offers an organized method for recognizing and resolving the objectives and challenges, making it suitable for the client's short-term therapy. This approach guarantees that all pertinent elements are taken into account and aids in guiding the treatment process. In order to obtain good results in a constrained amount of time, short-term therapy may still be helpful in giving prompt support and interventions. The problem-solving paradigm can assist shorten the process.

9. The problem-solving model's focus on the client's active participation in problem-solving and decision-making is one advantage of utilizing it in this situation. In the therapeutic process, this strengthens the client's sense of agency and autonomy. The problem-solving model's oversimplification of complicated situations and its insufficient attention to underlying systemic elements and power dynamics are drawbacks. In this situation, the ecological systems theory may direct treatments at many system levels and aid in offering a more thorough knowledge of the client's experiences.

1. The ecological systems theory has been decided upon as the appropriate theoretical direction for this particular scenario. This theory places a strong emphasis on the significance of understanding the person in the context of their many systems. These systems include the microsystem (the family), the mesosystem (the interactions between systems), the exosystem (the external impacts on systems), and the macrosystem (the societal influences).

2. In order to properly evaluate the client's issue orientation, it will be necessary to comprehend how Ella views the difficulty of the circumstance in which she now finds herself. Examining her ideas, emotions, and beliefs about her homelessness, abuse, and the dynamics of her family would be included in this process. It is also essential to evaluate her level of comprehension of the influence that these aspects have on her mental health, the quality of her relationships, and her general well-being.

3. The issue description and formulation for Ella would require, according to the ecological systems theory, acknowledging the connectivity between her unique experiences and the numerous systems she is a member of. This would include admitting the effects that her father's drinking and abuse had on the dynamics of her family, her choice to leave home and become homeless, and her engagement with the group of teenagers and women who were camping out in the park for the homeless. The approach would also take into account the role that social issues, such as the restricted employment options for her father and the religious views held by her mother, play in contributing to the situation.

4. Two possible answers for Ella might entail making changes both on an individual and a societal level.

At the level of the person, one potential approach would be to provide Ella with trauma-informed treatment in order to assist her in processing the abuse she suffered and in regaining her health. This might incorporate methods such as cognitive behavioral therapy (CBT) to challenge negative attitudes and beliefs, as well as eye movement desensitization and reprocessing (EMDR) to treat any trauma symptoms she may be having as a result of the experience.

At the systemic level, another approach may entail working with Ella's parents and the residential group home to provide family therapy sessions. This would involve working together to solve the problem. This might be helpful in addressing the underlying problems within the family structure, such as the effects of her father's alcoholism, the enabling behavior of her mother, and the need for greater communication and boundaries. It may also require offering emotional support and practical assistance in order to encourage her father to seek treatment for his alcoholism.

5. In order to put the individual-level solution into action, the therapist would need to form a solid therapeutic alliance with Ella and cultivate an atmosphere that is safe and encouraging for her to explore the range of feelings and experiences she has had. In order to assist Ella with the processing of her traumatic experiences and with her recovery from those experiences, the therapist may use trauma-focused therapies. The theoretical direction of the ecological systems theory would stress the significance of taking into account the interactions that take place between individuals and the many systems they make up. As a result, the therapist might also engage with other relevant experts, such as the personnel at the residential group home, to ensure that a coordinated and holistic approach is taken to providing assistance for Ella.

6. The degree to which Ella is able to mobilize the solutions for change will depend on a number of circumstances, including whether or not she is willing and ready for treatment, whether or not she is motivated to participate in the healing process, and the amount of support and resources that are accessible to her. In addition, the existence of any underlying mental health problems or persistent trauma symptoms may have an effect on her capacity to completely mobilize the answers. As a result, continuous evaluation and modification of the treatments may be required in order to handle any new obstacles or difficulties that may appear.

7. The therapist may use either qualitative or quantitative evaluation methods in order to determine whether or not the desired goal has been attained. The therapist is in a position to qualitatively evaluate Ella's increased coping abilities and interpersonal interactions, as well as her subjective experience and impression of improvement. Quantitatively, the therapist could use standardized measures such as the Trauma Symptom Inventory-2 (TSI-2), the Beck Depression Inventory (BDI), and the Child Behavior Checklist (CBCL) to evaluate changes in behavioral and emotional functioning. These measures include the Trauma Symptom Inventory-2 (TSI-2), which measures changes in trauma-related symptoms; the Beck Depression Inventory (BDI), which measures changes in depressive symptoms; and the Beck Depression Inventory (BDI), which measures changes in depressive symptoms.

8. The problem-solving model is an option for giving short-term therapy to this client because it offers a systematic method for identifying and resolving the client's issues and objectives. The therapy process may be guided by this model, which also helps to guarantee that all essential elements are taken into consideration. The problem-solving paradigm may assist shorten the process in order to obtain good results within a limited period, which can make short-term therapy more successful in giving immediate support and interventions.

9. One of the benefits of applying the problem-solving model to this situation is that it places a focus on the client's active participation in the process of resolving problems and making decisions. This gives the client more control over the therapy process and encourages them to act on their own initiative. However, one of the drawbacks of using the problem-solving approach is that it has the potential to oversimplify complicated problems and does not address the underlying systemic elements and power dynamics in an effective manner. In this particular scenario, the ecological systems theory may be of assistance in providing a more in-depth knowledge of the client's experiences and in guiding treatments at different levels of the system.

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