Arthur M. Nezu, PhDChristine Maguth Nezu, PhDAlexandra P. Greenfield, MS
Department of Psychology, Drexel University
Problem-solving therapy (PST) is a psychosocial intervention that trains individuals to adopt and effectively apply adaptive problem-solving attitudes (e.g., enhanced self-efficacy) and behaviors (e.g., planful problem solving) in order to help them effectively cope with the exigencies of stressful events (Nezu, 2004). The goal is not only to reduce psychopathology, but also to enhance psychological functioning in a positive direction in order to prevent relapse and the development of new distressing problems. Originally outlined by D’Zurilla and Goldfried (1971), the theory and practice of PST has been refined and significantly revised to assimilate recent research in psychopathology, cognitive science, and affective neuroscience. Because the therapy protocol has changed significantly from its earlier roots, we use the term contemporary problem-solving therapy to highlight these changes (Nezu, Greenfield, & Nezu, 2016).
Based on a biopsychosocial diathesis-stress model of psychopathology, PST involves training people to cope effectively with life stressors hypothesized to engender negative health and mental health outcomes (Nezu et al., 2016). These include major negative life events (e.g., death of a loved one, chronic illness, job loss) and ongoing daily problems (e.g., continuous tension with coworkers, reduced finances, marital difficulties). PST theory suggests that much of what is conceptualized as psychopathology is a function of ineffective coping with such stressors. As such, teaching individuals to become better problem solvers is hypothesized to lead to decreased extant physical and mental health problems, as well as improved resilience to future stressors. Scores of randomized controlled trials and meta-analyses (e.g., Barth et al., 2013; Bell & D’Zurilla, 2009; Cape, Whittington, Buszewicz, Wallace, & Underwood, 2010; Kirkham, Seitz, & Choi, 2015; Malouff, Thorsteinsson, & Schutte, 2007) indicate that PST is an effective treatment for a diverse population of individuals experiencing a wide range of psychological, behavioral, and health disorders.
According to the PST approach, certain major obstacles can impede effective problem resolution, including (a) cognitive overload, (b) emotional dysregulation, (c) biased cognitive processing of emotion-related information, (d) poor motivation, and (e) ineffective problem-solving strategies. To overcome such barriers, PST provides training in the following four major problem-solving “tool kits”: (a) problem-solving multitasking, (b) the stop, slow down, think, and act (S.S.T.A.) method of approaching problems, (c) healthy thinking and positive imagery, and (d) planful problem solving (see Nezu, Nezu, & D’Zurilla, 2013, for a detailed PST treatment manual).
Note that an individualized case formulation of a client’s specific problem-solving strengths and weaknesses should determine whether all strategies in all tool kits are taught and emphasized. In other words, it is not mandatory to employ all materials across all four tool kits during treatment. Rather, therapists should use assessment and outcome data to inform which tools to emphasize and include.
To help illustrate this overall approach, we first introduce Jessica, a client for whom PST was assessed as appropriate and potentially helpful. The remainder of the chapter provides brief descriptions of the PST tools with some illustrations of how they were applied to her case.
Jessica was a thirty-year-old medical student with a family history of anxiety and depression. She came to treatment with the view that she was incapable of meeting her goals in life. She believed that other people were always “happier” and less worried about their achievements, relationships, or value. When focused on academic goals, she would become obsessive and convinced that she could never achieve them. Further, if she became somewhat successful in her career, she felt that her personal life was certain to suffer, and that she would never have quality relationships or be able to experience enjoyable leisure activities simultaneously. Jessica’s personal and romantic relationships generally focused on sexual excitement or nurturing others. This frequently engendered obstacles to pursuing her own important life goals. The resulting sense of failure and comparison with others who were moving forward in their lives created a vicious cycle of stressful problems.
As a function of a formal assessment, the therapist determined that Jessica possessed a strong sense of purpose, a creative and skilled mind, and a desire for a loving connection with others. Her means of trying to solve problems or meet goals, however, was continually thwarted by her negative problem orientation (shame, worry, and pessimism) and her avoidance of meaningful connections. For example, when the one-sided relationships she had selected and created were not reciprocated, she experienced a sense of neediness, anger, failure, and dread. Due to her strong reactions to stress (i.e., feeling overwhelmed, depressed, and anxious), as well as her unsuccessful attempts to move toward her values and life dreams, the therapist determined that PST would be an appropriate therapeutic approach.
As we describe the major PST tools next, we also include relevant examples from Jessica’s treatment sessions.
One of the barriers to effective problem solving is the limited capacity of the brain to successfully perform multiple tasks simultaneously, especially when under stress. To overcome this barrier, the first PST tool kit involves training individuals to use three multitasking enhancement skills: externalization, simplification, and visualization.
Externalization involves displaying information externally. This procedure relieves the mind from having to actively hold information to be remembered. Externalization can include writing ideas down, drawing a diagram, making a list, creating an audio recording, or talking aloud.
Simplification involves breaking a problem down into more manageable pieces. To use this strategy, clients are taught to focus only on the most relevant information: to identify smaller, concrete steps to reach one’s goal and to translate complex, vague, and abstract concepts into more simple, specific, and concrete language. One way for individuals to practice using this skill is to write down a brief description of the problem (i.e., applying the externalization strategy), and then ask or imagine asking a friend to read the description and give feedback regarding its clarity.
Visualization may be used for a variety of purposes to aid the problem-solving process. When using visual imagery, clients are taught to engage all their senses (where relevant) to imagine seeing, smelling, tasting, touching, and hearing the experience they are creating in their mind. One form of visualization is problem clarification, in which clients create a visual representation of a problem they face or a goal they wish to achieve in order to gain clarity about it. A second form of visualization is imaginal rehearsal, in which clients practice planned solutions in their mind. This form of visualization can be especially useful when people are overwhelmed with considering how they will carry out a solution or personal action plan at a later time. A third form is guided imagery, a type of stress management that reduces one’s negative arousal. In this activity, the therapist provides detailed instructions that foster the client’s ability to take a mental trip to a relaxing “safe place,” such as a favorite vacation spot.
Jessica I felt overwhelmed. My chest started to tighten when I thought about meeting this guy—who I had just started to date—for drinks.
Therapist: Were you able to use any of the multitasking tools to manage this feeling of being overwhelmed, as we discussed?
Jessica: Yeah, I decided to use externalization combined with visualization—I listed some of my concerns, especially wanting to spend more time with him. I then wrote down my goals for changing the way I used to relate to men—I really want to be more honest in disclosing the things that are important to me. I visualized myself expressing to him that I wanted to be able to spend more time with him. I used the visualization to practice trying to be honest, but also fair and empathic, not demanding like before, saying that I understood his schedule was busy and taking responsibility for my schedule also being an obstacle, but that I did want to get more time to hang out—some day activities, and the like. He expressed some things about how it was difficult because our schedules didn’t always match up, that he really is trying to save more money this year, and so that means working more, etc. He didn’t necessarily say that he would meet me halfway, but I guess just me expressing this to him was important for me—as I was being honest. Overall, the actual date turned out pretty nice. I did feel less overloaded, more relaxed.
Stressful stimuli can engender significant neurobiological arousal that leads to an immediate negative emotional reaction. Given the speed with which these responses can be generated, such negative arousal can impact one’s problem-solving attempts in ways that can be detrimental, such as by being avoidant or impulsive rather than planful or rational. Applying the second PST tool kit—stop, slow down, think, and act (S.S.T.A)—can help individuals overcome the difficulties with managing such negative emotional reactions.
Jessica: Why can’t I ever just go into a situation without constant self-doubt? Other people are able to take a test or give a presentation without withdrawing to their room and continually worrying about everyone knowing how inadequate they are. I’m dreading taking the medical boards—what if I just lose it and freeze?
Therapist: Let’s see if we can use the simplification tool to first break down this situation, and then consider ways to help “retrain your brain” in order for you to focus on problem solving rather than the worry. The answer to your first question is simply that you are human. Everyone has self-doubt. The difference between you and someone else is that your self-doubt leads to more worry, which leads to more self-doubt, and so forth. In a matter of seconds, your arousal goes from zero to sixty—more like thirty to one hundred because you start off being aroused. It’s important for you to turn down the volume on this arousal long enough to allow your brain to start problem solving. The goal of this new tool kit is to buy some time, become more aware of your feelings, and minimize their negative impact on problem solving. It’s important to have emotions work in your favor by learning to become more aware, to better manage or regulate your negative emotions, and to embrace the lesson that your emotions are telling you. This set of tools is represented by the acronym S.S.T.A., which stands for stop, slow down, think, and act. It is best learned by continued practice.
Jessica: How can this help me get through my medical boards?
Therapist: Let’s first use visualization—put yourself in this situation right now. Imagine that you are in your den, studying for the board exam. You begin to experience self-doubt. What’s next?
Jessica: I think that I may not pass this… I start to feel sick to my stomach, and I keep saying over and over again: “Why can’t I be different, like everyone else? Why do I have to worry so much? Why am I so messed up?”
Therapist: Now stop! Start to breathe slowly, which, by the way, is one of several different slow-down techniques that I will teach you. Use this slow-down strategy to become aware of what is happening and what you are feeling.
Jessica: I’m scared and I feel inferior to everyone else.
Therapist: See what you discovered here by observing your inner experience? You feel the normal discomfort of fear that you could fail; but based on your past, you have learned to automatically tell yourself that this feeling means that there is something wrong with you. Because this is untrue and not helpful, we’re going to have you train your own brain to turn down the volume on that arousal, so that your brain can get back to focusing on studying without such interference from your worries. It’s like applying the brakes to the train early on, rather than letting the train leave the station and then trying to stop it.
(Note: Jessica found the slow-down techniques of S.S.T.A. and breathing slowly helpful and reported that she used them approximately ten times during her actual board examination, which, parenthetically, she successfully passed.)
When practicing the S.S.T.A. procedure, the therapist instructs clients to select a current problem, to use visualization to reexperience the situation in which the problem arose, and then to follow these steps.
This initial step helps individuals become more aware of their reactions to stressful stimuli and more attuned to the meaning and nature of their emotional experiences. The therapist teaches clients to identify unique triggers and increase their emotional awareness by stopping to notice their feelings throughout the day; the events that led to any change in emotions, physical sensations, and behavior; as well as the intensity of their feelings. They are further taught to use externalization to write these observations down, which can help them remember as well as clarify what they are feeling.
The third problem-solving tool kit—healthy thinking and positive imagery—is aimed at individuals for whom dealing with negative thinking and feelings of hopelessness interferes with effective problem solving. The ABC model of healthy thinking is one approach that draws heavily on other cognitive and behavioral strategies that help individuals to cognitively restructure their negative thinking by detecting irrational beliefs, by testing the validity of negative cognitions behaviorally, and by modifying maladaptive dysfunctional beliefs. According to this approach, clients are asked to identify the (A) activating event or stressful problem, (B) beliefs or thoughts about the problem, and their (C) consequential emotional reaction, and then they examine the accuracy and inaccuracy of the thoughts. These thoughts can be replaced with more positive self-statements. In addition, cognitive defusion, acceptance, and mindfulness methods (see chapters 23, 24, and 26) may be deployed at this point of PST.
The in-session activity called reverse advocacy role-play is another tool that can help individuals overcome negative thinking. In this activity, the therapist temporarily adopts a negative attitude toward a stressful problem and asks the client to assume the role of the therapist, whose objective is to provide reasons for why the negative statement is incorrect, irrational, or maladaptive. The process of verbalizing a more appropriate set of beliefs helps the individual to begin to personally adopt a more positive problem orientation and to become more aware of the possibility of greater cognitive flexibility during well-practiced patterns of negative thinking. This activity can also be used in a group setting, as participants can take turns representing both maladaptive and adaptive responses to a given problem.
To increase hopefulness and the adoption of a more positive problem orientation, a fourth form of visualization can be an effective tool. Individuals are asked to visualize the experience of having solved the problem (as compared to focusing on how to solve the problem). These images can also be linked to client values (see chapter 25) to further increase the client’s motivation. Additionally, by visualizing the simplification of large goals into smaller, more manageable objectives, individuals may become more engaged in planful problem solving.
The final tool kit focuses on teaching four planful problem-solving skills. The first is problem definition, whereby clients learn to take the opportunity to fully understand the nature of the problem before attempting to solve it. In describing this process to clients, it may be helpful to use the analogy of laying out a route for travel as being similar to the process of defining problems. In addition, successful problem definition involves seeking all available information about the problem and discriminating between facts and assumptions. A useful exercise to demonstrate this latter principle is to show clients a picture of an ambiguous situation taken from a magazine or newspaper. The therapist directs individuals to view the picture for a few moments, put it aside, and then write down everything they saw or thought was happening in the picture. They then look through the list, and along with feedback from the therapist, differentiate statements that describe facts from those that describe assumptions.
Problem definition also involves describing the facts about a problem in clear and unambiguous language, which clients can do using the externalization and simplification strategies from the multitasking tool kit. It’s very important that clients identify goals that are realistic and attainable. If a goal seems initially too large to accomplish, the client can use simplification to break the problem down into smaller ones while still keeping the final destination in mind. Once the clients have articulated a goal or set of goals, they are taught to identify the barriers to reaching such goals. This last activity is particularly important, as a client is unlikely to successfully resolve a given problem unless most of these barriers are overcome.
Jessica: With my medical school rotations I have no time for myself. I don’t do well with having to work nights at the hospital—afterward, I feel so tired that I just want to sleep. I start thinking that I’ll never have any quality relationships or a personal life.
After spending some time reviewing Jessica’s sense of feeling overwhelmed, and her assumption that the very existence of obstacles represents valid evidence that she will never have a personal life, she and her therapist began to collaborate on identifying goals for increasing satisfying personal time.
Jessica: It would give me more hope if I could get out once a week to do something for myself and feel more balanced.
Therapist: Great. So, let’s break this down to be more specific about what “balance” means to you.
Jessica: Not having to do with school or medicine, but something that makes me feel stronger, healthier, and more connected to people.
Therapist: Okay…so the goal is to once a week do something for yourself and feel more balanced, defined as “feeling stronger, healthier, and more connected to people”?
Jessica: Right, but with my schedule, I just don’t see…
Therapist: See what you’re doing? You are way ahead of me; we haven’t even finished defining this problem yet before you want to become negative. We do need to identify obstacles to your goal in order to identify solutions to overcome such obstacles. I know that your barriers are stressful and real… If they didn’t exist, you could go and simply achieve your goal. Sometimes, I think one of the biggest hurdles for you is to respect and validate that such obstacles are significant. Let’s start to list these barriers.
Jessica: Okay, so I have very little time. Maybe just two or three times a week that I could carve out a couple hours away from the hospital.
Therapist: Okay, very limited time…that certainly presents a challenge.
Jessica: And my few friends are often on different schedules.
Therapist: Another significant obstacle, especially for people at your age who are in the midst of building careers.
Jessica: I have no men in my life and don’t have time to set up a whole lot of dates.
Therapist: Right—no significant other, at this time, who you can rely on for support to set things up.
Jessica: Money.
Therapist: Limited finances provide one more obstacle. Any others?
Jessica: I’m tired when I get off call, and that puts me in such a crappy mood that I’m not even motivated to make plans.
Therapist: That list provides us with a comprehensive problem definition. Let’s recap the obstacles, which really underscore how stressful this problem is for you to work through. I’m really proud of you for trying. Obstacles include limited time, friends with different schedules, no significant other to rely on, limited finances, and negative mood when you are first off call.
Jessica: So you do seem to get why this is a tough problem. (Sighs.)
At the end of this problem-definition step, Jessica had a sense of being heard, of her goals being supported, and of her obstacles being both identified and validated. It was important for both her and the therapist to recognize that when going on to the next aspect of the problem-solving tool kit, Jessica would be generating creative ways to approach her goals and address her obstacles. For example, one way to manage the obstacle of low mood following being on call is to plan to sleep for several hours and to avoid planning activities for that particular time (as her mood may sabotage her best intentions and add to her feeling of being overwhelmed).
The second planful problem-solving skill is generating alternatives, which involves brainstorming a range of possible solutions to get closer to goals and to overcome identified obstacles, thus increasing cognitive flexibility (see chapter 21). Creating a pool of solution options can increase clients’ chances of arriving at the best solution, help them feel more hopeful, minimize black-and-white thinking, and reduce the tendency to act impulsively. There are three major brainstorming principles used to foster one’s creativity: quantity leads to quality (i.e., the more the better), defer judgment (i.e., withhold judgment until after a pool of ideas is generated), and variety enhances creativity (i.e., think of a wide variety of ideas). When clients feel stuck, the therapist might suggest combining two or more ideas to make a new one, taking one idea and slightly modifying it to generate a new approach, thinking of how others might solve the problem, or visualizing oneself or others overcoming the various obstacles to the goal. Clients can practice this basic creativity skill with a variety of hypothetical problems, such as generating ideas about what one might do with a single brick. It may also be helpful to create a more realistic problem with specific barriers, such as how one might meet new people after moving to another neighborhood while addressing barriers such as shyness or limited finances. By applying the brainstorming principles to scenarios that aren’t laden with emotion, clients can practice them to improve the generating-alternatives skill before applying it to the more emotionally charged real-world problems they came to therapy to overcome.
Decision making is the third planful problem-solving task. It involves initially screening out obvious ineffective solutions, predicting a range of possible consequences for the remaining solutions, conducting a cost-benefit analysis of the predicted outcomes, and developing a solution plan geared to achieving the articulated problem-solving goal. In weighing the pros and cons of the various solution ideas, individuals are taught to use the following criteria: the likelihood that the solution can overcome the major obstacles, the likelihood that the individual can carry out the solution, various personal consequences (e.g., time, effort, physical health), and various social consequences (e.g., effects on family and friends). They are also instructed to consider both short-term and long-term consequences. A solution plan, then, would include alternatives that are rated highly.
In the last planful problem-solving activity, solution implementation and verification, clients observe and monitor the effects of the chosen solution, determine if the problem is successfully resolved, and troubleshoot areas of difficulty when problem-solving efforts are not successful. In addition, it is important for clients to reinforce themselves for engaging in the planful problem-solving process, particularly individuals who believe they are poor problem solvers and doubt their ability to successfully resolve stressful problems. Examples include going to one’s favorite restaurant, buying a new dress, or simply “patting oneself on the back.”
Although each tool kit is introduced and learned in a linear fashion, the majority of PST sessions are aimed at integrating these strategies so a client can apply them to current, stressful life challenges. In actual practice, PST is applied less as a standard protocol and more as a flexibly implemented strategy—based on sound clinical judgment—that concentrates on an individual client’s targeted areas of practice and improvement. For example, extensive time was spent helping Jessica to better regulate her negative arousal when confronted with problems, to manage cognitive overload, and to decrease feelings of hopelessness.
Barth, J., Munder, T., Gerger, H., Nüesch, E., Trelle, S., Znoj, H., et al. (2013). Comparative efficacy of seven psychotherapeutic interventions for patients with depression: A network meta-analysis. PLoS Medicine, 10(5), e1001454.
Bell, A. C., & D’Zurilla, T. J. (2009). Problem-solving therapy for depression: A meta-analysis. Clinical Psychology Review, 29(4), 348–353.
Cape, J., Whittington, C., Buszewicz, M., Wallace, P., & Underwood, L. (2010). Brief psychological therapies for anxiety and depression in primary care: Meta-analysis and meta-regression. BMC Medicine, 8(Article 38).
D’Zurilla, T. J., & Goldfried, M. R. (1971). Problem solving and behavior modification. Journal of Abnormal Psychology, 78(1), 107–126.
Kirkham, J., Seitz, D. P., & Choi, N. G. (2015). Meta-analysis of problem solving therapy for the treatment of depression in older adults. American Journal of Geriatric Psychiatry, 23(3), S129–S130.
Malouff, J. M., Thorsteinsson, E. B., & Schutte, N. S. (2007). The efficacy of problem solving therapy in reducing mental and physical health problems: A meta-analysis. Clinical Psychology Review, 27(1), 46–57.
Nezu, A. M. (2004). Problem solving and behavior therapy revisited. Behavior Therapy, 35(1), 1–33.
Nezu, A. M., Greenfield, A. P., & Nezu, C. M. (2016). Contemporary problem-solving therapy: A transdiagnostic approach. In C. M. Nezu & A. M. Nezu (Eds.), The Oxford handbook of cognitive and behavioral therapies (pp. 160–171). New York: Oxford University Press.
Nezu, A. M., Nezu, C. M., & D’Zurilla, T. J. (2013). Problem-solving therapy: A treatment manual. New York: Springer.