Problem-solving therapy

1. Introduction

Version followed: contemporary PST as set out in Nezu, Nezu & D'Zurilla (2013), Problem-Solving Therapy: A Treatment Manual, updated as Emotion-Centered Problem-Solving Therapy (EC-PST) in Nezu & Nezu (2019), Emotion-Centered Problem-Solving Therapy: Treatment Guidelines. The brief seven-stage primary-care version (PST-PC: Mynors-Wallis 2005; Hegel & Areán manual) and PEARLS are given as variants where they differ.

Sources: this guide draws on these pages: the publisher pages and tables of contents for the 2013 manual and the 2019 EC-PST guidelines, the publisher page for the ADAPT self-help guide (Nezu, Nezu & D'Zurilla 2006), a PST group-session template based on the 2013 manual, the AIMS Center PST-PC page, a review of Mynors-Wallis's PST guide, the PEARLS intervention summary and Cuijpers et al. (2018). Verified: toolkit names and numbering in both editions, the ADAPT steps, the SSTA sequence, the multitasking skills (externalisation, visualisation, simplification), the brainstorming principles, the guided-practice / future-forecasting / termination phase, and the PST-PC and PEARLS session parameters. Not verifiable because the manual text itself is not drawn on: the detailed step order within each toolkit, reverse advocacy role-play, the content of the EC-PST "metamessages", the rapid problem-solving procedure, and details of the IMPACT adaptation. These remain [uncertain]. Wording is paraphrased throughout; no manual text is reproduced.

What it is. Problem-solving therapy is a brief, skills-based cognitive-behavioural intervention. It teaches people to cope with stressful problems, large and small, using a set way of thinking and acting. D'Zurilla & Goldfried (1971) first set it out as a five-stage training model. D'Zurilla & Nezu later developed it into the "social problem-solving" model, and the Nezus have since built it into an emotion-centred, transdiagnostic therapy. [source: D'Zurilla & Goldfried 1971; D'Zurilla & Nezu 2007; Nezu, Nezu & D'Zurilla 2013; Nezu & Nezu 2019]

Core idea of change. Much psychological distress results from stress that has not been handled well: major negative life events and the daily problems that pile up after them. PST frames this as a biopsychosocial diathesis–stress model. Effective real-life problem solving buffers that stress. Problem-solving ability has two parts: (a) problem orientation, the person's beliefs and emotional set about problems (positive versus negative), and (b) problem-solving style: planful/rational, impulsive/careless, or avoidant. Change comes from four things: building a positive orientation, regulating the emotional arousal that hijacks thinking under stress, reducing impulsive and avoidant coping, and practising planful problem solving on the client's real problems until it generalises. Problem-solving skills are the core; most PST manuals do not include formal cognitive restructuring. EC-PST "moves emotion to a critical position" across all its strategies. Emotions are treated as information to use, and as the main thing that disrupts problem solving when not regulated; the authors base this shift on affective-neuroscience findings. [source: Springer Publishing page for Nezu & Nezu 2019; Nezu, Nezu & Gerber 2019 abstract; Cuijpers et al. 2018; CDP group template (orientation and three styles); D'Zurilla & Nezu 2007] [uncertain: the four-part summary of change mechanisms has not been checked against manual text]

2. Framework

Format. Individual or group; face to face, by telephone or by video (the 2019 guidelines cover telehealth and community collaborative-care delivery). Length depends on the version: (a) contemporary PST and EC-PST are organised as "stepped care", so the number of toolkits and sessions is tailored rather than fixed. (b) Cuijpers et al. (2018) sort trials into three types. Extended PST typically has 10 or more sessions, is often run in groups, and also targets attitudes that block problem solving. Brief PST has 9 or fewer sessions, was developed for primary care, and can be delivered by trained nurses. Self-examination therapy is guided self-help: it focuses on the person's major life goals and the problems tied to them, and on accepting what cannot change. (c) PST-PC typically runs 6–10 sessions; the first lasts about one hour and later ones 30 minutes. Mynors-Wallis's guide describes a typical course as six weekly sessions totalling under four hours. (d) PEARLS has eight 50-minute home sessions over 19 weeks. (e) A group format based on the 2013 manual, used in military settings, runs four 90-minute sessions. [source: Springer pages for Nezu et al. 2013 and Nezu & Nezu 2019; Cuijpers et al. 2018; AIMS Center PST page; Tang 2006 review of Mynors-Wallis; ACL PEARLS summary; CDP PST group note template] [uncertain: the session length for full PST (often 45–60 minutes in trials) was not verified]

Phases (contemporary PST / EC-PST) [source: chapter structure of Nezu et al. 2013 and Nezu & Nezu 2019, from the publishers' tables of contents: introductory sessions; toolkits; guided practice, future forecasting and termination] [synthesis: the A–E grouping, session ranges and move-on criteria]

Tailoring rule. Profile the client's problem-solving style. A strong negative orientation, hopelessness or high emotional reactivity calls for more time on motivation, Stop and Slow Down, and healthy thinking. Deficits in planful skills call for more time on planful problem solving. A client whose main issue is an impulsive or avoidant style needs SSTA plus graded planful practice. A client who already problem-solves well may need only an abbreviated course. [source: both books organise the toolkits as "stepped care" (Springer pages for 2013 and 2019); 2019 Toolkit #3 targets low motivation and hopelessness and Toolkit #4 targets emotional dysregulation (2019 TOC)] [synthesis for the specific mapping]

PST-PC seven stages (the brief primary-care version; one cycle per session on a chosen problem). Descriptions label the stages slightly differently. Tang's (2006) review of Mynors-Wallis's guide gives: explanation of the treatment, identifying problems, clarifying problems, setting achievable goals, generating solutions, implementing solutions, evaluating the outcome. The list below uses the common PST-PC wording, in which choosing a solution and planning the action are separate stages. [source: Tang 2006 review of Mynors-Wallis 2005] [uncertain: the wording of the list below; the Hegel & Areán manual is not drawn on]:

1. Explain the treatment and its rationale (session 1); link symptoms to problems.
2. Clarify and define the problem.
3. Set an achievable goal.
4. Generate several solutions (brainstorm).
5. Weigh the pros and cons of each and choose one.
6. Make a concrete action plan (what, when, where, who) for the chosen solution.
7. Evaluate the outcome at the next session, then start the cycle on the same or a new problem.

Over the course, the client takes on more of the steps and the clinician's role moves from active guide to supporter. Later PST-PC versions (e.g., the IMPACT collaborative care programme) add scheduling of pleasant activities to every session. [source: Hegel & Areán manual; Unützer et al. 2002 (IMPACT)] [uncertain: details of the IMPACT adaptation not re-checked]

PEARLS (Program to Encourage Active, Rewarding Lives for Seniors): for adults aged 60 and over with minor depression or dysthymia who receive home-based social services. Eight 50-minute sessions are held in the client's home over 19 weeks, delivered by a trained social-service counsellor. Components: problem-solving treatment (recognising depressive symptoms, defining the problems that feed them, and devising steps to solve them), planning social and physical activity, planning pleasant events, and linking the client to community services and events. The efficacy trial held weekly case-review meetings. The developer supplies a brief fidelity instrument, quality-assurance forms and a 2005 counsellor manual. Training is optional (2-day, on-site or online). [source: ACL PEARLS intervention summary; Ciechanowski et al. 2004] [uncertain: psychiatric supervision arrangements are not described]

3. Guiding principles

[source: D'Zurilla & Nezu 2007; Nezu et al. 2013; Nezu & Nezu 2019; Mynors-Wallis 2005 for the PST-PC items. The one-line practical meanings are synthesis.]

• Problems are a normal part of life. Treat the client's problems as expected, not as proof of personal failure. Normalise early and often.
• Problems are challenges, not only threats. Help the client approach a problem as something to work on, without denying how hard it is.
• Emotions are information. Help the client notice feelings as signals that a problem exists and that something matters, rather than as something to suppress. [EC-PST emphasis]
• Emotional arousal disrupts problem solving. When the client is highly aroused, slow down before solving. Regulate first, then think.
• Brain overload is real. Under stress, working memory is limited. Get things out of the head: write them down, break them down, picture them.
• Avoid both impulsivity and avoidance. Name these styles as unhelpful habits and swap in planful steps. Do not blame the client for them.
• Self-efficacy and commitment matter as much as skill. Build confidence and motivation before expecting the client to act.
• Effective solutions balance goals and consequences. A good solution reaches the goal while making personal and social benefits as large as possible and costs as small as possible, in the short and long term.
• Some problems cannot be changed. Then the goal becomes emotion-focused. For unchangeable situations, set goals about coping, acceptance or meaning instead of fixing the situation.
• Facts before assumptions. Problem definition comes first. Separate what is known from what is inferred before generating solutions.
• Quantity breeds quality. In brainstorming, defer judgment and aim for many varied ideas.
• The client solves the problems; the therapist teaches the method. Do not hand over solutions. Coach, prompt and model the process.
• Use real problems. Practise on the client's current stressors, not hypothetical examples, except when teaching a step for the first time.
• Practise between sessions. Homework is where skills transfer. Set specific, achievable tasks every session.
• Collaborative and transparent. Share the formulation and the rationale. Agree the agenda and the choice of problem together.
• Tailor to the person's profile. Weight the toolkits according to the assessment, not a fixed script.
• Fade therapist support. Move from active guidance to the client leading by the final sessions (also central in PST-PC).
• Build in small wins. Choose early problems and goals the client is likely to succeed with, to build momentum (stressed in PST-PC).
• Attend to positive affect. Pair problem solving with pleasant activities and positive imagery so that therapy does not focus only on problems. [PST-PC (IMPACT) and PEARLS add pleasant activities; EC-PST uses positive imagery] [uncertain]

Note on these principles: the 2019 guidelines set out EC-PST "metamessages", and the 2013 manual sets out the therapist's role and a list of PST "do's and don'ts" (chapter 5 in each book). The list above is not checked against those chapters. [source: 2013 and 2019 tables of contents] [uncertain]

4. Intervention inventory

Order follows the 2013 manual: assessment and rationale; then the toolkits; then guided practice, future forecasting and ending; with PST-PC and PEARLS elements last. The two editions name and number the toolkits differently. 2013 manual: #1 problem-solving multitasking (overcoming cognitive overload: externalisation, visualisation, simplification); #2 the SSTA method (Stop, Slow down, Think, Act) for emotional dysregulation and poor problem solving under stress; #3 healthy thinking and positive imagery (overcoming negative thinking; positive imagery for hopelessness and visualising success); #4 planful problem solving, taught in brief or intensive form. 2019 EC-PST guidelines: #1 planful problem solving; #2 problem-solving multitasking ("brain overload"); #3 enhancing motivation for action (low motivation and hopelessness); #4 "Stop and Slow Down" (emotional dysregulation). Clients learn the planful steps through the acronym ADAPT: Attitude; Define the problem and set realistic goals; generate Alternatives; Predict consequences and develop a solution plan; Try out the solution and see whether it works (4.12–4.15). [source: Springer Publishing pages and tables of contents for Nezu et al. 2013 and Nezu & Nezu 2019; Springer page for Nezu, Nezu & D'Zurilla 2006, Solving Life's Problems; CDP PST group note template] [uncertain: where healthy-thinking work sits in the 2019 edition, which no longer lists it as a toolkit]

4.1 Assessment of stressors and problem-solving profile

• Purpose / when: Session 1 and at review points. Identifies what to work on and which toolkits to emphasise.
• Steps: (1) Get a list of current problems across areas (relationships, work/money, health, housing, caregiving, daily hassles), plus recent major events. (2) Assess symptoms and risk, including suicidal ideation, using standard measures your service uses. (3) Assess problem-solving style. The Social Problem-Solving Inventory–Revised (SPSI-R; D'Zurilla, Nezu & Maydeu-Olivares 2002) is the developers' measure. It is a licensed self-report with long and short forms and five scales: positive problem orientation, negative problem orientation, rational problem solving, impulsivity/carelessness style and avoidance style. Do not reproduce its items. The 2013 manual also contains its own Problem-Solving Test, with scoring instructions for scales of effective and ineffective problem solving, in an appendix [source: 2013 manual table of contents]. (4) Also ask how the client handled two or three recent problems: what they thought and felt, what they did, how quickly, and whether they put it off. (5) Write a shared formulation linking stressors, emotional reactions, problem-solving style and symptoms.
• Example language (illustrative): "Let's list what's been weighing on you lately, big and small. Then we'll look at how you usually tackle problems when you're stressed: do you tend to jump in fast, put things off, or work through them step by step?"
• Watch for: Long lists that overwhelm (move straight to externalisation and simplification); avoidant answers ("I don't really have problems, I'm just down"); risk that must be managed before any skills work. It is working when the client recognises their own style without feeling blamed.

4.2 Rationale and psychoeducation

• Purpose / when: Sessions 1–2, and repeat briefly whenever motivation dips.
• Steps: (1) Explain the link between stress and distress: major events and daily problems lead to emotional strain, which leads to symptoms, and the quality of problem solving shapes how strong that link is. (2) Describe the two parts of problem solving (orientation and style) and the three styles. (3) Explain "brain overload": under stress, people can hold only a little in mind, emotions take over and thinking narrows. (4) Preview the toolkits as skills to reduce overload, manage emotions, think helpfully and solve problems step by step. (5) Ask the client to link this to their own recent example. (6) Give a written summary to take home (use your own handout or the manual's).
• Example language (illustrative): "When we're under a lot of stress our brains get overloaded. It's like having too many browser tabs open. This therapy gives you tools to close some tabs, calm the system down, and tackle problems one at a time."
• Watch for: The client hearing "your problems are your fault". Stress that skills are learnable and that everyone's problem solving gets worse under stress. It is working when the client describes the model in their own words.

4.3 Externalisation (multitasking toolkit)

• Purpose / when: Reduce cognitive load. Use from session 1 and throughout, especially with complex problems, poor concentration, older adults or cognitive impairment. [source: CDP group note template (externalisation, visualisation and simplification for cognitive overload); 2013 Toolkit #1 / 2019 Toolkit #2] [uncertain: steps below not checked against manual text]
• Steps: (1) Put information on paper or a screen instead of holding it in mind: problem lists, facts, ideas, pros/cons tables, plans. (2) Use diagrams or flowcharts for problems with many parts. (3) Have the client keep a single notebook or app for all PST work. (4) Encourage reminders such as calendar alerts and sticky notes for action steps.
• Example language (illustrative): "Let's get this out of your head and onto the page so you don't have to juggle it all at once."
• Watch for: Clients with literacy or visual limits (use voice notes or drawings). It is working when the client starts writing things down unprompted.

4.4 Visualisation (multitasking toolkit)

• Purpose / when: Three uses: (a) clarify a problem by replaying it in sensory detail; (b) rehearse carrying out a solution; (c) relax (see 4.11). Use for vague problems, before hard actions, and for clients who "go blank" under pressure. [source: CDP group note template lists the same three uses of imagery: problem clarification, imaginal rehearsal and guided imagery for stress]
• Steps (rehearsal use): (1) Brief relaxation (a few slow breaths, eyes closed if comfortable). (2) Guide the client to imagine the setting in detail (place, people, sounds). (3) Have them picture themselves carrying out each step of the plan, including handling likely obstacles. (4) Debrief: what felt hard, and what to change in the plan. (5) Repeat as homework before the real attempt.
• Example language (illustrative): "Picture yourself walking into your manager's office tomorrow. What do you see? Now see yourself saying your first sentence... what happens next?"
• Watch for: Intrusive trauma images during imagery. Stop, ground the client and do not use imagery near trauma content without a plan. It is working when the client reports more confidence and fewer surprises when they act.

4.5 Simplification (multitasking toolkit)

• Purpose / when: Make large or abstract problems workable. Use when a problem is described globally ("my life is a mess") or a goal is too big. [source: CDP group note template; 2013 Toolkit #1]
• Steps: (1) Break a big problem into smaller sub-problems. (2) Break a goal into steps. (3) Rewrite abstract, emotional wording as specific, concrete terms. (4) Choose one sub-problem to start with, ideally one that is meaningful and likely to succeed.
• Example language (illustrative): "'Everything at home is falling apart' is too big to solve in one go. What's one piece of it, say the bills, the arguments, or the housework, that we could start with?"
• Watch for: Picking the hardest piece first. It is working when goals are specific enough that you can tell next week whether they were done.

4.6 Enhancing motivation for action and visualising success (EC-PST Toolkit #3; positive imagery in the 2013 Toolkit #3)

• Purpose / when: Early, especially for hopeless, depressed or avoidant clients who doubt that effort will pay off. Builds commitment to change.
• Steps: (1) Ask the client to choose a problem they want solved. (2) Guide a future-oriented imagery exercise: imagine the problem has been solved, then experience what life looks and feels like in sensory and emotional detail. (3) Then imagine the "road" that got them there, meaning the steps taken. (4) Debrief: what feelings came up, and what this says about why the problem matters. (5) Optionally list the costs and benefits of tackling the problem versus leaving it. (6) Use the image as a motivator to return to during homework. [source: 2019 TOC, Toolkit #3 "Enhancing Motivation for Action: Overcoming Low Motivation and Feelings of Hopelessness"; 2013 TOC, positive imagery for hopelessness and "Visualizing Success"; "Visualization for Success" exercise in Nezu et al. 2006] [uncertain: step order]
• Example language (illustrative): "Close your eyes and imagine it's six months from now and this problem is behind you. Where are you? What are you doing? How does your body feel?"
• Watch for: Inability to imagine a positive future (common in severe depression). Shorten the time frame, make the scene smaller, or describe it aloud together, and check for hopelessness and suicide risk. It is working when the client shows a flicker of positive feeling and says they are willing to try.

4.7 Stop: recognising emotional and stress cues (SSTA, emotion-regulation toolkit)

• Purpose / when: First half of the SSTA sequence (Stop, Slow down, Think, Act). Teaches the client to notice early signs of emotional arousal before reacting. Use for impulsive, emotionally reactive or easily overwhelmed clients.
• Steps: (1) Explain that strong emotions are signals and that acting at peak arousal tends to lead to impulsive or avoidant choices. (2) Help the client map their personal cues: bodily (tight chest, racing heart), thoughts ("I can't stand this") and behaviour (raised voice, withdrawing). (3) Agree on a personal "stop" signal, such as a word, an image of a stop sign or a hand gesture. (4) Practise noticing cues in session by recalling a recent upsetting problem. (5) Homework: self-monitor emotional cues and what triggered them. [source: CDP group note template (Stop, Slow down, Think and Act; identifying personal triggers; reactions-to-stress and triggers worksheets); 2013 manual ch. 8] [uncertain: the personal stop-signal step]
• Example language (illustrative): "When you notice your jaw tighten and the thought 'here we go again', that's your cue to stop, not to act."
• Watch for: Clients who cannot name feelings. Start with body sensations and a simple 0–10 distress rating. It is working when the client reports catching themselves before reacting.

4.8 Slow down: arousal-reduction strategies (SSTA)

• Purpose / when: After "Stop", lower arousal enough to think. Teach two or three strategies and have the client pick favourites.
• Steps: (1) Offer a menu of strategies: counting down slowly, slow diaphragmatic breathing, brief guided imagery (4.11), a mindful pause, physical activity such as a short walk, talking to someone supportive, and other calming or self-soothing actions the client already uses (for example prayer, or a deliberate yawn or smile). (2) Teach and practise one or two in session until the client can do them alone. (3) Link the sequence: notice cue, stop, slow down, then go on to think (healthy thinking / planful problem solving), then act. (4) Homework: practise daily when calm, and use when stressed. [source: CDP group note template (slow-down strategies practised in session, a four-step mindfulness method, daily practice); deep-breathing and safe-place visualisation exercises in Nezu et al. 2006] [uncertain: the full menu of slow-down strategies in the manuals; items beyond breathing, imagery and mindfulness]
• Example language (illustrative): "Let's practise slow breathing: in for a count of four, hold briefly, out for a count of six. We'll do five of those together."
• Watch for: Using "slow down" as long-term avoidance (it must lead to Think and Act); panic symptoms from over-breathing (slow down the pace). It is working when distress ratings drop after use and the client goes on to act.

4.9 Healthy thinking: identifying and changing negative self-talk

• Purpose / when: Address a negative problem orientation: thoughts that problems are threats, that one cannot cope, or that problems should not happen. Use when the SPSI-R or interview shows a high negative orientation, or when thoughts stall action. This is the "overcoming negative thinking" part of the 2013 Toolkit #3. The 2019 guidelines give Toolkit #3 to motivation and hopelessness and do not list healthy thinking as a separate toolkit. [source: 2013 and 2019 tables of contents]
• Steps: (1) Teach the link between an event, the thoughts about it and the emotional and behavioural reaction (an A-B-C-style framework). (2) Identify thoughts that come up around a current problem. (3) Spot common unhelpful thinking patterns, such as all-or-nothing thinking, overgeneralising, catastrophising, "should" statements and personalising. (4) Generate more helpful, realistic alternatives, especially self-statements that frame problems as normal, solvable challenges and affirm the client's ability to cope. (5) Write two or three coping self-statements on a card or in the phone. (6) Homework: notice the thoughts, label them and replace them during real problems. [source: Nezu et al. 2013; Nezu & Nezu 2019; D'Zurilla & Nezu 2007]
• Example language (illustrative): "You said 'This always happens to me, I'm useless.' If a friend said that, what would you point out? What's a fairer way to put it that still admits it's hard?"
• Watch for: Shallow "positive thinking" that the client does not believe. Aim for realistic, not upbeat. It is working when the client says the new statements are believable and starts approaching problems sooner.

4.10 Reverse advocacy role-play

• Purpose / when: A strategy distinctive to PST for loosening entrenched negative orientation beliefs. Use once the client has learned to spot unhelpful thoughts and needs practice disputing them. [uncertain: technique recalled from D'Zurilla & Nezu 2007 and the 2013 manual]
• Steps: (1) Explain the exercise and get consent: the therapist will argue for an unhelpful belief and the client will argue against it. (2) The therapist states a negative belief the client has expressed, for example that problems should not happen to good people, or that if you cannot solve something perfectly you shouldn't bother. (3) The client counters with reasons the belief is unhelpful or untrue. (4) The therapist pushes back mildly so the client has to elaborate. (5) Debrief: which counter-arguments felt strongest, and write them down. [source: D'Zurilla & Nezu 2007; Nezu et al. 2013]
• Example language (illustrative): "I'm going to play your inner critic for a minute and you argue back. Ready? 'There's no point trying to fix this, it'll just go wrong like everything else.'"
• Watch for: The client agreeing with the therapist's "critic" (stop the role-play, offer a counter-argument yourself, then try a milder belief); the client experiencing it as mockery (keep the tone warm and explain it again). It is working when the client produces counter-arguments of their own with more conviction.

4.11 Positive imagery (healthy thinking and positive imagery toolkit)

• Purpose / when: Counteract negative mood and arousal, and build hope. Use alongside SSTA and motivation work.
• Steps: (1) Help the client build a calming or pleasant scene in detail using all senses (a real or imagined safe, comfortable place). (2) Guide them through it for a few minutes. (3) Rate distress before and after. (4) Pair it with the "Slow down" step or use it before hard tasks. (5) Homework: daily brief practice. Future-oriented imagery of success (4.6) belongs to the same family. [source: 2013 Toolkit #3 (positive imagery); "Visualization: Travel to a Safe Place" exercise in Nezu et al. 2006; guided imagery for stress in the CDP template] [uncertain: exact protocol]
• Example language (illustrative): "Bring to mind a place where you feel safe and at ease. Notice what you can see... the sounds... the temperature on your skin."
• Watch for: Scenes that turn negative or trigger memories. Let the client choose or change the scene, and keep eyes-open options available. It is working when distress ratings drop and the client uses it on their own.

4.12 Planful problem solving, step 1: problem definition

• Purpose / when: The core of the planful toolkit. Always comes before generating solutions. A well-defined problem is often half solved. In ADAPT terms this is D (Define the problem and set realistic goals); A (Attitude) is the orientation work in 4.6 and 4.9. The 2013 manual offers brief and intensive forms of planful problem-solving training. [source: Nezu et al. 2006 publisher page; 2013 TOC]
• Steps: (1) Gather the available facts: who, what, where, when, how, and what has been tried. (2) Describe them in clear, concrete language without jargon or emotional overstatement. (3) Separate facts from assumptions and interpretations, and check the assumptions. (4) Identify what makes it a problem: the obstacles between the current state and what is wanted, conflicting goals, missing resources, or unknowns. (5) Set realistic, specific goals. Decide whether the goal is problem-focused (change the situation) or emotion-focused (change one's reaction, for situations that cannot be changed), or both. (6) Check that the goals are attainable, and break them down if not (4.5). (7) Check whether the stated problem is part of a larger underlying problem. [source: CDP group note template (gathering facts, separating facts from assumptions, clear language, realistic goals, breaking goals down, problem- versus emotion-focused goals, identifying obstacles); D'Zurilla & Nezu 2007; Tang 2006 review of Mynors-Wallis (clarifying problems, achievable goals)] [uncertain: step 7, checking for a larger underlying problem]
• Example language (illustrative): "What exactly happened, as a video camera would have recorded it? ... And which part of that is something you know for sure, versus something you're guessing about what she meant?" / "If this went well, what would be different by next Tuesday?"
• Watch for: Goals stated as wishes about other people's behaviour ("he'll stop being rude"). Reframe them as what the client can do. Vague goals ("feel better") need making concrete. It is working when the problem and goal are written in one or two concrete sentences that the client agrees with.

4.13 Planful problem solving, step 2: generating alternatives (brainstorming)

• Purpose / when: Widen the range of options and counter rigid or hopeless thinking. Use after the problem and goal are defined.
• Steps: (1) Explain the three brainstorming principles: quantity (more ideas make good ones more likely), deferment of judgment (no evaluating yet; silly ideas are welcome) and variety (ideas from different categories or strategies, not small variations of one). (2) Ask the client to list as many ideas as possible for each goal, written down (4.3). (3) Prompt for variety: "what's a completely different approach?" (4) Suggest combining or changing ideas to make new ones. (5) Use role models ("what would someone you admire do?") and visualisation to get unstuck. (6) The therapist may add an idea only after the client has produced several, and should present it as just one more option. This is ADAPT's "generate Alternatives" step. [source: CDP group note template (quantity, deferment and variety principles); Nezu et al. 2006; D'Zurilla & Goldfried 1971] [uncertain: steps 4–6 (combining ideas, role models, therapist's own ideas)]
• Example language (illustrative): "For the next few minutes, we're not judging. Let's aim for at least ten ideas, including wild ones. Wild ideas sometimes lead to workable ones."
• Watch for: The client judging each idea as it comes ("that won't work"). Gently remind them about deferring judgment. A run of near-identical ideas means you should prompt for a different category. It is working when the list contains many varied options generated mainly by the client.

4.14 Planful problem solving, step 3: decision making

• Purpose / when: Choose the most effective solution(s) and build a plan.
• Steps: (1) Screen out clearly unworkable or harmful options. (2) For the rest, predict the consequences on several criteria: how likely it is to reach the goal; how likely the client is to carry it out well; personal consequences (time, effort, emotional cost or benefit, physical wellbeing, fit with values); social consequences (effects on others and relationships); and short- versus long-term effects. (3) Rate each option simply (for example plus/minus/neutral, or a short numeric scale), written in a grid. (4) Pick the option or combination with the best overall profile. (5) Build a solution plan: simple (one action), complex (a sequence or combination) and, where possible, a contingency plan if the first choice fails. PST-PC uses a simpler pros-and-cons list for each option, then a choice. This is ADAPT's "Predict the consequences and develop a solution plan" step. [source: Nezu et al. 2006 publisher page (step name); D'Zurilla & Nezu 2007] [uncertain: the exact rating criteria have not been checked against the manual]
• Example language (illustrative): "Let's look at 'ask your sister to help on Thursdays'. How likely is it to solve the childcare gap? How likely are you to actually ask her? What would it cost you, and what would it do to your relationship with her?"
• Watch for: Picking the familiar option out of habit, or choosing something to please the therapist. Ask what makes the client confident about it. Endless weighing (avoidance) calls for a deadline to choose. It is working when the client can justify the choice and has a fallback.

4.15 Planful problem solving, step 4: solution implementation and verification

• Purpose / when: Carry out the plan and learn from the result. Covers the action plan given as homework and the review at the next session.
• Steps: (1) Strengthen motivation by comparing what happens if they act with what happens if they don't. (2) Make a concrete action plan: what, when, where, with whom, and what is needed. (3) Prepare: rehearse in session through role-play or visualisation (4.4), anticipate obstacles and plan responses. (4) Carry it out between sessions. (5) Self-monitor what was done and the outcome, both practical and emotional. (6) At the next session, compare the actual outcome with the goal. If it was satisfactory, the client credits and rewards themselves. If not, troubleshoot: was it the definition, the options, the choice or the execution? Then go back to the relevant step. This is ADAPT's "Try out the solution and see if it works" step. [source: Nezu et al. 2006 publisher page; Tang 2006 review of Mynors-Wallis (implementing solutions, evaluating the outcome); D'Zurilla & Nezu 2007] [uncertain: details of self-reward and troubleshooting]
• Example language (illustrative): "So the plan is: Wednesday after dinner you'll call the housing office, using the three points we wrote down. If you get voicemail, you'll leave a message and try again Friday morning. What could get in the way?"
• Watch for: Treating partial success as failure. Look at what moved and what was learned. Not attempting the plan is covered in Section 5. It is working when the client attempts plans more often and adjusts them after setbacks instead of giving up.

4.15a Rapid problem solving

• Purpose / when: A compressed pass through the planful steps for problems that must be handled within minutes, such as in-the-moment stressors or times when a full worksheet is impractical. Use it once the full steps have been practised. [source: a "Rapid Problem Solving" appendix is listed on the publisher page for Nezu, Nezu & D'Zurilla 2006] [uncertain: the procedure in that appendix was not seen; the steps below are reconstructed from the ADAPT sequence and are synthesis]
• Steps: (1) Pause, and use Stop and Slow Down if aroused. (2) State the problem and the goal in one sentence each. (3) Quickly list a few options without judging them. (4) Briefly predict the most important consequences and pick the best option. (5) Act. Afterwards, check whether it worked; if it did not, use the full planful steps later. [synthesis]
• Example language (illustrative): "You've got two minutes before the meeting. What's the problem in one sentence, what do you want to happen, and what are three things you could do?"
• Watch for: Using the quick version to skip definition on complex problems (switch to full planful work), or rushing that turns into impulsivity. It is working when the client handles small daily problems without needing a session. [synthesis]

4.16 Guided practice and fading (generalisation)

• Purpose / when: Middle and late sessions. Move from the therapist guiding to the client using the whole sequence independently.
• Steps: (1) Each session, the client chooses a current problem. (2) Early on, the therapist leads each step. Later, the client leads and the therapist prompts only when needed. (3) Use the full sequence: SSTA if the client is aroused, then healthy thinking, then planful steps, with externalisation throughout. (4) Ask the client to apply the method to a problem between sessions without help and report back. (5) Discuss using the tools on new kinds of problems and on everyday hassles, not only crises. [source: the "guided practice" and "integrating various problem-solving tools" sections in the 2013 TOC] [uncertain: the shift of responsibility in PST-PC]
• Example language (illustrative): "This time, you lead. Talk me through the steps on this problem as if I weren't here."
• Watch for: The client relying on the therapist to finish the steps. It is working when solo homework attempts show all the steps.

4.17 Between-session practice and self-monitoring

• Purpose / when: Every session. Skills transfer through practice.
• Steps: (1) Agree one or two specific tasks: an action plan, a toolkit exercise, or self-monitoring of stressors, emotions and how they were handled. (2) Check that the client understands and feels confident (a 0–10 confidence rating; if it is under about 7, simplify). (3) Review homework at the start of the next session, praising effort and troubleshooting barriers. The manual describes a structured problem-solving self-monitoring record that the client fills in about a problem and how they handled it. Use your own form or the manual's; it is not reproduced here. [source: Nezu et al. 2013] [uncertain: name and format of the self-monitoring tool not checked]
• Example language (illustrative): "On a scale of 0 to 10, how sure are you that you'll do this before next week? ... What would make it an 8?"
• Watch for: Tasks that are too large or vague. It is working when the completion rate rises.

4.18 PST-PC session structure (brief primary-care version)

• Purpose / when: Use the PST-PC format when sessions are short (about 30 minutes) or delivered by primary-care staff.
• Steps: Session 1 (about 1 hour): explain the treatment and how symptoms link to everyday problems; draw up a problem list; choose one problem that is important and likely to be solvable; work through the stages to an action plan; set homework. Later sessions (about 30 minutes): review the action plan and rate mood; evaluate the outcome; keep working on the same problem or choose a new one; complete the stages; set a new action plan. A structured worksheet mirrors the seven stages. Use your own version; the PST-PC manual's worksheet is not reproduced here. Final session: review the skills learned and plan how to use them independently. [source: AIMS Center PST page (6–10 sessions; first appointment about one hour including an introduction to PST; later appointments 30 minutes); Tang 2006 review of Mynors-Wallis (six weekly sessions)] [uncertain: session-by-session content beyond timings]
• Example language (illustrative): "Today we'll pick one problem, the one that's most bothering you that we have a fair chance of making progress on, and work out a plan you'll try before we meet again."
• Watch for: Choosing problems that cannot be solved in the time available, such as chronic illness itself. Pick a solvable aspect instead. It is working when an action plan is completed most weeks and mood ratings improve.

4.19 Pleasant activity scheduling (PST-PC/IMPACT, PEARLS)

• Purpose / when: Added in primary-care and older-adult versions to raise positive affect and activity alongside problem solving. Use with depressed, withdrawn or isolated clients.
• Steps: (1) Identify enjoyable or meaningful activities, social and physical, that are realistic for the client now. (2) Schedule specific ones each week as part of the action plan (what, when, with whom). (3) Review completion and mood effect at the next session, and adjust. [source: ACL PEARLS summary (planning social and physical activity, pleasant events, links to community services); Tang 2006 lists activity scheduling as an additional technique in Mynors-Wallis] [uncertain: how IMPACT's PST-PC integrates it has not been checked]
• Example language (illustrative): "Alongside the plan for the bills, let's choose one thing this week that's just for you. What used to give you a lift?"
• Watch for: Activities that are too ambitious, or that cost money or mobility the client lacks. It is working when the client completes them and mood ratings rise.

4.20 Future forecasting, ending and relapse prevention

• Purpose / when: Final one or two sessions.
• Steps: (1) Review the toolkits and which ones helped most. (2) Identify likely future stressors and early warning signs (such as old patterns of avoidance or impulsivity). (3) Write a personal plan: cues, SSTA steps, coping self-statements and a short reminder of the planful steps. (4) Agree when to seek help again or arrange booster sessions. [source: the chapter "Guided Practice, Future Forecasting, and Termination/Ending Treatment" in Nezu et al. 2013 and Nezu & Nezu 2019 (titles only seen)] [synthesis for plan content]
• Example language (illustrative): "Let's write your own short guide: the signs you're getting overloaded, and what you'll do first, second and third."
• Watch for: Anxiety about ending. Frame ending as the client now being their own problem solver. It is working when the client can describe the plan without notes.

5. Handling problems

The manuals cover some of these directly: tailoring to style deficits, SSTA for overwhelm, simplification for big problems, troubleshooting failed solutions, and the therapist not supplying answers. Most specific responses below are the writer's own synthesis and are marked accordingly. [source: Nezu et al. 2013; Mynors-Wallis 2005 where noted]

• Stuck: "there's nothing I can do" / no ideas. Check whether the problem is defined concretely (go back to 4.12). Lower the bar to "any idea at all, however unlikely". Use role models ("what would X do?") and visualisation. Offer one idea yourself only after the client has given several, as an addition. If the problem truly cannot be changed, switch to an emotion-focused goal: coping, acceptance or meaning. [source: D'Zurilla & Nezu 2007; Nezu et al. 2013 for brainstorming aids and emotion-focused goals] [synthesis for sequence]
• Stuck: the same problem every week with no movement. Review whether the goal is too big (simplify), whether the real obstacle was missed (redefine), or whether the plan is right but not being carried out (see non-adherence). Consider switching temporarily to a smaller, solvable problem to rebuild success. [synthesis]
• Client wants the therapist to solve it / passivity. Restate the rationale: the aim is a method they can use for life. Ask before you tell ("what's one option you can see?"). Praise their contributions specifically. Fade support visibly. [source: Mynors-Wallis 2005 (client-led by later sessions)] [synthesis for wording]
• Resistance: "my problem isn't problems, it's depression / my past." Validate this. Show how current stressors keep low mood going and how small wins change mood. Offer a time-limited trial of the approach ("let's try it on one thing for two weeks and see"). If the main issue truly is trauma, grief or personality patterns that PST does not target, discuss referral or combining with other treatment. [synthesis]
• Resistance: negative orientation ("problems are a sign I've failed"). Use healthy thinking (4.9), reverse advocacy role-play (4.10) and motivation imagery (4.6) before pushing planful steps. [source: Nezu et al. 2013 (tailoring to profile)]
• Overwhelm in session (crying, shutdown, flooding). Pause problem solving. Use SSTA: name the cues, slow breathing, grounding, a brief calming image. Resume with a smaller sub-problem or the externalised list. Agree a stop signal the client can use. [source: Nezu & Nezu 2019 (emotion regulation before problem solving)] [synthesis for in-session sequence]
• Overwhelm from too many problems. Externalise all of them, sort them (urgent, important, solvable soon) and choose one to start with. Reassure the client that the others are on the list and not forgotten. [source: Nezu et al. 2013 (externalisation, simplification)] [synthesis for sorting]
• Non-adherence to action plans. Without blame, explore what got in the way: practical barriers, low confidence, unclear plan, avoidance, or a changed situation. Treat the barrier as the next problem to solve, using the method. Make the next plan smaller, add a specific time and reminder, and rehearse it in session (4.4). Check confidence with a 0–10 rating. [synthesis; PST-PC treats unfinished plans as material for review] [uncertain]
• Impulsive clients who act before planning. Emphasise Stop and Slow Down. Add a rule to wait before acting on big decisions. Practise the consequence grid (4.14) on past impulsive choices. [source: Nezu et al. 2013 (SSTA for impulsive style)] [synthesis for rules]
• Avoidant clients who never choose. Set a deadline for decisions. Use a "good enough" criterion rather than a perfect one. Start with low-stakes problems. Do cost-of-avoidance work (4.15 step 1). [synthesis]
• Ruptures (client feels lectured, blamed or that the therapist is "too positive"). Name and explore the rupture openly. Acknowledge your part (for example, pushing solutions too fast). Validate the emotional load before returning to the steps. Agree whether to slow down or spend more time on emotions. [synthesis, drawing on general alliance-repair practice]
• Problem is about another person (partner, boss, family). Redefine the goal around what the client can do: their requests, boundaries, responses and emotional coping. Rehearse interpersonal solutions through role-play. [synthesis]
• Unsolvable problems (terminal illness, bereavement, chronic pain). Use emotion-focused goals, meaning-focused goals, and solvable sub-problems such as managing appointments, telling family or practical help. Combine with acceptance-oriented work if appropriate. [source: Nezu et al. 2013 (emotion-focused goals; PST used in medical populations)] [synthesis for specifics]
• Cognitive impairment, low literacy or older age. Simplify language, use more externalisation (large-print worksheets, pictures, a carer as helper), shorter sessions, more repetition and more structure. Problem Adaptation Therapy (PATH, Kiosses and colleagues) is a dedicated adaptation for older adults with cognitive impairment. [synthesis] [uncertain]
• Suicidal ideation or self-harm. Assess risk at intake and whenever hopelessness rises. Use your service's standard structured risk assessment and collaborative safety planning (warning signs, coping steps, social contacts, professional contacts, and lethal-means safety: secure storage or removal). Do not use PST in place of crisis care. Problem solving can then be applied to the stressors that drive the crisis once the client is safe. Escalate according to local protocol. The 2019 guidelines include a chapter on applying EC-PST to suicide prevention and treatment [source: 2019 TOC] [uncertain: its content was not seen]. [synthesis, aligned with current standard practice; PST has been studied with suicidal and self-harming patients] [uncertain]
• Severe illness, psychosis, active substance use or crisis. The AIMS Center lists PST-PC as not indicated as the primary treatment for substance abuse or dependence, acute primary PTSD, panic disorder, new-onset bipolar disorder or new-onset psychosis [source: AIMS Center PST page]. PST can be an add-on: stabilise first and coordinate with the wider treatment team. [synthesis]
• Group format problems (one member dominates, problems too varied). Rotate whose problem is used as the worked example. Have everyone brainstorm for the focal person. Pair members for homework check-ins. [synthesis]
• Telehealth delivery. Share the worksheet on screen or send it beforehand, have the client write their own copy, and confirm the action plan in writing at the end. [synthesis]

Sources

Sources:

• Problem-Solving Therapy for adult depression meta-analysis (Cuijpers et al. 2018), DOI landing page
• Emotion-Centered Problem-Solving Therapy: Treatment Guidelines – Springer Publishing
• Problem-Solving Therapy: A Treatment Manual – Springer Publishing
• Problem-Solving Therapy: A Treatment Manual – table of contents (library catalogue)
• Solving Life's Problems: A 5-Step Guide to Enhanced Well-Being – Springer Publishing
• Emotion-centered problem-solving therapy: An update (Nezu, Nezu & Gerber 2019), Drexel repository record
• Problem Solving Therapy Group Note Template – Center for Deployment Psychology
• Problem Solving Treatment (PST) – AIMS Center, University of Washington
• Tang (2006), review of Mynors-Wallis, Problem-solving treatment for anxiety and depression – Hong Kong Medical Journal
• PEARLS Intervention Summary – Administration for Community Living
• Emotion-Centered Problem-Solving Therapy – Bookmate listing

Attempted but not read: the Springer Connect sample chapter of the 2019 guidelines (DOI 10.1891/9780826143167.0001; HTTP 429). The manuals' own text was not available, so step-level detail inside each toolkit rests on the works below as the writer knows them and is tagged [uncertain] where it was not confirmed.

Books and papers cited:

• D'Zurilla, T. J., & Goldfried, M. R. (1971). Problem solving and behavior modification. Journal of Abnormal Psychology, 78, 107–126.
• D'Zurilla, T. J., & Nezu, A. M. (2007). Problem-Solving Therapy: A Positive Approach to Clinical Intervention (3rd ed.). Springer Publishing.
• D'Zurilla, T. J., Nezu, A. M., & Maydeu-Olivares, A. (2002). Social Problem-Solving Inventory–Revised (SPSI-R): Technical Manual. Multi-Health Systems.
• Nezu, A. M., Nezu, C. M., & D'Zurilla, T. J. (2013). Problem-Solving Therapy: A Treatment Manual. Springer Publishing.
• Nezu, A. M., & Nezu, C. M. (2019). Emotion-Centered Problem-Solving Therapy: Treatment Guidelines. Springer Publishing.
• Mynors-Wallis, L. (2005). Problem-Solving Treatment for Anxiety and Depression: A Practical Guide. Oxford University Press.
• Hegel, M. T., & Areán, P. A. (2003/2011). Problem-Solving Treatment for Primary Care (PST-PC): A Treatment Manual for Depression. Dartmouth / University of Washington (unpublished training manual). [uncertain: exact year and edition]
• Ciechanowski, P., et al. (2004). Community-integrated home-based depression treatment in older adults (PEARLS): a randomized controlled trial. JAMA, 291, 1569–1577.
• Unützer, J., et al. (2002). Collaborative care management of late-life depression in the primary care setting (IMPACT). JAMA, 288, 2836–2845.
• Cuijpers, P., et al. (2018). Problem-solving therapies for depression: a meta-analysis. European Psychiatry 48, 27–37 (DOI 10.1016/j.eurpsy.2017.11.006) [uncertain: title and pages; likely title "Problem-solving therapy for adult depression: an updated meta-analysis"].

• Nezu, A. M., Nezu, C. M., & D'Zurilla, T. J. (2006). Solving Life's Problems: A 5-Step Guide to Enhanced Well-Being. Springer Publishing.
• Nezu, A. M., Nezu, C. M., & Gerber, H. R. (2019). (Emotion-centered) problem-solving therapy: An update. Australian Psychologist, 54(5), 361–371.
• Tang, W. K. (2006). Review of Mynors-Wallis, Problem-solving treatment for anxiety and depression: a practical guide. Hong Kong Medical Journal, 12(6).