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What Is Problem-Solving Therapy?

Verywell / Madelyn Goodnight

Problem-Solving Therapy Techniques

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

Problem-solving therapy is a brief intervention that provides people with the tools they need to identify and solve problems that arise from big and small life stressors. It aims to improve your overall quality of life and reduce the negative impact of psychological and physical illness.

Problem-solving therapy can be used to treat depression , among other conditions. It can be administered by a doctor or mental health professional and may be combined with other treatment approaches.

At a Glance

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

Problem-solving therapy is based on a model that takes into account the importance of real-life problem-solving. In other words, the key to managing the impact of stressful life events is to know how to address issues as they arise. Problem-solving therapy is very practical in its approach and is only concerned with the present, rather than delving into your past.

This form of therapy can take place one-on-one or in a group format and may be offered in person or online via telehealth . Sessions can be anywhere from 30 minutes to two hours long. 

Key Components

There are two major components that make up the problem-solving therapy framework:

• Applying a positive problem-solving orientation to your life
• Using problem-solving skills

A positive problem-solving orientation means viewing things in an optimistic light, embracing self-efficacy , and accepting the idea that problems are a normal part of life. Problem-solving skills are behaviors that you can rely on to help you navigate conflict, even during times of stress. This includes skills like:

• Knowing how to identify a problem
• Defining the problem in a helpful way
• Trying to understand the problem more deeply
• Setting goals related to the problem
• Generating alternative, creative solutions to the problem
• Choosing the best course of action
• Implementing the choice you have made
• Evaluating the outcome to determine next steps

Problem-solving therapy is all about training you to become adaptive in your life so that you will start to see problems as challenges to be solved instead of insurmountable obstacles. It also means that you will recognize the action that is required to engage in effective problem-solving techniques.

Planful Problem-Solving

One problem-solving technique, called planful problem-solving, involves following a series of steps to fix issues in a healthy, constructive way:

• Problem definition and formulation : This step involves identifying the real-life problem that needs to be solved and formulating it in a way that allows you to generate potential solutions.
• Generation of alternative solutions : This stage involves coming up with various potential solutions to the problem at hand. The goal in this step is to brainstorm options to creatively address the life stressor in ways that you may not have previously considered.
• Decision-making strategies : This stage involves discussing different strategies for making decisions as well as identifying obstacles that may get in the way of solving the problem at hand.
• Solution implementation and verification : This stage involves implementing a chosen solution and then verifying whether it was effective in addressing the problem.

Other Techniques

Other techniques your therapist may go over include:

• Problem-solving multitasking , which helps you learn to think clearly and solve problems effectively even during times of stress
• Stop, slow down, think, and act (SSTA) , which is meant to encourage you to become more emotionally mindful when faced with conflict
• Healthy thinking and imagery , which teaches you how to embrace more positive self-talk while problem-solving

What Problem-Solving Therapy Can Help With

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

Mental Health Issues

Problem-solving therapy may help address mental health issues, like:

• Chronic stress due to accumulating minor issues
• Complications associated with traumatic brain injury (TBI)
• Emotional distress
• Post-traumatic stress disorder (PTSD)
• Problems associated with a chronic disease like cancer, heart disease, or diabetes
• Self-harm and feelings of hopelessness
• Substance use
• Suicidal ideation

Specific Life Challenges

This form of therapy is also helpful for dealing with specific life problems, such as:

• Death of a loved one
• Dissatisfaction at work
• Everyday life stressors
• Family problems
• Financial difficulties
• Relationship conflicts

Your doctor or mental healthcare professional will be able to advise whether problem-solving therapy could be helpful for your particular issue. In general, if you are struggling with specific, concrete problems that you are having trouble finding solutions for, problem-solving therapy could be helpful for you.

Benefits of Problem-Solving Therapy

The skills learned in problem-solving therapy can be helpful for managing all areas of your life. These can include:

• Being able to identify which stressors trigger your negative emotions (e.g., sadness, anger)
• Confidence that you can handle problems that you face
• Having a systematic approach on how to deal with life's problems
• Having a toolbox of strategies to solve the issues you face
• Increased confidence to find creative solutions
• Knowing how to identify which barriers will impede your progress
• Knowing how to manage emotions when they arise
• Reduced avoidance and increased action-taking
• The ability to accept life problems that can't be solved
• The ability to make effective decisions
• The development of patience (realizing that not all problems have a "quick fix")

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

Other Types of Therapy

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

This form of therapy was initially developed to help people combat stress through effective problem-solving, and it was later adapted to address clinical depression specifically. Today, much of the research on problem-solving therapy deals with its effectiveness in treating depression.

Problem-solving therapy has been shown to help depression in: 

• Older adults
• People coping with serious illnesses like cancer

Problem-solving therapy also appears to be effective as a brief treatment for depression, offering benefits in as little as six to eight sessions with a therapist or another healthcare professional. This may make it a good option for someone unable to commit to a lengthier treatment for depression.

Problem-solving therapy is not a good fit for everyone. It may not be effective at addressing issues that don't have clear solutions, like seeking meaning or purpose in life. Problem-solving therapy is also intended to treat specific problems, not general habits or thought patterns .

In general, it's also important to remember that problem-solving therapy is not a primary treatment for mental disorders. If you are living with the symptoms of a serious mental illness such as bipolar disorder or schizophrenia , you may need additional treatment with evidence-based approaches for your particular concern.

Problem-solving therapy is best aimed at someone who has a mental or physical issue that is being treated separately, but who also has life issues that go along with that problem that has yet to be addressed.

For example, it could help if you can't clean your house or pay your bills because of your depression, or if a cancer diagnosis is interfering with your quality of life.

Your doctor may be able to recommend therapists in your area who utilize this approach, or they may offer it themselves as part of their practice. You can also search for a problem-solving therapist with help from the American Psychological Association’s (APA) Society of Clinical Psychology .

If receiving problem-solving therapy from a doctor or mental healthcare professional is not an option for you, you could also consider implementing it as a self-help strategy using a workbook designed to help you learn problem-solving skills on your own.

During your first session, your therapist may spend some time explaining their process and approach. They may ask you to identify the problem you’re currently facing, and they’ll likely discuss your goals for therapy .

Keep In Mind

Problem-solving therapy may be a short-term intervention that's focused on solving a specific issue in your life. If you need further help with something more pervasive, it can also become a longer-term treatment option.

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

Cuijpers P, Wit L de, Kleiboer A, Karyotaki E, Ebert DD. Problem-solving therapy for adult depression: An updated meta-analysis . Eur Psychiatry . 2018;48(1):27-37. doi:10.1016/j.eurpsy.2017.11.006

Nezu AM, Nezu CM, D'Zurilla TJ. Problem-Solving Therapy: A Treatment Manual . New York; 2013. doi:10.1891/9780826109415.0001

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

Sorsdahl K, Stein DJ, Corrigall J, et al. The efficacy of a blended motivational interviewing and problem solving therapy intervention to reduce substance use among patients presenting for emergency services in South Africa: A randomized controlled trial . Subst Abuse Treat Prev Policy . 2015;10(1):46. doi:doi.org/10.1186/s13011-015-0042-1

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

Kirkham JG, Choi N, Seitz DP. Meta-analysis of problem solving therapy for the treatment of major depressive disorder in older adults . Int J Geriatr Psychiatry . 2016;31(5):526-535. doi:10.1002/gps.4358

Garand L, Rinaldo DE, Alberth MM, et al. Effects of problem solving therapy on mental health outcomes in family caregivers of persons with a new diagnosis of mild cognitive impairment or early dementia: A randomized controlled trial . Am J Geriatr Psychiatry . 2014;22(8):771-781. doi:10.1016/j.jagp.2013.07.007

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

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

By Arlin Cuncic, MA Arlin Cuncic, MA, is the author of The Anxiety Workbook and founder of the website About Social Anxiety. She has a Master's degree in clinical psychology.

Cognitive Behavioral Therapy

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

Posted February 2, 2022 | Reviewed by Ekua Hagan

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

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

The problem-solving technique

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

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

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

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

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

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

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

Advantages of the problem-solving technique

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

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

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

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

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

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

Author: Lydia Antonatos, LMHC

Lydia Angelica Antonatos LMHC

Lydia has over 16 years of experience and specializes in mood disorders, anxiety, and more. She offers personalized, solution-focused therapy to empower clients on their journey to well-being.

Problem-solving therapy (PST) is an intervention with cognitive and behavioral influences used to assist individuals in managing life problems. Therapists help clients learn effective skills to address their issues directly and make positive changes. PST is used in various settings to address mental health concerns such as depression, anxiety, and more.

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What Is Problem-Solving Therapy?

Problem-solving therapy (PST) is based on a model that the body, mind, and environment all interact with each other and that life stress can interact with a person’s predisposition for developing a mental condition. 2 Within this context, PST contends that mental, emotional, and behavioral struggles stem from an ongoing inability to solve problems or deal with everyday stressors. Therefore, the key to preventing health consequences and improving quality of life is to become a better problem-solver. 3 , 4

The problem-solving model has undergone several revisions but upholds the value of teaching people to become better problem-solvers. Overall, the goal of PST is to provide individuals with a set of rational problem-solving tools to reduce the impact of stress on their well-being.

The two main components of problem-solving therapy include: 3 , 4

• Problem-solving orientation: This focuses on helping individuals adopt an optimistic outlook and see problems as opportunities to learn from, allowing them to believe they can solve problems.
• Problem-solving style: This component aims to provide people with constructive problem-solving tools to deal with different life stressors by identifying the problem, generating/brainstorming solution ideas, choosing a specific option, and implementing and reviewing it.

Techniques Used in Problem-Solving Therapy

PST emphasizes the client, and the techniques used are merely conduits that facilitate the problem-solving learning process. Generally, the individual, in collaboration and support from the clinician, leads the problem-solving work. Thus, a strong therapeutic alliance sets the foundation for encouraging clients to apply these skills outside therapy sessions. 4

Here are some of the most relevant guidelines and techniques used in problem-solving therapy:

Creating Collaboration

As with other psychotherapies, creating a collaborative environment and a healthy therapist-client relationship is essential in PST. The role of a therapist is to cultivate this bond by conveying a genuine sense of commitment to the client while displaying kindness, using active listening skills, and providing support. The purpose is to build a meaningful balance between being an active and directive clinician while delivering a feeling of optimism to encourage the client’s participation.

This tool is used in all psychotherapies and is just as essential in PST. Assessment seeks to gather facts and information about current problems and contributing stressors and evaluates a client’s appropriateness for PST. The problem-solving therapy assessment also examines a person’s immediate issues, problem-solving attitudes, and abilities, including their strengths and limitations. This sets the groundwork for developing an individualized problem-solving plan.

Psychoeducation

Psychoeducation is an integral component of problem-solving therapy and is used throughout treatment. The purpose of psychoeducation is to provide a client with the rationale for problem-solving therapy, including an explanation for each step involved in the treatment plan. Moreover, the individual is educated about mental health symptoms and taught solution-oriented strategies and communication skills.

This technique involves verbal prompting, like asking leading questions, giving suggestions, and providing guidance. For example, the therapist may prompt a client to brainstorm or consider alternatives, or they may ask about times when a certain skill was used to solve a problem during a difficult situation. Coaching can be beneficial when clients struggle with eliciting solutions on their own.

Shaping intervention refers to teaching new skills and building on them as the person gradually improves the quality of each skill. Shaping works by reinforcing the desired problem-solving behavior and adding perspective as the individual gets closer to their intended goal.

In problem-solving therapy, modeling is a method in which a person learns by observing. It can include written/verbal problem-solving illustrations or demonstrations performed by the clinician in hypothetical or real-life situations. A client can learn effective problem-solving skills via role-play exercises, live demonstrations, or short-film presentations. This allows individuals to imitate observed problem-solving skills in their own lives and apply them to specific problems.

Rehearsal & Practice

These techniques provide opportunities to practice problem-solving exercises and engage in homework assignments. This may involve role-playing during therapy sessions, practicing with real-life issues, or imaginary rehearsal where individuals visualize themselves carrying out a solution. Furthermore, homework exercises are an important aspect when learning a new skill. Ongoing practice is strongly encouraged throughout treatment so a client can effectively use these techniques when faced with a problem.

Positive Reinforcement & Feedback

The therapist’s task in this intervention is to provide support and encouragement for efforts to apply various problem-solving skills. The goal is for the client to continue using more adaptive behaviors, even if they do not get it right the first time. Then, the therapist provides feedback so the client can explore barriers encountered and generate alternate solutions by weighing the pros and cons to continue working toward a specific goal.

Use of Analogies & Metaphors

When appropriate, analogies and metaphors can be useful in providing the client with a clearer vision or a better understanding of specific concepts. For example, the therapist may use diverse skills or points of reference (e.g., cooking, driving, sports) to explain the problem-solving process and find solutions to convey that time and practice are required before mastering a particular skill.

What Can Problem-Solving Therapy Help With?

Although problem-solving therapy was initially developed to treat depression among primary care patients, PST has expanded to address or rehabilitate other psychological problems, including anxiety , post-traumatic stress disorder , personality disorders , and more.

PST theory asserts that vulnerable populations can benefit from receiving constructive problem-solving tools in a therapeutic relationship to increase resiliency and prevent emotional setbacks or behaviors with destructive results like suicide. It is worth noting that in severe psychiatric cases, PST can be effectively used when integrated with other mental health interventions. 3 , 4

PST can help individuals challenged with specific issues who have difficulty finding solutions or ways to cope. These issues can involve a wide range of incidents, such as the death of a loved one, divorce, stress related to a chronic medical diagnosis, financial stress , marital difficulties, or tension at work.

Through the problem-solving approach, mental and emotional distress can be reduced by helping individuals break down problems into smaller pieces that are easier to manage and cope with. However, this can only occur as long the person being treated is open to learning and able to value the therapeutic process. 3 , 4

Lastly, a large body of evidence has indicated that PST can positively impact mental health, quality of life, and problem-solving skills in older adults. PST is an approach that can be implemented by different types of practitioners and settings (in-home care services, telemedicine, etc.), making mental health treatment accessible to the elderly population who often face age-related barriers and comorbid health issues. 1 , 5, 6

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Problem-Solving Therapy Examples

Due to the versatility of problem-solving therapy, PST can be used in different forms, settings, and formats. Following are some examples where the problem-solving therapeutic approach can be used effectively. 4

People who suffer from depression often evade or even attempt to ignore their problems because of their state of mind and symptoms. PST incorporates techniques that encourage individuals to adopt a positive outlook on issues and motivate individuals to tap into their coping resources and apply healthy problem-solving skills. Through psychoeducation, individuals can learn to identify and understand their emotions influence problems. Employing rehearsal exercises, someone can practice adaptive responses to problematic situations. Once the depressed person begins to solve problems, symptoms are reduced, and mood is improved.

The Veterans Health Administration presently employs problem-solving therapy as a preventive approach in numerous medical centers across the United States. These programs aim to help veterans adjust to civilian life by teaching them how to apply different problem-solving strategies to difficult situations. The ultimate objective is that such individuals are at a lower risk of experiencing mental health issues and consequently need less medical and/or psychiatric care.

Psychiatric Patients

PST is considered highly effective and strongly recommended for individuals with psychiatric conditions. These individuals often struggle with problems of daily living and stressors they feel unable to overcome. These unsolved problems are both the triggering and sustaining reasons for their mental health-related troubles. Therefore, a problem-solving approach can be vital for the treatment of people with psychological issues.

Adherence to Other Treatments

Problem-solving therapy can also be applied to clients undergoing another mental or physical health treatment. In such cases, PST strategies can be used to motivate individuals to stay committed to their treatment plan by discussing the benefits of doing so. PST interventions can also be utilized to assist patients in overcoming emotional distress and other barriers that can interfere with successful compliance and treatment participation.

Benefits of Problem-Solving Therapy

PST is versatile, treating a wide range of problems and conditions, and can be effectively delivered to various populations in different forms and settings—self-help manuals, individual or group therapy, online materials, home-based or primary care settings, as well as inpatient or outpatient treatment.

Here are some of the benefits you can gain from problem-solving therapy:

• Gain a sense of control over your life
• Move toward action-oriented behaviors instead of avoiding your problems
• Gain self-confidence as you improve the ability to make better decisions
• Develop patience by learning that successful problem-solving is a process that requires time and effort
• Feel a sense of empowerment as you solve your problems independently
• Increase your ability to recognize and manage stressful emotions and situations
• Learn to focus on the problems that have a solution and let go of the ones that don’t
• Identify barriers that may hinder your progress

How to Find a Therapist Who Practices Problem-Solving Therapy

Finding a therapist skilled in problem-solving therapy is not any different from finding any qualified mental health professional. This is because many clinicians often have knowledge in cognitive-behavioral interventions that hold similar concepts as PST.

As a general recommendation, check your health insurance provider lists, use an online therapist directory , or ask trusted friends and family if they can recommend a provider. Contact any of these providers and ask questions to determine who is more compatible with your needs. 3 , 4

Are There Special Certifications to Provide PST?

Therapists do not need special certifications to practice problem-solving therapy, but some organizations can provide special training. Problem-solving therapy can be delivered by various healthcare professionals such as psychologists, psychiatrists, physicians, mental health counselors, social workers, and nurses.

Most of these clinicians have naturally acquired valuable problem-solving abilities throughout their career and continuing education. Thus, all that may be required is fine-tuning their skills and familiarity with the current and relevant PST literature. A reasonable amount of understanding and planning will transmit competence and help clients gain insight into the causes that led them to their current situation. 3 , 4

Questions to Ask a Therapist When Considering Problem-Solving Therapy

Psychotherapy is most successful when you feel comfortable and have a collaborative relationship with your therapist. Asking specific questions can simplify choosing a clinician who is right for you. Consider making a list of questions to help you with this task.

Here are some key questions to ask before starting PST:

• Is problem-solving therapy suitable for the struggles I am dealing with?
• Can you tell me about your professional experience with providing problem-solving therapy?
• Have you dealt with other clients who present with similar issues as mine?
• Have you worked with individuals of similar cultural backgrounds as me?
• How do you structure your PST sessions and treatment timeline?
• How long do PST sessions last?
• How many sessions will I need?
• What expectations should I have in working with you from a problem-solving therapeutic stance?
• What expectations are required from me throughout treatment?
• Does my insurance cover PST? If not, what are your fees?
• What is your cancellation policy?

How Much Does Problem-Solving Therapy Cost?

The cost of problem-solving therapy can range from $25 to $150 depending on the number of sessions required, severity of symptoms, type of practice, geographic location, and provider’s experience level. However, if your insurance provider covers behavioral health, the out-of-pocket costs per session may be much lower. Medicare supports PST through professionally trained general health practitioners. 1

What to Expect at Your First PST Session

During the first session, the therapist will strive to build a connection and become familiar with you. You will be assessed through a clinical interview and/or questionnaires. During this process, the therapist will gather your background information, inquire about how you approach life problems, how you typically resolve them, and if problem-solving therapy is a suitable treatment for you. 3 , 4

Additionally, you will be provided psychoeducation relating to your symptoms, the problem-solving method and its effectiveness, and your treatment goals. The clinician will likely guide you through generating a list of the current problems you are experiencing, selecting one to focus on, and identifying concrete steps necessary for effective problem-solving. Lastly, you will be informed about the content, duration, costs, and number of therapy sessions the therapist suggests. 3 , 4

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Is Problem-Solving Therapy Effective?

Extensive research and studies have shown the efficacy of problem-solving therapy. PST can yield significant improvements within a short amount of time. PST is also useful for addressing numerous problems and psychological issues. Lastly, PST has shown its efficacy with different populations and age groups.

One meta-analysis of PST for depression concluded that problem-solving therapy was as efficient for reducing symptoms of depression as other types of psychotherapies and antidepressant medication. Furthermore, PST was significantly more effective than not receiving any treatment. 7 However, more investigation may be necessary about PST’s long-term efficacy in comparison to other treatments. 5,6

How Is PST Different From CBT & SFT?

Problem-solving, cognitive-behavioral, and solution-focused therapy belong to the cognitive-behavioral framework, sharing a common goal to modify thoughts, aptitudes, and behaviors to improve mental health and quality of life.

Problem-Solving Therapy Vs. Cognitive-Behavioral Therapy

Cognitive behavioral therapy (CBT) is a short-term psychosocial treatment developed under the premise that how we think affects how we feel and behave. CBT addresses problems arising from maladaptive thought patterns and seeks to challenge and modify these to improve behavioral responses and overall well-being. CBT is the most researched approach and preferred treatment in psychotherapy due to its effectiveness in addressing various problems like anxiety, sleep disorders, substance abuse, and more.

Like CBT, PST addresses mental, emotional, and behavioral issues. However, PST may provide a better balance of cognitive and behavioral elements.

Another difference between these two approaches is that PST mostly focuses on faulty thoughts about problem-solving orientation and modifying maladaptive behaviors that specifically interfere with effective problem-solving. Usually, PST is used as an integrated approach and applied as one of several other interventions in CBT psychotherapy sessions.

Problem-Solving Therapy Vs. Solution-Focused Therapy

Solution-focused therapy (SFT) , like PST, is a goal-directed, evidence-based brief therapeutic approach that encourages optimism, options, and self-efficacy. Similarly, it is also grounded on cognitive behavioral principles. However, it differs from problem-solving therapy because SFT is a semi-structured approach that does not follow a step-by-step sequential format. 8

SFT mainly focuses on solution-building rather than problem-solving, specifically looking at a person’s strengths and previous successes. SFT helps people recognize how their lives would differ without problems by exploring their current coping skills. Community mental health, inpatient settings, and educational environments are increasing the use of SFT due to its demonstrated efficacy. 8

Final Thoughts

Problem-solving therapy can be an effective treatment for various mental health concerns. If you are considering treatment, ask your doctor for recommendations or conduct your own research to learn more about this approach and other options available.

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Beaudreau, S. A., Gould, C. E., Sakai, E., & Terri Huh, J. W. (2017). Problem-Solving Therapy. In N. A. Pachana (Ed.), Encyclopedia of geropsychology : with 148 figures and 100 tables . Singapore: Springer.

Broerman, R. (2018). Diathesis-Stress Model. In T. Shackleford & V. Zeigler-Hill (Eds.), Encyclopedia of Personality and Individual Differences (Living Edition, pp. 1–3). Springer, Cham. https://doi.org/10.1007/978-3-319-28099-8_891-1

Mehmet Eskin. (2013). Problem solving therapy in the clinical practice . Elsevier.

Nezu, A. M., Nezu, C. M., & D’Zurilla, T. J. (2013). Problem-Solving Therapy A Treatment Manual . Springer Publishing Company.

Cuijpers, P., et al. (2018). Problem-solving therapy for adult depression: An updated meta-analysis. European Psychiatry   48 , 27–37. https://doi.org/10.1016/j.eurpsy.2017.11.006

Kirkham, J. G., Choi, N., & Seitz, D. P. (2015). Meta-analysis of problem-solving therapy for the treatment of major depressive disorder in older adults. International Journal of Geriatric Psychiatry , 31 (5), 526–535. https://doi.org/10.1002/gps.4358

Bell, A. C., & D’Zurilla, T. J. (2009). Problem-solving therapy for depression: A meta-analysis. Clinical Psychology Review , 29 (4), 348–353. https://doi.org/10.1016/j.cpr.2009.02.003

Proudlock, S. (2017). The Solution Focused Way Incorporating Solution Focused Therapy Tools and Techniques into Your Everyday Work . Routledge.

Nezu, A. M., Nezu, C. M., & Gerber, H. R. (2019). (Emotion‐centered) problem‐solving therapy: An update. Australian Psychologist , 54 (5), 361–371. https://doi.org/10.1111/ap.12418

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Open Access

Peer-reviewed

Research Article

Problem-solving interventions and depression among adolescents and young adults: A systematic review of the effectiveness of problem-solving interventions in preventing or treating depression

Roles Conceptualization, Data curation, Formal analysis, Writing – original draft, Writing – review & editing

* E-mail: [email protected]

Affiliation Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, United States of America

Roles Conceptualization, Writing – original draft

Affiliation Centre for Evidence and Implementation, London, United Kingdom

Roles Data curation

Roles Conceptualization, Writing – review & editing

Affiliation Department of Psychology, Virginia Commonwealth University, Richmond, VA, United States of America

Roles Conceptualization, Methodology

Roles Conceptualization, Project administration, Writing – review & editing

Affiliation Centre for Evidence and Implementation, Melbourne, Victoria, Australia

Roles Conceptualization, Formal analysis, Methodology, Writing – original draft, Writing – review & editing

Affiliation Department of Social Work, Monash University, Melbourne, Victoria, Australia

• Kristina Metz, 
• Jane Lewis, 
• Jade Mitchell, 
• Sangita Chakraborty, 
• Bryce D. McLeod, 
• Ludvig Bjørndal, 
• Robyn Mildon, 
• Aron Shlonsky

• Published: August 29, 2023
• https://doi.org/10.1371/journal.pone.0285949
• Peer Review
• Reader Comments

Problem-solving (PS) has been identified as a therapeutic technique found in multiple evidence-based treatments for depression. To further understand for whom and how this intervention works, we undertook a systematic review of the evidence for PS’s effectiveness in preventing and treating depression among adolescents and young adults. We searched electronic databases ( PsycINFO , Medline , and Cochrane Library ) for studies published between 2000 and 2022. Studies meeting the following criteria were included: (a) the intervention was described by authors as a PS intervention or including PS; (b) the intervention was used to treat or prevent depression; (c) mean or median age between 13–25 years; (d) at least one depression outcome was reported. Risk of bias of included studies was assessed using the Cochrane Risk of Bias 2.0 tool. A narrative synthesis was undertaken given the high level of heterogeneity in study variables. Twenty-five out of 874 studies met inclusion criteria. The interventions studied were heterogeneous in population, intervention, modality, comparison condition, study design, and outcome. Twelve studies focused purely on PS; 13 used PS as part of a more comprehensive intervention. Eleven studies found positive effects in reducing depressive symptoms and two in reducing suicidality. There was little evidence that the intervention impacted PS skills or that PS skills acted as a mediator or moderator of effects on depression. There is mixed evidence about the effectiveness of PS as a prevention and treatment of depression among AYA. Our findings indicate that pure PS interventions to treat clinical depression have the strongest evidence, while pure PS interventions used to prevent or treat sub-clinical depression and PS as part of a more comprehensive intervention show mixed results. Possible explanations for limited effectiveness are discussed, including missing outcome bias, variability in quality, dosage, and fidelity monitoring; small sample sizes and short follow-up periods.

Citation: Metz K, Lewis J, Mitchell J, Chakraborty S, McLeod BD, Bjørndal L, et al. (2023) Problem-solving interventions and depression among adolescents and young adults: A systematic review of the effectiveness of problem-solving interventions in preventing or treating depression. PLoS ONE 18(8): e0285949. https://doi.org/10.1371/journal.pone.0285949

Editor: Thiago P. Fernandes, Federal University of Paraiba, BRAZIL

Received: January 2, 2023; Accepted: May 4, 2023; Published: August 29, 2023

Copyright: © 2023 Metz et al. This is an open access article distributed under the terms of the Creative Commons Attribution License , which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Data Availability: All relevant methods and data are within the paper and its Supporting Information files.

Funding: This work was commissioned by Wellcome Trust and was conducted independently by the evaluators (all named authors). No grant number is available. Wellcome Trust had no role in study design, data collection and analysis, decision to publish or preparation of the manuscript. The authors declare no financial or other competing interests, including their relationship and ongoing work with Wellcome Trust. This does not alter our adherence to PLOS ONE policies on sharing data and materials.

Competing interests: The authors have declared that no competing interests exist.

Introduction

Depression among adolescents and young adults (AYA) is a serious, widespread problem. A striking increase in depressive symptoms is seen in early adolescence [ 1 ], with rates of depression being estimated to almost double between the age of 13 (8.4%) and 18 (15.4%) [ 2 ]. Research also suggests that the mean age of onset for depressive disorders is decreasing, and the prevalence is increasing for AYA. Psychosocial interventions, such as cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT), have shown small to moderate effects in preventing and treating depression [ 3 – 6 ]. However, room for improvement remains. Up to half of youth with depression do not receive treatment [ 7 ]. When youth receive treatment, studies indicate that about half of youth will not show measurable symptom reduction across 30 weeks of routine clinical care for depression [ 8 ]. One strategy to improve the accessibility and effectiveness of mental health interventions is to move away from an emphasis on Evidence- Based Treatments (EBTs; e.g., CBT) to a focus on discrete treatment techniques that demonstrate positive effects across multiple studies that meet certain methodological standards (i.e., common elements; 9). Identifying common elements allows for the removal of redundant and less effective treatment content, reducing treatment costs, expanding available service provision and enhancing scability. Furthermore, introducing the most effective elements of treatment early may improve client retention and outcomes [ 9 – 13 ].

A potential common element for depression intervention is problem-solving (PS). PS refers to how an individual identifies and applies solutions to everyday problems. D’Zurilla and colleagues [ 14 – 17 ] conceptualize effective PS skills to include a constructive attitude towards problems (i.e., a positive problem-solving orientation) and the ability to approach problems systematically and rationally (i.e., a rational PS style). Whereas maladaptive patterns, such as negative problem orientation and passively or impulsively addressing problems, are ineffective PS skills that may lead to depressive symptoms [ 14 – 17 ]. Problem Solving Therapy (PST), designed by D’Zurilla and colleagues, is a therapeutic approach developed to decrease mental health problems by improving PS skills [ 18 ]. PST focuses on four core skills to promote adaptive problem solving, including: (1) defining the problem; (2) brainstorming possible solutions; (3) appraising solutions and selecting the best one; and (4) implementing the chosen solution and assessing the outcome [ 14 – 17 ]. PS is also a component in other manualized approaches, such as CBT and Dialectical Behavioural Therapy (DBT), as well as imbedded into other wider generalized mental health programming [ 19 , 20 ]. A meta-analysis of over 30 studies found PST, or PS skills alone, to be as effective as CBT and IPT and more effective than control conditions [ 21 – 23 ]. Thus, justifying its identification as a common element in multiple prevention [ 19 , 24 ] and treatment [ 21 , 25 ] programs for adult depression [ 9 , 26 – 28 ].

PS has been applied to youth and young adults; however, no manuals specific to the AYA population are available. Empirical studies suggest maladaptive PS skills are associated with depressive symptoms in AYA [ 5 , 17 – 23 ]. Furthermore, PS intervention can be brief [ 29 ], delivered by trained or lay counsellors [ 30 , 31 ], and provided in various contexts (e.g., primary care, schools [ 23 ]). Given PS’s versatility and effectiveness, PS could be an ideal common element in treating AYA depression; however, to our knowledge, no reviews or meta-analyses on PS’s effectiveness with AYA specific populations exist. This review aimed to examine the effectiveness of PS as a common element in the prevention and treatment of depression for AYA within real-world settings, as well as to ascertain the variables that may influence and impact PS intervention effects.

Identification and selection of studies

Searches were conducted using PsycInfo , Medline , and Cochrane Library with the following search terms: "problem-solving", “adolescent”, “youth”, and” depression, ” along with filters limiting results to controlled studies looking at effectiveness or exploring mechanisms of effectiveness. Synonyms and derivatives were employed to expand the search. We searched grey literature using Greylit . org and Opengrey . eu , contacted experts in the field and authors of protocols, and searched the reference lists of all included studies. The search was undertaken on 4 th June 2020 and updated on 11 th June 2022.

Studies meeting the following criteria were included: (a) the intervention was described by authors as a PS intervention or including PS; (b) the intervention was used to treat or prevent depression; (c) mean or median age between 13–25 years; and (d) at least one depression outcome was reported. Literature in electronic format published post 2000 was deemed eligible, given the greater relevance of more recent usage of PS in real-world settings. There was no exclusion for gender, ethnicity, or country setting; only English language texts were included. Randomized controlled trials (RCTs), quasi-experimental designs (QEDs), systematic reviews/meta-analyses, pilots, or other studies with clearly defined comparison conditions (no treatment, treatment as usual (TAU), or a comparator treatment) were included. We excluded studies of CBT, IPT, Acceptance and Commitment Therapy (ACT), Dialectical Behaviour Therapy (DBT), and modified forms of these treatments. These treatments include PS and have been shown to demonstrate small to medium effects on depression [ 13 , 14 , 32 ], but the unique contribution of PS cannot be disentangled. The protocol for this review was not registered; however, all data collection forms, extraction, coding and analyses used in the review are available upon inquiry from the first author.

Study selection

All citations were entered into Endnote and uploaded to Covidence for screening and review against the inclusion/exclusion criteria. Reviewers with high inter-rater reliability (98%) independently screened the titles and abstracts. Two reviewers then independently screened full text of articles that met criteria. Duplicates, irrelevant studies, and studies that did not meet the criteria were removed, and the reason for exclusion was recorded (see S1 File for a list of excluded studies). Discrepancies were resolved by discussion with the team leads.

Data extraction

Two reviewers independently extracted data that included: (i) study characteristics (author, publication year, location, design, study aim), (ii) population (age, gender, race/ethnicity, education, family income, depression status), (iii) setting, (iv) intervention description (therapeutic or preventative, whether PS was provided alone or as part of a more comprehensive intervention, duration, delivery mode), (v) treatment outcomes (measures used and reported outcomes for depression, suicidality, and PS), and (vi) fidelity/implementation outcomes. For treatment outcomes, we included the original statistical analyses and/or values needed to calculate an effect size, as reported by the authors. If a variable was not included in the study publication, we extracted the information available and made note of missing data and subsequent limitations to the analyses.

RCTs were assessed for quality (i.e., confidence in the study’s findings) using the Cochrane Risk of Bias 2.0 tool [ 33 ] which includes assessment of the potential risk of bias relating to the process of randomisation; deviations from the intended intervention(s); missing data; outcome measurement and reported results. Risk of bias pertaining to each domain is estimated using an algorithm, grouped as: Low risk; Some concerns; or High risk. Two reviewers independently assessed the quality of included studies, and discrepancies were resolved by consensus.

We planned to conduct one or more meta-analyses if the studies were sufficiently similar. Data were entered into a summary of findings table as a first step in determining the theoretical and practical similarity of the population, intervention, comparison condition, outcome, and study design. If there were sufficiently similar studies, a meta-analysis would be conducted according to guidelines contained in the Cochrane Collaboration Handbook of Systematic Reviews, including tests of heterogeneity and use of random effects models where necessary.

The two searches yielded a total number of 874 records (after the removal of duplicates). After title and abstract screening, 184 full-text papers were considered for inclusion, of which 25 studies met the eligibility criteria and were included in the systematic review ( Fig 1 ). Unfortunately, substantial differences (both theoretical and practical) precluded any relevant meta-analyses, and we were limited to a narrative synthesis.

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https://doi.org/10.1371/journal.pone.0285949.g001

Risk of bias assessment

Risk of bias assessments were conducted on the 23 RCTs ( Fig 2 ; assessments by study presented in S1 Table ). Risk of bias concerns were moderate, and a fair degree of confidence in the validity of study findings is warranted. Most studies (81%) were assessed as ‘some concerns’ (N = 18), four studies were ‘low risk’, and one ‘high risk’. The most frequent areas of concern were the selection of the reported result (n = 18, mostly due to inadequate reporting of a priori analytic plans); deviations from the intended intervention (N = 17, mostly related to insufficient information about intention-to-treat analyses); and randomisation process (N = 13).

https://doi.org/10.1371/journal.pone.0285949.g002

Study designs and characteristics

Study design..

Across the 25 studies, 23 were RCTs; two were QEDs. Nine had TAU or wait-list control (WLC) comparator groups, and 16 used active control groups (e.g., alternative treatment). Eleven studies described fidelity measures. The sample size ranged from 26 to 686 and was under 63 in nine studies.

Selected intervention.

Twenty interventions were described across the 25 studies ( Table 1 ). Ten interventions focused purely on PS. Of these 10 interventions: three were adaptations of models proposed by D’Zurilla and Nezu [ 20 , 34 ] and D’Zurilla and Goldfried [ 18 ], two were based on Mynors-Wallis’s [ 35 ] Problem-Solving Therapy (PST) guide, one was a problem-orientation video intervention adapted from D’Zurilla and Nezu [ 34 ], one was an online intervention adapted from Method of Levels therapy, and three did not specify a model. Ten interventions used PS as part of a larger, more comprehensive intervention (e.g., PS as a portion of cognitive therapy). The utilization and dose of PS steps included in these interventions were unclear. Ten interventions were primary prevention interventions–one of these was universal prevention, five were indicated prevention, and four were selective prevention. Ten interventions were secondary prevention interventions. Nine interventions were described as having been developed or adapted for young people.

https://doi.org/10.1371/journal.pone.0285949.t001

Intervention delivery.

Of the 20 interventions, eight were delivered individually, eight were group-based, two were family-based, one was mixed, and in one, the format of delivery was unclear. Seventeen were delivered face-to-face and three online. Dosage ranged from a single session to 21, 50-minute sessions (12 weekly sessions, then 6 biweekly sessions); the most common session formar was once weekly for six weeks (N = 5).

Intervention setting and participants.

Seventeen studies were conducted in high-income countries (UK, US, Australia, Netherlands, South Korea), four in upper-middle income (Brazil, South Africa, Turkey), and four in low- and middle-income countries (Zimbabwe, Nigeria, India). Four studies included participants younger than 13 and four older than 25. Nine studies were conducted on university or high school student populations and five on pregnant or post-partum mothers. The remaining 11 used populations from mental health clinics, the community, a diabetes clinic, juvenile detention, and a runaway shelter.

Sixteen studies included participants who met the criteria for a depressive, bipolar, or suicidal disorder (two of these excluded severe depression). Nine studies did not use depression symptoms in the inclusion criteria (one of these excluded depression). Several studies excluded other significant mental health conditions.

Outcome measures.

Eight interventions targeted depression, four post/perinatal depression, two suicidal ideation, two resilience, one ‘problem-related distress’, one ‘diabetes distress’, one common adolescent mental health problem, and one mood episode. Those targeting post/perinatal depression used the Edinburgh Postnatal Depression Scale as the outcome measure. Of the others, six used the Beck Depression Inventory (I or II), two the Children’s Depression Inventory, three the Depression Anxiety Stress Scale-21, three the Centre for Epidemiologic Studies Depression Scale, one the Short Mood and Feelings Questionnaire, one the Hamilton Depression Rating Scale, one the depression subscale on the Schedule for Affective Disorders and Schizophrenia for School-Age Children, one the Strengths and Difficulties Questionnaire, one the Youth Top Problems Score, one the Adolescent Longitudinal Interval Follow-up Evaluation and Psychiatric Status Ratings, one the Kiddie Schedule for Affective Disorders and Schizophrenia, and one the Mini International Neuropsychiatric Interview.

Only eight studies measured PS skills or orientation outcomes. Three used the Social Problem-Solving Inventory-Revised, one the Problem Solving Inventory, two measured the extent to which the nominated problem had been resolved, one observed PS in video-taped interactions, and one did not specify the measure.

The mixed findings regarding the effectiveness of PS for depression may depend on the type of intervention: primary (universal, selective, or indicated), secondary or tertiary prevention. Universal prevention interventions target the general public or a population not determined by any specific criteria [ 36 ]. Selective prevention interventions target specific populations with an increased risk of developing a disorder. Indicated prevention interventions target high-risk individuals with sub-clinical symptoms of a disorder. Secondary prevention interventions include those that target individuals diagnosed with a disorder. Finally, tertiary prevention interventions refer to follow-up interventions designed to retain treatment effects. Outcomes are therefore grouped by intervention prevention type and outcome. Within these groupings, studies with a lower risk of bias (RCTs) are presented first. According to the World Health Organisation guidelines, interventions were defined as primary, secondary or tertiary prevention [ 36 ].

Universal prevention interventions

One study reported on a universal prevention intervention targeting resilience and coping strategies in US university students. The Resilience and Coping Intervention, which includes PS as a primary component of the intervention, found a significant reduction in depression compared to TAU (RCT, N = 129, moderate risk of bias) [ 37 ].

Selective prevention interventions

Six studies, including five RCTs and one QED, tested PS as a selective prevention intervention. Two studies investigated the impact of the Manage Your Life Online program, which includes PS as a primary component of the intervention, compared with an online programme emulating Rogerian psychotherapy for UK university students (RCT, N = 213, moderate risk of bias [ 38 ]; RCT, N = 48, moderate risk of bias [ 39 ]). Both studies found no differences in depression or problem-related distress between groups.

Similarly, two studies explored the effect of adapting the Penn Resilience Program, which includes PS as a component of a more comprehensive intervention for young people with diabetes in the US (RCT, N = 264, moderate risk of bias) [ 40 , 41 ]. The initial study showed a moderate reduction in diabetes distress but not depression at 4-, 8-, 12- and 16-months follow-up compared to a diabetes education intervention [ 40 ]. The follow-up study found a significant reduction in depressive symptoms compared to the active control from 16- to 40-months; however, this did not reach significance at 40-months [ 41 ].

Another study that was part of wider PS and social skills intervention among juveniles in state-run detention centres in the US found no impacts (RCT, N = 296, high risk of bias) [ 42 ]. A QED ( N = 32) was used to test the effectiveness of a resilience enhancement and prevention intervention for runaway youth in South Korea [ 43 ]. There was a significant decrease in depression for the intervention group compared with the control group at post-test, but the difference was not sustained at one-month follow-up.

Indicated prevention interventions

Six studies, including five RCTs and one QED, tested PS as an indicated prevention intervention. Four of the five RCTs tested PS as a primary component of the intervention. A PS intervention for common adolescent mental health problems in Indian high school students (RCT, N = 251, low risk of bias) led to a significant reduction in psychosocial problems at 6- and 12 weeks; however, it did not have a significant impact on mental health symptoms or internalising symptoms compared to PS booklets without counsellor treatment at 6- and 12-weeks [ 31 ]. A follow-up study showed a significant reduction in overall psychosocial problems and mental health symptoms, including internalizing symptoms, over 12 months [ 44 ]. Still, these effects no longer reached significance in sensitivity analysis adjusting for missing data (RCT, N = 251, low risk of bias). Furthermore, a 2x2 factorial RCT ( N = 176, moderate risk of bias) testing PST among youth mental health service users with a mild mental disorder in Australia found that the intervention was not superior to supportive counselling at 2-weeks post-treatment [ 30 ]. Similarly, an online PS intervention delivered to young people in the Netherlands to prevent depression (RCT, N = 45, moderate risk of bias) found no significant difference between the intervention and WLC in depression level 4-months post-treatment [ 45 ].

One RCT tested PS approaches in a more comprehensive manualized programme for postnatal depression in the UK and found no significant differences in depression scores between intervention and TAU at 3-months post-partum (RCT, N = 292, moderate risk of bias) [ 46 ].

A study in Turkey used a non-equivalent control group design (QED, N = 62) to test a nursing intervention against a PS control intervention [ 47 ]. Both groups showed a reduction in depression, but the nursing care intervention demonstrated a larger decrease post-intervention than the PS control intervention.

Secondary prevention interventions

Twelve studies, all RCTs, tested PS as a secondary prevention intervention. Four of the 12 RCTs tested PS as a primary component of the intervention. An intervention among women in Zimbabwe (RCT, N = 58, moderate risk of bias) found a larger decrease in the Edinburgh Postnatal Depression Scale score for the intervention group compared to control (who received the antidepressant amitriptyline and peer education) at 6-weeks post-treatment [ 48 ]. A problem-orientation intervention covering four PST steps and involving a single session video for US university students (RCT, N = 110, moderate risk of bias), compared with a video covering other health issues, resulted in a moderate reduction in depression post-treatment; however, results were no longer significant at 2-weeks, and 1-month follow up [ 49 ].

Compared to WLC, a study of an intervention for depression and suicidal proneness among high school and university students in Turkey (RCT, N = 46, moderate risk of bias) found large effect sizes on post-treatment depression scores for intervention participants post-treatment compared with WLC. At 12-month follow-up, these improvements were maintained compared to pre-test but not compared to post-treatment scores. Significant post-treatment depression recovery was also found in the PST group [ 12 ]. Compared to TAU, a small but high-quality (low-risk of bias) study focused on preventing suicidal risk among school students in Brazil (RCT, N = 100, low risk of bias) found a significant, moderate reduction in depression symptoms for the treatment group post-intervention that was maintained at 1-, 3- and 6-month follow-up [ 50 ].

Seven of the 12 RCTs tested PS as a part of a more comprehensive intervention. Two interventions targeted mood episodes and were compared to active control. These US studies focused on Family-Focused Therapy as an intervention for mood episodes, which included sessions on PS [ 51 , 52 ]. One of these found that Family-Focused Therapy for AYA with Bipolar Disorder (RCT, N = 145, moderate risk of bias) had no significant impact on mood or depressive symptoms compared to pharmacotherapy. However, Family-Focused Therapy had a greater impact on the proportion of weeks without mania/hypomania and mania/hypomania symptoms than enhanced care [ 53 ]. Alternatively, while the other study (RCT, N = 127, low risk of bias) found no significant impact on time to recovery, Family-Focused Therapy led to significantly longer intervals of wellness before new mood episodes, longer intervals between recovery and the next mood episode, and longer intervals of randomisation to the next mood episode in AYA with either Bipolar Disorder (BD) or Major Depressive Disorder (MDD), compared to family and individual psychoeducation [ 52 ].

Two US studies used a three-arm trial to compare Systemic-behavioural Family Therapy (SBFT) with elements of PS, to CBT and individual Non-directive Supportive therapy (NST) (RCT, N = 107, moderate risk of bias) [ 53 , 54 ]. One study looked at whether the PS elements of CBT and SFBT mediated the effectiveness of these interventions for the remission of MDD. It found that PS mediated the association between CBT, but not SFBT, and remission from depression. There was no significant association between SBFT and remission status, though there was a significant association between CBT and remission status [ 53 ]. The other study found no significant reduction in depression post-treatment or at 24-month follow-up for SBFT [ 54 ].

A PS intervention tested in maternal and child clinics in Nigeria RCT ( N = 686, moderate risk of bias) compared with enhanced TAU involving psychosocial and social support found no significant difference in the proportion of women who recovered from depression at 6-months post-partum [ 55 ]. However, there was a small difference in depression scores in favour of PS averaged across the 3-, 6-, 9-, and 12-month follow-up points. Cognitive Reminiscence Therapy, which involved recollection of past PS experiences and drew on PS techniques used for 12-25-year-olds in community mental health services in Australia (RCT, N = 26, moderate risk of bias), did not reduce depression symptoms compared with a brief evidence-based treatment at 1- or 2-month follow-up [ 56 ]. Additionally, the High School Transition Program in the US (RCT, N = 497, moderate risk of bias) aimed to prevent depression, anxiety, and school problems in youth transitioning to high school [ 57 ]. There was no reduction in the percentage of intervention students with clinical depression compared to the control group. Similarly, a small study focused on reducing depression symptoms, and nonadherence to antiretroviral therapy in pregnant women with HIV in South Africa (RCT, N = 23, some concern) found a significant reduction in depression symptoms compared to TAU, with the results being maintained at the 3-month follow-up [ 58 ].

Reduction in suicidality

Three studies measured a reduction in suicidality. A preventive treatment found a large reduction in suicidal orientation in the PS group compared to control post-treatment. In contrast, suicidal ideation scores were inconsistent at 1-,3- and 6- month follow-up, they maintained an overall lower score [ 50 ]. Furthermore, at post-test, significantly more participants in the PS group were no longer at risk of suicide. No significant differences were found in suicide plans or attempts. In a PST intervention, post-treatment suicide risk scores were lower than pre-treatment for the PST group but unchanged for the control group [ 12 ]. An online treatment found a moderate decline in ideation for the intervention group post-treatment compared to the control but was not sustained at a one-month follow-up [ 49 ].

Mediators and moderators

Eight studies measured PS skills or effectiveness. In two studies, despite the interventions reducing depression, there was no improvement in PS abilities [ 12 , 52 ]. One found that change in global and functional PS skills mediated the relationship between the intervention group and change in suicidal orientation, but this was not assessed for depression [ 50 ]. Three other studies found no change in depression symptoms, PS skills, or problem resolution [ 38 – 40 ]. Finally, CBT and SBFT led to significant increases in PS behaviour, and PS was associated with higher rates of remission across treatments but did not moderate the relationship between SBFT and remission status [ 53 ]. Another study found no changes in confidence in the ability to solve problems or belief in personal control when solving problems. Furthermore, the intervention group was more likely to adopt an avoidant PS style [ 46 ].

A high-intensity intervention for perinatal depression in Nigeria had no treatment effect on depression remission rates for the whole sample. Still, it was significantly effective for participants with more severe depression at baseline [ 55 ]. A PS intervention among juvenile detainees in the US effectively reduced depression for participants with higher levels of fluid intelligence, but symptoms increased for those with lower levels [ 42 ].The authors suggest that individuals with lower levels of fluid intelligence may have been less able to cope with exploring negative emotions and apply the skills learned.

This review has examined the evidence on the effectiveness of PS in the prevention or treatment of depression among 13–25-year-olds. We sought to determine in what way, in which contexts, and for whom PS appears to work in addressing depression. We found 25 studies involving 20 interventions. Results are promising for secondary prevention interventions, or interventions targeting clinical level populations, that utilize PS as the primary intervention [ 12 , 47 – 49 ]. These studies not only found a significant reduction in depression symptoms compared to active [ 48 , 49 ] and non-active [ 12 , 47 ] controls but also found a significant reduction in suicidal orientation and ideation [ 12 , 47 , 49 ]. These findings are consistent with meta-analyses of adult PS interventions [ 21 , 22 , 23 ], highlighting that PS interventions for AYA can be effective in real-world settings.

For other types of interventions (i.e., universal, selective prevention, indicated prevention), results were mixed in reducing depression. The one universal program was found to have a small, significant effect in reducing depression symptoms compared to a non-active control [ 37 ]. Most selective prevention programs were not effective [ 39 , 40 , 56 ], and those that did show small, significant effects had mixed outcomes for follow-up maintenance [ 41 , 42 ]. Most indicated prevention programs were not effective [ 30 , 31 , 45 – 47 ], yet a follow-up study showed a significant reduction in internalizing symptoms at 12-month post-treatment compared to an active control [ 44 ]. Given that these studies targeted sub-clinical populations and many of them had small sample sizes, these mixed findings may be a result of not having sufficient power to detect a meaningful difference.

Our review found limited evidence about PS skills as mediator or moderator of depression. Few studies measured improvements in PS skills; fewer still found interventions to be effective. The absence of evidence for PS abilities as a pathway is puzzling. It may be that specific aspects of PS behaviours and processes, such as problem orientation [ 59 ], are relevant. Alternatively, there may be a mechanism other than PS skills through which PS interventions influence depression.

Studies with PS as part of a wider intervention also showed mixed results, even amongst clinical populations. Although there was no clear rationale for the discrepancies in effectiveness between the studies, it is possible that the wider program dilutes the focus and impact of efficacious therapeutic elements. However, this is difficult to discern given the heterogeneity in the studies and limited information on study treatments and implementation factors. A broad conclusion might be that PS can be delivered most effectively with clinical populations in its purest PS form and may be tailored to a range of different contexts and forms, a range of populations, and to address different types of problems; however, this tailoring may reduce effectiveness.

Although the scale of impact is broadly in line with the small to moderate effectiveness of other treatments for youth depression [ 6 ], our review highlights shortcomings in study design, methods, and reporting that would allow for a better understanding of PS effectiveness and pathways. Studies varied in how well PS was operationalised. Low dosage is consistent with usage described in informal conversations with practitioners but may be insufficient for effectiveness. Fidelity was monitored in only half the studies despite evidence that monitoring implementation improves effectiveness [ 60 ]. There were references to implementation difficulties, including attrition, challenges in operationalizing online interventions, and skills of those delivering. Furthermore, most of the studies had little information about comorbidity and no analysis of whether it influenced outcomes. Therefore, we were unable to fully examine and conceptualize the ways, how and for whom PS works. More information about study populations and intervention implementation is essential to understand the potential of PS for broader dissemination.

Our review had several limitations. We excluded studies that included four treatments known to be effective in treating depression among AYA (e.g., CBT) but where the unique contribution of PS to clinical outcome could not be disentangled. Furthermore, we relied on authors’ reporting to determine if PS was included: details about operationalization of PS were often scant. Little evidence addressing the fit, feasibility, or acceptability of PS interventions was found, reflecting a limited focus on implementation. We included only English-language texts: relevant studies in other languages may exist, though our post-2000 inclusion criteria may limit this potential bias due to improved translation of studies to English over the years. Finally, the heterogeneity of study populations, problem severity, comparison conditions, outcome measures, and study designs, along with a relatively small number of included studies, limits confidence in what we can say about implementation and treatment outcomes.

Overall, our review indicates that PS may have the best results when implemented its purest form as a stand-alone treatment with clinical level AYA populations; tailoring or imbedding PS into wider programming may dilute its effectiveness. Our review also points to a need for continued innovation in treatment to improve the operationalizing and testing of PS, especially when included as a part of a more comprehensive intervention. It also highlights the need for study methods that allow us to understand the specific effects of PS, and that measure the frequency, dosage, and timing of PS to understand what is effective for whom and in what contexts.

Supporting information

S1 file. list of excluded studies..

https://doi.org/10.1371/journal.pone.0285949.s001

S2 File. PRISMA checklist.

https://doi.org/10.1371/journal.pone.0285949.s002

S1 Table. Individual risk of bias assessments using cochrane RoB2 tool by domain (1–5) and overall (6).

https://doi.org/10.1371/journal.pone.0285949.s003

Acknowledgments

All individuals that contributed to this paper are included as authors.

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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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• December 19, 2023

20 Cognitive Behavioral Therapy (CBT) Techniques with Examples

Muhammad Sohail

Table of contents.

Cognitive Behavioral Therapy (CBT) stands as a powerful, evidence-based therapeutic approach for various mental health challenges. At its core lies a repertoire of techniques designed to reframe thoughts, alter behaviors, and alleviate emotional distress. This article explores 20 most commonly used cbt techniques. These therapy techniques are scientifcally valid, diverse in their application and effectiveness, serve as pivotal tools in helping individuals navigate and conquer their mental health obstacles.

Cognitive Restructuring or Reframing:

This is the most talked about of all cbt techniques. CBT employs cognitive restructuring to challenge and alter negative thought patterns. By examining beliefs and questioning their validity, individuals learn to perceive situations from different angles, fostering more adaptive thinking patterns.

John, feeling worthless after a rejected job application, questions his belief that he’s incompetent. He reflects on past achievements and reframes the situation, realizing the rejection doesn’t define his abilities.

Guided Discovery:

In guided discovery, therapists engage individuals in an exploration of their viewpoints. Through strategic questioning, individuals are prompted to examine evidence supporting their beliefs and consider alternate perspectives, fostering a more nuanced understanding and empowering them to choose healthier cognitive pathways.

During therapy, Sarah explores her fear of failure. Her therapist asks, “What evidence supports your belief that you’ll fail? Can we consider alternate outcomes?” Guided by these questions, Sarah acknowledges her exaggerated fears and explores more balanced perspectives.

Journaling and Thought Records:

Writing exercises like journaling and thought records aid in identifying and challenging negative thoughts. Tracking thoughts between sessions and noting positive alternatives enables individuals to monitor progress and recognize cognitive shifts.

James maintains a thought journal. Between sessions, he records negative thoughts about social situations. He then challenges these thoughts, jotting down positive alternatives and notices a shift in his mindset.

Activity Scheduling and Behavior Activation:

By scheduling avoided activities and implementing learned strategies, individuals establish healthier habits and confront avoidance tendencies, fostering behavioral change.

Emily, struggling with social anxiety, schedules coffee outings with friends. By implementing gradual exposure, she confronts her fear and eventually feels more comfortable in social settings.

Relaxation and Stress Reduction Techniques:

CBT incorporates relaxation techniques like deep breathing, muscle relaxation, and imagery to mitigate stress. These methods equip individuals with practical skills to manage phobias, social anxieties, and stressors effectively.

David practices deep breathing exercises when faced with work stress. By incorporating this technique into his routine, he manages work-related anxiety more effectively.

Successive Approximation:

Breaking overwhelming tasks into manageable steps cultivates confidence through incremental progress, enabling individuals to tackle challenges more effectively.

Maria, overwhelmed by academic tasks, breaks down her study sessions into smaller, manageable sections. As she masters each segment, her confidence grows, making the workload seem more manageable.

Interoceptive Exposure:

This technique targets panic and anxiety by exposing individuals to feared bodily sensations, allowing for a recalibration of beliefs around these sensations and reducing avoidance behaviors.

Tom, experiencing panic attacks, deliberately induces shortness of breath in a controlled setting. As he tolerates this discomfort without avoidance, he realizes that the sensation, though distressing, is not harmful.

Play the Script Until the End:

Encouraging individuals to envision worst-case scenarios helps alleviate fear by demonstrating the manageability of potential outcomes, reducing anxiety.

Facing fear of public speaking, Rachel imagines herself stumbling during a presentation. By playing out this scenario mentally, she realizes that even if it happens, it wouldn’t be catastrophic.

Shaping (Successive Approximation):

Shaping involves mastering simpler tasks akin to the challenging ones, aiding individuals in overcoming difficulties through gradual skill development.

Chris, struggling with public speaking, begins by speaking to small groups before gradually addressing larger audiences. Each step builds his confidence for the next challenge.

Contingency Management:

This method utilizes reinforcement and punishment to promote desirable behaviors, leveraging the consequences of actions to shape behavior positively.

To encourage healthier eating habits, Sarah rewards herself with a favorite activity after a week of sticking to a balanced diet.

Acting Out (Role-Playing):

Role-playing scenarios allow individuals to practice new behaviors in a safe environment, facilitating skill development and desensitization to challenging situations.

Alex, preparing for a job interview, engages in role-playing with a friend. They simulate the interview scenario, allowing Alex to practice responses and manage anxiety.

Sleep Hygiene Training:

Addressing the link between depression and sleep problems, this technique provides strategies for improving sleep quality, a critical aspect of mental well-being.

Lisa, struggling with sleep, follows sleep hygiene recommendations. She creates a calming bedtime routine and eliminates screen time before sleep, noticing improvements in her sleep quality.

Mastery and Pleasure Technique:

Encouraging engagement in enjoyable or accomplishment-driven activities serves as a mood enhancer and distraction from depressive thoughts.

After feeling low, Mark engages in gardening (a mastery activity) and then spends time painting (a pleasure activity). He finds joy in these activities, which uplifts his mood.

Behavioral Experiments:

This technique involves creating real-life experiments to test the validity of certain beliefs or assumptions. By actively exploring alternative thoughts or behaviors, individuals gather concrete evidence to challenge and modify their existing perspectives.

Laura believes people judge her negatively. She experiments by initiating conversations at social gatherings and observes that most interactions are positive, challenging her belief.

Externalizing:

Externalizing helps individuals separate themselves from their problems by giving those issues an identity or persona. This technique encourages individuals to view their problems as separate entities, facilitating a more objective approach to problem-solving.

Adam, dealing with anger issues, visualizes his anger as a separate entity named “Fury.” This helps him view his emotions objectively and manage them more effectively.

Acceptance and Commitment Therapy (ACT):

ACT combines mindfulness strategies with commitment and behavior-change techniques. It focuses on accepting difficult thoughts and emotions while committing to actions aligned with personal values, promoting psychological flexibility.

Sarah practices mindfulness exercises to accept her anxiety while committing to attend social events aligned with her values of connection and growth.

Imagery-Based Exposure:

This technique involves mentally visualizing feared or distressing situations, allowing individuals to confront and manage their anxieties in a controlled, imaginative setting.

Jack, afraid of flying, visualizes being on a plane, progressively picturing the experience in detail until he feels more comfortable with the idea of flying.

Mindfulness-Based Stress Reduction (MBSR):

MBSR incorporates mindfulness meditation and awareness techniques to help individuals manage stress, improve focus, and enhance overall well-being by staying present in the moment.

Rachel practices mindfulness meditation daily. By focusing on the present moment, she reduces work-related stress and enhances her overall well-being.

Systematic Desensitization:

Similar to exposure therapy, systematic desensitization involves pairing relaxation techniques with gradual exposure to anxiety-inducing stimuli. This process helps individuals associate relaxation with the feared stimuli, reducing anxiety responses over time.

Michael, with a fear of heights, gradually exposes himself to elevators first, then low floors in tall buildings, gradually working up to higher levels, reducing his fear response.

Narrative Therapy:

Narrative therapy focuses on separating individuals from their problems by helping them reconstruct and retell their life stories in a more empowering and positive light, emphasizing strengths and resilience.

Emily reevaluates her life story by focusing on instances where she overcame challenges, emphasizing her resilience and strength rather than her setbacks.

Each of these CBT techniques plays a unique role in helping individuals transform their thoughts, behaviors, and emotions. While some focus on cognitive restructuring, others emphasize behavioral modification or stress reduction. Together, they form a comprehensive toolkit empowering individuals to navigate their mental health challenges and foster positive change in their lives.

more insights

Addiction Recovery and the Role of Society’s Perception of Mental Health

Discover how society’s perception of mental health impacts addiction recovery. Learn ways to support positive change in mental health.

Addiction Treatment: Trauma-Informed Care

Explore the concept of trauma-informed care and find out how this method is reshaping the world of addiction treatment.

The Availability Heuristic: Cognitive Bias in Decision Making

The availability heuristic is a cognitive bias that affects decision-making based on how easily information can be recalled or accessed.

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Problem-Solving Based Intervention for Informal Caregivers: A Scoping Review

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How to improve your problem solving skills and build effective problem solving strategies

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Effective problem solving is all about using the right process and following a plan tailored to the issue at hand. Recognizing your team or organization has an issue isn’t enough to come up with effective problem solving strategies. 

To truly understand a problem and develop appropriate solutions, you will want to follow a solid process, follow the necessary problem solving steps, and bring all of your problem solving skills to the table.   We’ll forst look at what problem solving strategies you can employ with your team when looking for a way to approach the process. We’ll then discuss the problem solving skills you need to be more effective at solving problems, complete with an activity from the SessionLab library you can use to develop that skill in your team.

Let’s get to it! 

Problem solving strategies

What skills do i need to be an effective problem solver, how can i improve my problem solving skills.

Problem solving strategies are methods of approaching and facilitating the process of problem-solving with a set of techniques , actions, and processes. Different strategies are more effective if you are trying to solve broad problems such as achieving higher growth versus more focused problems like, how do we improve our customer onboarding process?

Broadly, the problem solving steps outlined above should be included in any problem solving strategy though choosing where to focus your time and what approaches should be taken is where they begin to differ. You might find that some strategies ask for the problem identification to be done prior to the session or that everything happens in the course of a one day workshop.

The key similarity is that all good problem solving strategies are structured and designed. Four hours of open discussion is never going to be as productive as a four-hour workshop designed to lead a group through a problem solving process.

Good problem solving strategies are tailored to the team, organization and problem you will be attempting to solve. Here are some example problem solving strategies you can learn from or use to get started.

Use a workshop to lead a team through a group process

Often, the first step to solving problems or organizational challenges is bringing a group together effectively. Most teams have the tools, knowledge, and expertise necessary to solve their challenges – they just need some guidance in how to use leverage those skills and a structure and format that allows people to focus their energies.

Facilitated workshops are one of the most effective ways of solving problems of any scale. By designing and planning your workshop carefully, you can tailor the approach and scope to best fit the needs of your team and organization. 

Problem solving workshop

• Creating a bespoke, tailored process
• Tackling problems of any size
• Building in-house workshop ability and encouraging their use

Workshops are an effective strategy for solving problems. By using tried and test facilitation techniques and methods, you can design and deliver a workshop that is perfectly suited to the unique variables of your organization. You may only have the capacity for a half-day workshop and so need a problem solving process to match. 

By using our session planner tool and importing methods from our library of 700+ facilitation techniques, you can create the right problem solving workshop for your team. It might be that you want to encourage creative thinking or look at things from a new angle to unblock your groups approach to problem solving. By tailoring your workshop design to the purpose, you can help ensure great results.

One of the main benefits of a workshop is the structured approach to problem solving. Not only does this mean that the workshop itself will be successful, but many of the methods and techniques will help your team improve their working processes outside of the workshop. 

We believe that workshops are one of the best tools you can use to improve the way your team works together. Start with a problem solving workshop and then see what team building, culture or design workshops can do for your organization!

Run a design sprint

Great for: 

• aligning large, multi-discipline teams
• quickly designing and testing solutions
• tackling large, complex organizational challenges and breaking them down into smaller tasks

By using design thinking principles and methods, a design sprint is a great way of identifying, prioritizing and prototyping solutions to long term challenges that can help solve major organizational problems with quick action and measurable results.

Some familiarity with design thinking is useful, though not integral, and this strategy can really help a team align if there is some discussion around which problems should be approached first. 

The stage-based structure of the design sprint is also very useful for teams new to design thinking.  The inspiration phase, where you look to competitors that have solved your problem, and the rapid prototyping and testing phases are great for introducing new concepts that will benefit a team in all their future work. 

It can be common for teams to look inward for solutions and so looking to the market for solutions you can iterate on can be very productive. Instilling an agile prototyping and testing mindset can also be great when helping teams move forwards – generating and testing solutions quickly can help save time in the long run and is also pretty exciting!

Break problems down into smaller issues

Organizational challenges and problems are often complicated and large scale in nature. Sometimes, trying to resolve such an issue in one swoop is simply unachievable or overwhelming. Try breaking down such problems into smaller issues that you can work on step by step. You may not be able to solve the problem of churning customers off the bat, but you can work with your team to identify smaller effort but high impact elements and work on those first.

This problem solving strategy can help a team generate momentum, prioritize and get some easy wins. It’s also a great strategy to employ with teams who are just beginning to learn how to approach the problem solving process. If you want some insight into a way to employ this strategy, we recommend looking at our design sprint template below!

Use guiding frameworks or try new methodologies

Some problems are best solved by introducing a major shift in perspective or by using new methodologies that encourage your team to think differently.

Props and tools such as Methodkit , which uses a card-based toolkit for facilitation, or Lego Serious Play can be great ways to engage your team and find an inclusive, democratic problem solving strategy. Remember that play and creativity are great tools for achieving change and whatever the challenge, engaging your participants can be very effective where other strategies may have failed.

LEGO Serious Play

• Improving core problem solving skills
• Thinking outside of the box
• Encouraging creative solutions

LEGO Serious Play is a problem solving methodology designed to get participants thinking differently by using 3D models and kinesthetic learning styles. By physically building LEGO models based on questions and exercises, participants are encouraged to think outside of the box and create their own responses. 

Collaborate LEGO Serious Play exercises are also used to encourage communication and build problem solving skills in a group. By using this problem solving process, you can often help different kinds of learners and personality types contribute and unblock organizational problems with creative thinking. 

Problem solving strategies like LEGO Serious Play are super effective at helping a team solve more skills-based problems such as communication between teams or a lack of creative thinking. Some problems are not suited to LEGO Serious Play and require a different problem solving strategy.

Card Decks and Method Kits

• New facilitators or non-facilitators 
• Approaching difficult subjects with a simple, creative framework
• Engaging those with varied learning styles

Card decks and method kids are great tools for those new to facilitation or for whom facilitation is not the primary role. Card decks such as the emotional culture deck can be used for complete workshops and in many cases, can be used right out of the box. Methodkit has a variety of kits designed for scenarios ranging from personal development through to personas and global challenges so you can find the right deck for your particular needs.

Having an easy to use framework that encourages creativity or a new approach can take some of the friction or planning difficulties out of the workshop process and energize a team in any setting. Simplicity is the key with these methods. By ensuring everyone on your team can get involved and engage with the process as quickly as possible can really contribute to the success of your problem solving strategy.

Source external advice

Looking to peers, experts and external facilitators can be a great way of approaching the problem solving process. Your team may not have the necessary expertise, insights of experience to tackle some issues, or you might simply benefit from a fresh perspective. Some problems may require bringing together an entire team, and coaching managers or team members individually might be the right approach. Remember that not all problems are best resolved in the same manner.

If you’re a solo entrepreneur, peer groups, coaches and mentors can also be invaluable at not only solving specific business problems, but in providing a support network for resolving future challenges. One great approach is to join a Mastermind Group and link up with like-minded individuals and all grow together. Remember that however you approach the sourcing of external advice, do so thoughtfully, respectfully and honestly. Reciprocate where you can and prepare to be surprised by just how kind and helpful your peers can be!

Mastermind Group

• Solo entrepreneurs or small teams with low capacity
• Peer learning and gaining outside expertise
• Getting multiple external points of view quickly

Problem solving in large organizations with lots of skilled team members is one thing, but how about if you work for yourself or in a very small team without the capacity to get the most from a design sprint or LEGO Serious Play session? 

A mastermind group – sometimes known as a peer advisory board – is where a group of people come together to support one another in their own goals, challenges, and businesses. Each participant comes to the group with their own purpose and the other members of the group will help them create solutions, brainstorm ideas, and support one another. 

Mastermind groups are very effective in creating an energized, supportive atmosphere that can deliver meaningful results. Learning from peers from outside of your organization or industry can really help unlock new ways of thinking and drive growth. Access to the experience and skills of your peers can be invaluable in helping fill the gaps in your own ability, particularly in young companies.

A mastermind group is a great solution for solo entrepreneurs, small teams, or for organizations that feel that external expertise or fresh perspectives will be beneficial for them. It is worth noting that Mastermind groups are often only as good as the participants and what they can bring to the group. Participants need to be committed, engaged and understand how to work in this context. 

Coaching and mentoring

• Focused learning and development
• Filling skills gaps
• Working on a range of challenges over time

Receiving advice from a business coach or building a mentor/mentee relationship can be an effective way of resolving certain challenges. The one-to-one format of most coaching and mentor relationships can really help solve the challenges those individuals are having and benefit the organization as a result.

A great mentor can be invaluable when it comes to spotting potential problems before they arise and coming to understand a mentee very well has a host of other business benefits. You might run an internal mentorship program to help develop your team’s problem solving skills and strategies or as part of a large learning and development program. External coaches can also be an important part of your problem solving strategy, filling skills gaps for your management team or helping with specific business issues. 

Now we’ve explored the problem solving process and the steps you will want to go through in order to have an effective session, let’s look at the skills you and your team need to be more effective problem solvers.

Problem solving skills are highly sought after, whatever industry or team you work in. Organizations are keen to employ people who are able to approach problems thoughtfully and find strong, realistic solutions. Whether you are a facilitator , a team leader or a developer, being an effective problem solver is a skill you’ll want to develop.

Problem solving skills form a whole suite of techniques and approaches that an individual uses to not only identify problems but to discuss them productively before then developing appropriate solutions.

Here are some of the most important problem solving skills everyone from executives to junior staff members should learn. We’ve also included an activity or exercise from the SessionLab library that can help you and your team develop that skill. 

If you’re running a workshop or training session to try and improve problem solving skills in your team, try using these methods to supercharge your process!

Active listening

Active listening is one of the most important skills anyone who works with people can possess. In short, active listening is a technique used to not only better understand what is being said by an individual, but also to be more aware of the underlying message the speaker is trying to convey. When it comes to problem solving, active listening is integral for understanding the position of every participant and to clarify the challenges, ideas and solutions they bring to the table.

Some active listening skills include:

• Paying complete attention to the speaker.
• Removing distractions.
• Avoid interruption.
• Taking the time to fully understand before preparing a rebuttal.
• Responding respectfully and appropriately.
• Demonstrate attentiveness and positivity with an open posture, making eye contact with the speaker, smiling and nodding if appropriate. Show that you are listening and encourage them to continue.
• Be aware of and respectful of feelings. Judge the situation and respond appropriately. You can disagree without being disrespectful.   
• Observe body language. 
• Paraphrase what was said in your own words, either mentally or verbally.
• Remain neutral. 
• Reflect and take a moment before responding.
• Ask deeper questions based on what is said and clarify points where necessary.   

Active Listening   #hyperisland   #skills   #active listening   #remote-friendly   This activity supports participants to reflect on a question and generate their own solutions using simple principles of active listening and peer coaching. It’s an excellent introduction to active listening but can also be used with groups that are already familiar with it. Participants work in groups of three and take turns being: “the subject”, the listener, and the observer.

Analytical skills

All problem solving models require strong analytical skills, particularly during the beginning of the process and when it comes to analyzing how solutions have performed.

Analytical skills are primarily focused on performing an effective analysis by collecting, studying and parsing data related to a problem or opportunity. 

It often involves spotting patterns, being able to see things from different perspectives and using observable facts and data to make suggestions or produce insight. 

Analytical skills are also important at every stage of the problem solving process and by having these skills, you can ensure that any ideas or solutions you create or backed up analytically and have been sufficiently thought out.

Nine Whys   #innovation   #issue analysis   #liberating structures   With breathtaking simplicity, you can rapidly clarify for individuals and a group what is essentially important in their work. You can quickly reveal when a compelling purpose is missing in a gathering and avoid moving forward without clarity. When a group discovers an unambiguous shared purpose, more freedom and more responsibility are unleashed. You have laid the foundation for spreading and scaling innovations with fidelity.

Collaboration

Trying to solve problems on your own is difficult. Being able to collaborate effectively, with a free exchange of ideas, to delegate and be a productive member of a team is hugely important to all problem solving strategies.

Remember that whatever your role, collaboration is integral, and in a problem solving process, you are all working together to find the best solution for everyone. 

Marshmallow challenge with debriefing   #teamwork   #team   #leadership   #collaboration   In eighteen minutes, teams must build the tallest free-standing structure out of 20 sticks of spaghetti, one yard of tape, one yard of string, and one marshmallow. The marshmallow needs to be on top. The Marshmallow Challenge was developed by Tom Wujec, who has done the activity with hundreds of groups around the world. Visit the Marshmallow Challenge website for more information. This version has an extra debriefing question added with sample questions focusing on roles within the team.

Communication  

Being an effective communicator means being empathetic, clear and succinct, asking the right questions, and demonstrating active listening skills throughout any discussion or meeting. 

In a problem solving setting, you need to communicate well in order to progress through each stage of the process effectively. As a team leader, it may also fall to you to facilitate communication between parties who may not see eye to eye. Effective communication also means helping others to express themselves and be heard in a group.

Bus Trip   #feedback   #communication   #appreciation   #closing   #thiagi   #team   This is one of my favourite feedback games. I use Bus Trip at the end of a training session or a meeting, and I use it all the time. The game creates a massive amount of energy with lots of smiles, laughs, and sometimes even a teardrop or two.

Creative problem solving skills can be some of the best tools in your arsenal. Thinking creatively, being able to generate lots of ideas and come up with out of the box solutions is useful at every step of the process. 

The kinds of problems you will likely discuss in a problem solving workshop are often difficult to solve, and by approaching things in a fresh, creative manner, you can often create more innovative solutions.

Having practical creative skills is also a boon when it comes to problem solving. If you can help create quality design sketches and prototypes in record time, it can help bring a team to alignment more quickly or provide a base for further iteration.

The paper clip method   #sharing   #creativity   #warm up   #idea generation   #brainstorming   The power of brainstorming. A training for project leaders, creativity training, and to catalyse getting new solutions.

Critical thinking

Critical thinking is one of the fundamental problem solving skills you’ll want to develop when working on developing solutions. Critical thinking is the ability to analyze, rationalize and evaluate while being aware of personal bias, outlying factors and remaining open-minded.

Defining and analyzing problems without deploying critical thinking skills can mean you and your team go down the wrong path. Developing solutions to complex issues requires critical thinking too – ensuring your team considers all possibilities and rationally evaluating them. 

Agreement-Certainty Matrix   #issue analysis   #liberating structures   #problem solving   You can help individuals or groups avoid the frequent mistake of trying to solve a problem with methods that are not adapted to the nature of their challenge. The combination of two questions makes it possible to easily sort challenges into four categories: simple, complicated, complex , and chaotic .  A problem is simple when it can be solved reliably with practices that are easy to duplicate.  It is complicated when experts are required to devise a sophisticated solution that will yield the desired results predictably.  A problem is complex when there are several valid ways to proceed but outcomes are not predictable in detail.  Chaotic is when the context is too turbulent to identify a path forward.  A loose analogy may be used to describe these differences: simple is like following a recipe, complicated like sending a rocket to the moon, complex like raising a child, and chaotic is like the game “Pin the Tail on the Donkey.”  The Liberating Structures Matching Matrix in Chapter 5 can be used as the first step to clarify the nature of a challenge and avoid the mismatches between problems and solutions that are frequently at the root of chronic, recurring problems.

Data analysis 

Though it shares lots of space with general analytical skills, data analysis skills are something you want to cultivate in their own right in order to be an effective problem solver.

Being good at data analysis doesn’t just mean being able to find insights from data, but also selecting the appropriate data for a given issue, interpreting it effectively and knowing how to model and present that data. Depending on the problem at hand, it might also include a working knowledge of specific data analysis tools and procedures. 

Having a solid grasp of data analysis techniques is useful if you’re leading a problem solving workshop but if you’re not an expert, don’t worry. Bring people into the group who has this skill set and help your team be more effective as a result.

Decision making

All problems need a solution and all solutions require that someone make the decision to implement them. Without strong decision making skills, teams can become bogged down in discussion and less effective as a result. 

Making decisions is a key part of the problem solving process. It’s important to remember that decision making is not restricted to the leadership team. Every staff member makes decisions every day and developing these skills ensures that your team is able to solve problems at any scale. Remember that making decisions does not mean leaping to the first solution but weighing up the options and coming to an informed, well thought out solution to any given problem that works for the whole team.

Lightning Decision Jam (LDJ)   #action   #decision making   #problem solving   #issue analysis   #innovation   #design   #remote-friendly   The problem with anything that requires creative thinking is that it’s easy to get lost—lose focus and fall into the trap of having useless, open-ended, unstructured discussions. Here’s the most effective solution I’ve found: Replace all open, unstructured discussion with a clear process. What to use this exercise for: Anything which requires a group of people to make decisions, solve problems or discuss challenges. It’s always good to frame an LDJ session with a broad topic, here are some examples: The conversion flow of our checkout Our internal design process How we organise events Keeping up with our competition Improving sales flow

Dependability

Most complex organizational problems require multiple people to be involved in delivering the solution. Ensuring that the team and organization can depend on you to take the necessary actions and communicate where necessary is key to ensuring problems are solved effectively.

Being dependable also means working to deadlines and to brief. It is often a matter of creating trust in a team so that everyone can depend on one another to complete the agreed actions in the agreed time frame so that the team can move forward together. Being undependable can create problems of friction and can limit the effectiveness of your solutions so be sure to bear this in mind throughout a project. 

Team Purpose & Culture   #team   #hyperisland   #culture   #remote-friendly   This is an essential process designed to help teams define their purpose (why they exist) and their culture (how they work together to achieve that purpose). Defining these two things will help any team to be more focused and aligned. With support of tangible examples from other companies, the team members work as individuals and a group to codify the way they work together. The goal is a visual manifestation of both the purpose and culture that can be put up in the team’s work space.

Emotional intelligence

Emotional intelligence is an important skill for any successful team member, whether communicating internally or with clients or users. In the problem solving process, emotional intelligence means being attuned to how people are feeling and thinking, communicating effectively and being self-aware of what you bring to a room. 

There are often differences of opinion when working through problem solving processes, and it can be easy to let things become impassioned or combative. Developing your emotional intelligence means being empathetic to your colleagues and managing your own emotions throughout the problem and solution process. Be kind, be thoughtful and put your points across care and attention. 

Being emotionally intelligent is a skill for life and by deploying it at work, you can not only work efficiently but empathetically. Check out the emotional culture workshop template for more!

Facilitation

As we’ve clarified in our facilitation skills post, facilitation is the art of leading people through processes towards agreed-upon objectives in a manner that encourages participation, ownership, and creativity by all those involved. While facilitation is a set of interrelated skills in itself, the broad definition of facilitation can be invaluable when it comes to problem solving. Leading a team through a problem solving process is made more effective if you improve and utilize facilitation skills – whether you’re a manager, team leader or external stakeholder.

The Six Thinking Hats   #creative thinking   #meeting facilitation   #problem solving   #issue resolution   #idea generation   #conflict resolution   The Six Thinking Hats are used by individuals and groups to separate out conflicting styles of thinking. They enable and encourage a group of people to think constructively together in exploring and implementing change, rather than using argument to fight over who is right and who is wrong.

Flexibility 

Being flexible is a vital skill when it comes to problem solving. This does not mean immediately bowing to pressure or changing your opinion quickly: instead, being flexible is all about seeing things from new perspectives, receiving new information and factoring it into your thought process.

Flexibility is also important when it comes to rolling out solutions. It might be that other organizational projects have greater priority or require the same resources as your chosen solution. Being flexible means understanding needs and challenges across the team and being open to shifting or arranging your own schedule as necessary. Again, this does not mean immediately making way for other projects. It’s about articulating your own needs, understanding the needs of others and being able to come to a meaningful compromise.

The Creativity Dice   #creativity   #problem solving   #thiagi   #issue analysis   Too much linear thinking is hazardous to creative problem solving. To be creative, you should approach the problem (or the opportunity) from different points of view. You should leave a thought hanging in mid-air and move to another. This skipping around prevents premature closure and lets your brain incubate one line of thought while you consciously pursue another.

Working in any group can lead to unconscious elements of groupthink or situations in which you may not wish to be entirely honest. Disagreeing with the opinions of the executive team or wishing to save the feelings of a coworker can be tricky to navigate, but being honest is absolutely vital when to comes to developing effective solutions and ensuring your voice is heard. 

Remember that being honest does not mean being brutally candid. You can deliver your honest feedback and opinions thoughtfully and without creating friction by using other skills such as emotional intelligence. 

Explore your Values   #hyperisland   #skills   #values   #remote-friendly   Your Values is an exercise for participants to explore what their most important values are. It’s done in an intuitive and rapid way to encourage participants to follow their intuitive feeling rather than over-thinking and finding the “correct” values. It is a good exercise to use to initiate reflection and dialogue around personal values.

Initiative 

The problem solving process is multi-faceted and requires different approaches at certain points of the process. Taking initiative to bring problems to the attention of the team, collect data or lead the solution creating process is always valuable. You might even roadtest your own small scale solutions or brainstorm before a session. Taking initiative is particularly effective if you have good deal of knowledge in that area or have ownership of a particular project and want to get things kickstarted.

That said, be sure to remember to honor the process and work in service of the team. If you are asked to own one part of the problem solving process and you don’t complete that task because your initiative leads you to work on something else, that’s not an effective method of solving business challenges.

15% Solutions   #action   #liberating structures   #remote-friendly   You can reveal the actions, however small, that everyone can do immediately. At a minimum, these will create momentum, and that may make a BIG difference.  15% Solutions show that there is no reason to wait around, feel powerless, or fearful. They help people pick it up a level. They get individuals and the group to focus on what is within their discretion instead of what they cannot change.  With a very simple question, you can flip the conversation to what can be done and find solutions to big problems that are often distributed widely in places not known in advance. Shifting a few grains of sand may trigger a landslide and change the whole landscape.

Impartiality

A particularly useful problem solving skill for product owners or managers is the ability to remain impartial throughout much of the process. In practice, this means treating all points of view and ideas brought forward in a meeting equally and ensuring that your own areas of interest or ownership are not favored over others. 

There may be a stage in the process where a decision maker has to weigh the cost and ROI of possible solutions against the company roadmap though even then, ensuring that the decision made is based on merit and not personal opinion. 

Empathy map   #frame insights   #create   #design   #issue analysis   An empathy map is a tool to help a design team to empathize with the people they are designing for. You can make an empathy map for a group of people or for a persona. To be used after doing personas when more insights are needed.

Being a good leader means getting a team aligned, energized and focused around a common goal. In the problem solving process, strong leadership helps ensure that the process is efficient, that any conflicts are resolved and that a team is managed in the direction of success.

It’s common for managers or executives to assume this role in a problem solving workshop, though it’s important that the leader maintains impartiality and does not bulldoze the group in a particular direction. Remember that good leadership means working in service of the purpose and team and ensuring the workshop is a safe space for employees of any level to contribute. Take a look at our leadership games and activities post for more exercises and methods to help improve leadership in your organization.

Leadership Pizza   #leadership   #team   #remote-friendly   This leadership development activity offers a self-assessment framework for people to first identify what skills, attributes and attitudes they find important for effective leadership, and then assess their own development and initiate goal setting.

In the context of problem solving, mediation is important in keeping a team engaged, happy and free of conflict. When leading or facilitating a problem solving workshop, you are likely to run into differences of opinion. Depending on the nature of the problem, certain issues may be brought up that are emotive in nature. 

Being an effective mediator means helping those people on either side of such a divide are heard, listen to one another and encouraged to find common ground and a resolution. Mediating skills are useful for leaders and managers in many situations and the problem solving process is no different.

Conflict Responses   #hyperisland   #team   #issue resolution   A workshop for a team to reflect on past conflicts, and use them to generate guidelines for effective conflict handling. The workshop uses the Thomas-Killman model of conflict responses to frame a reflective discussion. Use it to open up a discussion around conflict with a team.

Planning 

Solving organizational problems is much more effective when following a process or problem solving model. Planning skills are vital in order to structure, deliver and follow-through on a problem solving workshop and ensure your solutions are intelligently deployed.

Planning skills include the ability to organize tasks and a team, plan and design the process and take into account any potential challenges. Taking the time to plan carefully can save time and frustration later in the process and is valuable for ensuring a team is positioned for success.

3 Action Steps   #hyperisland   #action   #remote-friendly   This is a small-scale strategic planning session that helps groups and individuals to take action toward a desired change. It is often used at the end of a workshop or programme. The group discusses and agrees on a vision, then creates some action steps that will lead them towards that vision. The scope of the challenge is also defined, through discussion of the helpful and harmful factors influencing the group.

Prioritization

As organisations grow, the scale and variation of problems they face multiplies. Your team or is likely to face numerous challenges in different areas and so having the skills to analyze and prioritize becomes very important, particularly for those in leadership roles.

A thorough problem solving process is likely to deliver multiple solutions and you may have several different problems you wish to solve simultaneously. Prioritization is the ability to measure the importance, value, and effectiveness of those possible solutions and choose which to enact and in what order. The process of prioritization is integral in ensuring the biggest challenges are addressed with the most impactful solutions.

Impact and Effort Matrix   #gamestorming   #decision making   #action   #remote-friendly   In this decision-making exercise, possible actions are mapped based on two factors: effort required to implement and potential impact. Categorizing ideas along these lines is a useful technique in decision making, as it obliges contributors to balance and evaluate suggested actions before committing to them.

Project management

Some problem solving skills are utilized in a workshop or ideation phases, while others come in useful when it comes to decision making. Overseeing an entire problem solving process and ensuring its success requires strong project management skills. 

While project management incorporates many of the other skills listed here, it is important to note the distinction of considering all of the factors of a project and managing them successfully. Being able to negotiate with stakeholders, manage tasks, time and people, consider costs and ROI, and tie everything together is massively helpful when going through the problem solving process. 

Record keeping

Working out meaningful solutions to organizational challenges is only one part of the process.  Thoughtfully documenting and keeping records of each problem solving step for future consultation is important in ensuring efficiency and meaningful change. 

For example, some problems may be lower priority than others but can be revisited in the future. If the team has ideated on solutions and found some are not up to the task, record those so you can rule them out and avoiding repeating work. Keeping records of the process also helps you improve and refine your problem solving model next time around!

Personal Kanban   #gamestorming   #action   #agile   #project planning   Personal Kanban is a tool for organizing your work to be more efficient and productive. It is based on agile methods and principles.

Research skills

Conducting research to support both the identification of problems and the development of appropriate solutions is important for an effective process. Knowing where to go to collect research, how to conduct research efficiently, and identifying pieces of research are relevant are all things a good researcher can do well. 

In larger groups, not everyone has to demonstrate this ability in order for a problem solving workshop to be effective. That said, having people with research skills involved in the process, particularly if they have existing area knowledge, can help ensure the solutions that are developed with data that supports their intention. Remember that being able to deliver the results of research efficiently and in a way the team can easily understand is also important. The best data in the world is only as effective as how it is delivered and interpreted.

Customer experience map   #ideation   #concepts   #research   #design   #issue analysis   #remote-friendly   Customer experience mapping is a method of documenting and visualizing the experience a customer has as they use the product or service. It also maps out their responses to their experiences. To be used when there is a solution (even in a conceptual stage) that can be analyzed.

Risk management

Managing risk is an often overlooked part of the problem solving process. Solutions are often developed with the intention of reducing exposure to risk or solving issues that create risk but sometimes, great solutions are more experimental in nature and as such, deploying them needs to be carefully considered. 

Managing risk means acknowledging that there may be risks associated with more out of the box solutions or trying new things, but that this must be measured against the possible benefits and other organizational factors. 

Be informed, get the right data and stakeholders in the room and you can appropriately factor risk into your decision making process. 

Decisions, Decisions…   #communication   #decision making   #thiagi   #action   #issue analysis   When it comes to decision-making, why are some of us more prone to take risks while others are risk-averse? One explanation might be the way the decision and options were presented.  This exercise, based on Kahneman and Tversky’s classic study , illustrates how the framing effect influences our judgement and our ability to make decisions . The participants are divided into two groups. Both groups are presented with the same problem and two alternative programs for solving them. The two programs both have the same consequences but are presented differently. The debriefing discussion examines how the framing of the program impacted the participant’s decision.

Team-building 

No single person is as good at problem solving as a team. Building an effective team and helping them come together around a common purpose is one of the most important problem solving skills, doubly so for leaders. By bringing a team together and helping them work efficiently, you pave the way for team ownership of a problem and the development of effective solutions. 

In a problem solving workshop, it can be tempting to jump right into the deep end, though taking the time to break the ice, energize the team and align them with a game or exercise will pay off over the course of the day.

Remember that you will likely go through the problem solving process multiple times over an organization’s lifespan and building a strong team culture will make future problem solving more effective. It’s also great to work with people you know, trust and have fun with. Working on team building in and out of the problem solving process is a hallmark of successful teams that can work together to solve business problems.

9 Dimensions Team Building Activity   #ice breaker   #teambuilding   #team   #remote-friendly   9 Dimensions is a powerful activity designed to build relationships and trust among team members. There are 2 variations of this icebreaker. The first version is for teams who want to get to know each other better. The second version is for teams who want to explore how they are working together as a team.

Time management 

The problem solving process is designed to lead a team from identifying a problem through to delivering a solution and evaluating its effectiveness. Without effective time management skills or timeboxing of tasks, it can be easy for a team to get bogged down or be inefficient.

By using a problem solving model and carefully designing your workshop, you can allocate time efficiently and trust that the process will deliver the results you need in a good timeframe.

Time management also comes into play when it comes to rolling out solutions, particularly those that are experimental in nature. Having a clear timeframe for implementing and evaluating solutions is vital for ensuring their success and being able to pivot if necessary.

Improving your skills at problem solving is often a career-long pursuit though there are methods you can use to make the learning process more efficient and to supercharge your problem solving skillset.

Remember that the skills you need to be a great problem solver have a large overlap with those skills you need to be effective in any role. Investing time and effort to develop your active listening or critical thinking skills is valuable in any context. Here are 7 ways to improve your problem solving skills.

Share best practices

Remember that your team is an excellent source of skills, wisdom, and techniques and that you should all take advantage of one another where possible. Best practices that one team has for solving problems, conducting research or making decisions should be shared across the organization. If you have in-house staff that have done active listening training or are data analysis pros, have them lead a training session. 

Your team is one of your best resources. Create space and internal processes for the sharing of skills so that you can all grow together. 

Ask for help and attend training

Once you’ve figured out you have a skills gap, the next step is to take action to fill that skills gap. That might be by asking your superior for training or coaching, or liaising with team members with that skill set. You might even attend specialized training for certain skills – active listening or critical thinking, for example, are business-critical skills that are regularly offered as part of a training scheme.

Whatever method you choose, remember that taking action of some description is necessary for growth. Whether that means practicing, getting help, attending training or doing some background reading, taking active steps to improve your skills is the way to go.

Learn a process 

Problem solving can be complicated, particularly when attempting to solve large problems for the first time. Using a problem solving process helps give structure to your problem solving efforts and focus on creating outcomes, rather than worrying about the format. 

Tools such as the seven-step problem solving process above are effective because not only do they feature steps that will help a team solve problems, they also develop skills along the way. Each step asks for people to engage with the process using different skills and in doing so, helps the team learn and grow together. Group processes of varying complexity and purpose can also be found in the SessionLab library of facilitation techniques . Using a tried and tested process and really help ease the learning curve for both those leading such a process, as well as those undergoing the purpose.

Effective teams make decisions about where they should and shouldn’t expend additional effort. By using a problem solving process, you can focus on the things that matter, rather than stumbling towards a solution haphazardly. 

Create a feedback loop

Some skills gaps are more obvious than others. It’s possible that your perception of your active listening skills differs from those of your colleagues. 

It’s valuable to create a system where team members can provide feedback in an ordered and friendly manner so they can all learn from one another. Only by identifying areas of improvement can you then work to improve them. 

Remember that feedback systems require oversight and consideration so that they don’t turn into a place to complain about colleagues. Design the system intelligently so that you encourage the creation of learning opportunities, rather than encouraging people to list their pet peeves.

While practice might not make perfect, it does make the problem solving process easier. If you are having trouble with critical thinking, don’t shy away from doing it. Get involved where you can and stretch those muscles as regularly as possible. 

Problem solving skills come more naturally to some than to others and that’s okay. Take opportunities to get involved and see where you can practice your skills in situations outside of a workshop context. Try collaborating in other circumstances at work or conduct data analysis on your own projects. You can often develop those skills you need for problem solving simply by doing them. Get involved!

Use expert exercises and methods

Learn from the best. Our library of 700+ facilitation techniques is full of activities and methods that help develop the skills you need to be an effective problem solver. Check out our templates to see how to approach problem solving and other organizational challenges in a structured and intelligent manner.

There is no single approach to improving problem solving skills, but by using the techniques employed by others you can learn from their example and develop processes that have seen proven results. 

Try new ways of thinking and change your mindset

Using tried and tested exercises that you know well can help deliver results, but you do run the risk of missing out on the learning opportunities offered by new approaches. As with the problem solving process, changing your mindset can remove blockages and be used to develop your problem solving skills.

Most teams have members with mixed skill sets and specialties. Mix people from different teams and share skills and different points of view. Teach your customer support team how to use design thinking methods or help your developers with conflict resolution techniques. Try switching perspectives with facilitation techniques like Flip It! or by using new problem solving methodologies or models. Give design thinking, liberating structures or lego serious play a try if you want to try a new approach. You will find that framing problems in new ways and using existing skills in new contexts can be hugely useful for personal development and improving your skillset. It’s also a lot of fun to try new things. Give it a go!

Encountering business challenges and needing to find appropriate solutions is not unique to your organization. Lots of very smart people have developed methods, theories and approaches to help develop problem solving skills and create effective solutions. Learn from them!

Books like The Art of Thinking Clearly , Think Smarter, or Thinking Fast, Thinking Slow are great places to start, though it’s also worth looking at blogs related to organizations facing similar problems to yours, or browsing for success stories. Seeing how Dropbox massively increased growth and working backward can help you see the skills or approach you might be lacking to solve that same problem. Learning from others by reading their stories or approaches can be time-consuming but ultimately rewarding.

A tired, distracted mind is not in the best position to learn new skills. It can be tempted to burn the candle at both ends and develop problem solving skills outside of work. Absolutely use your time effectively and take opportunities for self-improvement, though remember that rest is hugely important and that without letting your brain rest, you cannot be at your most effective. 

Creating distance between yourself and the problem you might be facing can also be useful. By letting an idea sit, you can find that a better one presents itself or you can develop it further. Take regular breaks when working and create a space for downtime. Remember that working smarter is preferable to working harder and that self-care is important for any effective learning or improvement process.

Want to design better group processes?

Over to you

Now we’ve explored some of the key problem solving skills and the problem solving steps necessary for an effective process, you’re ready to begin developing more effective solutions and leading problem solving workshops.

Need more inspiration? Check out our post on problem solving activities you can use when guiding a group towards a great solution in your next workshop or meeting. Have questions? Did you have a great problem solving technique you use with your team? Get in touch in the comments below. We’d love to chat!

James Smart is Head of Content at SessionLab. He’s also a creative facilitator who has run workshops and designed courses for establishments like the National Centre for Writing, UK. He especially enjoys working with young people and empowering others in their creative practice.

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Origins of Problem Solving as a Behavioral Treatment

Application of pst to diabetes: what is the evidence, example of traditional pst applied to diabetes self-management, current and future research directions, article information, evidence-based behavioral treatments for diabetes: problem-solving therapy.

Problem solving is an essential skill for effective diabetes self-management. Evidence suggests that problem-solving therapy (PST) approaches, used in the context of broader diabetes educational or lifestyle interventions, may be effective for mood and select diabetes outcomes. As a stand-alone treatment, formal PST adapted for diabetes self-management is a promising behavioral intervention for improving health-related problem-solving, diabetes self-care behaviors, and disease control.

All of the authors are based in Baltimore, Md. Kristina P. Schumann, MA, June A. Sutherland, MS, and Haseeb M. Majid, MA, are lifestyle interventionists in the Division of General Internal Medicine at Johns Hopkins School of Medicine. Felicia Hill-Briggs, PhD, ABPP, is an associate professor in the Departments of Medicine; Health, Behavior & Society; and Physical Medicine & Rehabilitation at the Johns Hopkins Medical Institutions and director of the cognition and behavior sub-core of the Johns Hopkins/University of Maryland Diabetes Research and Training Center.

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Kristina P. Schumann , June A. Sutherland , Haseeb M. Majid , Felicia Hill-Briggs; Evidence-Based Behavioral Treatments for Diabetes: Problem-Solving Therapy. Diabetes Spectr 1 May 2011; 24 (2): 64–69. https://doi.org/10.2337/diaspect.24.2.64

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Problem solving is a basic human thinking process. Many general counseling and psychotherapy approaches, such as cognitive behavioral therapy, include problem solving as a component of treatment for managing life problems and emotional disorders. 1   Similarly, educational and lifestyle interventions in diabetes often include elements of problem solving as part of broader intervention approaches. 2  

Among diabetes educators, problem solving is identified as necessary for patient mastery of diabetes self-management and as the skill most difficult to teach patients. 3   This article describes the origins of problem-solving therapy (PST) as a formal, stand-alone intervention approach for behavior change; application of this technique to diabetes care; and evidence of its effectiveness in improving diabetes outcomes.

Problem solving, which has its origins in the behavioral and cognitive basic sciences, 4 – 8   is an identified intervention approach for behavior change. 9 , 10   Cognitive psychology defines problem solving as involving the following components: the individual is goal-directed; reaching the goal requires a series of mental processes; and those processes are cognitive rather than automatic. 6 , 7   Problem solving can perhaps be described more simply as a series of cognitive operations used to figure out what to do when the way to reach a goal is not apparent.

Although problem solving is a counseling approach that may be incorporated within other intervention models, PST is a stand-alone intervention with a longstanding history. PST took root in clinical and counseling psychology in the 1960s and 1970s to address a variety of mental health disorders, including schizophrenia and psychotic disorders, depression and suicidality, social phobia, generalized anxiety disorder, and posttraumatic stress disorder. 11 , 12   PST has also been used to address marital/family distress, lifestyle management in people with mental retardation, stress management, ineffective coping, and substance abuse. 11  

There is a substantial evidence base for the effectiveness of PST in reducing symptoms of depression, anxiety, and stress. 12   Moreover, problem-solving approaches have been found effective in helping patients cope with cancer, enhancing weight loss maintenance, reducing pain, and lowering blood pressure. 12 – 16  

The PST model proposed by D'Zurilla and Goldfried 9   and refined by D'Zurilla and Nezu 11   is perhaps the most recognized PST approach. This intervention approach is based on the premise that humans are innate problem solvers but that there are significant individual differences in problem-solving abilities.

PST has historical roots in four different areas: 1 ) increased focus on human creativity, creativity research, and creative problem solving; 2 ) a positive approach to clinical intervention, which moves away from the medical model of pathology and focuses on building social competence through enhancing problem-solving abilities; 3 ) recognition of the importance of cognitive processes and self-control in behavior therapy, in which PST intends to teach patients a skill set they can apply across all life situations, resulting in generalized and lasting behavior change; and 4 ) Lazarus's relational model of stress, which describes stress as a result of person-environment interactions where the demands of the interaction exceed the individual's coping resources. 17  

D'Zurilla and Nezu 11   describe three levels of variables influencing the cognitive-behavioral process of problem solving. PST is effective in facilitating behavior change by intervening on these three levels. First, orienting responses refer to how individuals respond to problematic situations in terms of their thoughts and emotions. PST intervenes on these responses by teaching individuals how to effectively recognize and appraise problems while increasing their self-efficacy to cope with challenging situations. Second, problem-solving skills refer to the specific tasks that must be completed before a problem can be solved successfully. PST intends to teach problem-solving skills, thereby improving individuals' ability to manage challenging situations. Finally, basic cognitive abilities refer to specific abilities that directly affect individuals' capacity to learn and perform problem-solving skills. Examples of basic cognitive abilities include causal thinking, consequential thinking, and perspective taking.

Interventions often focus primarily on the first two levels because it is typically assumed that individuals come to treatment with basic cognitive abilities intact. This assumption may be incorrect for specific populations (e.g., people with schizophrenia), in which case deficits in this area should be included in the intervention. 11   PST also intervenes on individuals' emotional responses to life situations, which have a significant effect on all aspects of problem solving. PST aims to facilitate positive emotional reactions and reduce or eliminate negative emotional reactions (e.g., anxiety and anger). 11  

Traditional PST

Key components of PST are provided in Table 1 . The D'Zurilla and Nezu 11   PST uses a five-dimensional model of social problem solving, which includes two problem-orientation styles (positive and negative) and three problem-solving styles (rational, impulsive/careless, and avoidant). The model also identifies four rational problem-solving skills: problem definition and formulation, generation of alternatives, decision making, and solution implementation and verification. PST must be conducted in a sequential order, and a series of problem-solving therapy modules is available. 11  

The number of sessions required to complete PST varies depending on the purpose of the training, but ranges from 8 to 16 sessions. 11 , 12   The interventionist conducting PST uses didactic approaches, coaching, modeling, shaping, rehearsal, performance feedback, and positive reinforcement. Nezu et al. 18   have developed a user-friendly self-help guidebook to assist in training professionals in PST and to serve as a supporting reference for patients engaging in therapist-led PST. Successful implementation depends on adequate development of rapport between the facilitator and the patient(s). To evaluate success of PST, an assessment tool such as the Social Problem-Solving Inventory–Revised 19   is also recommended.

The American Association of Diabetes Educators (AADE) has identified problem solving as one of seven core diabetes self-management behaviors (AADE-7). 20   AADE defines problem solving as a learned behavior that includes generating a set of potential strategies for problem resolution, selecting the most appropriate strategy, applying the strategy, and evaluating the effectiveness of the strategy. In the AADE-7 framework, problem solving is conceptualized as intervening on barriers to self-care 21 , 22   and thereby enabling patients to carry out all other self-management behaviors (i.e., healthy eating, physical activity, self-monitoring, medication taking, risk reduction, and healthy coping). 2  

Hill-Briggs 21   proposed a model for understanding problem solving in the context of diabetes self-management. Based on the D'Zurilla and Nezu framework combined with theories of problem solving from cognitive psychology and education/learning theory, the model highlights four key components of problem solving that are particularly salient in disease self-management. First, problem-solving skill refers to the approach an individual takes to solving problems (i.e., rational, impulsive/careless, or avoidant), with a rational approach being most effective. Second, problem-solving orientation refers to individuals' attitudes and beliefs about their disease and the problems they encounter. Problem-solving orientation can be positive (e.g., problems viewed as a challenge) or negative (e.g., problems viewed as a threat). Third, transfer of past experience/learning refers to the use of previous experience in attempting to solve novel problems. This transfer of past experience can also be effective (e.g., using a solution that was effective in a similar situation in the past) or ineffective (e.g., trying an ineffective solution repeatedly in the same situation). The fourth component of problem solving is disease-specific knowledge . To solve problems related to disease self-management effectively, individuals must have a working knowledge base about the disease and its management. Each key component of problem solving operates within the problem environment , composed of the social/physical context and characteristics of the problem itself. 23  

The evidence base for problem solving as a diabetes self-management intervention approach was examined in a 2007 systematic review. 2   This review revealed problem solving as a frequently used component of interventions within diabetes education and care. Research with adult populations has demonstrated some effectiveness of interventions with a problem-solving component on outcomes including disease control, depressive symptoms, self-management behaviors, weight loss, self-efficacy, and quality of life. Research with children/adolescents has demonstrated effectiveness of problem-solving training in improving some self-management behaviors and psychosocial outcomes. 2  

Specifically, the review 2   yielded 36 quantitative, 11 conceptual, and 5 qualitative studies of problem solving in diabetes self-management and control. Studies examined in the review were conducted with children/adolescents (43%) and adults (57%). The samples were varied in terms of race and ethnicity, with Caucasian (25%), multiple ethnicities (most often Caucasian, African-American, and Latino) (22%), African-American (11%), and international (Japanese, Italian) (8%) populations represented.

Intervention studies were conducted with children/adolescents ( n = 8) and adults ( n = 8). The extent to which problem solving was involved in the intervention varied, but in most cases, problem solving was one component of a larger diabetes self-management intervention and was not the main focus of treatment. Outcomes reported in the systematic review included problem solving, self-management behaviors, physiological outcomes, and psychosocial outcomes. 2   Two of five studies with children and both studies with adults in which problem solving was assessed demonstrated a positive effect of the intervention on problem-solving ability. The studies with adults demonstrated maintenance of problem-solving abilities at follow-up (6 months and 5 years later). 2  

Twelve studies reported use of an intervention that was problem-solving based or included problem solving in a broader package of intervention approaches. Three of six studies with children demonstrated a positive effect of the intervention on dietary intake, self-monitoring of blood glucose (SMBG), and general treatment adherence, with effects lasting for up to 12 months. Additionally, four of six studies in adults demonstrated positive effects of the intervention on dietary behaviors (most common), SMBG, and exercise. Findings related to medication adherence in adults were mixed, and one study demonstrated no link between problem solving and foot inspections. 2  

All but two intervention studies assessed the effect of problem-solving training on glycemic control. Half of the adult studies demonstrated a positive effect of the intervention on A1C. The results in children/adolescents were even more mixed, with two studies showing a decrease in A1C, three studies showing no effect on glycemic control, and one study reporting higher A1C at follow-up in both the intervention and control groups. 2  

Two studies demonstrated a positive effect of the intervention on weight loss in adults, whereas one study demonstrated no effect on weight loss. Finally, two studies demonstrated a positive effect of the intervention on cardiovascular disease (CVD) markers (cholesterol and triglycerides). 2  

Three intervention studies assessed psychosocial outcomes in children/adolescents. Results indicated a positive effect of the intervention on self-efficacy, adjustment, parent-adolescent relationships, diabetes-related conflict, ability to use sick-day self-management guidelines, and quality of life. One study conducted with adults demonstrated a positive effect of the intervention on self-efficacy, whereas the other showed no effect on self-efficacy. Three studies with adults reported improvements in depressive symptoms post-intervention. Of the three studies that investigated quality of life in adults, two found no differences between the intervention and control groups in quality of life, whereas one showed improved quality of life in the intervention group. 2  

Several limitations in the research reviewed affected the conclusions that could be drawn regarding the effectiveness of PST for diabetes self-management. In the diabetes interventions reported to date, problem solving generally was added to self-management training as a very small, informal, or unstructured component within a package of intervention techniques and without incorporating all elements that constitute PST as a behavior-change intervention. Therefore, it has been difficult to determine to what extent problem solving (compared to the other offered interventions) contributed to outcomes. Moreover, few studies provided a description of the problem-solving component of the intervention package. Nonetheless, as a whole, evidence suggests that problem solving–related interventions are effective for select diabetes outcomes.

Not previously tested was whether traditional PST as a stand-alone intervention rather than a small component of a broader intervention package is effective for diabetes self-management and disease control. This was the focus of a recent investigation and is the subject of an ongoing trial.

Project DECIDE (Decision-making Education for Choices In Diabetes Everyday) began as a study funded by the National Institutes of Health (NIH) to translate traditional PST into a problem-based diabetes self-management training program. The DECIDE intervention centers on a series of learning modules that train patients in the problem-solving process as a life skill applied to diabetes self-management. This skill-training approach allows health/diabetes educators to relinquish the role of patients' problem-solver, a role that inadvertently disempowers patients. 24   For patients, the problem-based self-management approach allows them to identify and work toward solutions for daily barriers, life challenges, and competing priorities that directly impede their effective application of diabetes knowledge and self-management of diabetes in real life.

DECIDE Diabetes PST

Key components of the DECIDE self-management training are provided in Table 2 . The DECIDE program consists of a diabetes and CVD education module, which provides the booster patient education needed as a prerequisite for diabetes-related problem solving, followed by health-related problem-solving training modules modeled on the described D'Zurilla and Nezu approach. 11   Patients receive two workbooks: Diabetes and Your Heart: Your Facts and Information Workbook , which accompanies the education module, and Hitting the Targets for Diabetes and Your Heart: Your Problem-Solving Workbook , which accompanies the problem-solving training. The problem-solving modules also include take-home exercises, which provide opportunities for patients to practice newly learned problem-solving skills in their natural environments. Both patient workbooks were developed using guidelines for accessibility and usability for vulnerable adult populations 25 – 28   and have been found to be accessible and understandable to people with low and average literacy, 29   as well as people with mild to moderate visual and cognitive impairment. 30  

The pilot study tested a comprehensive DECIDE PST intervention (as shown in Table 2) and a condensed version, which consisted of the diabetes and CVD education module followed by one PST session. The condensed PST intervention and patient workbook covered all the problem-solving topics with abbreviated exercises. The study used two measures designed to assess problem solving in the context of health: the Diabetes Problem-Solving Scale 31   and the Health Problem-Solving Scale. 32  

The pilot study was conducted with an underserved patient population. Participants were 56 African Americans (59% female, mean age 61 years, 57% living in poverty) with a mean diabetes duration of 14 years. The vast majority of patients (86%) had suboptimal A1C (defined as > 7.0%). 33   Participants were randomized to the intensive ( n = 29) or condensed ( n = 27) DECIDE programs, which were delivered in group format.

At 3 months after intervention completion (6 months to 1 year from baseline), the intensive DECIDE PST resulted in improved diabetes knowledge, problem solving, and self-care and a reduction in A1C of 0.71%. For participants with suboptimal blood pressure or LDL cholesterol, benefits in these parameters were seen as well. The condensed intervention resulted in knowledge gain but not problem solving or clinical improvements. The study demonstrated that a diabetes PST delivered with the intensity of traditional PST (eight problem-solving sessions) was an effective intervention in a challenging adult patient population. 34   Participants in both the intensive and condensed interventions rated the problem solving–based self-management training as highly satisfactory, helpful, and easy to understand. 34  

Investigations are underway to test the effectiveness of different formats for delivery of the DECIDE approach to PST (i.e., self-study, individual, and group formats) and for greater dissemination (e.g., Internet-based and electronic education platforms) to patients who may benefit from this approach across clinic and community settings. Additionally, a search of active, federally funded research grants using the NIH RePORT database revealed a number of current research projects investigating problem solving among children/adolescents, ethnic minorities, and families. These studies generally describe use of problem solving as an intervention component rather than PST as a stand-alone intervention.

Future research should provide evidence of the effectiveness of PST across populations (e.g., different age-groups, sexes, and racial/ethnic minority groups for whom effectiveness of this approach has not yet been reported, including Asians, Latinos, and Native Americans). Additional research is needed to evaluate and disseminate effective tools for health care professionals' use in implementing problem-solving training and to establish best practices for training health care professionals in the delivery of problem-solving education to patients.

PST, both in its traditional format and in formats adapted for diabetes self-management, can be effective for multiple outcomes of interest to health care professionals treating patients with diabetes. A recent statement from a panel convened by AADE on the current state of the science of problem solving concluded that evidence supports problem solving as an important process, intervention, and skill in diabetes self-management. 35   It teaches patients the skills necessary to achieve goals related to recommended self-care behaviors.

Teaching the problem-solving process to patients is an important role health care professionals can play. Further attention is needed to the skills, experiences, and expectations health care professionals bring to problem-solving interventions and to ensuring that professionals are able to conduct thorough assessments and interventions using this approach. 35  

Although the activities of problem solving tend to be included routinely in clinical encounters, it is important that clinicians be able to distinguish between using the problem solving process with patients and teaching patients problem-solving as a self-management and life skill. Training patients in problem solving can be done using diabetes-focused PST. There remains a need for dissemination of effective problem-solving training materials and increased formal training opportunities for health care professionals interested in using this approach.

Preparation of this article was supported by National Institute of Diabetes and Digestive and Kidney Disease Diabetes Research and Training Center grant P60 DK079637 and National Heart, Lung, and Blood Institute grant R01 HL089751.

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6 Problem-Solving Therapy: Evidence-Based Practice

• Published: May 2017
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Chapter 6, “Problem-Solving Therapy: Evidence-Based Practice,” details the research evidence concerning the effectiveness of problem-solving therapy (PST) for use with older adults. Only meta-analyses or randomized control trials (RCT) were included in this review. One meta-analysis and fifteen randomized control trials were identified that investigated PST outcomes on older adult depression, health-related quality of life, and coping. Outcomes of these studies determined that this therapy is effective in reducing anxiety and depression, and increasing problem-solving abilities in both community-based and in-home settings. Additionally, consistent support was found for the efficacy of telephone and video-phone PST, suggesting that these alternate means of administration may help overcome barriers to the receipt of mental health services experienced by homebound elders.

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Cognitive Remediation Therapy: 13 Exercises & Worksheets

This can result in concentration, organizational, and planning difficulties that impact their quality of life and independent living.

Cognitive Remediation Therapy (CRT) helps by increasing awareness of intellectual difficulties and improving thinking skills. While originally designed for people with thinking problems associated with schizophrenia, it has also proven successful for those with other diagnoses (Bristol Mental Health, n.d.).

CRT works by encouraging a range of exercises and activities that challenge memory, flexible thinking, planning, and concentration problems.

This article explores CRT and its potential to help clients and includes techniques, activities, and worksheets to build effective therapy sessions.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into Positive CBT and give you the tools to apply it in your therapy or coaching.

This Article Contains:

What is cognitive remediation therapy (crt), how does cognitive remediation work, 8 techniques for your sessions, 7 exercises, activities, & games, 6 helpful worksheets and manuals, implementing online crt programs, 3 best software programs for helping your clients, a take-home message.

“Cognitive remediation is a behavioral treatment for people who are experiencing cognitive impairments that interfere with daily functioning” (Medalia, Revheim, & Herlands, 2009, p. 1).

Successful cognitive functions, including memory, attention, visual-spatial analysis, and abstract reasoning, are vital for engaging with tasks, the environment, and healthy relationships.

CRT improves cognitive processing and psychosocial functioning through behavioral training and increasing individual confidence in people with mental health disorders (Corbo & Abreu, 2018). Training interventions focus on the skills and supports required to “improve the success and satisfaction people experience in their chosen living, learning, working, and social environments” (Medalia et al., 2009, p. 2).

Exercises typically focus on specific cognitive functions, where tasks are repeated (often on a computer) at increasing degrees of difficulty. For example:

• Paying attention
• Remembering
• Being organized
• Planning skills
• Problem-solving
• Processing information

Based on the principles of errorless learning and targeted reinforcement exercises , interventions involve memory, motor dexterity, and visual reading tasks. Along with improving confidence in personal abilities, repetition encourages thinking about solving tasks in multiple ways (Corbo & Abreu, 2018).

While initially targeted for patients with schizophrenia, CRT is an effective treatment for other mental health conditions , including mood and eating disorders (Corbo & Abreu, 2018).

CRT is particularly effective when the cognitive skills and support interventions reflect the individual’s self-selected rehabilitation goals. As a result, cognitive remediation relies on collaboration, assessing client needs, and identifying appropriate opportunities for intervention (Medalia et al., 2009).

Cognitive remediation vs cognitive rehabilitation

CRT is one of several skill-training psychiatric rehabilitation interventions. And yet, cognitive remediation is not the same as cognitive rehabilitation (Tchanturia, 2015).

Cognitive rehabilitation typically targets neurocognitive processes damaged because of injury or illness and involves a series of interventions designed to retrain previously learned cognitive skills along with compensatory strategies (Tsaousides & Gordon, 2009).

While initially done in person, they can subsequently be performed remotely as required (Corbo & Abreu, 2018; Bristol Mental Health, n.d.).

Well-thought-out educational software provides multisensory feedback and positive reinforcement while supporting success, choice, and control of the learning process. Its design can target either specific cognitive functions or non-specific learning skills and mechanisms (Medalia et al., 2009).

CRT successfully uses the brain’s neuroplasticity and is often more effective in younger age groups who haven’t experienced the effects of long-term psychosis. It works by increasing activation and connectivity patterns within and across several brain regions involved in working memory and high-order executive functioning (Corbo & Abreu, 2018).

The Neuropsychological Educational Approach to Cognitive Remediation (NEAR) is one of several approaches that provide highly individualized learning opportunities. It allows each client to proceed at their own pace on tasks selected and designed to engage them and address their cognitive needs (Medalia et al., 2009).

NEAR and other CRT techniques are influenced by learning theory and make use of the following (Medalia et al., 2009):

• Errorless learning Encouraging the client to learn progressively, creating a positive experience without relying on trial and error.
• Shaping and positive feedback Reinforcing behaviors that approximate target behaviors (such as good timekeeping) and offering rewards (for example, monthly certificates for attendance).
• Prompting Using open-ended questions that guide the client toward the correct response.
• Modeling Demonstrating how to solve a problem.
• Generalizing Learning how to generalize learned skills to other situations.
• Bridging Understanding how to apply skills learned inside a session outside  in everyday life.

Encouraging intrinsic motivation (doing the tasks for the satisfaction of doing them rather than for external rewards) and task engagement are also essential aspects of successful CRT programs (Medalia et al., 2009).

Therapy is most effective when it successfully supports clients as they transfer learning skills into the real world.

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Cognitive remediation techniques must be selected according to the skills and needs of the client and typically fall into one of three major intervention categories (Medalia et al., 2009):

• Planning exercises, such as planning a trip to the beach to practice cognitive strategies
• Cueing and sequencing , such as adding signs or placing reminder notes at home to encourage completing everyday tasks (for example, brushing teeth)

Such techniques rely on several key principles, including “(1) teaching new, efficient, information processing strategies; (2) aiding the transfer of cognitive gains to the real world; and (3) modifying the local environment” (Medalia et al., 2009, p. 5).

• Restorative approaches Directly target cognitive deficits by repeating task practices and gradually increasing difficulty and complexity; along with regular feedback, they encourage accurate and high levels of performance.

Practice is often organized hierarchically, as follows:

• Elementary aspects of sensory processing (for example, improving auditory processing speed and accuracy)
• High-order memory and problem-solving skills (including executive functioning and verbal skills)

This technique assumes a degree of neuroplasticity that, with training, results in a greater degree of accuracy in sensory representations, improved cognitive strategies for grouping stimuli into more meaningful groups, and better recall.

• Repetition and reaching for increasing levels of task difficulty
• Modeling other people’s positive behavior
• Role-play  to re-enact experienced or imagined behavior from different perspectives
• Corrective feedback to improve and correct unwanted or unhelpful behavior

Complex social cognitive processes are typically broken down into elemental skills for repetitive practice, role-play, and corrective feedback.

Professor Dame Til Wykes: cognitive remediation therapy

It is vital that activities within CRT are interesting and engaging for clients. They must foster the motivation required to persevere to the end of the task or game.

The following three games and puzzles are particularly valuable for children and adolescents (modified from Tchanturia, 2015):

SET is a widely available card game that practices matching based on color, shape, shading, etc.

Clients must shift their thinking to identify multiple ways of categorizing and grouping cards, then physically sort them based on their understanding.

It may be helpful to begin with a limited set of cards to reduce the likelihood of the clients becoming overwhelmed by the game or finding it less enjoyable.

2. Rush Hour

Rush Hour is another fun game that balances problem-solving skills with speed.

Puzzles start simple and increase in complexity, with additional elements involved. Skills developed include problem-solving and abstract thinking, and the game requires a degree of perseverance.

Other activities require no specialist equipment and yet can be highly engaging and support clients in learning transferable skills (modified from Tchanturia, 2015).

• Bigger picture thinking This involves the client picturing a shape in their minds or looking at one out of sight of the therapist. They then describe the shape (without naming it), while the therapist attempts to draw it according to the instructions. This practice is helpful with clients who get overwhelmed by detail and cannot see the bigger picture.
• Word searches Word searches encourage the client to focus on relevant information and ignore everything else – an essential factor in central coherence. Such puzzles also challenge memory, concentration, and attention.
• Last word response Last word response is a challenging verbal game promoting cognitive flexibility. The first player makes up and says a sentence out loud. Each subsequent player makes up a new sentence, starting with the last word of the previous player’s sentence. For example, ‘ I like cheese’ may be followed by the next player saying, ‘ Cheese is my favorite sandwich ingredient ,’ etc.
• Dexterity Using your non-dominant hand once a week (for example, combing your hair or brushing your teeth) stimulates different parts of your brain, creating alternative patterns of neuron firing and strengthening cognitive functions.

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The following therapy worksheets help structure Cognitive Remediation Therapy sessions and ensure that the needs of clients are met using appropriately targeted CRT interventions (modified from Medalia et al., 2009; Medalia & Bowie, 2016):

Client referral to CRT

The Cognitive Remediation Therapy Referral Form captures valuable information when a client is referred from another agency or therapist so that the new therapist can identify and introduce the most appropriate CRT interventions. The form includes information such as:

Primary reasons

Secondary reasons

• Self-confidence
• Working with others
• Time management
• Goal-directed activities

Cognitive Appraisal for CRT

The Cognitive Appraisal for CRT form is helpful for identifying and recording areas of cognitive processing that cause difficulty for the client and require focus during Cognitive Remediation Therapy sessions.

Clients are scored on their degree of difficulty with the following:

• Paying attention during conversation
• Maintaining concentration in meetings
• Completing tasks once started
• Starting tasks
• Planning and organizing tasks and projects
• Reasoning and solving problems

Software Appraisal for CRT

The Software Appraisal for CRT form helps assess which software would be most helpful in a specific Cognitive Remediation Therapy session. It provides valuable input for tailoring treatment to the needs of the client.

For example:

• Level of reading ability required
• Cognitive deficits addressed by the software
• What is the multimedia experience like?
• How much input is required by the therapist?

Appraisal records become increasingly important as more software is acquired for clients with various cognitive deficits from multiple backgrounds.

Software Usage for CRT

The Software Usage for CRT form helps keep track of the software clients have tried and how effectively it supports them as they learn, develop, and overcome cognitive deficits.

The client considers the software they use and whether they practiced the following areas of cognition:

• Concentration
• Processing speed
• Multitasking
• Logic and reasoning
• Organization
• Fast responses
• Working memory

Thought Tracking During Cognitive Remediation Therapy

Thought Tracking During Cognitive Remediation Therapy is valuable for identifying and recording the client’s goals for that day’s Cognitive Remediation Therapy session and understanding how it relates to their overall treatment goals.

Planning to Meet Goals in CRT

The Planning to Meet Goals in CRT worksheet is for clients requiring support and practice in planning, goal-setting, and goal achievement.

Working with the client, answer the following prompts:

• What goal or project are you working toward?
• What date should it be completed by?
• Are there any obstacles to overcome to complete the goal?
• Are there any additional resources required?
• Then consider the steps needed to achieve the goal.

Other free resources

Happy Neuron provides several other free resources that are available for download .

Consider the five Cs when selecting online CRT programs (modified from Medalia et al., 2009):

• Cognitive – What target deficits are being addressed?
• Client – What interests and level of functioning does the client have?
• Computer – What computing requirements and compatibility factors need to be considered?
• Context – Does the software use real-world or fantasy activities and environments? Are they age and cognitive ability appropriate?
• Choice – Is the learner given choice and options to adapt the activity to their preferences?

Once you’ve ordered the software, give it a thorough review to understand when it is most appropriate to use and with whom.

For online CRT programs to be effective as teaching tools and activities, they should include the following features (modified from Medalia et al., 2009, p. 53):

• Intrinsically motivating
• Active use of information
• Multisensory strategies
• Frequent feedback
• Control over the learning process
• Positive reinforcement
• Application of newly acquired skills in appropriate contexts
• Errorless learning – challenging yet not frustrating

Therapists must become familiar with each program’s content and processes so that targeted deficits are fully understood and clients are engaged without confusion or risk of failure.

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These 17 Positive CBT & Cognitive Therapy Exercises [PDF] include our top-rated, ready-made templates for helping others develop more helpful thoughts and behaviors in response to challenges, while broadening the scope of traditional CBT.

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A great deal of software “targets different skills and offers a variety of opportunities for contextualization and personalization” (Medalia et al., 2009, p. 43).

We focus on three suppliers of extensive CRT software resources below (recommended by Medalia et al., 2009).

1. Happy Neuron

Happy Neuron provides a wide variety of online brain training exercises and activities to stimulate cognitive functioning in the following areas:

• Visual-spatial

When you’re performing well, the exercises become increasingly difficult.

The exercises are grouped into the following areas:

• Brain speed
• People skills
• Intelligence

3. Games for the Brain

Cognitive difficulties, such as challenges with paying attention, planning, remembering, and problem-solving, can further compound and exacerbate mental health issues

While initially created for schizophrenia, CRT is also valuable for other mental health problems, including eating and mood disorders. Treatments are effective in one-to-one and group sessions, and lessons can be transferred to the outside world, providing crucial gains for a client’s mental wellbeing and social interaction.

Through repeated and increasingly challenging skill-based interventions, CRT benefits cognitive functioning and provides confidence gains to its users. The treatment adheres to learning theory principles and targets specific brain processing areas such as motor dexterity, memory, and visual-spatial perception, along with higher-order functioning.

Involving clients in treatment choices increases the likelihood of ongoing perseverance, engagement, and motivation as activities repeat with increasing degrees of difficulty.

This article offers a valuable starting point for exploring CRT and its benefits, with several worksheets and forms to encourage effective treatment.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

• Bristol Mental Health. (n.d.). Cognitive remediation therapy: Improving thinking skills . Retrieved December 15, 2021, from http://www.awp.nhs.uk/media/424704/cognitive-remediation-therapy-022019.pdf
• Corbo, M., & Abreu, T. (2018). Cognitive remediation therapy: EFPT psychotherapy guidebook . Retrieved December 15, 2021, from https://epg.pubpub.org/pub/05-cognitive-remediation-therapy/release/3
• Medalia, A., & Bowie, C. R. (2016). Cognitive remediation to improve functional outcomes . Oxford University Press.
• Medalia, A., Revheim, N., & Herlands, T. (2009). Cognitive remediation for psychological disorders: Therapist guide . Oxford University Press.
• Tchanturia, K. (2015). Cognitive remediation therapy (CRT) for eating and weight disorders . Routledge.
• Tsaousides, T., & Gordon, W. A. (2009). Cognitive rehabilitation following traumatic brain injury: Assessment to treatment. Mount Sinai Journal of Medicine: A Journal of Translational and Personalized Medicine , 76 (2), 173-181.

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To my surprise this is a treatment that has not been discussed in the area I live and work. I just stumbled upon this when I was researching cognitive impairments with schizophrenia. I currently work on a team with multiple mental health professionals that go out into the community, to work with people diagnosed with Schizophrenia. It seems like most of what we do is manage and monitor symptoms. Are you aware of anyone or any agency in Buffalo, NY that uses this method of treatment? I am trying to figure out how to get trained and use it in practice, if that is possible. Any help will be greatly appreciated.

This looks like the treatment my daughter needs. She has struggled for years with the cognitive problems associated with depression. How do we find a therapist near us who can use these techniques?

I’m sorry to read that your daughter is struggling. You can find a directory of licensed therapists here (and note that you can change the country setting in the top-right corner). You’ll also find that there are a range of filters to help you drill down to the type of support you need: https://www.psychologytoday.com/us/therapists

I hope you find the help you need.

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Evidence-based psychosocial treatments of conduct problems in children and adolescents: an overview

Uberto gatti.

a Department of Health Sciences, Section of Criminology, University of Genoa, Genoa, Italy;

Ignazio Grattagliano

b Section of Forensic Psychiatry, University of Bari, Bari, Italy

Gabriele Rocca

The aims of the present study were to identify empirically supported psychosocial intervention programs for young people with conduct problems and to evaluate the underpinnings, techniques and outcomes of these treatments. We analyzed reviews and meta-analyses published between 1982 and 2016 concerning psychosocial intervention programs for children aged 3 to 12 years with conduct problems. Parent training should be considered the first-line approach to dealing with young children, whereas cognitive-behavioral approaches have a greater effect on older youths. Family interventions have shown greater efficacy in older youths, whereas multi-component and multimodal treatment approaches have yielded moderate effects in both childhood and adolescence.

Some limitations were found, especially regarding the evaluation of effects. To date, no single program has emerged as the best. However, it emerges that the choice of intervention should be age-specific and should take into account developmental differences in cognitive, behavioral, affective and communicative abilities.

Introduction

Behavioral problems in young people are common and costly, being the most frequent cause of referral of children and adolescents to mental health services (Rutter et al., 2008 ). This is not surprising, as antisocial behaviors in childhood and adolescence elicit significant social reactions and are closely associated with delinquency and mental health problems in adulthood (Loeber & Farrington, 2001 ; Moffitt, 1993 ; Reef, van Meurs, Verhulst, & van der Ende, 2010 ).

In Western countries, it has been reported that the prevalence of conduct problems in subjects between 5 and 15 years of age is 5–10% (Loeber & Farrington, 2001 ) and is steadily increasing, though it is not clear whether this rise is due to a real increase in the phenomenon or to better detection. The economic consequences are considerable: it is estimated that the costs incurred for youths with conduct problems are at least 10 times higher than in non-antisocial individuals by the time they reach 28 years of age (Scott, Knapp, Henderson, & Maughan, 2001 ).

Conduct problems cover a broad spectrum of behaviors and typically include troublesome, disruptive and aggressive behavior; an unwillingness or inability to perform school work; few positive interactions with adults; poor social skills; low self-esteem; non-compliance with instructions and emotional volatility (Furlong et al., 2012 ).

Extensive research in the fields of psychiatry, developmental psychopathology and criminology has furthered our understanding of the many factors that may be involved in the development of juveniles’ conduct problems. Each of these disciplines has its own tradition of assessment, which yields different outcomes (Loeber, Burke & Pardini, 2009 ).

Psychiatry adopts a mainly medical approach, classifying children with disruptive behaviors in clinical categories according to symptom-based criteria. Clearly, children with these diagnoses constitute only a subset of those with conduct problems, since different forms of aggressive and antisocial behavior become clinically relevant only when aggregated.

Developmental psychopathology does not focus on classification, but on the developmental mechanisms that can lead to conduct problems. It therefore analyzes individual differences in the qualitative and quantitative aspects of antisocial behaviors. Such analyses reveal, for instance, that the incidence of stealing and truancy increases with age, whereas the frequency of physical fighting tends to decrease (Barker et al., 2007 ).

By contrast, criminology does not adopt a medical approach, preferring to refer to the more specific notion of ‘behaviors that violate criminal laws’ and focusing mainly on sociological explanations of antisocial behaviors.

Research from each of these disciplines provides a unique perspective for understanding the course, causes and possible treatment of antisocial behaviors in young people, and the results obtained have had a significant impact on assessment and the design of more effective and specific interventions to prevent and treat this phenomenon.

In this manuscript, we focus on the psychosocial treatment of conduct problems in youth. Despite the widespread publication of lists of evidence-based interventions (Eyberg, Nelson, & Boggs, 2008 ), a large gap remains between the knowledge gained through empirical research and clinical practice (Garland, Hawley, Brookman-Frazee, & Hurlburt, 2008 ). Several programs have been proposed and evaluated (Substance Abuse and Mental Health Services Administration, 2011 ), but much remains to be learned about their implementation and about how to support their effective ongoing delivery in community-based settings.

In the first part of the manuscript, we focus on psychosocial interventions, reviewing the scientific literature on evidence-based treatments (EBTs) and evaluating the underpinnings, techniques and outcomes of these treatments. Some examples of the most widespread programs are also provided. We then conclude by discussing the critical issues raised and proposing some recommendations for future work to overcome these problems.

Conduct problems in youth: a brief overview

Before discussing treatment, it is important to delineate the clinical extent of the phenomenon.

Indeed, conduct problems cover a broad spectrum of acting-out behaviors, ranging from relatively minor oppositional behaviors, such as yelling and temper tantrums, to more serious forms of antisocial behavior, such as physical destructiveness, stealing and physical violence. Moreover, it should be remembered that aggressive and defiant behavior is an important part of normal child and adolescent development, which ensures physical and social survival.

As noted by Scott ( 2007 ), empirical studies do not suggest a level at which behaviors become qualitatively different, nor is there a single cut-off point at which they become impairing for the child or a clear problem for others.

One relevant question that is often raised in clinical and research practice is whether or not patterns of antisocial behavior should or should not be considered a psychopathological condition (Wakefield, Pottick, & Kirk, 2002 ). The answer is largely dependent on how one defines ‘mental disorder’ (First, Wakefield, et al., 2010 ). Indeed, picking a particular level of antisocial behavior that is classifiable as a ‘disorder’ is therefore necessarily arbitrary (Moffitt et al., 2007 ).

Although disruptive behaviors are seen to varying degrees during the development of most young people, they become clinically relevant when they are frequent, severe, persistent, not just isolated acts, and lead to distress and functional impairment (American Academy of Child & Adolescent Psychiatry, 1997 ).

The term ‘disruptive behavior disorders’ (DBDs) is an overarching expression used in psychiatric nosology to describe these conditions, in which conduct problems (e.g. breaking rules, disrupting the lives of caregivers, defying authority, etc.) are clinically significant and clearly beyond the realm of ‘normal’ functioning.

According to the psychiatric nosography (American Psychiatric Association, 2013 ), children with these patterns of disruptive behaviors may be diagnosed with Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD), when behavior involves significant violations of the rights of others and/or major societal norms.

Indeed it is important to bear in mind the different conception of the term ‘juvenile delinquency’, a socio-legal category that refers to children and adolescents who have been convicted of an offence that would be deemed a crime if committed by an adult. Most, but not all, recurrent juvenile offenders can be regarded as suffering from conduct disorder (Woolfenden, Williams, & Peat, 2001 ).

A comprehensive review of the literature (Boylan, Vaillancourt, Boyle, & Szatmari, 2007 ) found that the prevalence of ODD reported in community samples ranged from 2.6% to 15.6%, and in clinical samples from 28% to 65%. Moreover, although boys show higher prevalence rates than girls prior to adolescence, during adolescence boys and girls display equal rates of ODD.

There is evidence that ODD can be clearly distinguished from common problem behaviors among preschool children in both clinical (Keenan & Wakschlag, 2004 ) and community (Lavigne et al., 2001 ) samples. Although most empirical evidence supports a distinction between ODD and CD within a DBD spectrum, other evidence appears to support a distinction between ODD and aggressive CD and non-aggressive CD behaviors (Loeber, Burke, Lahey, Winters, & Zera, 2000 ).

The diagnosis of ODD is relatively stable over time, in that diagnostic criteria are reported to be met in two successive years in 36% of cases (Burke, Pardini, & Loeber, 2008 ). Moreover, ODD is a significant risk factor for CD, children with earlier-onset ODD displaying a three-fold higher incidence of CD (Burke, Loeber, Lahey, & Rathouz, 2005 ). In addition, youths with ODD appear to have significantly higher rates of co-morbid psychiatric disorders, such as ADHD, anxiety disorders, depressive disorders and substance use disorders, and ODD is associated with subsequent impairments in school and social functioning, even when other forms of psychopathology are taken into account (Greene et al., 2002 ).

CD is divided into childhood-onset and adolescent-onset subtypes, according to whether the first CD symptom emerges before or after the age of 10 years. Evidence suggests that childhood-onset CD is particularly associated with a more persistent and severe course than adolescent-onset CD, and is associated with a greater risk of antisocial behavior, violence and criminality in adulthood (Odgers et al., 2008 ). In addition, CD tends to progress from less to more severe problem behaviors, with a more rapid increase in this progression being observed in childhood-onset CD (Frick & Viding, 2009 ). Furthermore, there are developmental differences in the manifestation of CD symptoms; for example, the incidence of stealing and truancy increases with age, as does the total number of CD symptoms, whereas the initiation of physical fights tends to decrease (Barker et al., 2007 ).

Prevalence rates of CD in community samples have been found to range from 1.8% to 16.0% for boys, and 0.8% to 9.2% for girls (Loeber et al., 2000 ). In contrast to ODD, gender differences appear to remain consistent throughout development.

The stability of CD diagnoses is moderate to high, ranging from 44% to 88% (Loeber, Burke & Pardini, 2009), the course being strongly influenced by the age of onset. Indeed, in about half of those with early-onset CD, serious problems persist into adulthood, while the great majority (over 85%) of those with adolescent-onset CD discontinue their antisocial behavior by their early twenties (Moffitt & Scott, 2008 ). Moreover, childhood-onset CD is a strong predictor of antisocial personality disorder (APD), especially among subjects from families of low socio-economic status. On the other hand, the majority of children with CD will not progress to APD (Kim-Cohen et al., 2005 ). Other negative outcomes include substance-related disorders, internalizing psychopathology and all personality disorders (Morcillo et al., 2012 ).

Recent research has suggested that a minority of youths with CD display traits similar to those of adult psychopathy (Kahn, Frick, Youngstrom, Findling, & Youngstrom, 2012 ). For this reason in the DSM-5 it has been suggested a subtype “With a Callous-Unemotional Presentation” (American Psychiatric Association, 2013 ). To meet this specification, the young person must fulfill the criteria for CD and display two or more callous-unemotional (CU) characteristics. These include: lack of remorse or feelings of guilt, lack of empathy, unconcern over performance in important activities, and/or shallow affection, persistently for at least 12 months across multiple settings and relationships (Scheepers, Buitelaar, & Matthys, 2011 ). Youths with CU traits show more severe and stable conduct problems (Frick & Dickens, 2006 ), are more difficult to treat and often do not respond to typical treatments in mental health or juvenile justice settings (Stellwagen & Kerig, 2010 ).

While no single cause of ODD and CD has been identified, a number of risk factors have been found. These include biological (e.g. genes and neurotransmitters), perinatal (e.g. minor physical anomalies and low birth weight), cognitive (e.g. deficits in executive functioning), emotional (e.g. poor emotional regulation), personality (e.g. impulsivity), familial (e.g. ineffective discipline), peer (e.g. association with deviant peers) and neighborhood (e.g. high levels of exposure to violence) risk factors (for a review, see Murray & Farrington, 2010 ).

The bulk of the research has made it clear that causal models cannot focus on single risk factors or single domains of risk factors, since DBDs are the result of a complex interaction of multiple causal factors (Lahey & Waldman, 2012 ). From a diagnostic point of view, it should be highlighted that the diagnosis of DBDs is – and remains – mainly clinical, despite the availability of a wide range of instruments for measuring the symptoms of ODD and CD and for assisting the assessment process ( for a review, see Frick & Nigg, 2012 and Barry, Golmaryami, Rivera-Hudson, & Frick et al., 2013 ).

Identification of evidence-based treatments

To identify empirically supported psychosocial intervention programs for the young with conduct problems, we searched for and analyzed reviews and meta-analyses published between 1982 and 2016 concerning treatments for children and adolescents with disruptive behaviors.

Disruptive behaviors were broadly defined on the basis of the symptoms described in the psychiatric classification systems (DSM and ICD). Treatment was defined as any psychosocial intervention aimed at reducing aggressive, oppositional and disruptive behaviors or enhancing prosocial behavior.

Preventive interventions were included only if they involved children with early signs of disruptive behaviors (indicated prevention). Interventions designed with the primary goal of preventing conduct problems (universal and selected) were not included.

We considered as evidence-based the interventions that were recognized in most of the reviews and meta-analyses as well-established or probably efficacious according to the American Psychological Association’s criteria (Chambless & Hollon, 1998 ; Task Force APA, 1995 ) and/or which were identified as superior to the comparison on at least 50% of the disruptive behavior measures.

Two methods were used to identify the database: an internet-based search and a manual search. First, four internet-based databases (Cochrane Reviews, MEDLINE, PsycINFO and Scopus) were searched for articles published between January 1982 and December 2011. All the necessary terms referring to the treatment (psychosocial interventions; individual, family, multi-systemic, parent, school programs; etc.) and the participant groups (age 3–18 years, conduct disorder, oppositional defiant disorder, maladaptive aggression, disruptive behavior, juvenile delinquency) were used. Search terms were modified to meet the requirements of each database. Second, further articles were identified by means of a manual search of reference lists from the papers retrieved.

The reviews and meta-analyses examined are included in the reference section; Table 1 summarizes a few characteristics of the most relevant interventions. It is important to bear in mind that the inventory of studies analyzed is a ‘working list’; indeed, although we attempted to make an exhaustive review of the literature on the outcome of psychosocial treatment, our search may have missed some important treatments.

Evidence-based psychosocial treatments of conduct problems in children and adolescents: selected study characteristics.

Empirically supported intervention programs for youths with conduct problems

Psychosocial interventions for youths with conduct problems have been developed across a wide spectrum (from the individual level to the family and community levels) and over a range of theoretical frameworks (e.g. social learning theory, cognitive-behavioral therapy, systemic and psychodynamic approaches). On the whole, the range of treatments for child conduct problems that have been evaluated empirically may be broadly classified according to the key focus of delivery, in terms of whether they are child-focused, parent-focused, family-focused, multi-modal or multi-component.

With regard to interventions for the individual child, the most carefully evaluated methods are based on cognitive-behavioral principles (Furlong et al., 2012 ). More traditional forms of psychotherapy, such as psychodynamic therapy, have also been used, but some studies have stressed that these approaches have not been evaluated rigorously and are less supported by the existing evidence (Weiss, Catron, Harris, & Phung, 1999 ).

Child-focused programs

Broadly speaking, the child-focused cognitive-behavioral approach emphasizes helping the child to identify stimuli linked to aggressive and antisocial behaviors, to face cognitive distortions, to develop problem-solving skills and to cope with anger and frustration. Thus, the proposed mechanisms of therapeutic change are modifications of the child’s abilities in each of these skill areas (Nock, 2003 ).

Two of the best evaluated treatment models are Problem-Solving Skills Training (PSST) and the Anger Coping Program.

The PSST program was originally drawn up by Alan Kazdin for children aged 5–12 years who were referred for oppositional, aggressive and antisocial behaviors and who were hospitalized in the Child Psychiatric Intensive Care Service facility of the University of Pittsburg (Kazdin, Esveldt-Dawson, French, & Unis, 1987 ). In its most recent version, which was created at the Yale Parenting Center and Child Conduct Clinic, the age of the patients was raised to 14 years, though in exceptional cases older subjects are accepted (Kazdin & Weisz, 2003 ). In reality, the first approach adopted by Kazdin focused on the parents, not on the child. However, as it proved extremely difficult to involve the parents, owing to such obstacles as drug addiction, imprisonment, mental retardation or simple refusal, Kazdin was prompted to work out a program that could be implemented directly with the child.

The core program of Problem-Solving Skills Training consists of 12 weekly sessions of 30–50 min and utilizes cognitive and behavioral methods aimed at teaching the children new problem-solving techniques and improving their social skills. The advocates of this method claim that children suffering from disruptive disorder have cognitive deficits that lead them to interpret their surrounding social setting erroneously, to perceive the behavior of others as hostile and therefore to react aggressively. The program, which can be applied either in the clinic or at home, involves working individually with the child, with the therapist encouraging the child to adopt a progressively more positive approach to interpersonal relationships. This goal is achieved through various strategies, such as role-playing, reinforcement schedules, feedback, etc. The child is then helped to apply problem-solving skills in everyday life, in a variety of situations and contexts.

In the last 30 years, PSST has been implemented on thousands of children and has been amply evaluated (Weisz & Kazdin, 2010 ). The evidence indicates that it reduces the child’s aggressiveness both at home and at school, reduces the number of deviant behaviors and increases pro-social behaviors (Kazdin, Bass, Siegel, & Thomas, 1989 ). Moreover, research has demonstrated that the addition of a real-life practice (Kazdin et al., 1989 ) and/or of a parent training component (Kazdin, Siegel, & Bass, 1992 ) may have a greater impact on outcomes.

The Anger Coping Program is a structured 18-session cognitive-behavioral group intervention that has been refined over a period of 20 years from an earlier 12-session Anger Control Program by Larson and Lochman, ( 2002 ). This program has been used in school settings for children in Grades 4–6 with disruptive behavior disorders. Group sessions typically last 45–60 min and are moderately structured, with specific objectives and exercises for each session. The goals are to help children to cope with anger after provocation or frustration and to learn possible strategies for solving the problem or conflict they are experiencing (Lochman & Lenhart, 1993 ). Outcome research indicates that program participants display less disruptive-aggressive behavior, more time on-task in the classroom, lower levels of parent-rated aggression, higher self-esteem or perceived social competence, and a trend toward a reduction in teacher-rated aggression (Lochman, Curry, Dane, & Ellis, 2001 ).

A further evolution of the Anger Coping Program is the Coping Power Program, in which Lochman and Wells added a parent component designed to be integrated with the child component (Lochman & Wells, 2002 ). This program is intended for boys and girls, approximately 9–11 years of age (4th to 6th grade) who have been screened for disruptive and aggressive behavior and comprises 33 group sessions each lasting 60–90 min, with periodic individual meetings. Sessions include imagined scenarios, therapist modeling, role-play with corrective feedback, and assignments to practice outside sessions. Outcome analyses in randomized controlled intervention studies indicate that the Coping Power Program significantly reduces risks of self-reported delinquency, parent-reported aggression and teacher-reported behavioral problems at 1-year follow-up (Lochman et al., 2009 ).

Parents-focused programs

In the light of the research suggesting that child conduct problems develop as a result of maladaptive parent–child interactions, parenting interventions have been the most thoroughly studied treatment approaches for children who enact disruptive behaviors. The main goals of these interventions are to improve parents’ behavior management skills and the quality of the parent–child relationship. There are two main types of program: behavioral, focused on helping parents learn skills needed to address the causes of problem behaviors, and relationship, aimed at helping parents understand both their own and their child's emotions and behavior and at improving their communication with the child. However, most parenting programs combine elements of both (Gould & Richardson, 2006 ).

A well-known clinical intervention model designed to enhance effective parenting is the Parent Management Training–Oregon model (PMT–O) program. Developed at the end of the 1960s by the Oregon Social Learning Group, it is based on the ‘Living with children’ theory of Patterson and Guillion ( 1968 ). According to the authors (Patterson, Reid, Jones, & Conger, 1975 ), the aggressiveness and behavioral problems of children are inadvertently sustained by inadequate behaviors on the part of parents; by this token, inconsistent discipline, harsh and inappropriate punishments, and oppressive and inefficacious demands end up exacerbating, rather than reducing, the antisocial behavior of children.

The objective of the program, which is carried out in about 20 sessions, is to teach parents to avoid coercive practices and to improve their parenting skills. Thus, parents are taught to adopt more consistent behaviors, to utilize a rational system of rewards and minor punishments, to draw up clear codes of behavior that their children must respect, to devote more attention to their children and to help them to solve the problems of everyday life. The therapist works directly with the parents, generally at home, and only marginally interacts with the child. The parents are prompted to identify and define their child's behavior in a new way, to analyze in detail the problems raised by the child, and to learn how to react constructively so as to reinforce desirable behavior and progressively reduce undesirable behavior, the final goal being to get the child to learn specific educational skills.

PMT has been widely implemented for decades in many parts of the world and is utilized both as a single instrument of intervention and in combination with other components (child, school, etc.) in a multimodal setting. The program has been evaluated in various randomized controlled trials involving children aged 4–12 years and has proved superior to alternative treatments in reducing disruptive behaviors (Forgatch, Patterson, DeGarmo, & Beldavs, 2009 ; Hagen, Ogden, & Bjornebekk, 2011 ; Hautmann et al., 2009 ; Patterson, Chamberlain, & Reid, 1982 ). Several meta-analyses have confirmed this evidence and have demonstrated that this intervention is generally cost-effective (Dretzke et al., 2005 ; McCart, Priester, Davies, & Azen, 2006 ). Moreover, research shows that treatment effects may be generalized across settings, may be maintained for up to 2 years post-treatment, may benefit other children in the same family and also may extend to other deviant behaviors beyond those emphasized in treatment (Kjøbli, Hukkelberg, & Ogden et al., 2013 ).

The Helping the Non-Compliant Child Program (NCCP) and Parent–Child Interaction Therapy (PCIT) are two further examples of well-validated individual parent-training interventions for child conduct problems. The NCCP, developed by Forehand and McMahon (Forehand & McMahon, 1981 ), is a parent-training program for preschool and early school-age children (ages 3–8) with noncompliant behavior, and is aimed at creating a controlled environment in which parents can learn new ‘adaptive’ ways to interact with their children. Parents and children participate in 60–90-min sessions once or twice a week, with an average total of 8–10 sessions; sessions are typically conducted with individual families rather than in groups. Parents are instructed in skills aimed at interrupting the coercive cycle of parent–child interaction and at establishing positive, prosocial interaction patterns. They also learn a planned ignoring procedure for reducing undesirable behaviors on the part of the child (McMahon & Forehand, 2003 ).

The NCCP has been extensively researched and has proved superior to systemic family therapy in reducing child noncompliance in the clinic and at home (Wells & Egan, 1988 ). Moreover, it has shown many positive outcomes in both children and parents, with a maintenance effect ranging from 6 months to more than 14 years after treatment termination (McMahon & Forehand, 2003 ).

PCIT is a dyadic (parent–child) treatment program for children from 2 to 7 years of age with severe behavioral disorders. Originally developed by Sheila Eyberg, it targets change in parent–child interaction patterns through the use of play therapy (Eyberg & Calzada, 1998 ). This program is typically implemented in a community outpatient clinic and uses a two-stage approach aimed at relationship enhancement and child behavior management. Families meet for an average of 12 to 16 weekly 1-hour sessions, during which parents learn to build a supportive parent–child bond through play, to set realistic expectations, to improve consistency and to reduce the reinforcement of negative behavior (Eyberg, Boggs, & Algina, 1995 ).

PCIT has proved superior to waitlist control conditions in reducing disruptive behavior in young children (Nixon, Sweeney, Erickson, & Touyz, 2003 ; Schuhmann, Foote, Eyberg, Boggs, & Algina, 1998 ) and has demonstrated long-term maintenance of treatment gains of up to 6 years post-treatment (Hood & Eyberg, 2003 ). In a recent meta-analysis, the ability of PCIT to produce significant changes in negative child behavior was confirmed (Thomas & Zimmer-Gembeck, 2007 ).

The Triple P Positive Parenting Program is a multilevel parenting program designed to prevent and treat severe behavioral, emotional and developmental problems in children aged 0 to 16 years through enhancing the knowledge, skills and confidence of parents. Triple P incorporates five levels of interventions in a tiered continuum of increasing intensity. The rationale for this stepped-care strategy is that there are different levels of dysfunction and behavioral disturbance in children, and that parents may have different needs and desires regarding the type, intensity and mode of assistance they require (Sanders, Markie-Dadds, & Turner, 1999 ). Level 1 is a media-based information strategy designed to increase community awareness of parenting resources, encourage parents to participate in programs, and communicate solutions to common behavioral and developmental concerns. Level 2 provides specific advice on how to solve common child development issues and minor child behavior problems. It includes parenting ‘tip sheets’ and videotapes demonstrating specific parenting strategies. Level 3 involves active skills training that combines advice with rehearsal and self-evaluation in order to teach parents how to manage these behaviors. Level 4 is designed to teach positive parenting skills and their application to a range of target behaviors, settings and children. Level 4 is delivered in 10 individual or 8 group sessions, totaling about 10 hours. Level 5 is an enhanced behavioral strategy for families in which parenting difficulties are complicated by other sources of family distress. Variations of some Triple P levels are available for parents of young children with developmental disabilities (Stepping Stones Triple P) and for parents who have abused (Pathways Triple P) (Sanders, 2012 ).

Triple P has been used in many diverse cultural contexts, and the multilevel nature of the program enables various combinations of the levels and modalities within levels, tailored on local priorities, staffing and budget constraints. The program has a strong research base, which has revealed the effectiveness of various levels of Triple P for children with conduct problems from infancy to 16 years of age. In particular, a recent comprehensive meta-analysis confirmed the efficacy of Triple-P in improving parenting skills, child problem behavior and parental well-being. Moreover, the fact that Triple P comprises a diverse set of options for families from different social and cultural backgrounds, as well as for varying degrees of problems, seems to be evidence of the program’s ability to impact positively on parent–child interactions (Nowak & Heinrichs, 2008 ).

Family-focused programs

For what concerns intervention on the family, family therapy researchers have conceptualized child conduct problems not as the result of inept parenting practices or cognitive deficits in the child but, rather, as the result of maladaptive interactions and dynamics in the family as a whole (Nock, 2003 ).

Various approaches to family therapy have been developed and, among these, the Functional Family Therapy (FFT) program should be mentioned. Based on a systemic approach, this program was worked out more than 30 years ago by James Alexander and Bruce Parsons (Alexander & Parsons, 1973 ) and is widely used for the treatment of minors aged 11–18 years who display aggressive behavior or have problems of substance abuse. The idea underlying the program is that children's behavior problems are not due to cognitive deficits or to parental incapacity; rather, they are the expression of a malfunction of the whole family system, within which the child’s behavioral disorder exerts a function (e.g. reducing conflict between the parents). Only by improving the structures of communication and interaction among all members of the family, therefore, will it be possible to modify the child’s behavior.

The program generally consists of 8–12 one-hour sessions over a period of about three months. There are different phases to treatment: initially, there is a period of engagement and motivation, during which the therapist applies cognitive techniques in order to replace negative attitudes (lack of motivation, mistrust, etc) with positive ones and tries to gain acceptance, to acquire credibility and to initiate a therapeutic alliance with all of the family members. In the second phase (behavioral change), interactions among the various family members are assessed and oriented towards a better functioning of the family system. The therapist tries to make all members of the family understand what each expects from the others and to clarify the relationships among the various members. Changes in family interactions are induced by facilitating the identification of problems and improving communication (learning to listen, to use direct and clear messages, etc.) and developing the ability to solve problems. In general, the therapist tries to restructure family relationships through various techniques (such as cognitive reframing and skills training, for example) in order to modify behaviors. Subsequently, in the phase of generalization, this modification is reinforced and projected outside the immediate family circle (e.g. in the school or judicial spheres), and the family is prompted to become independent of the therapist (Alexander, Pugh, Parsons, & Sexton, 2000 ).

The effectiveness of functional family therapy has been researched for a long time, and evidence gleaned over follow-up periods of 1, 2, 3, and 5 years seems to support its superiority over control conditions and alternative treatment conditions in dealing with both status offenders and more serious juvenile offenders (Henggeler & Sheidow, 2012 ).

An emerging model for treating children with conduct problems is brief strategic family therapy (BSFT), a short-term family-treatment model developed over nearly 40 years of research at the University of Miami’s Center for Family Studies for children and adolescents aged 6 to 18 years. Briefly, BSFT is based on structural and strategic family theories, and uses family therapy techniques to modify the interactions within the family system that are maintaining the youth’s problem behavior. BSFT is delivered through weekly sessions in a clinic or the family home. Treatment, which typically lasts 4 months and comprises 8–24 sessions according to the family’s needs, focuses on three central constructs (system, structure/patterns of interaction, and strategy) involving three components: joining, diagnosis and restructuring (Szapocznik, Hervis, & Schwartz, 2003 ). The treatment developers have conducted several studies, which have demonstrated significant positive effects of BSFT in reducing anger and bullying behaviors among youths (Coatsworth, Santisteban, McBride, & Szapocznik, 2001 ).

Multimodal and multi-component programs

The combination of various treatment modalities involving different levels of intervention at the same time (individual, family, school, etc) led to the creation of multi-component or multimodal treatment approaches, which some regard as the most efficacious types of intervention (Burke, Loeber, & Birmaher, 2002 ). These approaches, which are more intensive and more complex than those that focus exclusively on the child or on the family, are not always limited to combining two or more types of treatment or to adding a standard component to enhance an existing treatment package; indeed, they often bring together those features of the various programs that are most suited to each individual case, either by addressing multiple risk factors in a comprehensive program or by focusing on the surrounding environment, in order to change the child’s behavior.

Some examples of this kind of intervention are: the Incredible Years (IY) Parents’, Teachers’ and Children’s Training Series program, which was initially developed by Carolyn Webster-Stratton for children 3–8 years of age with early-onset conduct problems (Webster-Stratton, 1992 ); the Montreal Longitudinal Experimental Study (MLES), drawn up by Richard Tremblay and designed to treat aggressive children (McCord, 1992 ); the Multi-systemic Therapy (MST) program, proposed by Henggeler for antisocial preadolescents and adolescents (Henggeler, Rodick, Borduin, Hanson, Watson & Urey, 1986 ), and the multidimensional treatment foster care (MTFC) program, developed by Chamberlain for youths who display chronic disruptive behavior (Chamberlain, 2003 ).

The IY series is broken down into three areas: a child-based program, a parent-based program and a teacher-based program. The general aim of the intervention is to reduce children’s aggressiveness by teaching parents and teachers how best to deal with disruptive behavior and to facilitate pro-social behavior.

Parents’ and children's sessions are held weekly in small groups. Parents watch videotapes that depict models of parents interacting with their children in various situations. They then discuss the contents with two group leaders and try out new techniques of intervention with their children through role play. In the children's group sessions (2 hours per week for about 6 months), the therapist also discusses a few videotapes, with a view to developing better social skills, fostering the ability to control impulses and emotions and improving the children's problem-solving skills. This program works on empathy, anger control, friendly relationships, communication, and relationships with the school and teachers. The teachers’ program consists of a four-day workshop, which focuses on learning the most effective classroom management strategies for coping with disruptive behavior and promoting positive relationships among pupils.

The basic program may be supplemented by further treatment modules, such as the ADVANCE program, which focuses on interpersonal issues such as communication and problem-solving (Webster-Stratton, 1994 ), and the School Readiness Series, which tackles school issues (Webster-Stratton, Reid, & Stoolmiller, 2008 ). Different combinations of the IY components are utilized, depending on the child population targeted (Webster-Stratton, 2008 ). The Incredible Years program, which has been implemented in the United States, Canada, Norway, Denmark, Great Britain and New Zealand, is one of the most widely used and amply tested intervention programs for children with disruptive behaviors (Webster-Stratton, Rinaldi, & Reid, 2010 ).

Three components were also used in the Montreal Longitudinal Experimental Study (Tremblay, Vitaro, Bertrand, et al., 1992 ). The first consisted of social skills training and aimed at promoting changes in behavior towards peers by fostering greater social acceptance of antisocial peers. Training was offered at school in small groups of 4–7 children, with a ratio of three pro-social children from the school to one disruptive child in each group. The second focus was that of training parents in effective child-rearing, based on the Oregon Social Learning Center Model (Patterson et al., 1975 ). The third domain, which served as a complement to parent training, was the provision of information and support for teachers involved with at-risk pupils.

The parent management skills training component was intended to improve parents’ disciplinary practices and to reduce their supervision deficits, whereas the social and social-cognitive skills training component, in which the children interacted with pro-social peers in small groups, was intended to reduce children’s aggressive and hyperactive behaviors by teaching them self-control strategies and alternative behaviors to aggression. The intervention program lasted 2 school years; children were 7 years old when the intervention started and 9 years old when it finished.

The long-term efficacy of the program was assessed when the subjects were 24 years old; it emerged that significantly more individuals in the intervention group had completed high school and graduated, and generally fewer had a criminal record in comparison with those allocated to the control group (Boisjoli, Vitaro, Lacourse, Barker, & Tremblay, 2007 ).

Multi-systemic therapy (MST), which was designed by Henggeler at the end of the 1970s, is one of the most intensive intervention programs and has chiefly been used to treat antisocial adolescents and pre-adolescents, even as an alternative to the traditional judicial pathway (Henggeler, Melton, & Smith, 1992 ). This program was based on the conviction that antisocial behavior is underpinned by multiple risk factors at the individual, family, school and community levels, and that only by acting simultaneously and intensively on all of these factors is it possible to achieve results.

This family-focused and community-based treatment program is implemented by a team of 3–4 therapists, who have a small caseload (5 families for each therapist). Therapists are available 24 hours a day, 7 days a week, and provide a service for 2–15 hours a week; moreover, they receive intensive training and continuous supervision. The program lasts 4–6 months and is carried out at the youths’ homes and in other places frequented by them. The therapists’ aims are to improve the child-rearing capacity of parents and to act on teachers, educators, community leaders and influential persons in general, with a view to transforming the social ecology of the minor in such a way as to create an environment that is more favorable to positive adaptation and less conducive to antisocial behavior.

The intervention targets young people, family relationships, peer relationships, the school and other social systems. According to Henggeler, MST must follow a series of principles: precise identification of the most appropriate treatment process for each specific case; appreciation of the youth’s positive features; creation of a sense of responsibility on the part of family members; a focus on the present, in order to solve current problems rather than dwelling on the past; point-by-point consideration of the appropriateness of the interventions in relation to the youth’s age and developmental stage; timely, continuous effort to bring about change, accompanied by frequent checks and responses; and a constant commitment to evaluating the functioning of the program, including consideration of the effects that will ensue once the intervention has been concluded (Henggeler, Melton, Brondino, Scherer, & Hanley, 1997 ).

More than 450 MST programs are currently utilized in 11 countries; each year, more than 15,000 youths with antisocial behavior are treated (Henggeler, Schoenwald, Borduin, Rowland, & Cunningham, 2009 ; Ogden & Halliday-Boykins, 2004 ; Sundell et al., 2008 ). Many published studies have asserted the efficacy of the MST programs in reducing antisocial behavior and the probability of being arrested, even in the long term (Henggeler et al., 1999 ; Timmons-Mitchell, Bender, Kishna, & Mitchell, 2006 ).

Nevertheless, these results have been called into question. Indeed, according to a Cochrane review in 2005 (Littell, Popa, & Forsythe et al., 2006 ), there are no significant differences, in terms of restrictive out-of-home placements and arrests or convictions, between MST and usual services. Pooled results that include studies with data of varying quality tend to favor MST, but these relative effects are not significantly different from zero. The study sample size is small, and effects are not consistent across studies; hence, it is not clear whether MST has clinically significant advantages over other services.

Finally, we should mention a type of program that is applied in particular circumstances, when parents categorically refuse any involvement or indulge in abusive behaviors. In these situations, the child may be removed from the home environment, temporarily if possible. At one time, antisocial youths with parents of this kind (and also from other types of problem families) were placed in institutions or reformatories. Several studies have shown, however, that putting problem youths together, even in therapeutic or educational facilities, actually worsens the situation, in that the influence of deviant peers outweighs that of educators and therapists (Dishion, McCord, & Poulin, 1999 ).

For youths with conduct disorders who cannot be treated in their own family setting, programs that make use of foster families have therefore been designed. An example of these is Multidimensional Treatment Foster Care (MTFC). Developed at the beginning of the 1980s by Patricia Chamberlain and coll. at the Oregon Social Learning Center, this program targeted violent delinquent youths who needed treatment outside their family environment (Chamberlain, 1994 ). Thereafter, a program was drawn up for aggressive children of preschool age (3–6 years) as an alternative to residential therapy (Chamberlain & Reid, 1998 ). The cases dealt with are often the result of referral by child welfare services or the juvenile justice system.

As with MST and FFT, many of the techniques used in MTFC are derived from behavioral and cognitive-behavioral approaches, implemented within a framework that highlights the critical role of foster parent supervision. In particular, therapists provide intensive support for the individual, the biological family (to which the minor will return if possible) and the foster family through daily contact, in order to monitor the evolution of the situation and to solve any problems that arise; they also act in the school and community settings. Founded on Social Learning Theory, the MTFC program helps parents, teachers and educators to acquire the skills needed in order to cope with the youth’s problems and behaviors by teaching them to set clear limits and rules and to support and encourage the youth’s progress by establishing close supervision. Therapists also strive to promote contact with pro-social peers and to discourage relationships with deviant youths.

The program is preceded by careful selection and training of the foster parents, who are the most important component of the therapeutic plan. Only one child or youth is placed with a foster family at a time. Throughout the program, the foster parents maintain a close relationship with the therapists through daily telephone calls, home visits and weekly meetings. During the daily telephone calls, the foster parents provide information on about 40 behaviors through the Parent Daily Report; this enables the supervisor to evaluate the progress of the treatment and to make any necessary adjustments.

The staff members who run the program have specific roles: the Program Supervisor, who is responsible for organizing all aspects of the treatment; the Foster Parents; the Consultant/Recruiter/Trainer, who constitutes the most direct means of support for foster parents; Skills Trainers/Playgroup Staff Members, who teach pro-social behavior and problem-solving skills to the child through intensive one-on-one interaction and skill practice in the community; the Family Therapist, who teaches the birth parents and foster parents how to effectively supervise, discipline and encourage the child; the PDR Caller, who contacts foster families each day by telephone for the Parent Daily Report (PDR); and the Consulting Psychiatrist, if psychiatric consultation is required.

From all of the above, it is clear that MTFC is a highly intensive program that requires very complex organization and a multiplicity of therapeutic and organizational skills. The final objective is to modify the behavior of these children or adolescents and to facilitate their return to the family of origin or, in the exceptional cases in which this is not possible, their placement with adoptive families.

Some studies seem to have demonstrated the efficacy of these programs in improving the behavior of the subjects treated and in reducing their aggressiveness (Chamberlain, Leve, & DeGarmo, 2007 ; Eddy, Whaley, & Chamberlain, 2004 ; Westermark, Hansson, & Olsson, 2011 ). This seems to be mainly due to an improvement in the family’s ability to manage the behavior of these subjects and to the fact that they are kept away from deviant peers (Eddy & Chamberlain, 2000 ).

Critical considerations and best-practice recommendations

This analysis reveals that the diagnostic category ‘conduct disorder’ is almost never used specifically by the operators who have designed and implemented psychosocial interventions aimed at treating children and adolescents who display antisocial, defiant or aggressive behaviors. Indeed, while conduct disorders are cited in almost all of the programs examined, in reality the inclusion criteria cover a range of behavioral problems that do not fully match the diagnostic categories used in medical nosography. Moreover, evaluation of the effects of such interventions considers different types of result, such as increased prosocial behavior and reduced antisocial behavior on the part of the minor, without specifically taking into account the diagnosis of conduct disorder.

In addition, it should be pointed out that the conceptual category ‘conduct disorder’ includes symptoms of behaviors that differ markedly from one another and that may require specific interventions. In this regard, it should be borne in mind, for example, that aggressive behaviors and theft constitute very different problems, which evolve differently over time and are underpinned by different risk factors. Specifically, the developmental trajectories of physical violence and theft during adolescence and early adulthood are different and differently related to neurocognitive functioning. Indeed, an important longitudinal study has demonstrated that the majority of subjects show an increased frequency of theft from adolescence to adulthood, whereas only a minority evince an increasing frequency of physical violence. In addition, the neurocognitive mechanisms seem to be different, in that executive function and verbal IQ performance have been negatively related to a high frequency of physical violence but positively related to a high frequency of theft (Barker et al., 2007 ).

Despite these conceptual limits, our literature analysis indicates that psychosocial interventions for minors with conduct problems are widely studied and can be considered a useful part of treatment planning for youths who display problems of adaptation.

By contrast, not least in the light of the difficulties of defining conduct disorders conceptually, the role of medical treatments is debated. Although the literature supporting the psychopharmacological management of aggressive and disruptive behavior in youth is growing, it still seems to be insufficient to determine the comparative risks and benefits of using drugs in pediatric populations, especially in the long term. A specific in-depth analysis of this treatment modality has been provided by the American Academy of Child and Adolescent Psychiatry and other groups, which have published practice parameters on the medical treatment of conduct disorders in youth (Gleason et al., 2007 ). However, the imbalance between the relatively strong evidence for psychotherapeutic interventions and the weak evidence for medication use justifies the view that psychotherapy is the first-line treatment for maladaptive aggression and conduct problems (Scotto Rosato et al., 2012 ).

A further cornerstone in the treatment of youths with conduct problems is the concept that it is important to intervene early in the developmental trajectory in order to prevent subsequent serious antisocial behaviors and other mental health problems in adulthood (McNeil, Capage, Bahl, & Blanc, 1999 ).

Despite extensive research into treatment, no single program has yet emerged as the best. However, on the basis of the bulk of evidence available, it emerges that the choice of intervention should be age-specific and should take into account developmental differences in cognitive, behavioral, affective and communicative abilities.

On the whole, according to the studies considered, clinical evidence suggests that, in dealing with younger children (<11 years old) with conduct problems (or with symptoms suggestive of high risk), parent-focused interventions seem to be more effective. By contrast, for older children (>11 years old), child-focused interventions appear to be more effective. For children in foster care, there is some evidence that foster carer-focused interventions are also effective. Interventions conducted separately on both the parents and the child are not clearly more effective than parent-focused interventions alone. Moreover, interventions delivered in school settings seems to be more effective than those delivered in the clinical setting.

According to the literature reviewed, parent training should be considered the first-line approach to dealing with young children, whereas cognitive-behavioral approaches have a greater effect on older youths, who probably have a greater capacity to benefit from this kind of treatment. In addition, family interventions addressing parent–child relationships and communication have shown greater efficacy in older youths, whereas multi-component and multimodal treatment approaches have shown moderate effects in both childhood and adolescence. For children with CU traits, treatments that intervene early in the parent–child relationship to teach parents ways of fostering empathic concern in their young child, or those that help the child develop cognitive perspective-taking skills, have shown evidence of effectiveness (Hawes & Dadds, 2005 ; Kolko & Pardini, 2010 ).

Finally, family engagement in treatment significantly influences outcomes. More positive child–therapist and parent–therapist alliances also predict greater improvement, fewer perceived barriers to participation in treatment and greater treatment acceptability (Scotto Rosato et al., 2012 ).

One limitation that emerges from the scientific literature is the lack of long-term assessments. Consequently, we do not know whether the positive effects recorded at the end of the treatment, or after a relatively short period, last throughout adolescence and into adulthood, nor whether any undesired effects arise. In this regard, we should remember the results obtained from one of the most interesting and prolonged studies carried out in criminology. This study analyzed the long-term efficacy of a delinquency-prevention psychosocial program carried out in Cambridge-Somerville. As reported by McCord ( 1978 ), some decades after intervention, the results were surprisingly negative; in spite of all the efforts made, all the support for the children and their families, and the intervention of counselors, the subjects treated suffered a higher percentage of mental illness, early death (before the age of 35 years), alcoholism, recidivism, failure at work, etc., during the course of their lives than did control subjects. While it would be fairly easy to explain the lack of success of preventive intervention if the results showed no difference between the treatment group and the control group, it is much more difficult to explain the worse outcome of the treated subjects. The lack of success might easily be attributed to the inefficacy of the program, insufficient support for minors and their families, or too little contact between operators and subjects. Such explanations, however, cannot justify the worse results obtained by treated subjects; moreover, they are at variance with McCord’s ( 1992 ) finding that the worst results were seen in those very cases in which the relationships between counselors and minors were most intense and long-standing.

An interpretation of these negative results was proposed by Dishion et al. ( 1999 ). Within the framework of the Cambridge–Somerville program, 125 youths were sent to summer camps once or more often. Examination of the long-term results revealed that those who had attended summer camps more than once were ten times more likely to have had a negative outcome (early death, mental illness or involvement in crime) than did control subjects. The authors ascertained that there was no significant initial difference between those who attended the camps and those who did not; they concluded therefore that failure could not have been due to a selection bias. In the light of these data, Dishion et al. ( 1999 ) reached the conclusion that placing at-risk minors in a group of deviant peers can produce highly negative effects on youths with behavior problems, and that this was why summer camp attendance had a deleterious effect. The Cambridge–Somerville findings were in agreement with other results, which demonstrated that placing problem youths in a group treatment program had produced long-term negative effects. Indeed, in terms of delinquency, these youths had a worse outcome than did control subjects who had not undergone any treatment. This was attributed to the fact that the negative influence of deviant peers outweighed the positive influence of the therapists. These results highlight the need to carry out long-term assessments in order to ascertain whether the results of intervention are stable and whether any side-effects emerge over the years.

A second problem is that, despite the rapid growth of empirically supported psychosocial interventions for children and adolescents, the variables that predict, influence or account for good or poor responses to treatments of conduct problems are still poorly understood. Much more research is needed in order to understand the circumstances under which treatments work and the ways in which treatments produce outcomes. Moreover, further efforts aimed at studying treatment replications in new populations or by community-based providers are needed.

Finally, an observation regarding the conceptual context in which the most common psychosocial programs set the behavioral problems of children and adolescents. Through the concept of conduct disorders, a process is often unleashed whereby problems that have a major environmental component become ‘medicalized’. Consequently, in many cases treatment focuses mainly on the child or, at best, on the family and school context, without specifically taking into account the social environment as a whole. This approach not only produces intervention that has a scant or temporary effect; it also limits social policy to acting on the effects of problem situations, rather than trying to eliminate their causes. In conclusion, further studies are necessary to evaluate in depth the effectiveness of psychosocial treatments for juvenile conduct problems.

Ethical standards

Declaration of conflicts of interest.

Gabriele Rocca has declared no conflicts of interest.

Ignazio Grattagliano has declared no conflicts of interest.

Uberto Gatti has declared no conflicts of interest.

Ethical approval

This article does not contain any studies with human participants or animals performed by any of the authors. Part of this article is published in a chapter of a French book “Psychiatrie de l’enfant et de l’adolescent Une approche basée sur les preuves” (by Holzer, L.; De Boeck-Solal: 2014).”

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Opioid Intervention Court Center of Excellence

Opioid Intervention Courts (OICs) are a new problem-solving court model designed to address the opioid epidemic and prevent overdose deaths. They can rapidly connect participants to evidence-based treatment including medication for addiction treatment (MAT) and other recovery support services. The New York State Unified Court System opened the country’s first OIC in Buffalo in 2017 with the explicit goal of saving lives. The OIC model was developed as a pre-plea, voluntary, medical triage for those at high risk of overdose entering the court system. OICs provide participants with immediate life-saving medical and behavioral health care with the goal of stabilizing individuals prior to the resolution of their case.

Opioid Intervention Court Implementation Courts interested in implementing an Opioid Intervention Court have the opportunity to learn from a variety of resources.

Opioid Intervention Court Evaluation The Opioid Intervention Court is a new and developing problem-solving court model. Evaluations have been conducted that show the effectiveness of this approach.

Medication for Opioid Use Disorder Medication for Addiction Treatment (MAT) is an evidence-based approach to effectively treat Opioid Use Disorder.

Role of Recovery Peer Advocates Certified Recovery Peer Advocates & Addiction Recovery Coaches are recovery professionals that bridge the gap between clinical intervention and community resources.

This project was supported by Grant No. 15PBJA-21-GG-04548-COAP awarded by the Bureau of Justice Assistance. The Bureau of Justice Assistance is a component of the Department of Justice’s Office of Justice Programs, which also includes the Bureau of Justice Statistics, the National Institute of Justice, the Office of Juvenile Justice and Delinquency Prevention, the Office for Victims of Crime, and the SMART Office. Points of view of opinions in this website are those of the author and do not necessarily represent the official position or policies of the U.S. Department of Justice. 

This website is funded in part through a grant from the Bureau of Justice Assistance, Office of Justice Programs, U.S. Department of Justice. Neither the U.S. Department of Justice nor any of its components operate, control, are responsible for, or necessarily endorse, this website (including, without limitation, its content, technical infrastructure, and policies, and any services or tools provided).