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What Is Problem-Solving Therapy?

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.

Daniel B. Block, MD, is an award-winning, board-certified psychiatrist who operates a private practice in Pennsylvania.

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.

Get Help Now

We've tried, tested, and written unbiased reviews of the best online therapy programs including Talkspace, BetterHelp, and ReGain. Find out which option is the best for you.

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.

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3.2: Problem Solving Approaches and Interventions

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• Page ID 43049

• Vera Kennedy
• West Hills College Lemoore

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There are six problem solving approaches and interventions most commonly used among practitioners. Each approach examines a different aspect of a social problem. The nature of the problem and people involved determines the most appropriate intervention to apply.

A social systems approach examines the social structure surrounding the problem or issue. This approach requires macro, meso, and micro levels of analysis (see pages 12-13) to help understand the structure of the problem and the arrangement of individuals and social groups involved. Analysis requires comprehension of the entire issue and parts associated, as well as, which components and protocols of the structure are independent or dependent of each other. Application of this approach requires grasp of the complete problem including the hierarchy, order, patterns, and boundaries of individuals and social groups including their interactions, relationships, and processes as a body or structure surrounding the issue (Bruhn and Rebach 2007).

The interventions deployed using a social systems approach focus on establishing and maintaining stability for all parties even while change is occurring. Social system interventions require change agents or leaders such as sociological practitioners to help control and guide inputs (what is put in or taken into the problem) and outputs (what is produced, delivered, or supplied resulting from change) used in problem solving (Bruhn and Rebach 2007). This approach requires the involvement of everyone in the social structure to design or re-design the system and processes around the issue.

The human ecology approach examines the “web of life” or the ecosystem of a social problem or issue. This approach is often visually represented by a spider web to demonstrate how lives are interlinked and interdependent. A human ecology approach focuses on macro and meso levels of analysis to develop knowledge about the social bonds, personal needs, and environmental conditions that impede or support life challenges and opportunities for individuals. Practitioners evaluate and analyze where individuals and groups fit in the social structure or ecosystem and their roles. The purpose of this approach is to identify cognitive and emotional boundaries people experience living in social systems to help confront and remove the obstacles they face.

Interventions applied in a human ecological approach target changes in families, institutions, and small communities. The goal is to confront the stressors and strain created by social situations and settings. Interventions from a human ecology approach help people determine acceptable behaviors within different social environments (Bruhn and Rebach 2007). Practitioners work with social groups to remove collaborative challenges between groups in a social ecosystem and the individuals working and living within them. Change is concentrated on developing a new system and process to support and remove obstacles for individuals effected by a social problem.

• Describe the social systems approach and explain what type of social problems or issues this approach is the most valid method to use.
• Describe the human ecology approach and explain what type of social problem or issues this approach is the most valid method to use.
• A county mental health court
• Gender neutral bathrooms on a college campus
• Anti-bullying campaign in local K-12 schools

A life cycle approach examines the developmental stages and experiences of individuals facing issues or various life crises. Meso and micro levels of analysis are required with this method. Data gathered assists practitioners in understanding the adaption of individuals or groups to change, challenges, and demands at each developmental stage of life (Bruhn and Rebach 2007). Analysis incorporates evaluation of interpersonal connections between a person and the environment, life transitions, and patterns. This approach if applicable when working with individuals, groups, and organizations, which all have and go through a life cycle and stages of development.

Interventions using this approach target changes in social norms and expectations of individuals or groups facing difficulties. Practitioners help identify the context and issues creating anxiety among individuals or groups and facilitate coping strategies to attack their issues. This approach builds on positive personal and social resources and networks to mend, retrain, or enable development and growth.

The clinical approach evaluates disease, illness, and distress. Both meso and micro levels of analysis are required for this method. Practitioners assess biological, personal, and environmental connections by surveying the patient or client’s background, and current and recent conditions (Bruhn and Rebach 2007). A Patient Evaluation Grid (PEG) is the most commonly used tool for data collection. This approach requires in-depth interactions with the patient or client to identify themes associated with their condition and the structure of the social system related to their illness and support. When applying this approach in medical practice, the evaluation and analysis leads to a diagnosis.

• Describe the life cycle approach and explain what type of social problems or issues this approach is the most valid method to use.
• Describe the clinical approach and explain what type of social problem or issues this approach is the most valid method to use.
• Policing strategies to reduce crime and improve community relationships
• Reductions in self-injury or cutting among teens
• A community college social work education degree program

Intervention in a clinical approach concentrates on removal of symptoms, condition, or changes in the individual to solve the problem. The overarching goal of this method is to prevent the problem from reoccurring and the solution from interfering with the individual’s functioning. Problem management must minimally disrupt the social system of the patient or client.

A social norms approach focuses on peer influences to provide individuals with accurate information and role models to induce change (Bruhn and Rebach 2007). This approach observes macro, meso, and micro levels of analysis. Intervention centers on providing correct perceptions about thinking and behavior to induce change in one’s thoughts and actions. This technique is a proactive prevention model aimed at addressing something from happening or arising.

There are three levels of intervention when applying a social norms approach (Bruhn and Rebach 2007). Practitioners use interventions independently or together for a comprehensive solution. At the universal level of intervention , all members of a population receive the intervention without identifying which individuals are at risk. A selective level of intervention directs assistance or services to an entire group of at risk individuals. When specific individuals are beyond risk and already show signs of the problem, they receive an indicated level of intervention . A comprehensive intervention requires an integration of all three levels.

Practitioners assist communities in problem solving by applying a community based approach . All three levels of analysis (macro, meso, and micro) are required for this method. The aim of this approach is to plan, develop, and implement community based interventions whereby local institutions and residents participate in problem solving and work towards preventing future issues. Practitioners work with communities on three outcomes, individual empowerment, connecting people, and improving social interactions and cooperation (Bruhn and Rebach 2007). Concentrating on these outcomes builds on community assets while tailoring solutions to local political, economic, and social conditions. By building bridges among individuals and groups in the community, practitioners facilitate connections between services, programs, and policies while attacking the problem from multiple vantage points.

A community based approach helps ensure problem analysis, evaluation, and interventions are culturally and geographically appropriate for local residents, groups, and organizations. To operate effectively, this intervention requires practitioners to help facilitate face-to-face interactions among community members and develop a communication pattern for solving community problems. To build an appropriate intervention, practitioners must develop knowledge and understanding about the purpose, structure, and process of each group, organization, and collaboration within the community (Bruhn and Rebach 2007). Upon implementation, a community based approach endows local residents and organizations to observe and monitor their own progress and solutions directly.

• Describe the social norms approach and explain what type of social problems or issues this approach is the most valid method to use.
• Describe the community based approach and explain what type of social problem or issues this approach is the most valid method to use.
• Human trafficking prevention program
• Reductions in electronic cigarette, vaping, and new tobacco product usage

• Open access
• Published: 24 August 2021

Problem-solving training as an active ingredient of treatment for youth depression: a scoping review and exploratory meta-analysis

• Karolin R. Krause   ORCID: orcid.org/0000-0003-3914-7272 1 , 2 ,
• Darren B. Courtney   ORCID: orcid.org/0000-0003-1491-0972 1 , 3 ,
• Benjamin W. C. Chan 4 ,
• Sarah Bonato   ORCID: orcid.org/0000-0002-5174-0047 1 ,
• Madison Aitken   ORCID: orcid.org/0000-0002-4921-5462 1 , 3 ,
• Jacqueline Relihan 1 ,
• Matthew Prebeg 1 ,
• Karleigh Darnay   ORCID: orcid.org/0000-0002-0395-8674 1 ,
• Lisa D. Hawke   ORCID: orcid.org/0000-0003-1108-9453 1 , 3 ,
• Priya Watson   ORCID: orcid.org/0000-0001-9753-6490 1 , 3 &
• Peter Szatmari   ORCID: orcid.org/0000-0002-4535-115X 1 , 3 , 5  

BMC Psychiatry volume  21 , Article number:  397 ( 2021 ) Cite this article

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Problem-solving training is a common ingredient of evidence-based therapies for youth depression and has shown effectiveness as a versatile stand-alone intervention in adults. This scoping review provided a first overview of the evidence supporting problem solving as a mechanism for treating depression in youth aged 14 to 24 years.

Five bibliographic databases (APA PsycINFO, CINAHL, Embase, MEDLINE, Web of Science) and the grey literature were systematically searched for controlled trials of stand-alone problem-solving therapy; secondary analyses of trial data exploring problem-solving-related concepts as predictors, moderators, or mediators of treatment response within broader therapies; and clinical practice guidelines for youth depression. Following the scoping review, an exploratory meta-analysis examined the overall effectiveness of stand-alone problem-solving therapy.

Inclusion criteria were met by four randomized trials of problem-solving therapy (524 participants); four secondary analyses of problem-solving-related concepts as predictors, moderators, or mediators; and 23 practice guidelines. The only clinical trial rated as having a low risk of bias found problem-solving training helped youth solve personal problems but was not significantly more effective than the control at reducing emotional symptoms. An exploratory meta-analysis showed a small and non-significant effect on self-reported depression or emotional symptoms (Hedges’ g = − 0.34; 95% CI: − 0.92 to 0.23) with high heterogeneity. Removing one study at high risk of bias led to a decrease in effect size and heterogeneity (g = − 0.08; 95% CI: − 0.26 to 0.10). A GRADE appraisal suggested a low overall quality of the evidence. Tentative evidence from secondary analyses suggested problem-solving training might enhance outcomes in cognitive-behavioural therapy and family therapy, but dedicated dismantling studies are needed to corroborate these findings. Clinical practice guidelines did not recommend problem-solving training as a stand-alone treatment for youth depression, but five mentioned it as a treatment ingredient.

Conclusions

On its own, problem-solving training may be beneficial for helping youth solve personal challenges, but it may not measurably reduce depressive symptoms. Youth experiencing elevated depressive symptoms may require more comprehensive psychotherapeutic support alongside problem-solving training. High-quality studies are needed to examine the effectiveness of problem-solving training as a stand-alone approach and as a treatment ingredient.

Peer Review reports

Depressive disorders are a common mental health concern in adolescence [ 1 , 2 , 3 ] and associated with functional impairment [ 4 ] and an increased risk of adverse mental health, physical health, and socio-economic outcomes in adulthood [ 5 , 6 , 7 , 8 ]. Early and effective intervention is needed to reduce the burden arising from early-onset depression. Several psychotherapies have proven modestly effective at reducing youth depression, including cognitive-behavioural therapy (CBT) and interpersonal therapy (IPT) [ 9 , 10 ]. Room for improvement remains; around half of youth do not show measurable symptom reduction after an average of 30 weeks of routine clinical care for depression or anxiety [ 11 ]. One barrier to greater impact is a lack of understanding of which treatment ingredients are most critical [ 12 , 13 ]. Identifying the “active ingredients” that underpin effective approaches, and understanding when and for whom they are most effective is an important avenue for enhancing impact [ 13 ]. Distilling interventions to their most effective ingredients while removing redundant content may also help reduce treatment length and cost, freeing up resources to expand service provision. Given that youth frequently drop out of treatment early [ 14 ], introducing the most effective ingredients at the start may also help improve outcomes.

One common ingredient in the treatment of youth depression is problem-solving (PS) training [ 15 ]. Problem solving in real-life contexts (also called social problem solving) describes “the self-directed process by which individuals attempt to identify [ …] adaptive coping solutions for problems, both acute and chronic, that they encounter in everyday living” (p.8) [ 16 ]. Within a relational/problem-solving model of stress and well-being, mental health difficulties are viewed as the result of maladaptive coping behaviours that cannot adequately safeguard an individual’s well-being against chronic or acute stressors [ 17 ]. According to a conceptual model developed by D’Zurilla and colleagues ([ 16 , 17 , 18 , 19 ]; see Fig.  1 ), effective PS requires a constructive and confident attitude towards problems (i.e., a positive problem orientation ), and the ability to approach problems rationally and systematically (i.e., rational PS style ). Defeatist or catastrophizing attitudes (i.e., a negative problem orientation ), passively waiting for problems to resolve (i.e., avoidant style ), or acting impulsively without thinking through possible consequences and alternative solutions (i.e., impulsive/careless style ) are considered maladaptive [ 16 , 18 , 20 ]. Empirical studies suggest maladaptive PS is associated with depressive symptoms in adolescents and young adults [ 21 , 22 , 23 , 24 , 25 ].

Dimensions of Problem-Solving (PS) Ability

Problem-Solving Therapy (PST) is a therapeutic approach developed by D’Zurilla and Goldfried [ 26 ] in the 1970s, to alleviate mental health difficulties by improving PS ability. Conceptually rooted in Social Learning Theory [ 27 ], PST aims to promote adaptive PS by helping clients foster an optimistic and self-confident attitude towards problems (i.e., a positive problem orientation), and by helping them develop and internalize four core PS skills: (a) defining the problem; (b) brainstorming possible solutions; (c) appraising solutions and selecting the most promising one; (d) implementing the preferred solution and reflecting on the outcome ([ 16 , 17 , 18 , 19 ]; see Fig. 1 ). PST is distinct from Solution-Focused Brief Therapy (SFBT), which has different conceptual roots and emphasizes the construction of solutions over the in-depth formulation of problems [ 28 ].

PS training is also a common ingredient of other psychosocial depression treatments [ 15 , 20 ], such as CBT and Dialectical Behaviour Therapy (DBT) [ 15 , 29 , 30 , 31 , 32 ] that typically focus on strengthening PS skills rather than problem orientation [ 20 ]. In IPT, PS training focuses on helping youth understand and resolve relationship problems [ 29 , 30 , 33 , 34 ]. PS training is also a common component of family therapy [ 35 ], cognitive reminiscence therapy [ 36 ], and adventure therapy [ 37 ]. The extent to which PS training in these contexts follows the conceptual model by D’Zurilla and colleagues varies. Hereafter, we will use the term PST (“Problem-Solving Therapy”) where problem-solving training constitutes a stand-alone intervention; and we will use the term “PS training” where it is mentioned as a part of other therapies or discussed more broadly as an active ingredient of treatment for youth depression.

Meta-analyses considering over 30 randomized control trials (RCTs) of stand-alone PST for adult depression suggest it is as effective as CBT and IPT, and more effective than waitlist or attention controls [ 38 , 39 , 40 ]. PST has been applied with children, adolescents, and young adults [ 41 , 42 , 43 , 44 , 45 , 46 ], but dedicated manuals for different developmental stages are not readily available. In an assessment of fit between evidence-based therapy components and everyday coping skills used by school children, PS skills were the third most frequently endorsed skill set in terms of frequency of habitual use and perceived effectiveness, suggesting these skills are highly transferable and relevant to youth [ 47 ]. PS training can be brief (i.e., involve fewer than 10 sessions) [ 38 ], and has been delivered to youth by trained clinicians [ 45 ], lay counsellors [ 46 ], and via online platforms [ 44 ]. It can also be adapted for primary care [ 40 ]. In light of its versatility and of its effectiveness in adults, PS training is a prime candidate for a treatment ingredient that deserves greater scrutiny in the context of youth depression. However, no systematic evidence synthesis has yet examined its efficacy and effectiveness in this population.

This study had two sequential parts. First, we conducted a mixed-methods scoping review to map the available evidence relating to PS training as an active ingredient for treating youth depression. Youth were defined as aged 14 to 24 years, broadly aligning with United Nations definitions [ 48 ]. In a subsequent step, we conducted an exploratory meta-analysis to examine the overall efficacy of free-standing PST, based on clinical trials identified in the scoping review.

Scoping review

Scoping review methodology was used to provide an initial overview of the available evidence [ 49 ]. The review was pre-registered on the Open Science Framework [ 50 ] and adhered to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) extension for Scoping Reviews checklist [ 51 ] (Additional File  1 ). The review was designed to integrate four types of literature: (a) qualitative studies reporting on young people’s experiences with PS training; (b) controlled clinical trials testing the efficacy of stand-alone PST; (c) studies examining PS-related concepts as predictors, moderators, or mediators of treatment response within broader therapeutic interventions (e.g., CBT); and (d) clinical practice guidelines (CPGs) for youth depression. In addition, the search strategy included terms designed to identify relevant conceptual articles that are discussed here as part of the introduction [ 52 ].

Search strategy

Five bibliographic databases (APA PsycINFO, CINAHL, Embase, MEDLINE, Web of Science) and the grey literature were systematically searched for (a) empirical studies published from database inception through June 2020, and (b) CPGs published between 2005 and July 2020. Reference lists of key studies were searched manually, and records citing key studies were searched using Google Scholar’s “search within citing articles” function [ 52 ]. The search strategy was designed in collaboration with a research librarian (SB) and combined topic-specific terms defining the target population (e.g., “depression”; “adolescent?”) and intervention (e.g., “problem-solving”) with methodological search filters combining database-specific subject headings (e.g., “randomized controlled trial”) and recommended search terms. The search for CPGs built upon a previous systematic search [ 53 , 54 ], which was updated and expanded to cover additional languages and databases. A multi-pronged grey literature search retrieved records from common grey literature databases and CPG repositories, websites of relevant associations, charities, and government agencies. The search strategy is provided in Additional File  2 .

Inclusion and exclusion criteria

Empirical studies were included if the mean participant age fell within the eligible range of 14 to 24 years, and at least 50% of participants showed above-threshold depressive or emotional symptoms on a validated screening tool. Controlled clinical trials had to compare the efficacy or effectiveness of PST as a free-standing intervention with a control group or waitlist condition. Secondary analyses were considered for their assessment of PS ability as a predictor, moderator, or mediator of treatment response if they reported on data from controlled clinical trials of broader therapy packages. Records were included as CPGs if labelled as practice guidelines, practice parameters, or consensus or expert committee recommendations, or explicitly aimed to develop original clinical guidance [ 53 , 54 ]; and if focused on indicated psychosocial treatments for youth depression (rather than prevention, screening, or pharmacological treatment). Doctoral dissertations were included. Conference abstracts, non-controlled trials, and prevention studies were excluded. Language of publication was restricted to English, French, German, and Spanish.

All records identified were imported into the EPPI-Reviewer 4.0 review software [ 55 ], and underwent a two-stage screening process (Fig.  2 ). Title and abstract screening was conducted in duplicate for 10% of the identified records, yielding substantial inter-rater agreement ( kappa  = .75 and .86, for empirical studies and CPGs, respectively). Of studies retained for full text screening, 20% were screened in duplicate, yielding substantial agreement ( kappa  = .68 and .71, for empirical studies and CPGs, respectively). Disagreements were resolved through discussion.

PRISMA Flow Chart of the Study Selection Process

Data extraction and synthesis

Data were extracted using templates tailored to each literature type (e.g., the Cochrane data collection form for RCTs). Information extracted included: citation details; study design; participant characteristics; and relevant qualitative or quantitative results. Additional information extracted from CPGs included the issuing authority, the target population, the treatment settings to which the guideline applied, and any recommendations in relation to PS training. Data from clinical trials and secondary analyses were extracted in duplicate, and any discrepancies were discussed and resolved. Data synthesis followed a five-step process of data reduction, display, comparison, conclusion drawing, and verification [ 56 ]. Scoping review findings were summarized in narrative format. In addition, effect sizes reported in PST trials for depression severity were entered into an exploratory meta-analysis (see below).

The Centre for Addiction and Mental Health (CAMH) implements a Youth Engagement Initiative that brings the voices of youth with lived experience of mental health difficulties into research and service design [ 57 , 58 , 59 ]. Two youth partners were co-investigators in this review and consulted with a panel of twelve CAMH youth advisors to inform the review process and help contextualize findings. Formal approval by a Research Ethics Board (REB) was not required, as youth were research partners rather than participants.

To incorporate a variety of perspectives, the review team convened for an inference workshop where emerging review findings and feedback from youth advisors were discussed and interpreted. The multidisciplinary team involved a methodologist; two child and adolescent psychiatrists with expertise in CBT, DBT, and IPT; a psychologist with expertise in parent-adolescent therapy; a research librarian; a family doctor; a biostatistician; a clinical epidemiologist; two youth research partners; and a youth engagement coordinator.

Exploratory Meta-analysis

Although meta-analyses are not typical components of scoping reviews [ 60 ], an exploratory meta-analysis was conducted following completion of the scoping review and narrative synthesis, to obtain an initial indication of the efficacy of stand-alone PST based on the clinical trials identified in the review. The PICO statement that guided the meta-analysis is shown in Table  1 .

Quality assessment

Risk of bias for included PST trials was appraised using the Cochrane Collaborations Risk of Bias (ROB) 2 tool [ 61 ]. Ratings were performed independently by two reviewers (KRK and MA), and consensus was formed through discussion. In addition, a Grading of Recommendations Assessment, Development, and Evaluation (GRADE) appraisal was conducted (using the GRADEpro software; [ 62 ] to characterize the quality of the overall evidence. The evidence was graded for risk of bias, imprecision, indirectness, inconsistency, and publication bias [ 63 ]. A GRADE of “high quality” indicates a high level of confidence that the true effect lies close to the estimate; “moderate quality” indicates moderate confidence; “low quality” indicates limited confidence; and “very low quality” indicates very little confidence in the estimate. ROB ratings and GRADE appraisal results are provided in Additional File  6 .

Statistical analysis

The meta-analysis was conducted using the meta suite of commands in Stata 16.1. Effect sizes (Hedges’ g) and their confidence intervals were calculated based on the mean difference in depression severity scores between the PST and control conditions at the first post-treatment assessment [ 64 ]. Hedges’ g is calculated by subtracting the post-treatment mean score of the intervention group from the score of the control group, and by dividing the mean difference by the pooled standard deviation. Effect sizes between g = 0.2 and 0.5 indicate a small effect; g = 0.5 to 0.8 indicates a moderate effect; and g ≥ 0.8 indicates a large effect. Effect sizes were adjusted using the Hedges and Olkin small sample correction [ 64 ]. Pooled effect sizes were computed using a random effects model to account for heterogeneity in intervention settings, modes of delivery, and participant age and depression severity. The I 2 statistic was computed as an indicator of effect size heterogeneity. Higgins et al. [ 65 ] suggest that an I 2 below 30% represents low heterogeneity while an I 2 above 75% represents substantial heterogeneity. Investigations of heterogeneity are unlikely to generate valuable insights in small study samples, with at least ten studies recommended for meta-regression [ 65 ]. We conducted limited exploratory subgroup analysis by computing a separate effect size after excluding studies with high risk of bias. We inspected the funnel plot and considered conducting Egger’s test to examine the likelihood and extent of publication bias [ 66 ].

Selection and inclusion of studies

The search for empirical studies identified 563 unique records (Fig. 2 ), of which 148 were screened in full. Inclusion criteria were met by four RCTs of free-standing PST and four secondary analyses of clinical trials investigating PS-related concepts as predictors, mediators, or moderators of treatment response. No eligible qualitative studies that explicitly examined youth experiences of PS training were identified. The search for CPGs identified 9691 unique records, of which 41 were subject to full text screening, and 23 were included in the review. Below we present scoping review findings for all literature types, followed by the results from the meta-analysis for stand-alone PST trials.

Clinical trials of PST

Characteristics of the included PST trials are shown in Table  2 . Studies were published between 2008 and 2020 and included 524 participants (range: 45 to 251), with a mean age of 16.7 years (range: 12–25; 48% female). Participants had a diagnosis of major depressive disorder (MDD; k  = 1), elevated anxiety or depressive symptoms ( k  = 1), or various mild presenting problems including depression ( k  = 2). Treatment covered PS skills but not problem orientation (i.e., youth’s problem appraisals) and was delivered face to face ( k =  3) or online ( k  = 1) in five to six sessions. PST was compared with waitlist controls ( k  = 2), PS booklets ( k =  1), and supportive counselling ( k  = 1). Risk of bias was rated as medium for two [ 44 , 45 ], and high for one study [ 43 ] due to concerns about missing outcome data and the absence of a study protocol.

Eskin and colleagues [ 43 ] randomized 53 Turkish high school and university students with MDD to six sessions of PST or a waitlist. The study reports a significant treatment effect on self-reported depressive symptoms (d = − 1.20; F [1, 42] = 10.3, p  < .01.), clinician-reported depressive symptoms (d = − 2.12; F [1, 42] = 37.7, p  < .001), and recovery rates, but not on self-reported PS ability (d = − 0.46; F [1, 42] = 2.2, p  > .05). Risk of bias was rated as high due to 37% of missing outcome data in the control group and the absence of a published trial protocol.

Michelson and colleagues [ 46 ] compared PST delivered by lay counsellors in combination with booklets, to PS booklets alone in 251 high-school students with mild mental health difficulties (53% emotional problems) in low-income communities in New Delhi, India. At six weeks, the intervention group showed significantly greater progress towards overcoming idiographic priority problems identified at baseline (d = 0.36, p  = .002), but no significant difference in self-reported mental health difficulties (d = 0.16, p  = .18). Results were similar at 12 weeks, including no significant difference in self-reported emotional symptoms (d = 0.18, p  = .089). As there was no long-term follow-up, it is unknown whether reduced personal problems translated into reduced emotional symptoms in the longer term. Perceived stress at six weeks was found to mediate treatment effect on idiographic problems, accounting for 15% of the overall effect at 12 weeks.

Two trials found no significant effect of PST on primary or secondary outcomes: Hoek and colleagues [ 44 ] randomized 45 youth with elevated depression or anxiety symptoms to five sessions of online PST or a waitlist control; Parker and colleagues [ 45 ] randomized 176 youth with mixed presenting problems (54% depression) to either PST with physical activity or PST with psychoeducation, compared with supportive counselling with physical activity or psychoeducation [ 45 ]. Drop-out from PST was high in both studies, ranging from 41.4% [ 45 ] to 72.7% [ 44 ].

PS-related concepts as predictors, moderators, or mediators of treatment response

The review identified four secondary analyses of RCT data that examined PS-related concepts as predictors, moderators, or mediators of treatment response (see Table  3 , below). Studies were published between 2005 and 2014 and included data from 761 participants with MDD diagnoses, and a mean age of 15.2 years (range: 12–18; 61.2% female).

A secondary analysis of data from the Treatment for Adolescents with Depression Study (TADS, n  = 439) [ 79 ] explored whether baseline problem orientation and PS styles were significant predictors or moderators of treatment response to Fluoxetine, CBT, or a combination treatment at 12 weeks [ 70 ]. Negative problem orientation and avoidant PS style each predicted less improvement in depression symptom severity ( p  = .001 and p  = .003, respectively), while positive problem orientation predicted greater improvement ( p  = .002). There was no significant moderation effect. Neither rational PS style nor impulsive-careless PS style predicted or moderated change in depressive symptoms.

A secondary analysis of data from the Treatment of Resistant Depression in Adolescents (TORDIA) study [ 80 ] examined the impact of specific CBT components on treatment response at 12 weeks in youth treated with a selective serotonin reuptake inhibitor (SSRI) in combination with CBT ( n  = 166) [ 71 ]. Youth who received PS training were 2.3 times ( p  = .03) more likely to have a positive treatment response than those not receiving this component. A significant effect was also observed for social skills training (Odds Ratio [OR] = 2.6, p  = .04) but not for seven other CBT components. PS and social skills training had the most equal allocation ratios between youth who received them (52 and 54%, respectively) and youth who did not. Balanced allocation provides maximum power for a given sample size [ 81 ]. With allocation ratios between 1:3 and 1:5, analysis of the remaining seven components may have been underpowered. Of further note, CBT components were not randomly assigned but selected based on individual clinical needs. The authors did not correct for multiple comparisons as part of this exploratory analysis.

Dietz and colleagues [ 73 ] explored the impact of social problem solving on treatment outcome based on data from a trial comparing CBT and Systemic Behaviour Family Therapy (SBFT) with elements of PS training on the one hand, with Non-Directive Supportive Therapy on the other hand ( n  = 63). Both CBT and SBFT were associated with significant improvements in young people’s interpersonal PS behaviour (measured by coding videotaped interactions between youth and their mothers) over the course of treatment (CBT: b* = 0.41, p  = .006; SBFT: b* = 0.30, p  = .04), which in turn were associated with higher rates of remission (Wald z = 6.11, p  = .01). However, there was no significant indirect effect of treatment condition via youth PS behaviour, and hence, no definitive evidence of a formal mediation effect [ 82 ].

Kaufman and colleagues [ 72 ] examined data from a trial comparing an Adolescent Coping with Depression (CWD-A) group-based intervention with a life-skills control condition in 93 youth with comorbid depression and conduct disorder. The secondary analysis explored whether change in six CBT-specific factors, including the use of PS and conflict resolution skills, mediated the effectiveness of CWD-A. There was no significant improvement in PS ability in CWD-A, compared with the control, and hence no further mediation analysis was conducted.

PS training in clinical practice guidelines

We identified 23 CPGs from twelve countries relevant to youth depression (see Additional File  4 ), issued by governments ( k  = 6), specialty societies ( k  = 3), health care providers ( k  = 4), independent expert groups ( k  = 2), and others, or a combination of these. Of these 23 CPGs, 15 mentioned PS training in relation to depression treatment for youth, as a component of CBT ( k  = 7), IPT ( k  = 4), supportive therapy or counselling ( k  = 3), family therapy ( k  = 1), DBT ( k  = 1), and psychoeducation ( k  = 1).

None of the reviewed CPGs recommended free-standing PST as a first-line treatment for youth depression. However, five CPGs mentioned PS training as a treatment ingredient or adjunct component in the context of recommending broader therapeutic approaches. The World Health Organization’s updated Mental Health Gap Action Programme guidelines recommended PS training as an adjunct treatment (e.g., in combination with antidepressant medication) for older adolescents [ 83 ]. A guideline by Orygen (Australia) suggested that for “persistent sub-threshold depressive symptoms (including dysthymia) or mild to moderate depression”, options should include “6–8 sessions of individual guided self-help based on the principles of CBT, including behavioural activation and problem-solving techniques” [ 84 ]. The Chilean Ministry of Health recommended supportive clinical care with adjunctive psychoeducation and PS tools, or supportive counselling for individuals aged 15 and older with mild depression (p. 52) [ 85 ]. The Cincinnati Children’s Hospital Medical Centre recommended four to eight sessions of supportive therapy for mild or uncomplicated depression, highlighting “problem solving coping skills” as one element of supportive therapy (p. 1) [ 86 ]. Fifth, the American Academy of Child and Adolescent Psychiatry’s 2007 practice parameter suggested each phase of treatment for youth depression should include psychoeducation and supportive management, which might include PS training (p. 1510) [ 87 ]. CPGs did not specify whether PS training should incorporate specific modules, or whether the term was used loosely to describe unstructured PS support.

Meta-analysis

Each of the four RCTs of free-standing PST identified by the scoping review contributed one comparison to the exploratory meta-analysis of overall PST efficacy (see Fig.  3 ). Self-rated depression or emotional symptom severity scores were reported by all four studies and constituted the primary outcome for the meta-analysis. We conducted additional exploratory analysis for clinician-rated depression severity as reported in two studies [ 43 , 45 ]. The pooled effect size for self-reported depression severity was g = − 0.34 (95% CI: − 0.92 to 0.23). Heterogeneity was high ( I 2  = 88.37%; p  < .001). Due to the small number of studies included, analysis of publication bias via an examination of the funnel plot and tests of funnel plot asymmetry could not be meaningfully conducted [ 88 , 89 ]. The funnel plot is provided in Additional File  5 for reference (Fig. S3).

Forest Plot: Random Effects Model with Self-Reported Depression or Emotional Symptoms as Primary Outcome (Continuous)

To achieve the best possible estimate of the true effect size and reduce heterogeneity we computed a second model excluding the one study with high risk of bias (i.e., [ 43 ]). The resulting effect size was g = − 0.08 (95% CI: − 0.26 to 0.10), with no significant heterogeneity ( I 2  = 0.00%; p  = 0.72; see Fig. S1 in Additional File 5 ). The pooled effect size for clinician-rated depression severity was g = − 1.39 with a wide confidence interval (95% CI: − 4.03 to 1.42) and very high heterogeneity ( I 2  = 97.41%, p  < 0.001; see Fig. S2 in Additional File 5 ).

Overall quality of the evidence

According to the GRADE assessment, the overall quality of the evidence was very low, with concerns related to risk of bias, the inconsistency of results across studies, the indirectness of the evidence with regards to the population of interest (i.e., only one trial focused exclusively on youth with depression), and imprecision in the effect estimate (Table S4 in Additional File 6 ).

This scoping review aimed to provide a first comprehensive overview of the evidence relating to PS training as an active ingredient for treating youth depression. The evidence base relating to the efficacy of PST as a stand-alone intervention was scarce and of low quality. Overall, data from four trials suggested no significant effect on depression symptoms. The scoping review identified some evidence suggesting PS training may enhance treatment response in CBT. However, this conclusion was drawn from secondary analyses where youth were not randomized to treatment with and without PS training, and where primary studies were not powered to test these differences. Disproportionate exposure to comparator CBT components also limits these findings. PST was not recommended as a stand-alone treatment for youth depression in any of the 23 reviewed CPGs; however, one guideline suggested it could be provided alongside other treatments for older adolescents, and four suggested PS training as a component of low-intensity psychosocial interventions for youth with mild to moderate depression.

Given the limited evidence base, only tentative suggestions can be made as to when and for whom PS training is effective. The one PST trial with a low risk of bias enrolled high-school students from low-income communities in New Delhi, and found that PST delivered by lay counselors in combination with PST booklets was more effective at reducing idiographic priority problems than booklets alone, but not at reducing mental health symptoms [ 46 ]. Within a needs-based framework of service delivery (e.g., [ 90 ]), PST may be offered as a low-intensity intervention to youth who experience challenges and struggle with PS—including in low-resource contexts. Future research could explore whether PS training might be particularly helpful for youth facing socioeconomic hardship and related chronic stressors by attenuating potentially harmful impacts on well-being [ 91 ]. If findings are promising, PS training may be considered for targeted prevention (e.g., [ 42 ]). However, at this time there is insufficient evidence to support PS training on its own as an intervention aimed at providing symptom relief for youth experiencing depression.

The PST manual suggests cognitive overload, emotional dysregulation, negative thinking and hopelessness can interfere with PS [ 16 ]. Youth whose depression hinders their ability to engage in PST may require additional support through more comprehensive therapy packages such as CBT or IPT with PS training. In the TORDIA study [ 80 ], where PS training was found to be one of the most effective components, it was generally taught alongside cognitive restructuring, behavioural activation, and emotion regulation, which may have facilitated youths’ ability to absorb PS training [ 71 ]. The focus of these other CBT components on changing negative cognitions and attributions may fulfil a similar function as problem orientation modules in stand-alone PST. Research that is powered to explore such mechanisms is needed. Future research should also apply methodologies designed to identify the most critical elements in a larger treatment package (e.g., dismantling studies; or sequential, multiple assignment, randomized trials) to examine the role of PS training when delivered alongside other components. While one trial focusing on CBT components is currently underway [ 92 ], similar research is needed for other therapies (e.g., IPT, DBT, family therapy).

The included PST trials provided between five and six sessions and covered PS skills but not problem orientation. Meta-analyses of PST for adult depression suggest treatment effectiveness may be enhanced by longer treatment duration (≥ 10 sessions) [ 38 ], and coverage of problem orientation alongside PS skills [ 39 ]. As per the PST treatment manual, strengthening problem orientation fosters motivation and self-efficacy and is an important precondition for enhancing skills [ 93 , 94 ]. In addition, only one youth PST trial assessed PS ability at baseline [ 43 ]. A meta-analysis of PST for adult depression [ 39 ] suggests that studies including such assessments show larger effect sizes, with therapists better able to tailor PST to individual needs. Future research should seek to replicate these findings specifically for youth depression.

Drop out from stand-alone PST was high in two out of four studies, ranging from 41.4% [ 45 ] to 72.7% [ 44 ]. Since its development in the 1970s, PST has undergone several revisions [ 16 , 93 , 95 , 96 , 97 ] but tailoring to youth has been limited. To contextualize the review findings, the review team consulted a panel of twelve youth advisors at the Centre for Addiction and Mental Health (without sharing emerging findings so as not to steer the conversation). Most had participated in PS training as part of other therapies, but none had received formal PST. A key challenge identified by youth advisors was how to provide PS training that is universally applicable and relevant to different youth without being too generic, rigid or schematic; and how to accommodate youth perspectives, complex problems, and individual situations and dispositions. Youth advisors suggested reviewing and reworking PS training with youth in mind, to ensure it is youth-driven, strengths-based, comprehensive, and personalized (see Fig. S4 in Additional File  7 for more detail). Youth advisors emphasized that PS training should identify the root causes underpinning superficial problems and address these through suitable complementary intervention approaches, if needed.

Solution-focused brief therapy (SFBT) has emerged as an antithesis to PST where more emphasis is given to envisaging and constructing solutions rather than analysing problems [ 28 ]. This may be more consistent with youth preferences for strengths-based approaches but may provide insufficiently comprehensive problem appraisals. Future research should compare the effectiveness and acceptability of PST and SFBT and consider possible benefits of combining the advantages of both approaches, to provide support that is strengths-based and targets root problems. More generally, given the effectiveness of PST in adults, future studies could examine whether there are developmental factors that might contribute to reduced effectiveness in youth and should be considered when adapting PST to this age group.

Strengths and limitations

This scoping review applied a broad and systematic approach to study identification and selection. We searched five bibliographic databases, and conducted an extensive grey literature search, considering records published in four languages. Nevertheless, our search may have missed relevant studies published in other languages. We found only a small number of eligible empirical studies, several of which were likely underpowered. As stated above, studies analysing PS-related concepts as predictors, moderators, or mediators of treatment response within broader therapies were heterogenous and limited by design and sample size constraints.

Similarly, there was heterogeneity in recruitment and intervention settings, age groups, and delivery formats across the four RCTs of stand-alone PST, and the overall quality of the evidence was very low. As reflected in our GRADE appraisal, one important limitation was the indirectness of the available evidence: Only one PST trial focused specifically on youth with an MDD diagnosis, while the remaining three included youth with a mix of mental health problems. Although outcomes were reported in terms of depression or emotional symptom severity, this was not based on a subgroup analysis focused specifically on youth with depression. Impact on this group may therefore have been underestimated. In addition, the only PST trial with a low risk of bias did not administer a dedicated depression symptom scale. Instead, our exploratory meta-analysis included scores from the 5-item SDQ emotional problems subscale, which assesses unhappiness, worries, clinginess, fears, and somatic symptoms—and may not have captured nuanced change in depression severity [ 98 , 99 ]. Other concerns that led us to downgrade the quality of the evidence related to considerable risk of bias, with only one out of four studies rated as having a low risk; and imprecision with several studies involving very small samples. Due to the small number of eligible studies, it was not possible to identify the factors driving treatment efficacy via meta-regression. The long-term effectiveness of PS training, or the conditions under which long-term benefits are likely to be realized also could not be examined [ 38 ].

PS training is a core component of several evidence-based therapies for youth depression. However, the evidence base supporting its efficacy as a stand-alone treatment is limited and of low quality. There is tentative evidence suggesting PS-training may drive positive outcomes when provided alongside other treatment components. On its own, PS training may be beneficial for youth who are not acutely distressed or impaired but require support with tackling personal problems. Youth experiencing moderate or severe depressive symptoms may require more comprehensive psychotherapeutic support alongside PS training, as there is currently no robust evidence for the ability of free-standing PST to effectively reduce depression symptoms.

High-quality trials are needed that assess PST efficacy in youth with mild, moderate, and severe depression, in relation to both symptom severity and idiographic treatment goals or priority problems. These studies should examine the influence of treatment length and module content on treatment impact. Dedicated studies are also needed to shed light on the role of PS training as an active ingredient of more comprehensive therapies such as CBT, DBT, IPT, and family therapy. Future studies should include assessments of adverse events and of cost effectiveness. Given high drop-out rates in several youth PST trials, it is important to adapt PS training approaches and therapy manuals as needed, following a youth-engaged research and service development approach [ 57 ], to ensure their relevance and acceptability to this age group.

Availability of data and materials

All data generated or analysed during this study are included in this published article and its supplementary information files.

Abbreviations

Avoidance style

Beck Depression Inventory

Centre for Addiction and Mental Health

Cognitive behavioural therapy

Children’s Depression Rating Scale—Revised

Center for Epidemiologic Studies Depression Scale

Clinical Global Impression Scale—Improvement

Cumulative Index to Nursing and Allied Health Literature

Clinical practice guideline

Adolescent Coping with Depression [intervention name]

Dialectical behaviour therapy

Grading of Recommendations Assessment, Development, and Evaluation

Impulsivity/Carelessness Style

Interpersonal psychotherapy

The Kiddie Schedule for Affective Disorders and Schizophrenia

Lifeskills training

Major depressive disorder

Medical Literature Analysis and Retrieval System Online

Negative problem orientation

Nondirective supportive therapy

Positive problem orientation

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

• Problem solving

Problem-solving training

Problem-Solving Therapy

Randomized controlled trial

Research ethics board

Risk of bias

Rational problem-solving style

Systemic Behaviour Family Therapy

Strengths and Difficulties Questionnaire

Solution-Focused Brief Therapy

Social Problem-Solving Inventory Revised

Selective serotonin reuptake inhibitors

Treatment for Adolescents with Depression Study

Treatment of Resistant Depression in Adolescents

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Acknowledgments

We would like to thank the members of the Centre for Addiction and Mental Health (CAMH) youth advisory group for their valuable insights and suggestions. The systematic search for clinical practice guidelines presented in this review was based on a search strategy developed by Dr. Kathryn Bennett. We would like to thank Dr. Bennett for agreeing to the reuse of the strategy as part of this review. We would also like to thank the Cundill Centre for Child and Youth Depression for providing institutional support to this project.

This work was funded by a Wellcome Trust Mental Health Priority Area “Active Ingredients” commission awarded to KRK, DBC and PS, and the Centre for Addiction and Mental Health, Toronto, Canada.

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Karolin R. Krause, Darren B. Courtney, Sarah Bonato, Madison Aitken, Jacqueline Relihan, Matthew Prebeg, Karleigh Darnay, Lisa D. Hawke, Priya Watson & Peter Szatmari

Evidence Based Practice Unit, University College London and Anna Freud National Centre for Children and Families, London, UK

Karolin R. Krause

Department of Psychiatry, University of Toronto, Toronto, ON, Canada

Darren B. Courtney, Madison Aitken, Lisa D. Hawke, Priya Watson & Peter Szatmari

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Contributions

KRK, DBC and PS formulated the research questions and designed the study. SB conducted the systematic search for clinical practice guidelines and the grey literature search, and advised on the search for retrieving empirical studies, which was led by KRK. KRK, DBC and BWCC performed the screening of records for inclusion criteria. Data extraction was performed by KRK and BWCC. The risk of bias assessment for included randomized control trials was conducted by KRK and MA. The youth consultation was led by JR, MP and KD with input from LDH and KRK. Data analysis was led by KRK. All authors contributed to the interpretation of emerging findings through an internal findings workshop and through several rounds of feedback on the draft manuscript, which was drafted by KRK. All authors have reviewed and approved the final manuscript.

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Correspondence to Karolin R. Krause .

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Supplementary Information

Additional file 1..

Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) Checklist.

Additional file 2.

Search Strategy.

Additional file 3.

List of Studies Included in the Scoping Review.

Additional file 4.

Characteristics of Included Clinical Practice Guidelines.

Additional file 5.

Additional Data and Outputs from the Meta-Analysis.

Additional file 6.

Risk of Bias Assessment and GRADE Appraisal.

Additional file 7.

Illustration of Insights from the Consultation of Youth Advisors.

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Krause, K.R., Courtney, D.B., Chan, B.W.C. et al. Problem-solving training as an active ingredient of treatment for youth depression: a scoping review and exploratory meta-analysis. BMC Psychiatry 21 , 397 (2021). https://doi.org/10.1186/s12888-021-03260-9

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DOI : https://doi.org/10.1186/s12888-021-03260-9

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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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In This Article Expand or collapse the "in this article" section Brief Therapies in Social Work: Task-Centered Model and Solution-Focused Therapy

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Brief Therapies in Social Work: Task-Centered Model and Solution-Focused Therapy by Cynthia Franklin , Krystallynne Mikle LAST REVIEWED: 30 September 2013 LAST MODIFIED: 30 September 2013 DOI: 10.1093/obo/9780195389678-0188

Brief therapies serve as evidenced-based practices that place a strong emphasis on effective, time-limited treatments that aid in resolving clients’ presenting problems. The resources presented in this article summarize for professionals and educators the abundant literature evaluating brief therapies within social work practice. Brief therapies have appeared in many different schools of psychotherapy, and several approaches have also evolved within social work practice, but two approaches—the task-centered model and solution-focused brief therapy (SFBT)—stand out as being grounded in research and have also gained international acclaim as important interventions for implementation and further study. These two approaches are the focus of this bibliography. The task-centered model and SFBT were developed by social work practitioners and researchers for the purposes of making clinical practice more effective, and they share a common bond in hoping to improve the services delivered to clients. Since the development of the task-centered and solution-focused approaches, brief therapies have become essential to the work of all types of psychotherapists and clinicians, and many of the principles and practices of brief therapy that are a part of the task-centered and solution-focused approaches are now essential to psychotherapy training. Clinical social workers practicing from the perspective of the task-centered model and SFBT approaches work from several brief therapy assumptions. The first regards the client/therapist relationship. The best way to help clients is to work within a collaborative relationship to discover options for coping and new behavior that may also lead to specific tasks and solutions for change that are identified by the client. Second is the assumption that change can happen quickly and can be lasting. Third, focus on the past may not be as helpful to most clients as a focus on the present and the future. The fourth regards a pragmatic perspective about where the change occurs. The best approach to practice is pragmatic, and effective practitioners recognize that what happens in a client’s life is more important than what happens in a social worker’s office. The fifth assumption is that change can happen more quickly and be maintained when practitioners utilize the strengths and resources that exist within the client and his or her environment. The next assumption is that a small change made by clients may cause significant and major life changes. The seventh assumption is associated with creating goals. It is important to focus on small, concrete goal construction and helping the client move toward small steps to achieve those goals. The next regards change. Change is viewed as hard work and involves focused effort and commitment from the client and social worker. There will be homework assignments and following through on tasks. Also, it is assumed that it is important to establish and maintain a clear treatment focus (often considered the most important element in brief treatment). Parsimony is also considered to be a guiding principle (i.e., given two equally effective treatments, the one requiring less investment of time and energy is preferable). Last, it is assumed that without evidence to the contrary, the client’s stated problem is taken as the valid focus of treatment. The task-centered model and SFBT have developed a strong empirical base, and both approaches operate from a goal-oriented and strengths perspective. Both approaches have numerous applications and have successfully been used with many different types of clients and practice settings. Both approaches have also been expanded to applications in macro social work that focus on work within management- and community-based practices. For related Oxford Bibliographies entries, see Task-Centered Practice and Solution-Focused Therapy .

Task-Centered Model Literature

The task-centered model is an empirically grounded approach to social work practice that appeared in the mid-1960s at Columbia University and was developed in response to research reports that indicated social work was not effective with clients. William J. Reid was the chief researcher who helped develop this model, and he integrated many therapeutic perspectives to create the task-centered approach, including ideas from behavioral therapies. The task-centered model evolved out of the psychodynamic practice and uses a brief, problem-solving approach to help clients resolve presenting problems. The task-centered model is currently used in clinical social work and group work and may also be applied to other types of social work practice.

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29 Response to Intervention: Conceptual Foundations and Evidence-Based Practices

Frank M. Gresham, Department of Psychology, Louisiana State University, Baton Rouge, LA

• Published: 21 November 2012
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Response to intervention (RTI) is based on the notion of determining whether an adequate or inadequate change in academic or behavioral performance has been accomplished by an intervention. In an RTI approach, decisions regarding changing or intensifying an intervention are based on how well or how poorly a student responds to an evidence-based intervention that is implemented with integrity. RTI is used to make important educational decisions about services for children in schools, including (but not exclusively) special education and related services. RTI has three defining features: (a) delivery of high-quality interventions that are evidence-based, (b) assessment of the rate and level performance using data-based practices, and (c) making important educational decisions about children and youth. RTI typically takes place in a three-tier model that includes universal, selected, and intensive interventions. Two basic approaches to RTI practice are problem solving approaches and standard protocol approaches, with the former approach being emphasized in this chapter. This chapter concludes with a discussion of treatment strengths and how it might be operationalized in the delivery of RTI-based approaches in schools.

Students’ academic and behavioral difficulties are addressed in school settings using a predictable three-stage process of referral, testing, and placement. Historically, school psychologists have engaged in a process whereby they receive referrals from teachers, conduct comprehensive assessments, and make special education eligibility recommendations based on established criteria (Bocian, Beebe, MacMillan, & Gresham, 1999 ). Teacher referrals are based primarily on a student’s performance relative to the modal performance of a given classroom, and thus the guiding principle is one of relativity . The testing stage of this process is based primarily on norm-referenced tests, and the guiding principle is one of acceptability —is the performance acceptable relative to normative standards? Placement recommendations are based on the principle of profitability , which reflects the collective perception that special education services at a given school site will benefit the child.

More often than not, the assessment data used to make these placement recommendations have little, if anything, to do with recommended intervention strategies (Gresham & Witt, 1997 ; Reschly, 2008 ). Despite a longstanding tradition, the “refer–test–place” approach to the identification of students with disabilities has several drawbacks. The procedures used by schools to identify students with learning and/or behavioral difficulties are often confusing, logically inconsistent, and fraught with much “diagnostic error” (Gresham, 2002 ; 2008 ; MacMillan & Siperstein, 2002 ; Ysseldyke & Marston, 1999 ).

There are two different routes whereby children become qualified as being eligible for special education (MacMillan, Gresham, Bocian, & Siperstein, 1997 ). Children qualified via route 1 include children with sensory (deaf or blind), physical (orthopedic), medical (chronic illnesses), or mental (moderate-severe-profound mental retardation) disabilities. The overwhelming majority of these cases are diagnosed by physicians employing medical histories, physical examinations, and laboratory tests to determine the correct diagnosis. Most children with these disabilities are identified prior to school entry (often shortly after birth), and there is little disagreement among medical or educational professionals concerning the validity of the diagnosis. The reason for this high level of agreement is that these children display highly visible or salient characteristics, about which there is little room for disagreement.

Children deemed eligible for special education via route 2 create much consternation and disagreement among educational, psychological, and medical professionals. These children may be identified as having a specific learning disability, mild mental retardation, emotional disturbance, or attention-deficit/hyperactivity disorder. Unlike children with sensory or physical impairments, children with these so-called “mild” or high-incidence disabilities are deemed eligible using procedures that are plagued with much diagnostic error (Gresham, 2008 ). Children functioning around the margin of a disability group create special problems in assessment, measurement, and special education eligibility determination. It is difficult to know the precise point where low academic achievement becomes a “specific learning disability,” or when a behavior problem becomes an “emotional disturbance.” This is because these disabilities are measurement bound, and hence are identified based on the degree of impairment rather than the kind of impairment (e.g., deaf, blind, or orthopedic impairment).

There are two basic types of diagnostic error for high-incidence disabilities: false positive errors and false negative errors . False positive errors (“false alarms”) occur when children are identified as having a disability (e.g., specific learning disability) when in fact they do not have a disability. False negative errors (“misses”) occur when children are not identified as having a disability when in fact they do have a disability. False positive and false negative errors may also occur among various disability categories. For example, children meeting well-established criteria for mild mental retardation may be incorrectly identified as having a specific learning disability. In these cases, two diagnostic errors occur. Failure to identify a child with mental retardation is a false negative error (a “miss”), and instead classifying the child as having a specific learning disability is a false positive error (a “false alarm”).

A typical error in this process occurs when school psychologists attempt to differentiate children with learning disabilities (discrepant low achievers) from students who are “garden-variety” low achievers (nondiscrepant low achievers). In fact, attempts to differentiate learning disabled from discrepant and nondiscrepant low achiever populations are futile, based on a large body of research showing that these children share salient characteristics making them part of the same population (Fletcher, Francis, Shaywitz, Lyon, Foorman, Steubing, et al., 1998 ; Gresham, 2002 ; Gresham, MacMillan, & Bocian, 1996 ; Steubing, Fletcher, LeDoux, Lyon, Shaywitz, & Shaywitz, 2002 ).

Research by Gresham and colleagues suggested that schools frequently do not base their classification and placement decisions on state or district guidelines for high-incidence disabilities of mild mental retardation or specific learning disabilities (Gresham, MacMillan, & Bocian, 1998 ). Numerous interviews of these schools’ placement committees indicated that they were basing their eligibility decisions based on their perceptions of what is best for a given child in terms of educational needs and supports, and not based on some equivocal and arbitrary authoritative definition of a mild disability. Based on these problems with the traditional “refer–test–place” approach, an alternative approach based on response to intervention is recommended.

Response to Intervention: An Alternative Approach

The notion of response to intervention, or RTI, is based on the concept of determining whether an adequate or inadequate change in academic or behavioral performance has been achieved by an intervention (Gresham, 2002 ). In an RTI approach, decisions regarding changing or intensifying an intervention are made based on how well or how poorly a student responds to an evidence-based intervention that is implemented with integrity. RTI logic is used to select and/or modify interventions, based on how the child responds to that intervention. RTI assumes that if a child shows an inadequate or weak response to the best intervention available and feasible within a given setting, then that child can and should be eligible for additional assistance, including special education and related services. RTI is not used exclusively to make special education entitlement decisions, although it can be used for that purpose. RTI is a philosophy of behavior change based on treatment response, rather than diagnostic assessment of unobservable and highly inferential psychological or emotional processes.

RTI logic is not a new concept in other fields. The field of medicine provides a useful example of how physicians use RTI principles in their everyday practice to treat physical problems. Physicians assess weight, blood pressure, and heart rate every time they see a patient, because these three factors are important indicators of general physical health, and have scientifically established benchmarks for typical and atypical functioning. If these weight and blood pressure measurements exceed benchmark criteria, then a physician may recommend that the patient diet, exercise, and quit smoking. The next time the patient sees the physician, these same indicators are measured; if the indicators show no change, then the physician may place the patient on a special diet and exercise regimen, and tell the patient to stop smoking. The next time the patient sees the physician, these same indicators are measured, and if they still show nochange, the physician may put the patient on medication, refer to a dietician, and send the patient to a smoking cessation clinic. Finally, the next time the physician sees the patient, and the same indicator data are in the atypical range, then upon further assessment the patient may require surgery to prevent mortality.

Several important points should be recognized in considering the above example. First, intervention intensity was increased only after the data suggested that the patient showed an inadequate response to intervention. Second, treatment decisions were based on objective data collected continuously over time (data-based decision making). Third, the data that were collected were well-established indicators of general physical health. Finally, decisions about treatment intensity were based on the collection of more and more data, as the patient moved through each stage of treatment intensification. RTI can and should be used in schools in a parallel manner, to make important educational decisions for children and youth.

The concept of RTI can also be found in the experimental analysis of behavior literature that has studied the conditions under which behavior shows “resistance to extinction” (Nevin, 1988 ). Gresham ( 1991 ) applied this literature to the field of behavior disorders in describing how and why certain behaviors are highly resistant to change (i.e., they do not respond to intervention efforts). Using an analogy to Newtonian physics, Nevin ( 1988 ) used the term behavioral momentum to explain a behavior’s resistance to change. That is, a moving body possesses both mass and velocity, and will maintain constant velocity under constant conditions. The velocity of an object will change only in proportion to an external force, and in inverse proportion to its mass. Considering the momentum metaphor, an effective intervention (“force”) will result in a high level of momentum (“responsiveness”) for the behavior in question.

For example, an intervention designed to decrease rates of disruptive and oppositional behavior in a classroom would be considered successful if it rapidly decreased these problem behaviors, and reliably, during intervention, and if these behavioral decreases persisted after the intervention was withdrawn. In contrast, if disruptive and oppositional behaviors returned to baseline levels after the intervention was withdrawn, teachers would not be satisfied with the intervention no matter how well the student behaved during intervention. Many behaviors are highly resistant to intervention efforts, and therefore require strong and consistent applications of powerful interventions (i.e., those with a large amount of “force”).

Evolution of the RTI Concept

The historical basis of RTI, at least in special education, can be traced to the National Research Council (NRC) report (Heller, Holtzman, & Messick, 1982 ) in which the validity of the special education classification system was evaluated on the basis of three criteria: (a) the quality of the general education program, (b) the value of the special education program in producing important outcomes for students, and (c) the accuracy and meaningfulness of the assessment process in the identification of disability. Vaughn and Fuchs ( 2003 ) suggested that the first two criteria emphasized the quality of instruction, whereas the third criterion involved judgments of the quality of instructional environments, and the student’s response to instruction delivered in those environments. The third criterion described in the NRC Report is consistent with Messick’s ( 1995 ) notion of evidential and consequential bases of test use and interpretation . That is, there must be evidential and consequential bases for using and interpreting tests in a certain way. If these bases do not exist, then we may conclude that there is insufficient evidence for the validity of a given assessment procedure.

An important aspect in the evolution of the RTI concept is the notion of treatment validity (sometimes called treatment utility of assessment ). Treatment validity can be defined as the extent to which any assessment procedure contributes to beneficial outcomes for individuals (Cone, 1989 ; Fuchs & Fuchs, 1998 ; Hayes, Nelson, & Jarrett, 1987 ). A central feature of treatment validity is that there must be a clear and unambiguous relationship between the assessment data collected and the recommended intervention.

For any assessment procedure to have treatment validity, it must lead to the identification of relevant areas of concern (academic or behavioral), inform treatment planning, and be useful in evaluating treatment outcomes. Traditionally, many assessment procedures in school psychology have failed to demonstrate treatment validity because they do not inform instructional or behavioral intervention practices (Cronbach, 1975 ; Gresham, 2002 ; Gresham & Witt, 1997 ; Reschly, 2008 ). The concept of RTI depends largely on the treatment validity of measures used to determine adequate or inadequate treatment response. In short, assessment procedures having treatment validity not only inform the selection of intervention procedures, they also are used to evaluate treatment outcomes.

The RTI concept further evolved as a viable alternative to the IQ–achievement discrepancy approach to identifying learning disabilities from the LD Initiative, which was a working group meeting held in Washington, D.C. and sponsored by the Office of Special Education Programs in May, 1999. Based on the LD Initiative, a national conference was held in Washington, D.C. in August, 2001, entitled the LD Summit . Nine white papers were written and presented over a 2-day period to a group of LD professionals and stakeholders from all over the United States. One paper (Gresham, 2002 ) specifically addressed the literature on responsiveness to intervention that was responded to by four well-known professionals in the field of LD (Fuchs, 2002 ; Grimes, 2002 ; Vaughn, 2002 ; Vellutino, 2002 ). Gresham’s paper argued that a student’s inadequate response to an empirically validated intervention, implemented with integrity, can and should be used as evidence of the presence of LD, and should be used in eligibility decisions. RTI was viewed as a viable and superior alternative to defining LD on the basis of IQ–achievement discrepancy approaches, which have a myriad of conceptual and measurement difficulties.

Subsequent to the LD Summit, the President’s Commission on Excellence in Special Education (2002) emphasized RTI as a viable alternative to IQ–achievement discrepancy in the identification of LD. In December, 2004, President Bush signed into law the reauthorization of the Individuals with Disabilities Education Improvement Act (IDEIA, 2004 ). The law states that a child may be determined to have a specific learning disability based on how that child responds to a scientific, research based intervention or RTI.

Features of RTI

RTI involves the provision of high quality interventions matched to student need, frequent progress monitoring to guide decisions about changes in interventions, and using student data to guide important educational decisions. RTI models have three defining characteristics: (a) delivery of high quality interventions that are evidence based, (b) rate and level of performance, and (c) important educational decisions. High quality interventions are those that are matched to student need, scientifically based, and individually based. Rate and level of student performance involves the assessment of the rate of change in behavior over time, the relative standing of student behavior on important academic or behavioral dimensions, and data-based decision making on student response to interventions. Important educational decisions are those that are based on student response to intervention across multiple tiers of intervention, differing in intensity. These decisions might be made about changes in the intensity of intervention, special education eligibility, and/or exiting special education (Gresham, 2002 , 2006 ).

The effectiveness of schoolbased interventions is based on several interrelated factors that must be considered in the design, implementation, and evaluation process. It is unfortunate that some school based professionals engage in a fruitless search for “silver bullet” interventions that will be universally effective with all students, will work every time, will be easy to implement, and will maintain their effectiveness over a long period of time. Such interventions do not exist. Interventions implemented in schools often do not enjoy empirical support, and are chosen for reasons such as personal appeal, popularity, acceptability, and/or ease of implementation rather than research supporting their use.

The following medical analogy illustrates the above logic. If surgeons adopted a procedure that has a 20% mortality rate over one that has a 10% mortality rate because: (a) it is easier to do, (b) the surgeon was trained in it, and (c) the surgeon just likes it better, such a practice would not be tolerated. However, intervention strategies in schools are often driven by a similar logic. Intervention practices in schools are based, in part, on the fact that many educators have not been trained in empirically supported intervention methods, and/or they simply may be invested in philosophical or theoretical approaches that are at odds with more effective intervention strategies (Gresham, 2004 ).

RTI and the Three-Tier Model

Perhaps the most important concept in a RTI approach to service delivery in schools is the notion of matching the intensity of the intervention to the intensity and severity of the presenting problem behavior. One approach adopted by the U.S. Public Health Service describes three levels of “prevention” outcomes: primary prevention, secondary prevention, and tertiary prevention. This approach considers prevention as an outcome, rather than simply a means to an end. Primary prevention efforts seek to prevent harm, whereas secondary prevention efforts seek to reverse harm. Tertiary prevention efforts target the most severe academic and/or behavior difficulties and attempt to reduce harm (Walker, Ramsay, & Gresham, 2004 ).

This prevention model has subsequently been recast in terms of types of interventions that differ in the nature, comprehensiveness, and intensity of the interventions, as well as the degree of unresponsiveness of an individual’s behavior to a given intervention. This model of intervention typically is composed of three tiers of intervention intensity: universal interventions, selected interventions, and targeted/intensive interventions.

Universal Interventions

These interventions are designed to target and affect all students, and are delivered in the same manner and under the same conditions. These interventions are delivered in a classwide, schoolwide, or districtwide level, with each student receiving the same “dosage” of the intervention. Some examples of universal interventions are vaccinations, schoolwide discipline plans, districtwide bully prevention programs, and districtwide adopted reading, mathematics, and language arts curricula.

Universal interventions accomplish two major goals of education: the academic and social development of students. Implementing best practice, evidence-based interventions focuses on reducing or eliminating academic or behavioral difficulties before they become more severe. Estimates suggest that universal interventions will be effective with 80%–90% of any given school population. This figure may be higher or lower depending on the severity level of academic and behavioral challenges in any given school or school district, as well as on the quality of the particular universal intervention that is implemented.

Selected Interventions

These interventions focus on the weak or nonresponders to universal interventions. It is estimated that approximately 5%–10% of the school population may require some form of selected interventions. These students are at risk for severe academic or behavioral difficulties if more intense interventions are not implemented. Many of these students will respond to relatively simple, individually focused academic and behavioral interventions. These interventions are delivered in general education classrooms, and are typically developed in a consultation framework between general education teachers and support personnel (e.g., school psychologists or school counselors).

The goal of selected interventions is to provide more intense, individually prescribed intervention strategies to remediate academic and/or behavioral difficulties. These strategies are not complicated or comprehensive, but should be evidence based. Numerous examples of these types of interventions can be found in the area of academics (see Daly, Chafouleas, & Skinner, 2005 ) and social behavior (see DuPaul& Stoner, 2003 ; Miltenberger, 2004 ).

Targeted/Intensive Interventions

The most intense level of intervention focuses on students that are the most resistant to change, and who exhibit chronic academic or behavioral difficulties. It is estimated that this group of students constitutes about 1%–5% of any given school population. In terms of behavioral difficulties, these students are responsible for 40%–50% of behavioral disruptions in schools, and they drain 50%–60% of school building and classroom resources (Walker et al., 2004 ). In the area of reading, these students are weak responders to universal and selected intervention efforts, and will require very intensive phonics-based reading instruction (Vaughn, Linan-Thompson, & Hickman, 2003 ; Vellutino, 1987 ).

For behavioral difficulties, these interventions usually are based on a functional behavioral assessment (FBA) to determine the consequent events maintaining problem behaviors. FBA is defined as a collection of methods for collecting information regarding antecedents, behaviors, and consequences, to determine the function (purpose or “cause”) of problem behavior (Gresham, Watson, & Skinner, 2001 ). Once behavioral function is determined, this information is used to design interventions to reduce competing problem behaviors, and to increase positive replacement behaviors that serve the same behavioral function.

For academic difficulties, intense remedial efforts are typically delivered in a small group pull-out setting, and involve a relatively large number of hours of instruction. For example, intensive reading interventions by Vellutino and colleagues (Vellutino, Scanlon, Sipay, Small, Pratt, Chen et al., 1996 ), Torgesen and colleagues (Torgesen, Alexander, Wagner, Rashotte, Voeller, & Conway, 2001 ), and Vaughn et al. ( 2003 ) require anywhere from 35 to 68 hours of intense, phonics-based reading instruction. Even despite these intense intervention efforts, approximately 25% of the poor reader population will show an inadequate or weak response to intervention (Torgesen, Wagner, Rashotte, Rose, Lindamood, Conway, et al., 1999).

Response to Intervention Models

Two basic approaches are used to deliver interventions in a RTI approach: (a) problem-solving approaches, and (b) standard protocol approaches (Fuchs, Mock, Morgan, & Young, 2003 ). Some RTI models combine these two approaches, particularly within a multi-tier model of service delivery described earlier (see Barnett, Daly, Jones, & Lentz, 2004 ; Duhon, Noell, Witt, Freeland, Dufrene, & Gilbertson, 2004 ; VanDerHeyden, Witt, & Naquin, 2003 ). These particular models are best described as multi-tier RTI approaches to intervention. Despite these two basic RTI approaches, this chapter will concentrate on problem-solving RTI, because this approach is the most commonly used by school psychologists.

Problem Solving Approaches

Problem solving can be traced back to the behavioral consultation model first described by Bergan ( 1977 ), and later revised and updated by Bergan and Kratochwill ( 1990 ). Behavioral consultation takes place in a sequence of four phases: (a) problem identification, (b) problem analysis, (c) plan implementation, and (d) plan evaluation. The goal in behavioral consultation is to define the problem in clear, unambiguous, and operational terms, to identify environmental conditions related to the referral problem, to design and implement an intervention plan with integrity, and to evaluate the effectiveness of the intervention (Bergan & Kratochwill, 1990 ). More recently, the behavioral consultation model was described by Tilly ( 2002 ) in the form of four fundamental questions governing the identification and intervention of school based academic and behavioral problems: (a) What is the problem? (b) Why is the problem happening? (c) What should be done about it?, and (d) Did it work? Each of these steps is described briefly in the following sections.

Problem Identification

Problems are defined, in a problem solving approach, as a discrepancy between current and desired levels of performance. As such, the larger this discrepancy, the larger the problem. For example, if a student’s current rate of oral reading fluency is 50 words correct per minute, and the desired rate is 100 words correct per minute (based on a benchmark standard), then there is a 50%, or 50-word discrepancy between current and desired levels of performance. This same logic can be applied to any type of referral problem (academic or behavioral) as the first step in a problem solving approach.

A critical aspect of problem identification is the operational definition of the referral problem into specific, measurable terms that permit direct, objective assessment of the behavior or skill in question. Operational definitions are objective, clear, and complete. These definitions are objective if they can be read, repeated, and paraphrased by others. Operational definitions are clear if two or more observers of a behavior or skill are able to read the definition and use it to record and measure the behavior or skill. Operational definitions are complete if they specify the boundary conditions for inclusion of behaviors that are not part of the definition. For example, an operational definition of noncompliance might be as follows: Noncompliance is defined as the student not complying with a verbal request or directive from the teacher within 5 seconds after the request or directive has been given. Examples of verbal requests or directives are being told to sit down, begin work, copy from the board, come to the teacher’s desk, and so forth. Any other behaviors that do not meet this operational definition are not considered to be part of the response class of noncompliance.

Problem Analysis

Another important aspect of problem solving is to determine why the problem is occurring. At this stage, the distinction between “can’t do” (acquisition or skill deficits) and “won’t do” (motivational or performance deficits) is critical (Gresham, 1981 ; VanDerHeyden & Witt, 2008 ). “Can’t do” problems are considered to be acquisition deficits, meaning that the child does not have the skill or behavior in his or her repertoire. For example, if the child does not engage in appropriate social interactions with peers on the playground, then it may be because the child lacks appropriate peer group entry strategies. In this case, the acquisition deficit should be remediated by directly teaching the child appropriate peer group entry strategies.

“Won’t do” problems are considered to be performance or motivational deficits, meaning that the child knows how to perform the skill or behavior, but does not do so. Reasons for not performing the behavior or skill may be due to the lack of opportunities to perform the skill or behavior, or the lack of or low rate of reinforcement for performing the behavior or skill. In cases like these, remedial interventions would involve providing multiple opportunities to perform the behavior or skill, and increasing the rate of reinforcement for skill or behavioral performance.

Plan Implementation

The implementation of an intervention plan, designed in the problem analysis state of problem solving, is a critical aspect of the RTI enterprise. All RTI approaches argue for the implementation of scientific, evidence-based interventions; however, this is only part of the task in plan implementation. A fundamental principle of any intervention in a problem solving approach, particularly interventions delivered by third parties such as teachers or parents, is that the intervention will be delivered as intended or planned (Gresham, 1989 ). This is known as treatment integrity or treatment fidelity . From a research perspective, it must be demonstrated that changes in a dependent variable (behavior or skill) can be attributed to systematic, manipulated changes in the independent variable (i.e., the treatment). From a practice perspective, consultants collaboratively designing and assisting in the implementation of interventions must take steps to ensure that the intervention is implemented as intended. Poorly implemented interventions are likely to be ineffective in changing behavior. Treatment integrity, therefore, becomes a cornerstone of any RTI model.

Treatment integrity focuses on the accuracy and consistency with which interventions are delivered in schools or classrooms. Accuracy refers to the degree to which an intervention is implemented according to an established set of procedures. Consistency refers to the degree to which the intervention is implementedwhen it is supposed to be implemented (each subject period, on the half hour, daily). The ineffectiveness of many interventions designed in a problem solving approach may be due to the poor integrity with which these interventions are implemented, and poor integrity can result from inaccuracy, inconsistency, or both (Gresham, 1997 ). Deviations from an agreed-upon intervention plan or protocol explain why many interventions delivered in schools are not used, and are rendered ineffective. Without assessment of treatment integrity in an RTI approach, one cannot know if a given treatment was simply ineffective, or if the treatment would have been effective had it been implemented with good integrity.

Plan Evaluation

An essential component of the RTI approach is the determination of what constitutes an adequate or inadequate response to intervention. This determination is somewhat easier for academic performance than it is for social behavior. For academic performance, curriculum based measurement (CBM) typically is used to index response to intervention. CBM has the most well-established empirical history, and close connection to problem solving based assessment practices (Deno, 2005 ; Shinn, 2008 ). CBM measures are considered to be among the most highly regarded assessment tools for continuous progress monitoring to quantify student performances in reading, mathematics, and written language in short-term interventions. To be useful in formative evaluations, progress monitoring tools must meet technical adequacy standards (reliability and validity), must be sensitive to short-term changes in academic performance, and must be time-efficient so that teachers can monitor student performance frequently (1–2 times per week). CBM indices are ideal in an RTI approach because there are well-established benchmarks for both level and trend (growth) in the basic areas of academic performance (see Shinn, 2008 ).

Unfortunately, there is no CBM analogue for dependably measuring students’ response to short-term interventions in the area of social behavior. Progress monitoring for students’ social behavior is important, because educators need to determine whether a student’s rate of progress in a social-behavioral intervention is adequate to reach an acceptable criterion of proficiency in a reasonable period of time. The purpose of progress monitoring of social behavior is to establish students’ rates of improvement, to identify students who are not responding to an intervention, and to use these data to make decisions about continuing, altering, or terminating intervention based on how students are responding.

For students’ social behavior, several methods have been proposed and used, to determine whether a student is showing an adequate or acceptable response to intervention. These methods include: (a) absolute change in behavior, (b) percent change from baseline, (c) reliable change index, (d) effect size estimates, and (e) social validation of behavior change (see Gresham, 2005). Each of these methods has advantages and disadvantages, and will be described briefly in the following section.

Absolute change in behavior is the degree or amount of change an individual makes that does not involve comparison to other groups. Absolute change can be calculated in one of three ways: (a) the amount of change from baseline to post-intervention levels of performance; (b) an individual no longer meeting established criteria for a diagnosis (e.g., classification of emotionally disturbed or DSM-IV diagnoses); and (c) the total elimination of behavior problems. Absolute change is straightforward, intuitively logical, and easy to calculate. It is also consistent with a problem solving approach to defining problems as the discrepancy between expected and desired levels of performance described earlier. Using this approach, a problem is considered “solved” if the degree of absolute change is large relative to the three criteria described above.

There are some problems with using metrics of absolute change. For instance, an individual might show a relative large amount of absolute change from baseline to post-intervention levels of performance, but this change may not be large enough to allow that individual to function successfully within a general education setting. Absolute change also interacts with tolerance levels for problem behavior at the classroom and school levels. That is, even though a change in behavior is large, the behavior pattern still might not be tolerated by significant others in the school environment. Also, an individual may no longer meet the diagnostic criteria for an emotional disturbance, but this may be due to biases operating in the diagnostic and eligibility decision-making process.

Percent change from baseline is another metric that can be used to index response to intervention. This metric involves comparing the median level of performance in baseline to the median level of performance in intervention. For example, if the median frequency of a behavior in baseline is 8, and the median frequency of behavior after intervention is 2, then the percent change from baseline would be 75% (8–2/8=75%). The advantage of this metric is that outliers or aberrant data points, or floor and ceiling effects, do not greatly affect this metric, mainly because the median rather than the mean is used in its calculation. Percent change is commonly used in medicine to evaluate the effects of medical treatments, such as drugs to reduce cholesterol or blood pressure.

There are well established medical benchmarks for desirable levels of blood cholesterol (<200 dl ) and blood pressure (120/80) indexed to important medical outcomes (e.g., cardiovascular disease or mortality rates). Unfortunately, there are no such benchmarks for many behaviors targeted for intervention. There are no clear guidelines for determining the magnitude of behavior change that is sufficient to indicate an individual has demonstrated an adequate response to intervention. As such, this metric should be supplemented by other measures or indicators or response to intervention.

The reliable change index (RCI) is based on the notion that an individual’s behavior during intervention is sufficiently large to have surpassed the margin of measurement error. RCI is calculated by subtracting an individual’s mean score after baseline (posttest score) from the pretest score, and dividing this difference by the standard error of difference between posttest and pretest scores (Jacobson, Follette, & Revenstorf, 1988 ). The standard error of difference represents the variability in the distribution of change scores if no change had occurred, and is based on the standard deviation of pretest scores and the test/retest reliability of the measure used to index behavior change. An RCI of 1.96 ( p <.05) would be considered a statistically reliable change in behavior.

RCI has the advantage of quantifying reliable changes from baseline to post-intervention levels of performance, and confidence intervals can be placed around change scores to avoid overinterpretation of results. The RCI is affected by the reliability (stability) of outcome measures used. If a measure is highly reliable (stable), then small changes in behavior might be considered statistically reliable, but not educationally significant or important. In contrast, if a measure has relatively low reliability (stability), then large changes in behavior may be educationally important but statistically unreliable.

Perhaps the most serious drawback of RCI is that it cannot be used to estimate reliable changes in behavior using direct observations of behavior. No “test-retest” reliability coefficient is calculated in using direct observations of behavior. “Reliability” in direct observations is typically calculated by interobserver agreement indices. This is not the same as stability of behavior over time, in the traditional use of that term, and thus cannot be used to calculate RCI.

Two types of effect size estimates for the individual case are typically used to gauge response to intervention. The first estimate is a modification of Cohen’s d that is used in meta-analytic research. This effect size is calculated by subtracting the intervention mean from the baseline mean, and dividing by the standard deviation of baseline data points (Busk & Serlin, 1992 ). A drawback of this effect size estimate is that it can yield large effect size estimates that cannot be interpreted in the same way as effect sizes calculated in meta-analytic research.

A second effect size metric is the percent of nonoverlapping data points (PND) computed by calculating the percentage of nonoverlapping data points between baseline and intervention phases (Mastropieri & Scruggs, 1985–1986). If the goal of an intervention is to decrease behavior, one computes PND by counting the number of intervention data points exceeding the highest data point in baseline, and dividing by the total number of data points in the intervention phase. For example, if 8 of 10 data points in intervention exceeded the highest baseline data point, the PND would be 80%. Alternatively, if the goal of intervention is to increase behavior, then one calculates PND by counting the number of intervention data points that are below the lowest baseline data point, and dividing by the total number of data points in the intervention phase.

PND was proposed to provide a quantitative index to document the effects of an intervention that is easy to calculate. There are, however, some drawbacks of using this method that should be noted. One, PND often does not reflect the magnitude of behavior change in an intervention. That is, one can have 100% nonoverlapping data points in the treatment phase, yet have an extremely weak treatment effect. Two, unusual baseline trends (high and low data points) can skew the interpretation of PND. Three, PND is greatly affected by floor and ceiling effects. Four, aberrant or outlier data points can make interpretation of PND difficult (see Strain, Kohler, & Gresham, 1998 for a discussion). Five, there are no well-established guidelines for what constitutes a large, medium, or small effect using PND.

Perhaps the most essential and relevant means of determining adequate response to intervention is social validation . Social validity addresses three fundamental questions with respect to intervention: What should we change? How should we change it? How will we know it was effective? There are often disagreements among professionals and treatment consumers on these three fundamental questions (see Hawkins, 1991 ; Schwartz & Baer, 1991 ). Wolf ( 1978 ) described the social validation process as involving the social significance of intervention goals, the social acceptability of intervention procedures, and the social importance of intervention outcomes. This last aspect of the social validation process is the most relevant in quantifying and evaluating treatment effectiveness in a RTI approach.

Establishing the social importance of the effects of intervention attests to the practical or educational significance of behavior change. Do the quantity and quality of the changes in behavior make a difference in the student’s behavioral functioning and adjustment? In short, do the changes in behavior have habilitative validity (Hawkins, 1991 )? Is the student’s behavior now in the functional range, subsequent to the intervention? These questions capture the essence of establishing the social importance of intervention effects.

A way of establishing the social importance of intervention effects is to view behavioral functioning (academic or social) as belonging to either a functional or dysfunctional distribution. An example might be socially validating a behavioral intervention by showing the student’s behavior moved from a dysfunctional to a functional range of performance. Using teacher and/or parent ratings on nationally normed behavior rating scales is one means of quantifying the social importance of intervention outcomes (Gresham & Lopez, 1996 ). Moving a student’s problem behavior ratings from the 95th percentile to the 50th percentile would represent a socially important change. Similarly, changing a target behavior problem measured by direct observations into the range of nonreferred peers would also corroborate the behavior ratings, and therefore could be considered socially important.

Social importance can also be conceptualized and evaluated on several levels: proximal effects, intermediate effects, and distal effects (Fawcett, 1991 ). Proximal effects are changes in target behaviors produced by the intervention such as increases in social skills, decreases in aggressive behavior, or increases in oral reading fluency. Proximal effects can be evaluated by visual inspection of graphed data, percent change from baseline, and/or the reliable change index. Intermediate effects can be evaluated by more molar assessments, such as substantial changes in ratings on normed behavior rating scales, teacher ratings of academic performance, or standardized tests of academic achievement. Distal effects can be evaluated by changes on social impact measures such as office discipline referrals, suspension/expulsion rates, school attendance, promotion/retention status, or incarceration rates.

It should be noted that social impact measures are not particularly sensitive in detecting short-term changes in behavior produced by interventions. Many treatment consumers may consider these social impact measures to be the most important metrics in gauging successful intervention outcomes; however, exclusive reliance on these measures might ignore or mask a great deal of behavior change (see Kazdin, 2003 ).

It is often the case that rather large and sustained changes in behavior are required before these changes are reflected on social impact measures. A method based on just noticeable differences (JNDs) has been recommended to index intervention outcomes (Sechrest, McKnight, & McKnight, 1996 ). A JND approach answers the question: How much of a difference in behavior is required before it is “noticed” by significant others (teachers, parents, school personnel), or reflected on other social impact measures? For example, how much of a decrease in aggressive/disruptive behavior in the classroom and on the playground is required, before it is reflected in a decrease and subsequent elimination of office discipline referrals? Similarly, how much of an increase in oral reading fluency is necessary before it is reflected in a student’s performance on a high-stakes achievement test?

Conclusion and Future Directions

RTI is a process of providing high quality interventions that are matched to student need, and uses frequent progress monitoring of student response to interventions to assist in making important educational decisions. At the most basic level, all RTI approaches share three common features: (a) use of evidence-based interventions, (b) assessing the rate and level of student performance in those interventions, and (c) use of individual student responsiveness data to make educational decisions. The key concept in any RTI approach is that the intensity of an intervention is matched to the intensity and severity of academic or behavioral difficulties. RTI is typically conceptualized in a three-tier model that describes three levels of prevention: primary prevention, secondary prevention, and tertiary prevention. These three levels of prevention seek to prevent, reverse, and reduce harm, respectively.

An important and unresolved concept in RTI is treatment strength (see Yeaton & Sechrest, 1981 ). What makes a given intervention or treatment strong? In pharmacological interventions, more of a drug necessarily makes it stronger (e.g., 100 milligrams is twice as strong as 50 milligrams—assuming no drug tolerance effects). However, in education or psychology, administering more of a treatment does not necessarily make it stronger. For example, doubling the amount of an ineffective treatment would have nothing to do with its strength in changing behavior, because the treatment does not have the active ingredients necessary to change behavior.

Another dimension of treatment strength is duration of the treatment. Are longer treatments stronger than thosedelivered with shorter durations? This depends on the inherent properties of the treatment that constitutes its ability to change behavior. For example, is a 3-month treatment stronger than a 1-month treatment? Again, administering a longer duration of treatment would not necessarily result in larger changes in behavior if the treatment contains few or no active ingredients to promote behavior change. In fact, there are cases in which longer treatments may lose their effectiveness over time. A good example is the concept of reinforcer satiation in which a reinforcer loses its effectiveness over time (i.e., children get tired of the reinforcer).

A third dimension of treatment strength is the intensity of the treatment. Treatment intensity can refer to how many times the treatment is delivered (e.g., twice a day, once per day, once per week). Treatment intensity can also be conceptualized as the consistency with which a treatment is delivered. This concept captures the notion of treatment integrity, or the degree to which a treatment is implemented as planned or intended.

In an RTI approach to intervention service delivery, the strength of educational or psychological interventions cannot be reliably defined a priori, because there is not a one-to-one correspondence between the “dosage” of a treatment and subsequent response to a treatment. Several assumptions may be helpful in considering the notion of treatment strength. One, stronger treatments often result in greater behavior change than weaker treatments. It is unclear, however, what makes a treatment “strong.” A defensible approach to determining treatment strength can be found in the meta-analytic literature on academic and behavioral interventions. That is, treatments producing larger effect sizes can legitimately be considered stronger than treatments producing smaller effect sizes. In other words, evidence-based treatments are de facto stronger than treatments having little or no empirical evidence to support their use. For example, a treatment that produces an effect size of d =.80 will be much stronger than another treatment that produces an effect size of d =.20.

Another assumption in treatment strength is the effect of treatment integrity. That is, treatment strength may be diluted or enhanced by the level of treatment integrity. For example, an evidence-based treatment delivered with 100% integrity should be stronger than that same treatment delivered with only 50% integrity. However, treatment integrity does not necessarily result in stronger treatments (i.e., 100% of a weak treatment may not equal 50% of a strong treatment). Moreover, each component of a treatment may not be equally strong in producing behavior change (Gresham, 1989 ).

This chapter discussed RTI from the perspective of a three-tier approach to service delivery in schools. Instead of diagnosing within-child conditions (e.g., specific learning disabilities or emotional disturbance), the RTI approach focused on four stages of a problem solving process: problem identification, problem analysis, plan implementation, and plan evaluation. Each of these steps in the problem solving process takes place at each of three levels of intervention: universal, selected, and intensive. This chapter concluded with a discussion of how strength of treatments can moderate treatment outcomes, and discussed unresolved issues in conceptualizing and operationalizing treatment strength.

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The Six-Step Crisis Intervention Model Explained

When an individual experiences a crisis, the proper response can make a life-saving difference. Mental health professionals must understand these nuanced situations and enact steps to bring the patient back to a healthy place. One model that can guide these responses is Gilliland's six-step crisis intervention strategy. By moving through the steps with care and concern for the individual, mental health professionals can help guide the person in crisis away from dangerous actions and toward their pre-crisis state.

We'll take a closer look at this crisis intervention model and how crisis workers can use it to assist their clients.

Table of Contents

Step 1: Define the Problem

Step 2: ensure the individual's safety, step 3: provide support, step 4: explore alternatives, step 5: make plans, step 6: obtain commitment, the benefits of the six-step crisis intervention model, tips for using the six-step crisis intervention model, when to use the six-step crisis intervention model, implementing the six-step crisis intervention model, download our comprehensive crisis intervention toolkit.

What is the Six-Step Crisis Intervention Model?

According to the creators of the six-step model , a crisis occurs when someone perceives or experiences an event or situation as intolerable, with demands that exceed their current resources and coping mechanisms. When this happens, they need assistance to regain control and stabilize. The six-step model enlists a systematic process of listening and responding to empower the individual and help them return to their pre-crisis psychological state. Assessments occur at every step, and the crisis worker listens attentively to make their evaluations.

The six steps involved in this method include three listening-oriented steps and three action-oriented steps. The first three focus on listening.

Step number one asks the crisis worker to define the problem. This first stage establishes a connection between the crisis worker and the client as they begin discussing the issue. To fully understand the situation and form a bond with the client, the crisis worker implements:

• Active listening:  Active listening requires placing your full attention on the client, demonstrating acceptance and removing biases. The crisis worker must understand the client's perspective without allowing their feelings to get in the way. This type of listening also helps improve the relationship between the two parties.
• Empathy:  Practicing empathy is about taking someone else's point of view and showing them that you understand them. It asks you to remove any judgment or biases and accept the patient as a whole person, not define them by their current situation. It also requires being in the present and putting the other person and their feelings first. Empathy is essential throughout the six-step process, especially when establishing the relationship.
• Genuineness: People can often tell when you aren't being genuine. In a crisis, this can quickly paint you as untrustworthy and break down the relationship between crisis worker and client. Speak genuinely but carefully and solidify your position as a trustworthy partner in their mental health.
• Understanding: You also need to show the client that you understand their situation. You may use language that confirms you understand the problem or relate to their issue somehow.

The crisis worker should look at the problem from the client's point of view. They should try to understand where the client is coming from and their available resources, such as coping skills or caring friends and family.

A vital part of any crisis intervention plan is ensuring the individual cannot harm themselves or others. At this stage, the crisis worker conducts suicide risk assessments and homicide risk assessments. You may evaluate factors like agitation or the client's potential for causing harm.

Another important step here is controlling the individual's access to dangerous items. These can be as clear-cut as firearms or as subtle as office supplies, like staplers and paper cutters. The client's location and the resources of the mental health crisis system will make a big difference in this step.

For example, an inpatient psychiatric client likely has far less access to harmful items than a client being treated through a mobile care unit. That client might be able to use a variety of dangerous instruments and lack supervision when the crisis worker leaves.

The crisis worker must help transition the client into a safe environment before they can work on the next steps.

In the third step, the crisis worker shows the client that they accept and care for them. They'll discuss the problem and offer support for meeting basic needs. These might come in the form of:

• Emotional support: The crisis worker must express emotional support through statements that illustrate empathy, trust, and care. Emotional support can also come from trusted friends and family.
• Instrumental support: Instrumental support refers to services and aid, like shelter and food. Fulfilling basic needs is a necessary prerequisite for the problem-solving that occurs in the next three action steps.
• Informational support: By providing informational support, the crisis worker offers advice and suggestions. You might teach the individual about healthy coping strategies or reassure them that many resources are available.

The goal of these supports is to set the person up so they can understand the options available for dealing with the situation.

As we switch gears into the action steps, step four is about finding new solutions and navigating possibilities. The crisis worker collaborates with the person in crisis to explore these options. If their coping skills are weaker, the crisis worker may need to offer more assistance at this step, but it's important to draw on assessments first to understand the client's capabilities.

Other elements that the crisis workers might draw on during this step include situational supports, like people in the individual's life who care about them or coping mechanisms that can help them through the situation so they can move into the problem-solving stage.

During this step, it's necessary to use and cultivate positive, constructive thinking patterns. The crisis worker may need to spend some time helping the client reframe their thoughts in more positive ways.

With trust established and options explored, it's time to make a plan. During step five, the individual and the crisis worker continue to collaborate, building a plan with clear, concrete steps that will help the client regain control. These plans must be realistic and achievable.

They should empower the client, making them feel like they can accomplish the tasks and take ownership of the recovery process. This step relies heavily on collaboration with the client because it helps them take control, using their existing resources and capabilities.

The individual's plan should be detailed and straightforward. It might involve referrals and resources like people or groups that can help the client, such as support groups, medical providers, or food banks.

The last step is to obtain commitment. Getting commitment might be as simple as asking the client to verbalize the plan or as complex as writing up a document and having both parties sign it. In either case, the crisis worker needs to confirm that the client fully understands the plan and feels capable of following through.

The crisis worker should also make plans to follow up with the client. You can create a sense of accountability and, of course, help ensure the client's well-being. If the client needs further care, the crisis worker can also make referrals.

Crisis intervention is a powerful tool. An unmanaged crisis can lead to significant psychological stress, which can link to major depressive disorder or other mental health conditions. Crisis intervention has proven efficacy in preventing mental illness from developing and helping to treat patients currently suffering from one.

Studies have even shown that emergency departments with crisis intervention teams saw reduced return visits and shorter durations of stay. They reduced the number of repeat admissions and found that the interventions were more effective than standard care in improving the patient's mental health.

We know that crisis intervention can be a critical part of improving psychiatric case outcomes. The six-step model emphasizes two distinct components of helping someone with a problem — listening and taking action. It covers vital steps of crisis intervention, like creating a bond with the client, identifying resources, and guiding them toward a healthy solution. It also offers a clear, systematic approach that helps ensure the crisis worker accomplishes the tasks that can help the client.

Although the six-step crisis model is fairly straightforward, it still requires the nuance demanded of crisis intervention. Some things to keep in mind when using the six-step crisis model include:

• Accurate assessments: This strategy is based on the results of your assessments. They must be accurate. Crisis workers must remember that every person and situation is unique. Generalizations can lead to dangerous errors that divert the treatment plan. Robust assessment tools can be particularly useful in the six-step strategy.
• Empowerment: Crises occur when a person loses control and feels unsafe. The six-step model focuses on restoring that power through collaboration. The crisis worker should maintain an open mind when problem-solving and look for routes that help the person regain control. A heavy-handed approach might be necessary for some patients, but they should contribute to the best of their ability.
• Action-oriented strategizing: Crisis intervention is focused on action and the situation at hand. Crisis workers should recognize the impacts of the situation, anticipate its effects and help the client create a plan. Each step in the process should be geared toward that end goal.
• Focus on the present: Similarly, crisis intervention offers immediate support. Unlike long-term solutions like psychotherapy, the crisis worker must provide immediate support, like coping skills that the patient can use right away or access to resources that they can use to quickly return to the pre-crisis state.
• A holistic view of the client: The crisis worker needs to maintain their holistic view of the client, considering the whole person instead of separating them from their cognitive and emotional function.

Crisis intervention is an immediate, short-term response to mental, physical, emotional and behavioral distress. It is not a long-term option like psychotherapy or similar treatments. The goal is to restore the person's functioning to before the crisis and reduce the opportunity for long-term trauma. It aims to help the client get access to assistance, support and resources that help them become stable.

The six-step model can be used in many situations, but some common triggers for crises include:

• Family situations: Some family situations — like child or spousal abuse, unplanned pregnancy or serious or chronic illness — can cause stress and lead to a crisis.
• Economic situations: Financial strain from the loss of a job, eviction, theft, medical expenses, gambling or poverty can trigger many crises based on the sudden or chronic financial strain they create.
• Community situations: An individual's community can also contribute to their mental state. For example, someone facing violence in their neighborhood, poor housing or inadequate community resources might experience a crisis.
• Significant life events: Some events often viewed as happy situations can paradoxically trigger crises. These might include marriage, the birth of a child or a promotion at work. Other significant events, like raising a rebellious adolescent, losing a loved one or seeing a grown child leave the nest can also cause a crisis.
• Natural elements: Plenty of natural disasters can trigger crises, such as floods, hurricanes and fires. They might involve harm to a loved one or the destruction of possessions, creating states of distress. Even seemingly minor events, like a bout of gloomy or hot weather, can put someone into a crisis state.

Some signs that someone is in crisis and may need the help of an intervention strategy include:

• Feelings of hopelessness.
• Difficulty eating or sleeping.
• Depression.
• Neglected personal hygiene.

Symptoms can vary widely, but remember that a crisis intervention plan is generally warranted when the situation exceeds the patient's resources and coping skills.

Implementing the six-step crisis intervention model will look different for various providers, such as inpatient crisis teams or mobile crisis response units. Still, completing the six steps typically requires robust documentation to ensure appropriate billing procedures , patient assessment, and follow-up care. Without the proper documentation solution, you might be spending too much time on paperwork and not enough time on the client. Or you might completely neglect your notes. To make the process easier, use a documentation platform that allows for quick, intuitive note-taking.

ICANotes is that platform, offering a cloud-based solution for mobile, inpatient, or outpatient crisis intervention. It eliminates the busy work, allowing you to focus on your patient and their acute problems without ignoring necessary documentation procedures. ICANotes mental health EHR software also supports a range of other tasks, like billing, reporting, referrals, e-prescribing and scheduling . From initial suicide risk assessments to referrals to other mental health professionals, ICANotes simplifies the entire process.

If the six-step crisis intervention model is part of your practice, ICANotes can help. With intuitive note-taking features and an array of assessment tools, you can successfully follow the patient-centered approach of this model. Collect all the information you need to make an accurate evaluation and help the patient move forward. To learn more about ICANotes and how it can help you with the 6-step model, explore its features or reach out to us today for more information!

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Response to Intervention

• Living reference work entry
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• Jacob Tickle 4 ,
• Sandy Sut Ieng Cheang 5 &
• Rik Carl D’Amato 4  

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Response to intervention (RTI) is defined as a problem-solving model that provides assessment and interventions to students based on their response to the targeted curriculum and instructions (Witsken et al. 2008 ). The uniqueness of this approach is that student’s needs can be met in the classroom without any type of formal psychological diagnosis. There are multiple steps RTI uses to diagnose student’s learning or behavioral problems. The basic components are (1) school-wide screening, (2) progress monitoring, (3) tiered service delivery, and (4) fidelity of implementation.

Historical Background

According to the original law, Public Law 94-142 ( 1975 ), for example, a discrepancy between achievement and intellectual ability was required to classify students as learning disabled. If students qualified, special education programs were developed to enhance their academic performance. Special education services were based on the concept of having individualized instruction to...

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D’Amato, R. C., Zafiris, C., MsConnell, E., & Dean, R. S. (2011). The history of school psychology: Understanding the past to not repeat it. In M. Bray & T. Kehl (Eds.), Oxford handbook of school psychology (pp. 9–60). New York: Oxford.

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Fuchs, D., & Fuchs, L. S. (2006). Introduction to response to intervention: What, why, and how valid is it? Reading Research Quarterly, 41 (1), 93–99.

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Johnson, E., Mellard, D. F., Fuchs, D., McKnight, M. A. (2006). Responsiveness to intervention (RTI): How to do it. National Research Center on learning disabilities, U. S. Office of Special Education Programs. www.nrcld.org

Public Law 94-142. (1975). Federal Register, 42 , 42474, 20 U.S.C.

Individuals with Disabilities Education Improvement Act of 2004, P.L., 108-446, 20 U.S.C.

Reynolds, C. R., & Shaywitz, S. E. (2009). Response to intervention: Ready or not? Or, from wait-to-fail to watch-them-fail. School Psychology Quarterly, 24 (2), 130–145.

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Telzrow, C. F., McNamara, K., & Hollinger, C. L. (2000). Fidelity of problem-solving implementation and relationship to student performance. School Psychology Review, 29 (3), 443–461.

Tilly, W. D., III. (2003). How many tiers are needed for successful prevention and early intervention? Heartland Area Education Agency’s evolution from four to three tiers . Paper presented at the National Research Center on learning disabilities responsiveness-to-intervention symposium, Kansas City, MO.

Traughber, M. C., & D’Amato, R. C. (2005). Integrating evidence-based neuropsychological services into school settings: Issues and challenges for the future. In R. C. D’Amato, E. Fletcher-Janzen, & C. R. Reynolds (Eds.), Handbook of school neuropsychology (pp. 827–858). New York: Wiley.

Witsken, D., Stoeckel, A., & D’Amato, R. C. (2008). Leading educational change using a neuropsychological response-to-intervention approach: Linking our past, present, and future. Psychology in the Schools, 45 (9), 781–798.

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Tickle, J., Cheang, S.S.I., D’Amato, R.C. (2017). Response to Intervention. In: Kreutzer, J., DeLuca, J., Caplan, B. (eds) Encyclopedia of Clinical Neuropsychology. Springer, Cham. https://doi.org/10.1007/978-3-319-56782-2_1485-2

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The Problem Management Helping Model in Grief and Counseling

Helping individuals from one point of need to the final point of self resilience and healing is the process of counseling itself, however, many times counselors helping others with grief, issues of loss, or problems in life become loss in the process.  Maintaining a sense of direction when helping is key.  While there is a partnership in the counseling relationship, the counselor still nonetheless is the guider within the partnership.  The counselor directs the process and guides it to its eventual end point.   Whatever counseling philosophy or model one incorporates, it is still essential to have a template of how to help resolve a particular issue.  Problem Management is a key arrow and guiding modality to help counselors and clients stay on track and have a sense of direction.  It is essentially the compass or navigation control in the counseling session.  Good counselors understand its use and properly utilize it during counseling.  In this short blog, we will review its essential nature in counseling and how to properly incorporate it with a client.

Problem Management: Four Questions

When a client attends counseling, he/she is looking for guidance in a particular struggle.  Whether it is more complex trauma or loss, or instead a simpler issue revolving around a decision to find a job or not, clients are seeking guidance.  While the clients ultimately determine the outcome, they seek guidance with options and how to accomplish a given thing.  Counselors can help guide clients through Problem Management and its four questions.  The process involves the current picture, preferred picture, a way forward and action itself.

First, the counselor will ask questions about the current problem and current picture..  According to Egan, one should ask a client, what his/her issues or concerns pertain to (2019, p. 45)?   Within this first stage of helping the client, the counselor can help the client discover and identify the issue.  The first task involves the story itself.  What is the primary problem and main concerns (Egan, 2019, p. 48)?  When discussing the story, the counselor should help the client possibly see new perspectives to the problem and what may be really going on beyond the client’s initial story.  Finally, the counselor should be able to direct the client to the right story and what  he/she should be working on.  This process leads to first listening, but then helping the client identify beyond his/her perceptions and find the right story and the keys surrounding it (Egan, 2019, p. 48).  For example, a person who is obese may discuss multiple issues revolving around self image and poor diet/health.  Discussing the primary problem and identifying perceptions of self image and directing the person to the core of the problem is important.  Leading the client to the right story and issue sometimes takes time, but is essential.

After helping the client identify the right issue at hand, the counselor needs to help the client look beyond the current picture and propose a preferred picture.  The primary question should include what does a better picture look like? Within this phase, according to Egan, the counselor helps the client determine problem managing outcomes and set goals (2019, p. 48).   What are the possibilities for a better outcome entail?  What goals and outcomes are truly the most critical and important?  Finally, what is the client willing to do to achieve these outcomes (2019, p.48). Ultimately, these better outcomes and preferred pictures involve effort.  In this phase, again the example of the obese client will see a preferred picture of weight loss, better health and higher self esteem.

Following the preferred picture, the counselor looks to guide the client forward.  The counseling sessions look to help the person move forward with a plan.  The client and counselor should brain storm with possible ideas and strategies to resolve a particular issue.  The counselor will help narrow down the best fit strategies for the particular client and then help the client organize a way to accomplish these goals (Egan, 2019, P. 48).  In the case and example of the obese client, the counselor will discuss diet and exercise strategies and then see which particular strategies fit best with the client’s work and life schedule.  The counselor will then help coordinate first steps and possible times to put things into action.

These three phases of identifying problems, seeking better outcomes and making plans all lead to a call to action.  How well will this call to action being implemented depends on many subjective factors within the client.

Clients and Change

Counselors can only direct, they cannot force a client to change.  Hence it is important to help facilitate change but not to expect perfection.  Change takes time.  Some clients may be more resilient to let downs, or more focused in accomplishing a task.   It is important to expect a back and forth wavering between stages.  Clients when they finally become aware of a problem enter into various phases to push forward in change.  According to Egan, individuals looking for change after initial awareness of a problem, will still waver, until the awareness leads to a heightened level (2019, p. 56). This leads to preliminary actions and a search for remedies.  Within this, individuals estimate costs and weigh those costs of a change.  They soon turn to more rational decision that is not only rational but tied to emotional change.  This leads to serious action.  However, these actions still require maintenance and the reality that relapse can occur (Egan, 2019, p.57-58).

It is the counselors job to help nurture positive change and guide clients through pitfalls.  Those facing addiction issues, or in our example, one facing weight loss challenges, will wish to change but may sometimes not be emotionally tied to the rational decision enough to take the serious action.  Others may do well for a few months and not be able to maintain what is demanded, or worst, yet relapse into addiction, or fall off their diet.  Counselors are there to help guide in those cases and foster resilience.  This may involve returning to the Problem Management model at an earlier stage to again find grounding and direction.

This is why counselors must ever remain flexible in their approach.  Somethings may work for one client but not another.  Counselors need to constantly “mine” various approaches or counseling philosophies that will help a particular client (Egan, 2019, p. 58).   The counselor then organizes what works best, evaluates it and incorporates it into the various phases of the Problem Management Model (2019, p, 58-59)

Pitfalls to Avoid in Problem Management

When helping clients identify issues, outcomes and plans of action, there are some pitfalls that counselors need to avoid.  Counselors need to avoid a lack of plan in their work.  Some helpers go session by session without a uniform plan set into play.  Others on the contrary attempt to implement to many plans at once.  While there are many good models, not all models fit for a particular person, so each model and stage of helping, needs to be tailored to the individual client.  Avoiding rigidness and being flexible in approach is key with an understanding that one can go back and forth between stages.  It is also important to include the client in the process.  Since counseling is a partnership, then it is essential to share the helping models with the client.  This is an element of psycho-educational healing.  A client who is part of the process understands the points of reference and can better track oneself in the healing and change process (Egan, 2019, p. 60-61).  Finally, while important as it is to utilize flexibility, a good counselor can recognize lack of progress on part of the client and when to help the client push forward (Egan, 2019, p52).

Hence the process while simple in theory is more difficult when people become involved.  People are complex and no one person is the same.  This leads to the need of flexibility, testing and feedback, and trying other things within the parameters of the Problem Management model.  Some clients may process the issue quicker, others may take longer.  Some my engage in a certain stage a different way than another, while others will regress or progress.   This is why counseling while a science is also an art.  The individual talents of a counselor go well beyond the models and theories but also helping others implement what needs to be done through a variety of skills that involve evaluation and guidance.

It is essential to have a plan.  Counseling is structured while also flexible.  It has a purpose and a plan to reach a goal.  The flexibility is how to reach that goal not the goal itself.  Problem Management helps the counseling relationship stay structured in regards to the issue.  It helps identify the issue, state the better outcome and help give the tools and plans to accomplish it.  Counselors need to work their clients to the desired change but while doing so understand the nature of change within the human person and the need to keep trying when results do not appear.  The counselor not only guides the client to facilitate positive change but also helps the client get up when the client falls.

Please also review AIHCP’s Grief Counseling Certification as well as its Christian Counseling Program .  AIHCP also offers Spiritual Counseling, Stress Management, Crisis Intervention and Anger Management programs to help train professionals in facilitating positive changes in clients.  Utilization of a Problem Management paradigm is essential in all of these models.  AIHCP’s programs are all independent study and online.

Egan, G & Reese, R. (2019). “The Skilled Helper: A Problem Management and Opportunity-Development Approach to Helping” (11th Ed.) Cengage.

Additional Resources

“Problem-Solving Models: What They Are and How To Use Them”. (2023). Indeed Editorial Staff. Indeed.  Access here

Cuncic, A. (2024). “What Is Problem-Solving Therapy?”. Very Well Mind.  Access here

Antonatos, L. (2023). “Problem-Solving Therapy: How It Works & What to Expect”. Choosing Therapy.  Access here