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

Author: Lydia Antonatos, LMHC

Lydia Angelica Antonatos LMHC

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

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

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What Is Problem-Solving Therapy?

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

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

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

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

Techniques Used in Problem-Solving Therapy

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

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

Creating Collaboration

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

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

Psychoeducation

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

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

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

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

Rehearsal & Practice

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

Positive Reinforcement & Feedback

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

Use of Analogies & Metaphors

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

What Can Problem-Solving Therapy Help With?

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

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

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

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

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

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Problem-Solving Therapy Examples

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

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

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

Psychiatric Patients

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

Adherence to Other Treatments

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

Benefits of Problem-Solving Therapy

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

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

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

How to Find a Therapist Who Practices Problem-Solving Therapy

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

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

Are There Special Certifications to Provide PST?

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

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

Questions to Ask a Therapist When Considering Problem-Solving Therapy

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

Here are some key questions to ask before starting PST:

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

How Much Does Problem-Solving Therapy Cost?

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

What to Expect at Your First PST Session

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

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

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Is Problem-Solving Therapy Effective?

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

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

How Is PST Different From CBT & SFT?

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

Problem-Solving Therapy Vs. Cognitive-Behavioral Therapy

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

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

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

Problem-Solving Therapy Vs. Solution-Focused Therapy

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

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

Final Thoughts

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

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For Further Reading

• 12 Strategies to Stop Using Unhealthy Coping Mechanisms
• Depression Therapy: 4 Effective Options to Consider
• CBT for Depression: How It Works, Examples, & Effectiveness

What Is Exposure and Response Prevention Therapy?

ERP therapy alters OCD’s pattern by addressing both obsessions and compulsions. In ERP, an individual is encouraged to confront the stimuli that trigger distress related to their obsessions while also resisting the urge to perform compulsions in an attempt to reduce their distress.

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Problem-Solving Therapy Infographics

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

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

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

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

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

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

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

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

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

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Cognitive Behavioral Therapy

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

Posted February 2, 2022 | Reviewed by Ekua Hagan

• What Is Cognitive Behavioral Therapy?
• Find a therapist who practices CBT
• Problem-solving is one technique used on the behavioral side of cognitive-behavioral therapy.
• The problem-solving technique is an iterative, five-step process that requires one to identify the problem and test different solutions.
• The technique differs from ad-hoc problem-solving in its suspension of judgment and evaluation of each solution.

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

The problem-solving technique

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

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

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

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

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

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

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

Advantages of the problem-solving technique

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

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

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

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

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What Is Cognitive Behavioral Therapy (CBT)?

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Cognitive behavioral therapy (CBT) is a type of psychotherapeutic treatment that helps people learn how to identify and change the destructive or disturbing thought patterns that have a negative influence on their behavior and emotions.

Cognitive behavioral therapy combines cognitive therapy with behavior therapy by identifying maladaptive patterns of thinking, emotional responses, or behaviors and replacing them with more desirable patterns.

Cognitive behavioral therapy focuses on changing the automatic negative thoughts that can contribute to and worsen our emotional difficulties, depression , and anxiety . These spontaneous negative thoughts also have a detrimental influence on our mood.

Through CBT, faulty thoughts are identified, challenged, and replaced with more objective, realistic thoughts.

Everything You Need to Know About CBT

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Types of Cognitive Behavioral Therapy

CBT encompasses a range of techniques and approaches that address our thoughts, emotions, and behaviors. These can range from structured psychotherapies to self-help practices. Some of the specific types of therapeutic approaches that involve cognitive behavioral therapy include:

• Cognitive therapy centers on identifying and changing inaccurate or distorted thought patterns, emotional responses, and behaviors.
• Dialectical behavior therapy (DBT)  addresses destructive or disturbing thoughts and behaviors while incorporating treatment strategies such as emotional regulation and mindfulness.
• Multimodal therapy suggests that psychological issues must be treated by addressing seven different but interconnected modalities: behavior, affect, sensation, imagery, cognition, interpersonal factors, and drug/biological considerations.
• Rational emotive behavior therapy (REBT) involves identifying irrational beliefs, actively challenging these beliefs, and finally learning to recognize and change these thought patterns.

While each type of cognitive behavioral therapy takes a different approach, all work to address the underlying thought patterns that contribute to psychological distress.

Cognitive Behavioral Therapy Techniques

CBT is about more than identifying thought patterns. It uses a wide range of strategies to help people overcome these patterns. Here are just a few examples of techniques used in cognitive behavioral therapy. 

Identifying Negative Thoughts

It is important to learn what thoughts, feelings, and situations are contributing to maladaptive behaviors. This process can be difficult, however, especially for people who struggle with introspection . But taking the time to identify these thoughts can also lead to self-discovery and provide insights that are essential to the treatment process.

Practicing New Skills

In cognitive behavioral therapy, people are often taught new skills that can be used in real-world situations. For example, someone with a substance use disorder might practice new coping skills and rehearse ways to avoid or deal with social situations that could potentially trigger a relapse.

Goal-Setting

Goal setting can be an important step in recovery from mental illness, helping you to make changes to improve your health and life. During cognitive behavioral therapy, a therapist can help you build and strengthen your goal-setting skills .

This might involve teaching you how to identify your goal or how to distinguish between short- and long-term goals. It may also include helping you set SMART goals (specific, measurable, attainable, relevant, and time-based), with a focus on the process as much as the end outcome.

Problem-Solving

Learning problem-solving skills during cognitive behavioral therapy can help you learn how to identify and solve problems that may arise from life stressors, both big and small. It can also help reduce the negative impact of psychological and physical illness.

Problem-solving in CBT often involves five steps:

• Identify the problem
• Generate a list of potential solutions
• Evaluate the strengths and weaknesses of each potential solution
• Choose a solution to implement
• Implement the solution

Self-Monitoring

Also known as diary work, self-monitoring is an important cognitive behavioral therapy technique. It involves tracking behaviors, symptoms, or experiences over time and sharing them with your therapist.

Self-monitoring can provide your therapist with the information they need to provide the best treatment. For example, for people with eating disorders, self-monitoring may involve keeping track of eating habits, as well as any thoughts or feelings that went along with consuming a meal or snack.

Additional cognitive behavioral therapy techniques may include journaling , role-playing , engaging in relaxation strategies , and using mental distractions .

What Cognitive Behavioral Therapy Can Help With

Cognitive behavioral therapy can be used as a short-term treatment to help individuals learn to focus on present thoughts and beliefs.

CBT is used to treat a wide range of conditions, including:

• Anger issues
• Bipolar disorder
• Eating disorders
• Panic attacks
• Personality disorders

In addition to mental health conditions, cognitive behavioral therapy has also been found to help people cope with:

• Chronic pain or serious illnesses
• Divorce or break-ups
• Grief or loss
• Low self-esteem
• Relationship problems
• Stress management

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Benefits of Cognitive Behavioral Therapy

The underlying concept behind CBT is that thoughts and feelings play a fundamental role in behavior. For example, a person who spends a lot of time thinking about plane crashes, runway accidents, and other air disasters may avoid air travel as a result.

The goal of cognitive behavioral therapy is to teach people that while they cannot control every aspect of the world around them, they can take control of how they interpret and deal with things in their environment.

CBT is known for providing the following key benefits:

• It helps you develop healthier thought patterns by becoming aware of the negative and often unrealistic thoughts that dampen your feelings and moods.
• It is an effective short-term treatment option as improvements can often be seen in five to 20 sessions.
• It is effective for a wide variety of maladaptive behaviors.
• It is often more affordable than some other types of therapy .
• It is effective whether therapy occurs online or face-to-face.
• It can be used for those who don't require psychotropic medication .

One of the greatest benefits of cognitive behavioral therapy is that it helps clients develop coping skills that can be useful both now and in the future.

Effectiveness of Cognitive Behavioral Therapy

CBT emerged during the 1960s and originated in the work of psychiatrist Aaron Beck , who noted that certain types of thinking contributed to emotional problems. Beck labeled these "automatic negative thoughts" and developed the process of cognitive therapy. 

Where earlier behavior therapies had focused almost exclusively on associations, reinforcements , and punishments to modify behavior, the cognitive approach addresses how thoughts and feelings affect behaviors.

Today, cognitive behavioral therapy is one of the most well-studied forms of treatment. It has been shown to be effective in the treatment of a range of mental conditions, including anxiety, depression, eating disorders, insomnia, obsessive-compulsive disorder , panic disorder, post-traumatic stress disorder , and substance use disorder.

• Research indicates that cognitive behavioral therapy is the leading evidence-based treatment for eating disorders .
• CBT has been proven helpful in those with insomnia, as well as those who have a medical condition that interferes with sleep, including those with pain or mood disorders such as depression.
• Cognitive behavioral therapy has been scientifically proven to be effective in treating symptoms of depression and anxiety in children and adolescents.
• A 2018 meta-analysis of 41 studies found that CBT helped improve symptoms in people with anxiety and anxiety-related disorders, including obsessive-compulsive disorder and post-traumatic stress disorder.
• Cognitive behavioral therapy has a high level of empirical support for the treatment of substance use disorders, helping people with these disorders improve self-control , avoid triggers, and develop coping mechanisms for daily stressors.

CBT is one of the most researched types of therapy, in part, because treatment is focused on very specific goals and results can be measured relatively easily.

Verywell Mind's Cost of Therapy Survey , which sought to learn more about how Americans deal with the financial burdens associated with therapy, found that Americans overwhelmingly feel the benefits of therapy:

• 80% say therapy is a good investment
• 91% are satisfied with the quality of therapy they receive
• 84% are satisfied with their progress toward mental health goals

Things to Consider With Cognitive Behavioral Therapy

There are several challenges that people may face when engaging in cognitive behavioral therapy. Here are a few to consider.

Change Can Be Difficult

Initially, some patients suggest that while they recognize that certain thoughts are not rational or healthy, simply becoming aware of these thoughts does not make it easy to alter them.

CBT Is Very Structured

Cognitive behavioral therapy doesn't focus on underlying, unconscious resistance to change as much as other approaches such as  psychoanalytic psychotherapy . Instead, it tends to be more structured, so it may not be suitable for people who may find structure difficult.

You Must Be Willing to Change

For cognitive behavioral therapy to be effective, you must be ready and willing to spend time and effort analyzing your thoughts and feelings. This self-analysis can be difficult, but it is a great way to learn more about how our internal states impact our outward behavior.

Progress Is Often Gradual

In most cases, CBT is a gradual process that helps you take incremental steps toward behavior change . For example, someone with social anxiety might start by simply imagining anxiety-provoking social situations. Next, they may practice conversations with friends, family, and acquaintances. By progressively working toward a larger goal, the process seems less daunting and the goals easier to achieve.

How to Get Started With Cognitive Behavioral Therapy

Cognitive behavioral therapy can be an effective treatment choice for a range of psychological issues. If you or someone you love might benefit from this form of therapy, consider the following steps:

• Consult with your physician and/or check out the directory of certified therapists offered by the National Association of Cognitive-Behavioral Therapists to locate a licensed professional in your area. You can also do a search for "cognitive behavioral therapy near me" to find local therapists who specialize in this type of therapy.
• Consider your personal preferences , including whether face-to-face or online therapy will work best for you.
• Contact your health insurance to see if it covers cognitive behavioral therapy and, if so, how many sessions are covered per year.
• Make an appointment with the therapist you've chosen, noting it on your calendar so you don't forget it or accidentally schedule something else during that time.
• Show up to your first session with an open mind and positive attitude. Be ready to begin to identify the thoughts and behaviors that may be holding you back, and commit to learning the strategies that can propel you forward instead.

What to Expect With Cognitive Behavioral Therapy

If you're new to cognitive behavioral therapy, you may have uncertainties or fears of what to expect. In many ways, the first session begins much like your first appointment with any new healthcare provider.

During the first session, you'll likely spend some time filling out paperwork such as HIPAA forms (privacy forms), insurance information, medical history, current medications, and a therapist-patient service agreement. If you're participating in online therapy, you'll likely fill out these forms online.

Also be prepared to answer questions about what brought you to therapy, your symptoms , and your history—including your childhood, education, career, relationships (family, romantic, friends), and current living situation.

Once the therapist has a better idea of who you are, the challenges you face, and your goals for cognitive behavioral therapy, they can help you increase your awareness of the thoughts and beliefs you have that are unhelpful or unrealistic. Next, strategies are implemented to help you develop healthier thoughts and behavior patterns.

During later sessions, you will discuss how your strategies are working and change the ones that aren't. Your therapist may also suggest cognitive behavioral therapy techniques you can do yourself between sessions, such as journaling to identify negative thoughts or practicing new skills to overcome your anxiety .

If you are having suicidal thoughts, contact the  National Suicide Prevention Lifeline  at  988 for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911.

For more mental health resources, see our  National Helpline Database .

Hofmann SG, Asnaani A, Vonk IJ, Sawyer AT, Fang A. The efficacy of cognitive behavioral therapy: A review of meta-analyses . Cognit Ther Res . 2012;36(5):427-440. doi:10.1007/s10608-012-9476-1

Merriam-Webster. Cognitive behavioral therapy .

Rnic K, Dozois DJ, Martin RA. Cognitive distortions, humor styles, and depression . Eur J Psychol. 2016;12(3):348-62. doi:10.5964/ejop.v12i3.1118

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

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

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

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

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

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

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

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

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

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

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

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

Beck JS. Cognitive Behavior Therapy: Basics and Beyond .

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

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

Effective problem-identification and problem-solving in counselling – in 4 steps

By Author Elly Prior

Posted on Published: 24-09-2010  - Last updated: 10-07-2022

Categories Counselling and therapy

Discover how to identify and address your (or your client’s ) problems effectively

You’re searching out information about problem-solving in counselling as a beginning therapist or as a client. I’ve got you either way.

What qualifies me to write about problem-solving skills in the counselling process?

Well, I’ve 24 years experiences in counselling – you can find out about my counselling/therapy journey on my About page .

It’s my aim to walk you through my strategy for problem-identification and solving problems in the counselling process.

If you’re here as a client, please note, that the steps below are only a small and specific part of how a therapist might help you in counselling. There’s much more to being an effective counsellor!

Nevertheless, problem-solving is an essential part of the counselling process.

As a therapist, you’ll want to know how to deal with challenges in the client-counsellor relationship as well as helping a client to deal with their particular issues.

Let’s start with taking a look at why effective problem-identification is so important…

Identifying the problem

Uncovering essential information as part of your problem-solving strategy in counselling will prevent you from:

• solving only part of the problem and the real problem rearing it’s ugly head again in the future
• solving a problem that’s really only a diversion – a red herring.
• solving a problem that’s only a symptom of an underlying issue
• misusing your resources (usually your imagination!) or leaving vital resources unused
• becoming too absorbed and emotional reducing your ability to consider the problem in a wider context.

Abstract and over-generalised thinking causes minor issues to appear much bigger than they really are. And, significant problems are more likely to appear unmanageable.

Self-hypnosis to improve critical thinking

Self-hypnosis is not only effective in reducing stress.

You can amplify your critical thinking with the Improve Your Critical Thinking hypnosis download.

Get all your questions about hypnosis answered – see my article Hypnotherapy online FAQ page .

Problem-solving skills in counselling

As a therapist or counsellor you need to be adept at problem-solving skills before you can teach and empower a client to solve their own problems.

Whether or not you are a (beginning) therapist, here’s what I would do…

As human beings, the more emotional we are, the more limited our thinking becomes. We get stuck through black and white thinking. Not very helpful if we need to identify and analyse a problem!

My first strategy, therefore, is to calm yourself with a breathing exercise. You’ll find one in my article Uncommon stress relief tips .

(As a therapist, I would, of course, have already established rapport with my client.)

Abstract and over-generalised thinking causes minor issues to appear much bigger than they really are.

Familiarise yourself with your essential emotional needs and your innate resources – the human givens (article includes a free worksheet). In other words, get back to the basics – know what you were born with.

When you can meet your essential needs in balance, making good use of your inborn resources, you and your loved ones are much more likely to thrive.

These two steps should ideally form the basis of your problem-solving strategy in counselling.

Case study of the application of my problem-solving strategy

The case study below is an example of how a sense of calmness and careful examination of the problem simply made it disappear.

My client here was a young person in college but the problem-solving strategy could be applied to any situation.

Limited thinking – a case study

Jenny was unhappy, hated college, and decided she was going to change colleges after her exams. She didn’t want to do the all-important final two years where she was currently studying. Jenny was the victim of emotional, black and white thinking.

First, I spent some time calming her right down with some breathing exercising while having her imagine being in beautiful surroundings (our imagination is an inborn resource!).

Next, when she was in a much calmer state of mind, we examined all the factors that had created the problem.

I helped her to think clearly by asking pertinent questions (see steps below). We explored what precisely she thought was so awful and how often she was troubled by that.

I also asked her who and what she liked and valued.

What was the exact problem that had lead her to want to move college?

Well, there were three separate problems.

She disliked two teachers, one of whom she only saw for one hour a week. She found one subject really hard but hadn’t asked for help. She had fallen out with a friend but had already made new friends.

The real problem was her perception of the situation and the high level of emotions.

In a calm state, she was able to see things in a different light and the problem was solved.

Much to her surprise, she found that in reality things were not so bad after all and she was happy to stay. The situation hadn’t changed, but her perception of it had.

Problem-identification in the counselling process

Step 1: identify the problem by gathering essential information.

The real problem may actually be very different from the one you think you have! Take your time with my problem-solving techniques – there’s no need to rush the steps.

Don’t even worry if it takes you several days to answer the questions – think of this as a project and a new start.  So why not pour yourself a drink, kick off your shoes and get started…

Take a big sheet of paper, draw a circle for each of the contributing factors and write in the details to start off your problem-solving steps:

Identify the timing

• When exactly does the problem occur?
• When exactly is it at its worst?
• When does it not occur?
• Can you identify a pattern from this information?

Identify the place

• Where exactly does the problem mostly occur?
• Where does it not occur?
• Can you identify a pattern?

Identify the sequence in the process

• What exactly happens before the problem occurs?
• How exactly does the problem start?
• What happens that causes the problem to continue?
• What exactly was your train of thought?
• What are you doing/feeling/seeing/hearing?

Gather information about other people

Friend or foe – how are they detracting from or contributing to your problem?

• What significant people are present or absent when the problem occurs?
• What do others/your partner/friend/colleague/family think about the problem?
• Who doesn’t know about the problem and should know?
• What do you anticipate they might think when they find out?
• Can one of them play devil’s advocate to give you a completely different perspective?
• Can you identify a pattern from the information you’ve gathered?

Become clear about your (client’s) role

• What part of the problem is for you to sort out and no-one else?
• What do you think are your personal weaknesses?
• What evidence of those do you have?
• What actions can you take to turn those weaknesses into strengths?
• Are you able to separate yourself from the problem by giving it a colour, name or shape?
• What part of the problem do you actually have (some) control over? 
• What assumptions did you make when you previously tried to sort out this problem?
• Do you need help with the problem?

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Problem-solving in the counselling process

A hugely important part of my counselling process was to identify my client’s resources.

Identify your (client’s) resources and strengths

The most important aspect of any problem-solving strategy is to take stock of your personal resources for solving the problem(s).

• What parts of your role as a partner/colleague/employee/friend are working well?
• What evidence do you have for that?
• What exactly are you doing that makes it work well?
• What skills and resources do you use in your spare time and at work?
• What are your achievements? (These could be large one-offs or simple everyday ones, e.g. passing your driving test, getting your PhD or cooking a meal)
• Who has solved a similar problem? How did they do it?
• Who can help and/or advise you whilst remaining objective?
• Who can support and encourage you whilst remaining objective?
• Who do you admire? And how do you imagine they might have solved the problem?
• What would you consider to be life’s little treats? (e.g. a hot bath, first flowers in spring, looking at art, reading an inspiring book, etc.) It’s vital to be aware of what would make you feel good, what you consider to be a reward when you want to recharge your energy.

Beyond the problem

• What would you be doing/concentrating on if you didn’t have this particular problem right now?
• How exactly would you and/or the situation be different?
• What would your friends/family/colleagues notice about you/the situation?
• What would happen if you just ignored the problem?
• Could you view the present situation as an alternative solution, even though it’s clearly not ideal?
• Are there any possible benefits of the situation?
• Can you make any other changes, without having to solve the problem first?
• How would you ideally like it to end?
• What small steps can you take towards an eventual solution or part-solution?
• What can you do today that will make a difference tomorrow?
• Are there any other opportunities to turn a negative in a positive?
• What will you settle for if all else fails?

Solving problems in counselling

Step 2: analyse and identify the exact problem.

You’ll have already gathered specific details about the problem(s).

So, take a deep breath, have a break and make yourself another drink. Then we can continue problem-identification in the counselling process …

• Decide on your headings: either for every aspect of that one problem or for all of the  different  problems. Break things up into smaller parts if necessary
• Draw a mind map or flow-chart, or  draw  the problem in  whatever  way makes sense to you
• Include your resources (i.e. your strengths and capabilities) under each heading
• Think about whose problem it really is – it might not be yours… but do be honest with yourself
• Write a short statement about how you feel about the problem and what exactly it is (this will help you to communicate more effectively with others)

How to solve problems in the counselling process

Step 3: solving the problem(s).

The tree which moves some to tears of you, is in the eyes of others merely a green thing that stands in the way.” William Blake

The next strategy is to devise a solution – finally!

10-point problem-solving plan

• Decide what the ideal solution for you would be.
• Decide what you can live with.
• Decide on an alternative solution.
• Decide on the steps you can take right now to bring about some change. This will help you to feel more positive and in control.
• Decide who you need to ask for help.
• Decide what you think other people might need from you and check with them.
• Decide who you need to have a conversation with, what you would say and when that might be possible.
• Make a list with exact timings of your planned actions. This is one of the most important techniques.
• Set a review date to hold yourself (and maybe others) to account.
• Sleep on it, but have a notepad by the side of your bed. Just as you drift off you may come up with a brilliant idea. If you don’t write it down there and then, you’ll probably have forgotten by the morning!

You’ve now identified exactly what the problems and potential solutions are. Perhaps you’ve even broken them up into smaller parts.  

The next step is to deal with the smallest (or easiest) one first, to help build your confidence.

Alternatively, you can decide to go for the big one the moment you get out of bed and … get it done!

Related articles

• How to fix common relationship problems
• How to fix a broken marriage
• 23 reasons why you’re feeling anxious ‘for no reason’
• 19 reasons you’re stressed ‘for no reason’
• How to deal with depression without drugs

You may also be interested in:

• Free printable PDF of my list with emotions and feelings
• How to start your own therapy or counselling website
• Multiple types of nonverbal communication
• Free printable stress management worksheets

Step 4 – Review your problem-solving strategies

There’s no point in having a plan with problem-solving strategies if you don’t take the time to review it.

As a counsellor, I would use the following counselling sessions to keep track of my client’s progress, of course.

If you’re working by yourself, you’ll need to also check your progress against your action points and their respective dates. 

The following questions will help you to mark the progress you’ve made…

• What precise steps have you taken to solve the problem (or even just part of it)?
• Which strategies were successful and which were less so?
• What should you continue to do? (i.e. what works!)
• What parts of the plan could do with an update?
• Are other people keeping to their side of the bargain?
• What can you do to encourage or remind them?
• Set another review date.

There is no failure, only feedback!

The above problem-solving strategies in counselling can stop you from getting stuck and becoming overwhelmed.

Once you’ve got a robust process in place, you’ll be able to work through any problem you encounter now and in the future.

All you have to remember is to stay calm, ask the right questions, and draw on your innate resources to make your solutions a reality.

You’ve got this!

• Individual online therapy
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Click the button and…

Other Helpful Links

The Six Types of Socratic Questions

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Intervention & Strategies in Counseling and Psychotherapy

DOI link for Intervention & Strategies in Counseling and Psychotherapy

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Psychology has recently shifted toward a phenomological approach closely aligned with theories originally put forth by noted psychologist Alfred Adler. However, modern approaches are often presented in a language that differs from the original theories, with no acknowledgment to the contributions of Adler. Interventions and Strategies in Counseling and Psychotherapy corrects this oversight, illustrating the many ways in which Adlerian ideas underpin and influence contemporary therapeutic approaches. Original chapters by leading thinkers in the field address the practice of counseling and psychotherapy from a social-cognitive perspective and logically combine classic Adlerian theories with proven and effective methods from other approaches. The book covers a wide range of topics including play therapy, parent education, couples therapy, and problem-solving counseling. This book is essential reading not only for Adlerian psychologists, but also counselors, psychologists, and psychotherapists of any theoretical stripe who wish to keep their practical skills up-to-date. It is also of use to graduate and doctoral students enrolled in counseling and psychology programs.

TABLE OF CONTENTS

Chapter | 13  pages, the vision of adler, chapter | 16  pages, brief therapy strategies and techniques, chapter | 12  pages, problem-solving counseling, chapter | 15  pages, hypnotherapy, chapter | 27  pages, clinical therapy, couple therapy, chapter | 34  pages, family therapy, chapter | 26  pages, open–forum family counseling, chapter | 19  pages, play therapy, chapter | 11  pages, parenting education, chapter | 14  pages, the integration of dsm–iv diagnoses and adlerian psychotherapy, chapter | 24  pages, the scientific study of adlerian theory.

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• 22 Best Counseling Interventions & Strategies for Therapists

65+ Counseling Methods & Techniques to Apply With Your Clients

Hedonic vs. Eudaimonic Wellbeing: How to Reach Happiness

22 Best Counseling Interventions & Strategies for Therapists

22 Best Counseling Interventions & Strategies for Therapists – When individuals arrive for counseling, they typically seek change , clarity, advice, and help to overcome their difficulties.

Counseling is highly beneficial, with “far-reaching effects in life functioning” (Cochran & Cochran, 2015, p. 7).

While therapeutic relationships are vital to a positive outcome, so too are the selection and use of psychological interventions targeting the clients’ capability, opportunity, motivation, and behavior (Michie et al., 2014).

This article introduces some of the best interventions while identifying the situations where they are likely to create value for the client, helping their journey toward meaningful, value-driven goals.

What Is a Counseling Intervention?

“Changing ingrained behavior patterns can be challenging” and must avoid or at least reduce the risk of reverting (Michie et al., 2014, p. 11).

The American Psychological Association (n.d., para. 1) describes an intervention as “any action intended to interfere with and stop or modify a process, as in treatment undertaken to halt, manage, or alter the course of the pathological process of a disease or disorder.”

Interventions are intentional behaviors or “change strategies” introduced by the counselor to help clients implement problem management and move toward goals (Nelson-Jones, 2014):

• Counselor-centered  interventions are where the counselor does something to or for the client, such as providing advice.
• Client-centered  interventions empower the client, helping them develop their capacity to intervene in their own problems (for example, monitoring and replacing unhelpful thinking).

Creating or choosing the most appropriate intervention requires a thorough assessment of the client’s behavioral targets, what is needed, and how best to achieve them (Michie et al., 2014).

The selection of the intervention is guided by the:

• Nature of the problem
• Therapeutic orientation of the counselor
• Willingness and ability of the client to proceed

During counseling, various interventions are likely to be needed at different times. For that reason, counselors will require a broad range of techniques that fit the client’s needs, values, and culture (Corey, 2013).

In recent years, an increased focus has been on the use of evidence-based practice, where the choice and use of interventions is based on the best available research to make a difference in the lives of clients (Corey, 2013).

List of Popular Therapeutic Interventions

Various therapeutic interventions can be beneficial at different points in the treatment, depending on the client’s needs.

“Clients are hypothesis makers and testers” who have the reflective capacity to think about how they  think  (Nelson-Jones, 2014, p. 261).

Helping clients attend to their thoughts and learn how to instruct themselves more effectively can help them break repetitive patterns of  insufficiently strong mind skills  while positively influencing their feelings.

The following list includes some of the most popular interventions used in a variety of therapeutic settings (modified from Magyar-Moe et al., 2015; Sommers-Flanagan & Sommers-Flanagan, 2015; Cochran & Cochran, 2015; Corey, 2013):

Detecting and disputing demanding rules

Rigid, demanding thinking is identified by ‘musts,’ ‘oughts,’ and ‘shoulds’ and is usually unhelpful to the client.

For example:

I must do well in this test, or I am useless. People must treat me in the way I want; otherwise, they are awful.

Clients can be helped to dispute such thinking using “reason, logic, and facts to support, negate or amend their rules” (Nelson-Jones, 2014, p. 265).

Such interventions include:

• Functional disputing Pointing out to clients that their thinking may stand in the way of achieving their goals
• Empirical disputing Encouraging clients to evaluate the facts behind their thoughts
• Logical disputing Highlighting the illogical jumps in their thinking from preferences to demands
• Philosophical disputing Exploring clients’ meaning and satisfaction outside of life issues

Identifying automatic perceptions

Our perceptions greatly influence how we think. Clients can benefit from recognizing they have choices in how they perceive things and avoiding jumping to conclusions.

• Creating self-talk Self-talk can be helpful for most clients and can target anger management, stress handling, and improving confidence. For example:

This is not the end of the world. I’ve done this before; I can do it well again.

• Creating visual perceptions Building on the client’s existing visual images can be helpful in understanding and working through problematic situations (and their solutions).

One simple exercise to help clients see the strong relationship between visualizing and feeling involves asking clients to think of someone they love. Almost always, they form a mental image along with a host of feelings.

Visual relaxation is a powerful self-helping skill involving clients taking time out of their busy life to find calm through vividly picturing a real or imagined relaxing scene.

Creating better expectations

Clients’ explanatory styles (such as expecting to fail) can create self-fulfilling prophecies. Interventions can help by:

• Assessing the likelihood of risks or rewards
• Increasing confidence in the potential for success
• Identifying coping skills and support factors
• Time projection Imagery can help by enabling the client to step into a possible future where they manage and overcome difficult times or worrying situations.

For example, the client can imagine rolling forward to a time when they are successful in a new role at work or a developing relationship.

Creating realistic goals

Goals can motivate clients to improve performance and transition from where they are now to where they would like to be. However, it is essential to make sure they are realistic, or they risk causing undue pressure and compromising wellbeing.

The following interventions can help (Nelson-Jones, 2014):

• Stating clear goals The following questions are helpful when clients are setting goals:

Does the goal reflect your values? Is the goal realistic and achievable? Is the goal specific? Is the goal measurable? Does the goal have a timeframe?

Helping clients to experience feelings

Counseling can influence clients’ emotions and their physical reactions to emotions by helping them (Nelson-Jones, 2014):

• Experience feelings
• Express feelings
• Manage feelings
• Empty chair dialogue This practical intervention involves the client engaging in an imaginary conversation with another person; it helps “clients experience feelings both of unresolved anger and also of weakness and victimization” (Nelson-Jones, 2014, p. 347).

The client may be asked to shift to the empty chair and play the other person’s part to explore conflict, interactions, and emotions more fully (Corey, 2013).

How to Craft a Treatment Plan 101

“Counselors and counseling trainees make choices both concerning specific interventions and about interventions used in combination” (Nelson-Jones, 2014, p. 223).

Through early and continued engagement with the client throughout the counseling approach, the counselor and client set specific, measurable, and achievable goals and create a treatment plan with a defined intervention strategy (Dobson, 2010).

The  treatment plan  becomes a map, combining interventions to reach client goals and overcome problems – to get from where they are now to where they want to be. However, no plan should be too fixed or risk preventing the client’s progress in their ‘wished-for’ direction. Rather, it must be open for regular revisit and modification (Nelson-Jones, 2014).

Counseling and therapeutic treatment plans vary according to the approaches used and the client’s specific needs but should be strength-based and collaborative. Most treatment plans typically consider the following points (modified from GoodTherapy, 2019):

• History and assessment  – E.g., psychosocial history, symptom onset, past and present diagnoses, and treatment history
• Present concerns  – The current concerns and issues that led the client to counseling
• Counseling contract  – A summary of goals and desired changes, responsibility, and the counseling approach adopted
• Summary of strengths  – It can be helpful to summarize the client’s strengths, empowering them for goal achievement.
• Goals  – Measurable treatment goals are vital to the treatment plan.
• Objectives  – Goals are broken down into smaller, achievable outcomes that support achievement during counseling.
• Interventions  – Interventions should be planned early to support objectives and overall goals.
• Tracking progress and outcomes  – Regular treatment plan review should include updating progress toward goals.

While a vital aspect of the counseling process is to ensure that treatment takes an appropriate direction for the client, it is also valuable and helpful for clients and insurance companies to understand likely timescales.

13 Helpful Therapy Strategies

While there are many counseling strategies and interventions available, some have particular value in dealing with clients presenting specific (and combined) issues, including the following.

“Depression is one of the most common mental health disorders with a high burden of disease and the leading cause of years of life lost due to disability” (Hu et al., 2020, p. 1).

• Exercise interventions Research has shown that even low-to-moderate levels of exercise can help manage and treat depression (Hu et al., 2020).
• Gratitude Practicing gratitude can profoundly affect how we see our lives and those around us. Completing gratitude journals and reviewing three positive things that have happened at the end of the day have been shown to decrease depression and promote wellbeing (Shapiro, 2020).
• Behavioral activation Scheduling activities that result in positive emotions can help manage and overcome depression (Behavioral Activation for Depression, n.d.).

Anxiety can stop clients from living their lives fully and experiencing positive emotions. Many interventions can help, including:

• Understanding your anxiety triggers Interoceptive exposure techniques focus on reproducing sensations associated with anxiety and other difficult emotions. Clients benefit from learning to identify anxiety triggers, behavioral changes, and associated bodily sensations (Boettcher et al., 2016).
• Using a building image Clients are asked to form a mental image of themselves as a building. Their description of its state of repair and quality of foundation provides helpful insight into the client’s wellbeing and degree of anxiety (Thomas, 2016).

Grief therapy

Grief therapy helps clients accept reality, process the pain, and adjust to a new world following the loss of a loved one. Several techniques can help, including (modified from (Worden, 2018):

• Creating memory books Compiling a memory book containing photographs, memorabilia, stories, and poems can help families come together, share their grief, and reminisce.
• Directed imagery Like the ‘empty chair’ technique, through imagining the missing loved one in front of them, the grieving person is given the opportunity to talk to them.

Substance abuse

“There has been significant progress and expansion in the development of evidence-based psychosocial treatments for substance abuse and dependence” (Jhanjee, 2014, p. 1). Psychological interventions play a growing role in disorder treatment programs; they include:

• Brief optimistic interventions Brief advice is delivered following screening and assessment to at-risk individuals to reduce drinking and other harmful activities.
• Motivational interviewing This technique involves using targeted questioning while expressing empathy through reflective listening to resolve client ambivalence about their substance abuse.

Marriage therapy

Interventions are a vital aspect of marriage therapy, often targeting communication skills, problem-solving, and taking responsibility (Williams, 2012).

They can include the following interventions:

• Taking responsibility It is vital that clients take responsibility for their actions within a relationship. The counselor will work with the couple, asking the following questions, as required (modified from Williams, 2012):

How have you contributed to the relationship’s problems? What changes are needed to improve the relationship? Are you willing to make the changes needed?

• Create an action plan Once the couple agrees, the changes will be combined into a plan, with specific actions to help them achieve their goal.

Helping cancer patients

“There is no evidence to suggest that having counseling will help treat or cure your cancer”; however, it may help with coping, relationship issues, and dealing with practical problems (Cancer Research UK, 2019, para. 16).

Several counseling interventions that have proven helpful with the psychological burden include (Guo et al., 2013):

• Psychoeducation Sharing the importance of mental wellbeing and coping with the client and involving them in their cancer treatment can reduce anxiety and improve confidence.
• Cognitive-Behavioral Therapy Replacing incorrect or unhelpful beliefs can help the client achieve a more positive outlook regarding the treatment.

Interventions & Strategies for Career Counseling

Career counselors help individuals or groups cope more effectively with career concerns, including (Niles & Harris-Bowlsbey, 2017):

• Career choice
• Managing career changes and transitions
• Job-related stress
• Looking for a job

While there are many interventions and strategies, the following are insightful and effective:

• Creating narratives Working with clients to build personal career narratives can help them see their movement through life with more meaning and coherence and better understand their decisions. Such an intervention can be valuable in looking forward and choosing the next steps.
• Group counseling Multiple group sessions can be arranged to cover different aspects of career-related issues and related emotional issues. They may include role-play or open discussion around specific topics.

2 Best Interventions for Group Counselors

Group sessions in counseling either involve individual members bringing topics for discussion to share with others or are psychoeducational, where the entire group discusses a subject.

The ultimate goals are usually to “help group members respond to each other with a combination of therapeutic attending, and sharing their own reactions and related experiences” (Cochran & Cochran, 2015, p. 329).

Examples of group interventions include:

• Circle of friends This group intervention involves gathering a child’s peers into a circle of friendly support to encourage and help them with problem-solving. The intervention has led to increased social acceptance of children with special needs (Magyar-Moe et al., 2015).
• Group mindfulness Mindfulness in group settings has been shown to be physically and mentally beneficial (Shapiro, 2020). New members may start by performing a body-scan meditation where they bring awareness to each part of their body before turning their attention to their breathing.

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Defining the Counseling Process and Its Stages

The process begins with exploring the challenges a client faces before assisting them in resolving developmental and situational difficulties (Sajjad, 2017).

The counselor supports clients with physical, emotional, and mental health issues, helping them resolve crises, reduce feelings of distress, and improve their sense of wellbeing (American Psychological Association, 2008).

When successful, treatment can change how a client thinks, feels, and behaves regarding an upsetting experience or situation (Krishnan, n.d.).

This article explores what counseling is and is not, and the stages and steps involved in a successful outcome.

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This Article Contains

Defining the counseling process, the stages of the counseling process, 7 steps in the counseling process, real-life examples of the counseling phases, 12 valuable skills for each phase, a look at the process in group counseling, a take-home message, frequently asked questions.

All of us will, occasionally, take on the role of counselor. We informally offer family, friends, and colleagues advice regarding their relationships, finances, career, and education.

On the other hand, “a professional counselor is a highly trained individual who is able to use a different range of counseling approaches with their clients” (Krishnan, n.d., p. 5).

Counseling as a profession involves (Krishnan, n.d.):

• Dedicated time set aside to explore difficulties, stressful situations, or emotional upset faced by a client
• Helping that client see their situation and feelings from a different viewpoint, potentially to facilitate change
• Building a relationship based on trust and confidentiality

The counseling process should not include:

• Providing advice
• Being judgmental
• Pushing the counselor’s values
• Encouraging the client to behave as the counselor would in their own life
• Emotional attachment between the counselor and client

According to the American Psychological Association (2008), counseling psychologists “help people with physical, emotional and mental health issues improve their sense of wellbeing, alleviate feelings of distress and resolve crises.”

Counseling works with clients from childhood through to old age, focusing on “developmental (lifespan), environmental and cultural perspectives,” including (American Psychological Association, 2008):

• Issues and concerns in education and career
• Decisions regarding school, work, and retirement transitions
• Marital and family relationship difficulties
• Managing stressful life events
• Coping with ill health and physical disability
• Mental disorders
• Ongoing difficulties with getting along with people in general

While we often see counseling and psychotherapy as interchangeable, there are subtle distinctions. Counseling is typically short term, dealing with present issues and involving a helping approach that “highlights the emotional and intellectual experience of a client,” including how they feel and think about a problem or concern (Krishnan, n.d., p. 6).

Psychotherapy is often a longer term intensive treatment, helping the client overcome profound difficulties resulting from their psychological history and requiring them to return to earlier experiences (Krishnan, n.d.; Australia Counselling, n.d.).

The counseling process has been described as both an art and a science, helping to bring about changes in thought, emotion, and behavior in the client (Sajjad, 2017).

Counselors and clients must both be aware that the counseling process requires patience. There is rarely a quick fix, and things may need to get worse before they get better. In addition, the counseling process is collaborative. The counselor does not fix the client; the work requires interaction and commitment from both parties (Krishnan, n.d.).

The counseling process is a planned and structured dialogue between client and counselor. The counselor is a trained and qualified professional who helps the client identify the source of their concerns or difficulties; then, together, they find counseling approaches to help deal with the problems faced (Krishnan, n.d.).

Hackney and Cormier (2005) propose a five-stage model for defining the counseling process through which both counselor and client move (Krishnan, n.d.).

Stage one: (Initial disclosure) Relationship building

The counseling process begins with relationship building . This stage focuses on the counselor engaging with the client to explore the issues that directly affect them.

The vital first interview can set the scene for what is to come, with the client reading the counselor’s verbal and nonverbal signals to draw inferences about the counselor and the process. The counselor focuses on using good listening skills and building a positive relationship.

When successful, it ensures a strong foundation for future dialogue and the continuing counseling process.

Stage two: (In-depth exploration) Problem assessment

While the counselor and client continue to build a beneficial, collaborative relationship, another process is underway: problem assessment .

The counselor carefully listens and draws out information regarding the client’s situation (life, work, home, education, etc.) and the reason they have engaged in counseling.

Information crucial to subsequent stages of counseling includes identifying triggers, timing, environmental factors, stress levels, and other contributing factors.

Stage three: (Commitment to action) Goal setting

Effective counseling relies on setting appropriate and realistic goals, building on the previous stages. The goals must be identified and developed collaboratively, with the client committing to a set of steps leading to a particular outcome.

Stage four: Counseling intervention

This stage varies depending on the counselor and the theories they are familiar with, as well as the situation the client faces.

For example, a behavioral approach may suggest engaging in activities designed to help the client alter their behavior. In comparison, a person-centered approach  seeks to engage the client’s self-actualizing tendency.

Stage five: Evaluation, termination, or referral

Termination may not seem like a stage, but the art of ending the counseling is critical.

Drawing counseling to a close must be planned well in advance to ensure a positive conclusion is reached while avoiding anger, sadness, or anxiety (Fragkiadaki & Strauss, 2012).

Part of the process is to reach an early agreement on how the therapy will end and what success looks like. This may lead to a referral if required.

While there are clear stages to the typical counseling process, other than termination, each may be ongoing. For example, while setting goals, new information or understanding may surface that requires additional assessment of the problem.

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Many crucial steps go together to form the five stages of the counseling process. How well they are performed can affect the success of each stage and overall outcome of counseling (Krishnan, n.d.).

Key steps for the client

The client must take the following four steps for counseling to be successful (Krishnan, n.d.):

• Willingness Being willing to seek and attend counseling is a crucial step for any individual. It involves the recognition that they need to make changes and require help to do so. Taking the next action often involves overcoming the anxiety of moving out of the comfort zone and engaging in new thinking patterns and behaviors.
• Motivation Being willing to make changes and engage in them involves maintaining and sustaining motivation. Without it, the counseling process will falter when the real work begins.
• Commitment The client may be willing and motivated, but change will not happen without continued patience and commitment. Commitment may be a series of repeating decisions to persist and move forward.
• Faith Counseling is unlikely to succeed unless the client has faith in themselves, the counselor, and the process. Taking the step to begin and continue with counseling requires the belief that it can be successful.

Key steps for the counselor

Each step in the counseling process is vital to forming and maintaining an effective counselor–client relationship. Together they support what Carl Rogers (1957) describes as the core conditions for successful therapy:

• Unconditional positive regard Through acceptance and nonjudgmental behavior, the therapist makes space for the needs of the client and treats them with dignity. For more on developing this, we have these Unconditional Positive Regard worksheets , which may prove helpful.
• Empathy The counselor shows genuine understanding, even if they disagree with the client.
• Congruence The words, feelings, and actions of the counselor embody consistency.

Counselors often help clients make important and emotional decisions in their lives. To form empathy, they must intimately take part in the client’s inner realm or inscape .

Several well-performed steps can help the counselor engage with the client and ensure they listen openly, without judgment or expectation. The counselor must work on the following measures to build and maintain the relationship with the client (Krishnan, n.d.):

• Introduce themselves clearly and with warmth.
• Invite the client to take a seat.
• Address the client by the name they are most comfortable with.
• Engage in relaxed social conversation to reduce anxiety.
• Pay attention to nonverbal communication to identify the client’s emotional state.
• Invite the client using open questions to explain their reason for coming to counseling.
• Allow the client time to answer fully, without pressure.
• Show that they are interested in the client as a person.

Each of the above steps is important. Taken together, they can facilitate the formation of a valuable counseling relationship.

Ultimately, counseling is collaborative and requires a series of ongoing steps – some taken by the client, others by the counselor, and several jointly. For a successful outcome, appropriate resources, time, and focus must be given to each one, and every win must be recognized and used to support the next.

While there are guiding theories and principles, the counselor must make the counseling process specific to the individual.

The following two real-life examples provide a brief insight into the counseling process and richness of the scenarios counselors face.

Lost direction

‘Jenny’ arrived in counseling with little income, no sense of direction, and lacking a sense of control over her life (Fielding, 2014).

The counselor began by forming a picture of her situation and what had led her to that point.

Sessions then moved on to explore Jenny’s beliefs about herself: where they came from, how they affected her, and their appropriateness for current and future circumstances.

A series of brainstorming sessions were used to understand Jenny’s needs, family relationships, and past, and identify her irrational beliefs. Once Jenny uncovered her core beliefs, the counselor worked with her to replace them with more rational ones.

Jenny ended counseling overjoyed with her new preferred beliefs, along with a renewed sense of confidence and control over her life.

Saving a marriage

It is not just individuals who need help, but relationships too. When ‘John’ and ‘Sue-Anne’ attended counseling early on in their marriage, it was because, having lost their group of friends, they found themselves on their own with only each other’s company (Starak, 2010).

Early on in counseling, it became clear that they both needed time to ponder some serious questions, including:

Who am I? What values do I bring to this relationship?

The exercises helped John and Sue-Anne better understand their values, strengths, and what motivated their daily actions. By focusing on what each of them wanted their relationship to look like, they could clarify how much time they wanted to spend together and their roles within the marriage.

The counseling process enabled them to form a shared picture of how their marriage and life would look from now on.

Good communication is vital to all stages of counseling. Skills should ideally include (Krishnan, n.d.; Lesley University, n.d.; American Psychological Association, 2008):

• Active listening techniques
• Clarification
• Effective questioning

Beyond that, to build rapport with the client, counselors must also:

• Be able to experience and show empathy (rather than sympathy)
• See things from the client’s perspective
• Have a genuine interest in others’ wellbeing
• Use self-reflection to observe themselves and empathize with others
• Show accessibility and authenticity during counseling sessions
• Be flexible in their views and thinking regarding differing values and multicultural issues
• Be able to maintain a sense of humor
• Be resilient and able to bounce back from difficult situations

A mental health practitioner delivering positive outcomes in increasingly diverse populations benefits from developing theory, knowledge, and skills.

Partly due to its high degree of success, low cost, and wide availability, group therapy can be a good option for many clients.

It is essential to remember that group therapy is not the same as individual therapy performed within a group setting; it has specific and dedicated techniques and an additional skillset. Unfortunately, however, training has not always kept up with the specialist needs of group therapy (Novotney, 2019).

There are other, unique considerations and processes involved when offering and running group therapy, including being able to (Novotney, 2019):

• Get the right fit Not all clients are suitable for group therapy. They may be better placed in a one-to-one setting. High-quality screening is required to ensure the fit of the individual to the group and vice versa.

The Group Readiness Questionnaire has been designed to identify risk factors and the potential for dropout.

• Explain expectations upfront Individuals’ expectations of group therapy must be realistic. Change takes time, whether in a group or an individual setting. Also, the counselor must educate clients that group therapy is not about shouting and heated exchanges. Sessions can be fun and rewarding.
• Build cohesion quickly The issues being addressed can set the tone of the group and the speed at which it bonds. Grief groups, for example, often form cohesion quickly, while others can take more work and require splitting into smaller groups or pairs.
• Seek feedback Early and regular feedback can help assess how individuals and the group are functioning and whether dropout is likely.
• Identify and address ruptures Group work can lead to disagreements. Concerns and ruptures should be worked through early on, either bringing up issues directly with the members involved or more generally as a group.

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Counseling helps clients by bringing much-needed change to their lives (Sajjad, 2017).

While personal and theoretical approaches may vary, a professional counselor will typically begin by building a relationship with the client before understanding their situation and their reason for seeking help. They can then explore how to move forward and assist the client in changing their thinking, emotional responses, and behavior.

Whether performed individually or as a group, empathy and a collaborative approach are crucial to therapeutic success. The stronger the relationship and the more committed and motivated the client, the more likely a robust and appropriate outcome is reached.

When successful, counseling offers the client the opportunity to change by establishing specific goals, improving their coping skills, promoting decision making, and improving relationships across life domains (Sajjad, 2017).

Time spent gaining knowledge, training, and practicing is vital to gaining the required skills for this challenging yet rewarding profession. In return, mental health professionals have the potential to help people in a wide variety of situations live more productive and satisfying lives.

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

The 10 principles of counseling are:

• Respect for client autonomy
• Empathy and understanding
• Non-judgmental attitude
• Confidentiality
• Cultural sensitivity and competence
• Trust and rapport
• Collaborative approach
• Professional boundaries
• Self-awareness and self-reflection
• Ethical and legal standards

The 5 C’s of counseling refer to the essential qualities that a counselor should possess:

• Competence: possessing the necessary knowledge and skills to effectively help clients
• Compassion: showing empathy and caring for clients
• Confidence: having confidence in oneself and one’s abilities as a counselor
• Connection: building a strong therapeutic relationship with clients
• Character: demonstrating ethical and professional behavior

The golden rule in counseling is to treat others how you would like to be treated. This means being respectful, empathetic, and non-judgmental with clients, and creating a safe and supportive environment for them to explore their issues and concerns. It also means adhering to ethical and professional standards and always acting in the best interest of the client.

• American Psychological Association. (2008). Counseling psychology. Retrieved June 17, 2021, from https://www.apa.org/ed/graduate/specialize/counseling
• Australia Counselling. (n.d.). What’s the difference between counselling and psychotherapy?  Retrieved June 17, 2021, from https://www.australiacounselling.com.au/whats-difference-between-counselling-and-psychotherapy/
• Fielding, L. (2014, November 25). A case of lost direction.  Australian Institute of Professional Counsellors.  Retrieved June 17, 2021, from https://www.aipc.net.au/articles/a-case-of-lost-direction/
• Fragkiadaki, E., & Strauss, S. M. (2012). Termination of psychotherapy: The journey of 10 psychoanalytic and psychodynamic therapists. Psychology and Psychotherapy: Theory, Research and Practice , 85 (3), 335–350.
• Hackney, H., & Cormier, L. S. (2005). The professional counselor: A process guide to helping . Pearson.
• Krishnan, S. (n.d.). The counselling process . Retrieved June 15, 2021, from http://www.dspmuranchi.ac.in/pdf/Blog/stages%20of%20counselling.pdf
• Lesley University. (n.d.). 6 critical skills every counselor should cultivate. Retrieved June 17, 2021, from https://lesley.edu/article/6-critical-skills-every-counselor-should-cultivate
• Novotney, A. (2019). Keys to great group therapy. Monitor on Psychology. Retrieved June 17, 2021, from https://www.apa.org/monitor/2019/04/group-therapy
• Rogers, C. R. (1957). The necessary and sufficient conditions of therapeutic personality change. Journal of Consulting Psychology , 21 , 95–103.
• Sajjad, K. S. M. (2017). Essentials of counseling . Abosar Prokashana Sangstha.
• Starak, Z. (2010, October 6). How to save your marriage by creating a relationship. Australian Institute of Professional Counsellors. Retrieved June 17, 2021, from https://www.aipc.net.au/articles/how-to-save-your-marriage-by-creating-a-relationship/

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Wow u have been helpful with these notes am grateful

I wish to thank you very much for this useful article, which throws more light on both the concept and process of counselling. I am a Guidance – Counsellor in a secondary school where students have a lot of behavioural issues. I believe this article has thrown more light that will help me figure out how best to journey with them.

I loved this article. So precise and to the point and so easy to understand. I am an undergraduate psychology student and needed to study this topic for my exam. From the examination point of view this is perfect.

The theme of Counseling explained in practical and easily understandable language.Respect to the client and unconstitutional positive regard, confidentiality and maintaining professional etiquette must be of prime concern. I am highly benefited.

I love the simplicity, directness and comprehensiveness of this well written article on Counselling. It contains all that’s needed to impart the knowledge and skills of this important and useful process that counselling is.

Well written article and simplest in all forms of understanding. Very useful in imparting knowledge to others

The articles here are very informative and relevant to my work. I am a counseling psychologist from Kenya. I would love to learn more.

This peice is carefully researched and clearly presented in a simple and clear term. I hope this is collectively applied in all areas to solve psychological problems.

Refugee needs counseling to reduce mental tension. I wish I could have such a book. Domestic conflict and violence are rampant in the community.Thanks.(Koboko Uganda)

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What is Cognitive Behavioral Therapy?

Cognitive behavioral therapy (CBT) is a form of psychological treatment that has been demonstrated to be effective for a range of problems including depression, anxiety disorders, alcohol and drug use problems, marital problems, eating disorders, and severe mental illness. Numerous research studies suggest that CBT leads to significant improvement in functioning and quality of life. In many studies, CBT has been demonstrated to be as effective as, or more effective than, other forms of psychological therapy or psychiatric medications.

It is important to emphasize that advances in CBT have been made on the basis of both research and clinical practice. Indeed, CBT is an approach for which there is ample scientific evidence that the methods that have been developed actually produce change. In this manner, CBT differs from many other forms of psychological treatment.

CBT is based on several core principles, including:

• Psychological problems are based, in part, on faulty or unhelpful ways of thinking.
• Psychological problems are based, in part, on learned patterns of unhelpful behavior.
• People suffering from psychological problems can learn better ways of coping with them, thereby relieving their symptoms and becoming more effective in their lives.

CBT treatment usually involves efforts to change thinking patterns. These strategies might include:

• Learning to recognize one’s distortions in thinking that are creating problems, and then to reevaluate them in light of reality.
• Gaining a better understanding of the behavior and motivation of others.
• Using problem-solving skills to cope with difficult situations.
• Learning to develop a greater sense of confidence in one’s own abilities.

CBT treatment also usually involves efforts to change behavioral patterns. These strategies might include:

• Facing one’s fears instead of avoiding them.
• Using role playing to prepare for potentially problematic interactions with others.
• Learning to calm one’s mind and relax one’s body.

Not all CBT will use all of these strategies. Rather, the psychologist and patient/client work together, in a collaborative fashion, to develop an understanding of the problem and to develop a treatment strategy.

CBT places an emphasis on helping individuals learn to be their own therapists. Through exercises in the session as well as “homework” exercises outside of sessions, patients/clients are helped to develop coping skills, whereby they can learn to change their own thinking, problematic emotions, and behavior.

CBT therapists emphasize what is going on in the person’s current life, rather than what has led up to their difficulties. A certain amount of information about one’s history is needed, but the focus is primarily on moving forward in time to develop more effective ways of coping with life.

Source: APA Div. 12 (Society of Clinical Psychology)

• Research article
• Open access
• Published: 26 October 2011

Problem-solving therapy for depression and common mental disorders in Zimbabwe: piloting a task-shifting primary mental health care intervention in a population with a high prevalence of people living with HIV

• Dixon Chibanda 1 ,
• Petra Mesu 2 ,
• Lazarus Kajawu 1 , 2 ,
• Frances Cowan 3 , 4 ,
• Ricardo Araya 5 &
• Melanie A Abas 6  

BMC Public Health volume  11 , Article number:  828 ( 2011 ) Cite this article

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There is limited evidence that interventions for depression and other common mental disorders (CMD) can be integrated sustainably into primary health care in Africa. We aimed to pilot a low-cost multi-component 'Friendship Bench Intervention' for CMD, locally adapted from problem-solving therapy and delivered by trained and supervised female lay workers to learn if was feasible and possibly effective as well as how best to implement it on a larger scale.

We trained lay workers for 8 days in screening and monitoring CMD and in delivering the intervention. Ten lay workers screened consecutive adult attenders who either were referred or self-referred to the Friendship Bench between July and December 2007. Those scoring above the validated cut-point of the Shona Symptom Questionnaire (SSQ) for CMD were potentially eligible. Exclusions were suicide risk or very severe depression. All others were offered 6 sessions of problem-solving therapy (PST) enhanced with a component of activity scheduling. Weekly nurse-led group supervision and monthly supervision from a mental health specialist were provided. Data on SSQ scores at 6 weeks after entering the study were collected by an independent research nurse. Lay workers completed a brief evaluation on their experiences of delivering the intervention.

Of 395 potentially eligible, 33 (8%) were excluded due to high risk. Of the 362 left, 2% (7) declined and 10% (35) were lost to follow-up leaving an 88% response rate (n = 320). Over half (n = 166, 52%) had presented with an HIV-related problem. Mean SSQ score fell from 11.3 (sd 1.4) before treatment to 6.5 (sd 2.4) after 3-6 sessions. The drop in SSQ scores was proportional to the number of sessions attended. Nine of the ten lay workers rated themselves as very able to deliver the PST intervention.

We have found preliminary evidence of a clinically meaningful improvement in CMD associated with locally adapted problem-solving therapy delivered by lay health workers through routine primary health care in an African setting. There is a need to test the effectiveness of this task-shifting mental health intervention in an appropriately powered randomised controlled trial.

Trial registration

ISRCTN: ISRCTN25476759

Peer Review reports

Mental disorders cause considerable suffering, disability and social exclusion in Africa, and are poorly recognised and undertreated [ 1 , 2 ]. In Zimbabwe, common mental disorders, such as depression mixed with anxiety, are found in over 25% of those attending primary health care services or maternal services, and in up to 30% of females in the community [ 3 – 5 ]. In the Zimbabwean Shona language, thinking too much ( kufungisisa ), along with deep sadness ( kusuwisisa ), and painful heart (moyo unorwadza) are terms in common use for emotional distress being close to European and American categories of common forms of depression and anxiety [ 3 , 6 ]

There is increasing evidence, mainly from other world regions but also rapidly growing evidence from within low income countries, that improving mental health is a low cost approach to improve quality of life and reduce disability [ 7 , 8 ]. Very little of this evidence, however, is from Africa. In Chile, low intensity low-cost treatments for depression have been integrated into primary health care [ 9 ]. These include, for example, psycho education, problem-solving therapy and self-help approaches [ 10 , 11 ]. Problem-solving therapy has been shown to be effective for depression and common mental health problems [ 12 , 13 ]. Previous attempts to deliver care for common mental disorders through primary care clinics in Zimbabwe although promising in the short-term had shown little long-term success due to reliance on overstretched nursing staff and lack of supervision [ 14 ]. In 2005, a government operation in Mbare , a township in Harare, resulted in many people becoming homeless or losing their livelihoods [ 15 ] and was perceived by the Mbare community to lead to high rate of emotional distress. Local stakeholders identified the need for a community mental health intervention. This had to be at no extra cost to the primary health care clinic, to utilise space outside the overcrowded clinic rooms, and to use methods already tested locally. A pilot intervention based on a problem-solving approach was identified [ 16 ]. It was suggested this be delivered by lay health workers via a 'Friendship Bench' ( Chigaro Chekupanamazano ) placed in the clinic grounds, and that a system of supervision and stepped care be part of the package. A team comprising psychologists, a primary care nurse and a psychiatrist adapted existing training materials on problem solving therapy [ 16 , 17 ] in the light of experience working with lay workers and general nurses in primary care. Adaptations included at least one home visit by the lay workers early in the therapy given it is normal practice for lay workers to visit clients in their homes, and encouraging clients to schedule some positive activities that really mattered to them to make life more rewarding. The training and the intervention were pre-tested in 5 lay workers and 143 primary care clients and found to be acceptable to them and to the lay workers. The aim of this pilot was to gather preliminary data on the effectiveness of this intervention and to see if the intervention would be feasible, and if so to gather ideas about how best to implement it on a larger scale.

Mbare is a high density suburb or township in the south of Harare. It is characterized by ethnic diversity and high unemployment with most residents relying on informal trading. The literacy rate is estimated to be over 90%. There are three government run Primary Health Care (PHC) clinics, staffed almost exclusively by general nurses, for a population of approximately 200 000. The study took place in all three clinics.

Twenty lay workers, locally termed health promoters, support the nurses at these three clinics. The lay workers are a respected group of primary health care providers, commonly referred to as ambuya utano (grandmother health provider) (Figure 1 ). In Mbare , all lay workers are female, literate, have at least primary school education, and have lived locally for at least 15 years. Their mean age is 58 years. Their main role is in community health outreach, which includes supporting people living with HIV/AIDS and Tuberculosis by providing individual and family support (practical, psychological and spiritual) and encouraging medication adherence. They also deliver community health education and promotion e.g. through encouraging immunisation and methods to control disease outbreaks. Lay workers report weekly to the environmental health officer and a nurse-manager. The lay workers cover geographical patches, which are sections of the community demarcated by the City of Harare according to street grids. Each geographical patch has approximately 3000 inhabitants. Ten lay workers were selected at random for this pilot: three from two of the clinics and four from the largest clinic.

Some of the lay health workers involved in the Friendship Bench project, sitting in front of one of the Benches .

Participants

Inclusion criteria: aged 18 and over; residents of geographical patches in Mbare , Harare, covered by the ten selected lay workers; score > 7 on Shona Symptom Questionnaire screen for common mental disorders. Exclusion criteria: requiring acute medical attention such that they cannot participate; severe psychiatric symptoms and/or risk to self or others requiring specialist referral as assessed by primary care research nurse

Ethical approval was obtained from the Medical Research Council of Zimbabwe and written informed consent was sought from all participants. The study was registered as a non-controlled trial http://www.controlled-trials.com/ISRCTN25476759

Recruitment

We aimed to recruit from the clinic staff, from the community, and from the lay workers themselves. The psychiatrist (DC) and psychologists (PM, KJ) presented to the clinic nursing staff and to all 20 lay workers the rationale for the project and referral methods to the friendship Bench. Notices written in the local vernacular language explaining the location and uses of the benches were placed at six different points within the entrance hall and waiting area of each clinic.

The lay workers introduced and publicised the Friendship Bench to the community through community stakeholders' meetings and during visits to people's homes, churches, schools and police stations. They introduced it as an adjunct to their normal daily community health outreach activity. They described the Friendship Bench approach as aimed at addressing common mental health issues such as kufungisisa (thinking too much) as a result of, among other things, HIV infection, AIDS, domestic violence, family sickness and poverty.

Clients were either referred or could self refer to the Friendship Bench, which was available Mon-Friday 9.00 am to 12.00 pm at each clinic. Those referred or who self-referred were directed by nursing or reception staff to sit on the Friendship Bench which in each clinic was a large wooden bench located under a tree within sight of the lay workers' office. One duty lay worker was responsible for the Bench each day on rotation and would approach the Bench after a potential client sat on it. The duty lay worker was responsible for collecting data on inclusion criteria including residential and basic demographic information and on psychological symptoms using the Shona Symptom Questionnaire (SSQ) [ 4 ]. She also gathered information on recent stressors using a brief life events screen based on one used previously in Harare [ 18 ]. Everyone was offered some education, advice and often sign-posted to support services. Those meeting inclusion criteria were referred to a research nurse for assessment of risk to self or to others (e.g. suicidal ideation, history of deliberate self harm, very severe symptoms). She referred those excluded on these grounds to the visiting psychiatrist (DC). She invited those meeting eligibility criteria to participate in the pilot and took written informed consent. She then referred them back to the lay worker who made arrangements for their first Friendship Bench session within 2-5 days with a lay worker that covered their geographical patch.

Outcome measure

The main outcome measure was the Shona Symptom Questionnaire (SSQ). The SSQ is a 14-item screening tool for common mental disorders, integrating local idioms and internationally recognised items for emotional distress. It was developed and validated in Zimbabwe using exemplary cross-cultural methods [ 4 ]. It is self-administered and has a reliable internal consistency (r = 0.85) and satisfactory sensitivity and specificity, with a score of > = 8 being the cut-point. It is based on a yes/no response and asks about symptoms such as thinking too much, failing to concentrate, work lagging behind, insomnia, suicidal ideation, unhappiness and so on, over a 1 week period. All participants were approached six to eight weeks after their first treatment session to complete a self-administered SSQ which was collected by the research nurse in the absence of the attending lay worker.

The Intervention

The intervention consisted of brief individual talking therapy based on problem-solving therapy delivered by a lay worker. Most sessions took place sitting on a bench termed "The Friendship Bench" ( Chigaro Chekupanamazano ). The Friendship Benches were made for the project by local craftsmen (see Figure 1 ). They are located within the grounds of each of the three participating clinics in a discrete area under the trees in the clinic gardens.

Table 1 shows the activities involved in the delivery of the Friendship Bench. The lay worker would initially explain to all participants how to self-administer the screening tool, the Shona Symptom Questionnaire. Problem-solving therapy (PST) included identification and exploration of problems, and identification and implementation of solutions, based on prior principles [ 19 ]. Our PST was a locally developed seven-step plan previously used in partnership with government, lay and traditional care providers [ 16 ]. Up to a maximum of 6 sessions on the Bench were offered with the second session taking place at the client's home and sometimes also one of the later sessions. Those most in financial need were referred to two local income-generating projects (peanut butter making; recycling). The problem solving therapy was enhanced with a component of activity scheduling in that clients were also encouraged to carry out activities that really mattered to them to make life more rewarding. Home visits included prayer. Prayer was already a well recognised part of the support provided by LW in their community health outreach role in Mbare , which has a 98% Christian population with more than 70 Christian faith groups. On average each prayer lasts 15-30 minutes and is delivered by one lay worker together with the family. The aim of the prayer is to comfort the sick and the family. The use of prayer in formal gatherings related to health is a common practice in Zimbabwe. The existing prayer format used prior to the introduction of the Friendship Bench was incorporated in the six sessions without any alterations.

Training, selection and supervision of facilitators

All 20 lay workers were trained.

We provided an 8-day training run by two clinical psychologists (PM and LK), a general nurse trained in systemic counselling (ST) and a psychiatrist (DC). This covered didactic lectures on common mental disorders (CMD), including kufungisisa (thinking too much) but particularly focussed on skills to identify CMD using the Shona Symptoms Questionnaire [ 4 ], and to manage CMD using simple psycho-education and problem-solving therapy [ 16 – 19 ]. Lay workers then took part in two days of pre-testing including screening, identification, and referral processes within the clinic, and referral of 'red flags' (critical case-situations such as suicidal risk). We made use of practise with clients on the Friendship Bench and in clients' homes'. We developed a client referral manual, which included a list of NGO's, private and public institutions, and church organizations to be used by lay workers or patients.

Ten lay workers were selected at random for the pilot: three from two of the clinics and four from the largest clinic.

A daily peer-support group for lay workers was introduced. The peer group meetings were facilitated by one of the lay workers who would then present during weekly group supervision where all lay workers participated. A clinic staff nurse trained in counseling provided weekly group supervision at the largest clinic. The clinical psychologist and the psychiatrist provided further supervision every fortnightly and monthly, respectively.

We developed a brief 6-item questionnaire with a 4-point Likert scale for the lay workers to evaluate the PST intervention. For instance, we asked them to rate the ease with which they had learned the problem-solving therapy approach, the ease with which they delivered the intervention and the proportion of clients who appeared to benefit from the PST approach. We asked the lay workers to complete this once 6 weeks after the study has begun. We also carried out one focus group with 6 of the 10 workers and asked them to describe their experiences of delivering the intervention. Their responses were recorded in writing and analysed for content and themes by two of the authors.

Data analysis

Descriptive statistics (means and standard deviations and proportions) were estimated for those who participated, who declines, who were lost to follow, and who were excluded due to psychiatric risk. We used t-tests and regression models to test changes in SSQ scores before and after completion of the treatment, adjusting for SSQ scores at baseline. Data were entered and analysed using EpiInfo 2002 and STATA 10.0 (Release 10, College Station, TX: Stata Corporation. 2003) after range checks and double entry of all questionnaires.

Recruitment and attrition at follow-up

Between July and November 2007, 948 persons visited the Bench. Of these 948 persons who visited the Bench, 395 (42%) scored above the cut-point of the Shona Symptom Questionnaire (SSQ). Among these, 33 (8%) with a mean SSQ score of 11.8 (sd 1.2) were excluded from the pilot study due to being severely depressed and/or suicidal and were referred to the psychologist or psychiatrist (see Figure 2 ). Of the 362 invited to take part, 2% (7) declined and 10% (35) were lost to follow-up leaving an 88% response rate (320 participants). Of the 395, 188 (48%) presented with an HIV-related problem of whom 166 (88%) participated.

Flow diagram of recruitment into the study .

Table 2 shows the characteristics of the 395 who scored above the cut-point of the SSQ, according to whether or not they entered the study. Participants were more likely to be female. More of those who participated were female and married (70% female, 57% married) compared to those who declined (42% female, 43% married) or who were those lost to follow-up (40% female, 41% married). Those with less than eight years of education were more likely to be lost to follow-up than to participate. The primary reasons presented for visiting the Bench among those who participated were HIV-related, somatic complaints and domestic violence.

Most of those who participated were referred to the Friendship Bench by clinic staff (35%) and lay workers (24%). Other common forms of referral were: friend/relative (13%), self-referral (12%) or police (9%).

Psychological symptoms scores before and after the six-week intervention period

All participants completed a minimum of 3 sessions over a six week period with 20%, 30%, 21% and 30% completing 3, 4, 5 or 6 sessions respectively.

The mean SSQ score for the 320 cases was 11.3 (sd 1.4) before treatment. After receiving between 3 to 6 sessions the mean score dropped by 4.8 points to 6.5 (sd 2.4) [t = 13.6 (p = 0.0087)]. For those completing 3 or more sessions, 66% recovered to below case level on the SSQ at 6-8 weeks

Table 3 shows the drop in SSQ scores according to the number of sessions attended, adjusting for baseline SSQ score. The more sessions attended the larger the drop in SSQ scores with a drop of more than 3 points observed among those who attended all six sessions.

Lay workers evaluation

Nine of the ten lay workers rated themselves as very able to deliver the PST intervention. All of them rated at least half of their clients as benefiting from PST with 7/10 rating 'more than half' of their clients benefiting from the intervention. Themes emerging from the focus group suggested that the lay workers viewed effective ingredients of the Friendship Bench to include:

Their position of trust in the community-clients viewed them as wise and confidential. The clients viewed them as 'persons who would not gossip' which was 'reassuring in a small community'

Being able to visit clients in their homes which they felt instilled hope

Minimising stigma associated with having a mental health problem. The lay workers heard from their clients that as they were already connected with public health work (rather than psychiatry) and carried out home visits routinely as part of their work on public health promotion and that it was not stigmatising for clients with kufungisisa (thinking too much) to be visited.

The structured 'talk therapy' helped them to monitor the progress and challenges that clients were facing.

Breaking down the problems into specific and manageable steps

Giving feedback to clients.

In the focus group, the lay workers reported several case histories of their clients. These included the following:

A female client who had been to the bench with a score of 12/14 on the SSQ at baseline and subsequently received 2 home visits described the lay health workers as 'bringing peace' in her home, and 'less agitation' from her partner. Her score dropped to 7/14 after six sessions.

ii) A female client with an SSQ of 11/14 dropped to 6/14 after five sessions which included a home visit after she presented with being unable to come to terms with her HIV status.

iii) A female senior member of the local protestant church described the home visits as 'hope for those of us who are unable to open up in a church congregation about our HIV status'. Her score went down to 5/14 from 10/14 after 6 sessions.

This is the first example of lay health workers in Africa delivering a low intensity mental health intervention, using locally adapted tools, for common mental disorders in primary care. We have shown that it is feasible for lay workers to deliver this intervention for depression and common mental disorders, and that recruitment to the intervention from primary care, community agencies and self-referral was also feasible (Figure 2 ). The treatment appeared acceptable to the community and the lay workers were able to integrate the intervention into their routine work. Preliminary findings also show that the intervention is efficacious in reducing psychological morbidity, with a drop in score of nearly 5 points on the 14-item psychological outcome scale after 3-6 sessions, and efficacy proportional to the number of sessions attended. Over half of those who participated had presented with a problem related to HIV.

Chance does not seem a likely explanation for our finding as the significance value for the drop in score after 3-6 sessions was at p < 0.01 level. Bias may explain some of the results in that women and married participants were more likely to participate than to decline or to be lost to follow-up and those with lower education were more likely to be lost to follow-up than to participate. However, overall, the response rate of 88% was extremely high so it appears unlikely that bias is playing a major role in explaining the results. Measurement error is also unlikely to explain the findings. The Shona Symptom Questionnaire was developed using optimal cross-cultural methods and has been validated against an international diagnostic interview with most of those scoring at or above the recommended cut-off having mixed depression and anxiety or pure depression using ICD criteria [ 4 ].

We do not have a comparison group from the same study who did not receive the intervention. However, a prospective study in primary care in Harare showed that a mean drop in score of 4.7 (sd 6.3) on the SSQ was associated with recovery from 'case' to 'non-case' and with significantly less disability [ 20 ] (see Table 3 of the Patel paper). These authors further report that those who experienced a drop in score of 4 or more points on the SSQ were more likely to self-report an improvement in health than those who remained at case-level on the SSQ. Our crude mean drop in score of 4.8 points thus appears to represent a meaningful drop in score indicating efficacy of the Friendship Bench intervention. Furthermore, our finding that drop in score was significantly correlated with the number of sessions attended, even after adjusting for baseline SSQ score, adds weight to our assertion that the intervention appears to be efficacious. In our pilot, 34% remained cases at 6-8 weeks follow-up after the intervention, whereas in the Patel et al study [ 20 ], where there was no specific intervention, 48% of primary health care attenders remained cases.

The quantitative findings are supported by the lay workers evaluation. All of them rated at least half of their clients as benefiting from problem-solving therapy with 7/10 rating 'more than half' of their clients benefiting from the intervention. Themes that emerged from qualitative work support the argument that implementing this intervention through an existing public health intervention and by mature women with a position of trust in the community, helps explain its apparent efficacy. The lay workers-or 'grandmother health providers' are viewed as wise, confidential, authoritative and not prone to gossip. As the lay workers were already respected for their public health work, participants said they did not find it not stigmatising to be visited.

The intervention is theoretically closely linked to problem-solving therapy, which has been shown to be effective for depression and common mental health problems [ 12 , 13 ], together with an activity scheduling component [ 21 ]. It incorporates local adaptations that are integral to the routine work of the therapists who are culturally sanctioned lay health workers, known and respected as 'grandmother health providers'. For instance, the inclusion of Christian prayer for 15 minutes during 1 or 2 of the 6 sessions was part of the existing practice of the lay workers and it would have been inappropriate to remove that normal practice. While there is no evidence from randomised controlled trials that prayer is an effective treatment for depression in Christians, there is some suggestion from non-randomised studies with small samples that religious activities may benefit depression [ 22 ].

In 1994 we showed that major barriers to up-scaling mental health care in this setting include lack of supervision, and lack of recording systems for common mental disorders. We provided evidence that problems in improving primary mental health care may be less with the attitudes (or even the training) of primary care staff and more with bureaucratic limitations such as the inadequacy of the diagnostic codes, absence of mental health supervision, lack of protocol for following-up CMD patients, lack of medicines, and lack of incentives to see patients with CMD [ 23 ]. The Friendship Bench has managed to address some of these challenges, especially through making use of lay workers and providing a system for them of peer and nurse-led supervision, with an available step up to specialist care which has been used in less than 10% of cases screening positive for CMD. An emphasis on local concepts and terms helped to reduce stigma of mental disorders. The local knowledge of the lay workers facilitated linkage with two local income-generating projects (peanut butter making; recycling) for those in most financial need.

Our decision to use problem-solving therapy was anchored in earlier evidence that kufungisisa and common mental disorders were associated with everyday social and health problems [ 16 , 24 ], and that the community trusted the lay health workers to aid them in resolving these problems using culturally accepted methods, which sometimes included prayer. This is consistent with the traditionally accepted rationale for using problem-solving therapy [ 19 ]. We found that those who used a greater number of sessions benefited more. Thus in future work it will be important to optimise adherence to the intervention and to follow-up clients. Given the value found in Western settings of written materials for clients in low-intensity psychological treatments, we wish to develop these for clients in Zimbabwe, with the aim of increasing the efficacy of the therapy. We will also add training in more collaborative structured approaches to activity scheduling for clients who remain depressed despite problem-solving therapy.

Of the 320 participants in this pilot, just over half had presented with an HIV-related problem. There is need to evaluate whether treatment for depression might improve physical health outcomes such as medication adherence in those who have depression co-morbid with physical illness [ 25 ].

With the large treatment gap that currently exists in low and middle income countries for mental health care, lay workers may be able to play a pivotal role [ 26 ]. In Zimbabwe, earlier work has shown the feasibility of using lay workers to prevent mother to child transmission of HIV, and to screen for psychological morbidity [ 5 , 27 , 28 ]. While there is evidence supporting the effectiveness of task-shifting in HIV [ 29 ], immunization, malaria prevention, and management of upper respiratory infections [ 30 ], ours is an important study given the dearth of evidence on lay workers addressing depression and common mental health problems in Africa.

Limitations of the study include the short follow-up period of 6 weeks. Also, the observed drop in SSQ score after six sessions of problem-solving therapy was not controlled for potential confounding factors such as socio-economic position [ 31 ]. The fundamental limitation to this study is the absence of a comparison group receiving 'usual care' or a placebo intervention, if one could be found. Furthermore, the lay workers were not observed during the course of their work and what they did in practice could have differed from their training. The low level of attrition among the participants is unusual; however, this could be attributed to the short follow up period, the close proximity of participants to the local study area, and the ability of the lay workers and research nurse to physically follow up participants in the community, and is consistent with high follow-up rates found in previous research in Harare [ 20 ]. The City of Harare Health Department continued the Friendship Bench after the pilot. In the 14 months from January 2008 to February 2009, 2348 clients had visited the Friendship Bench with 973 having received the problem-solving intervention. In view of this it is imperative to rigorously test this intervention.

We have found preliminary evidence that lay primary health care workers can deliver locally adapted problem-solving therapy in Harare, Zimbabwe and that this can be associated with a meaningful reduction in symptoms of depression and common mental disorders. The problem solving therapy was integrated into the routine work load of the community based lay workers whose roles include supporting people living with HIV and carrying out health promotion activities. There is need to carry out appropriately powered randomised controlled trials to test if this task-shifting mental health intervention is effective compared to usual care in reducing psychological symptoms and also in improving physical health outcomes in those who have depression co-morbid with physical illness.

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Acknowledgements

We thank Dr. F Lovemore Director of the Counselling Services Unit (CSU), and Dr. P Chonzi and Dr S Mungofa, Directors of The City of Harare Health Department, Harare hospital psychiatric unit and the Mbare community; Shirly Tshimanga (ST), nursing staff at the three clinics, Church groups, Local police, Schools, NGO's and the health promoters for their continued support of the Friendship Bench. Written consent was provided by the lay health workers for the photograph shown in Figure 1 .

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Dixon Chibanda & Lazarus Kajawu

Counselling Services Unit, Harare, Zimbabwe

Petra Mesu & Lazarus Kajawu

Centre for Sexual Health and HIV Research, University College London, London, UK

Frances Cowan

Department of Community Medicine, University of Zimbabwe, Harare, Zimbabwe

School of Social and Community Medicine, Bristol, UK

Ricardo Araya

King's College London, Institute of Psychiatry, London, UK

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DC was responsible for study design, data collection, writing manuscript and analysis of the data. PM and LK responsible for study design and review of second draft. FC reviewed second draft. RA assisted with analysing data and editing manuscripts.

MA developed Multiple Symptoms Card, made comments on first draft of manuscript, responsible for second draft of manuscript, contributed to revisions following referees comments and to writing of final draft. All authors read and approved the manuscript.

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Chibanda, D., Mesu, P., Kajawu, L. et al. Problem-solving therapy for depression and common mental disorders in Zimbabwe: piloting a task-shifting primary mental health care intervention in a population with a high prevalence of people living with HIV. BMC Public Health 11 , 828 (2011). https://doi.org/10.1186/1471-2458-11-828

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DOI : https://doi.org/10.1186/1471-2458-11-828

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