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What Is Problem-Solving Therapy?

Arlin Cuncic, MA, is the author of "Therapy in Focus: What to Expect from CBT for Social Anxiety Disorder" and "7 Weeks to Reduce Anxiety." She has a Master's degree in psychology.

problem solving therapy protocol

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

problem solving therapy protocol

Verywell / Madelyn Goodnight

Problem-Solving Therapy Techniques

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

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

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

At a Glance

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

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

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

Key Components

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

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

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

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

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

Planful Problem-Solving

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

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

Other Techniques

Other techniques your therapist may go over include:

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

What Problem-Solving Therapy Can Help With

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

Mental Health Issues

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

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

Specific Life Challenges

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

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

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

Benefits of Problem-Solving Therapy

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

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

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

Other Types of Therapy

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

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

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

  • Older adults
  • People coping with serious illnesses like cancer

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

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

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

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

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

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

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

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

Keep In Mind

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

Get Help Now

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

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

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

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

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

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

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

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

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

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

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

By Arlin Cuncic, MA Arlin Cuncic, MA, is the author of "Therapy in Focus: What to Expect from CBT for Social Anxiety Disorder" and "7 Weeks to Reduce Anxiety." She has a Master's degree in psychology.

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9: Problem Solving Therapy

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Risk Management and Treatment » Non-pharmacologic Treatments 9 : Problem Solving Therapy

We suggest offering problem-solving based psychotherapies to: a) Patients with a history of more than one incident of self-directed violence to reduce repeat incidents of such behaviors; b) Patients with a history of recent self-directed violence to reduce suicidal ideation; and/or c) Patients with hopelessness and a history of moderate to severe traumatic brain injury

Reviewed New-replaced

Grades and Definitions ✖

Recommendation resources.

Problem-Solving Therapy (PST) for Suicide Prevention is a brief form of evidence-based treatment that teaches and empowers patients to solve the here-and-now problems contributing to suicidal ideation, self-directed violence and hopelessness. It has been shown to help increase self-efficacy and reduce risk of self-harm and suicide.

Training Resources

This section includes links to recommended trainings about PST.

This section includes links to recommended manuals about PST.

CPG Webinar

This section includes links to recommended articles about CBT-SP.

This section includes links to recommended podcasts about Caring Contacts.


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10 Best Problem-Solving Therapy Worksheets & Activities

Problem solving therapy

Cognitive science tells us that we regularly face not only well-defined problems but, importantly, many that are ill defined (Eysenck & Keane, 2015).

Sometimes, we find ourselves unable to overcome our daily problems or the inevitable (though hopefully infrequent) life traumas we face.

Problem-Solving Therapy aims to reduce the incidence and impact of mental health disorders and improve wellbeing by helping clients face life’s difficulties (Dobson, 2011).

This article introduces Problem-Solving Therapy and offers techniques, activities, and worksheets that mental health professionals can use with clients.

Before you continue, we thought you might like to download our three Positive Psychology Exercises for free . These science-based exercises explore fundamental aspects of positive psychology, including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

This Article Contains:

What is problem-solving therapy, 14 steps for problem-solving therapy, 3 best interventions and techniques, 7 activities and worksheets for your session, fascinating books on the topic, resources from positivepsychology.com, a take-home message.

Problem-Solving Therapy assumes that mental disorders arise in response to ineffective or maladaptive coping. By adopting a more realistic and optimistic view of coping, individuals can understand the role of emotions and develop actions to reduce distress and maintain mental wellbeing (Nezu & Nezu, 2009).

“Problem-solving therapy (PST) is a psychosocial intervention, generally considered to be under a cognitive-behavioral umbrella” (Nezu, Nezu, & D’Zurilla, 2013, p. ix). It aims to encourage the client to cope better with day-to-day problems and traumatic events and reduce their impact on mental and physical wellbeing.

Clinical research, counseling, and health psychology have shown PST to be highly effective in clients of all ages, ranging from children to the elderly, across multiple clinical settings, including schizophrenia, stress, and anxiety disorders (Dobson, 2011).

Can it help with depression?

PST appears particularly helpful in treating clients with depression. A recent analysis of 30 studies found that PST was an effective treatment with a similar degree of success as other successful therapies targeting depression (Cuijpers, Wit, Kleiboer, Karyotaki, & Ebert, 2020).

Other studies confirm the value of PST and its effectiveness at treating depression in multiple age groups and its capacity to combine with other therapies, including drug treatments (Dobson, 2011).

The major concepts

Effective coping varies depending on the situation, and treatment typically focuses on improving the environment and reducing emotional distress (Dobson, 2011).

PST is based on two overlapping models:

Social problem-solving model

This model focuses on solving the problem “as it occurs in the natural social environment,” combined with a general coping strategy and a method of self-control (Dobson, 2011, p. 198).

The model includes three central concepts:

  • Social problem-solving
  • The problem
  • The solution

The model is a “self-directed cognitive-behavioral process by which an individual, couple, or group attempts to identify or discover effective solutions for specific problems encountered in everyday living” (Dobson, 2011, p. 199).

Relational problem-solving model

The theory of PST is underpinned by a relational problem-solving model, whereby stress is viewed in terms of the relationships between three factors:

  • Stressful life events
  • Emotional distress and wellbeing
  • Problem-solving coping

Therefore, when a significant adverse life event occurs, it may require “sweeping readjustments in a person’s life” (Dobson, 2011, p. 202).

problem solving therapy protocol

  • Enhance positive problem orientation
  • Decrease negative orientation
  • Foster ability to apply rational problem-solving skills
  • Reduce the tendency to avoid problem-solving
  • Minimize the tendency to be careless and impulsive

D’Zurilla’s and Nezu’s model includes (modified from Dobson, 2011):

  • Initial structuring Establish a positive therapeutic relationship that encourages optimism and explains the PST approach.
  • Assessment Formally and informally assess areas of stress in the client’s life and their problem-solving strengths and weaknesses.
  • Obstacles to effective problem-solving Explore typically human challenges to problem-solving, such as multitasking and the negative impact of stress. Introduce tools that can help, such as making lists, visualization, and breaking complex problems down.
  • Problem orientation – fostering self-efficacy Introduce the importance of a positive problem orientation, adopting tools, such as visualization, to promote self-efficacy.
  • Problem orientation – recognizing problems Help clients recognize issues as they occur and use problem checklists to ‘normalize’ the experience.
  • Problem orientation – seeing problems as challenges Encourage clients to break free of harmful and restricted ways of thinking while learning how to argue from another point of view.
  • Problem orientation – use and control emotions Help clients understand the role of emotions in problem-solving, including using feelings to inform the process and managing disruptive emotions (such as cognitive reframing and relaxation exercises).
  • Problem orientation – stop and think Teach clients how to reduce impulsive and avoidance tendencies (visualizing a stop sign or traffic light).
  • Problem definition and formulation Encourage an understanding of the nature of problems and set realistic goals and objectives.
  • Generation of alternatives Work with clients to help them recognize the wide range of potential solutions to each problem (for example, brainstorming).
  • Decision-making Encourage better decision-making through an improved understanding of the consequences of decisions and the value and likelihood of different outcomes.
  • Solution implementation and verification Foster the client’s ability to carry out a solution plan, monitor its outcome, evaluate its effectiveness, and use self-reinforcement to increase the chance of success.
  • Guided practice Encourage the application of problem-solving skills across multiple domains and future stressful problems.
  • Rapid problem-solving Teach clients how to apply problem-solving questions and guidelines quickly in any given situation.

Success in PST depends on the effectiveness of its implementation; using the right approach is crucial (Dobson, 2011).

Problem-solving therapy – Baycrest

The following interventions and techniques are helpful when implementing more effective problem-solving approaches in client’s lives.

First, it is essential to consider if PST is the best approach for the client, based on the problems they present.

Is PPT appropriate?

It is vital to consider whether PST is appropriate for the client’s situation. Therapists new to the approach may require additional guidance (Nezu et al., 2013).

Therapists should consider the following questions before beginning PST with a client (modified from Nezu et al., 2013):

  • Has PST proven effective in the past for the problem? For example, research has shown success with depression, generalized anxiety, back pain, Alzheimer’s disease, cancer, and supporting caregivers (Nezu et al., 2013).
  • Is PST acceptable to the client?
  • Is the individual experiencing a significant mental or physical health problem?

All affirmative answers suggest that PST would be a helpful technique to apply in this instance.

Five problem-solving steps

The following five steps are valuable when working with clients to help them cope with and manage their environment (modified from Dobson, 2011).

Ask the client to consider the following points (forming the acronym ADAPT) when confronted by a problem:

  • Attitude Aim to adopt a positive, optimistic attitude to the problem and problem-solving process.
  • Define Obtain all required facts and details of potential obstacles to define the problem.
  • Alternatives Identify various alternative solutions and actions to overcome the obstacle and achieve the problem-solving goal.
  • Predict Predict each alternative’s positive and negative outcomes and choose the one most likely to achieve the goal and maximize the benefits.
  • Try out Once selected, try out the solution and monitor its effectiveness while engaging in self-reinforcement.

If the client is not satisfied with their solution, they can return to step ‘A’ and find a more appropriate solution.

Positive self-statements

When dealing with clients facing negative self-beliefs, it can be helpful for them to use positive self-statements.

Use the following (or add new) self-statements to replace harmful, negative thinking (modified from Dobson, 2011):

  • I can solve this problem; I’ve tackled similar ones before.
  • I can cope with this.
  • I just need to take a breath and relax.
  • Once I start, it will be easier.
  • It’s okay to look out for myself.
  • I can get help if needed.
  • Other people feel the same way I do.
  • I’ll take one piece of the problem at a time.
  • I can keep my fears in check.
  • I don’t need to please everyone.

Worksheets for problem solving therapy

5 Worksheets and workbooks

Problem-solving self-monitoring form.

Answering the questions in the Problem-Solving Self-Monitoring Form provides the therapist with necessary information regarding the client’s overall and specific problem-solving approaches and reactions (Dobson, 2011).

Ask the client to complete the following:

  • Describe the problem you are facing.
  • What is your goal?
  • What have you tried so far to solve the problem?
  • What was the outcome?

Reactions to Stress

It can be helpful for the client to recognize their own experiences of stress. Do they react angrily, withdraw, or give up (Dobson, 2011)?

The Reactions to Stress worksheet can be given to the client as homework to capture stressful events and their reactions. By recording how they felt, behaved, and thought, they can recognize repeating patterns.

What Are Your Unique Triggers?

Helping clients capture triggers for their stressful reactions can encourage emotional regulation.

When clients can identify triggers that may lead to a negative response, they can stop the experience or slow down their emotional reaction (Dobson, 2011).

The What Are Your Unique Triggers ? worksheet helps the client identify their triggers (e.g., conflict, relationships, physical environment, etc.).

Problem-Solving worksheet

Imagining an existing or potential problem and working through how to resolve it can be a powerful exercise for the client.

Use the Problem-Solving worksheet to state a problem and goal and consider the obstacles in the way. Then explore options for achieving the goal, along with their pros and cons, to assess the best action plan.

Getting the Facts

Clients can become better equipped to tackle problems and choose the right course of action by recognizing facts versus assumptions and gathering all the necessary information (Dobson, 2011).

Use the Getting the Facts worksheet to answer the following questions clearly and unambiguously:

  • Who is involved?
  • What did or did not happen, and how did it bother you?
  • Where did it happen?
  • When did it happen?
  • Why did it happen?
  • How did you respond?

2 Helpful Group Activities

While therapists can use the worksheets above in group situations, the following two interventions work particularly well with more than one person.

Generating Alternative Solutions and Better Decision-Making

A group setting can provide an ideal opportunity to share a problem and identify potential solutions arising from multiple perspectives.

Use the Generating Alternative Solutions and Better Decision-Making worksheet and ask the client to explain the situation or problem to the group and the obstacles in the way.

Once the approaches are captured and reviewed, the individual can share their decision-making process with the group if they want further feedback.


Visualization can be performed with individuals or in a group setting to help clients solve problems in multiple ways, including (Dobson, 2011):

  • Clarifying the problem by looking at it from multiple perspectives
  • Rehearsing a solution in the mind to improve and get more practice
  • Visualizing a ‘safe place’ for relaxation, slowing down, and stress management

Guided imagery is particularly valuable for encouraging the group to take a ‘mental vacation’ and let go of stress.

Ask the group to begin with slow, deep breathing that fills the entire diaphragm. Then ask them to visualize a favorite scene (real or imagined) that makes them feel relaxed, perhaps beside a gently flowing river, a summer meadow, or at the beach.

The more the senses are engaged, the more real the experience. Ask the group to think about what they can hear, see, touch, smell, and even taste.

Encourage them to experience the situation as fully as possible, immersing themselves and enjoying their place of safety.

Such feelings of relaxation may be able to help clients fall asleep, relieve stress, and become more ready to solve problems.

We have included three of our favorite books on the subject of Problem-Solving Therapy below.

1. Problem-Solving Therapy: A Treatment Manual – Arthur Nezu, Christine Maguth Nezu, and Thomas D’Zurilla

Problem-Solving Therapy

This is an incredibly valuable book for anyone wishing to understand the principles and practice behind PST.

Written by the co-developers of PST, the manual provides powerful toolkits to overcome cognitive overload, emotional dysregulation, and the barriers to practical problem-solving.

Find the book on Amazon .

2. Emotion-Centered Problem-Solving Therapy: Treatment Guidelines – Arthur Nezu and Christine Maguth Nezu

Emotion-Centered Problem-Solving Therapy

Another, more recent, book from the creators of PST, this text includes important advances in neuroscience underpinning the role of emotion in behavioral treatment.

Along with clinical examples, the book also includes crucial toolkits that form part of a stepped model for the application of PST.

3. Handbook of Cognitive-Behavioral Therapies – Keith Dobson and David Dozois

Handbook of Cognitive-Behavioral Therapies

This is the fourth edition of a hugely popular guide to Cognitive-Behavioral Therapies and includes a valuable and insightful section on Problem-Solving Therapy.

This is an important book for students and more experienced therapists wishing to form a high-level and in-depth understanding of the tools and techniques available to Cognitive-Behavioral Therapists.

For even more tools to help strengthen your clients’ problem-solving skills, check out the following free worksheets from our blog.

  • Case Formulation Worksheet This worksheet presents a four-step framework to help therapists and their clients come to a shared understanding of the client’s presenting problem.
  • Understanding Your Default Problem-Solving Approach This worksheet poses a series of questions helping clients reflect on their typical cognitive, emotional, and behavioral responses to problems.
  • Social Problem Solving: Step by Step This worksheet presents a streamlined template to help clients define a problem, generate possible courses of action, and evaluate the effectiveness of an implemented solution.
  • 17 Positive Psychology Exercises If you’re looking for more science-based ways to help others enhance their wellbeing, check out this signature collection of 17 validated positive psychology tools for practitioners . Use them to help others flourish and thrive.

While we are born problem-solvers, facing an incredibly diverse set of challenges daily, we sometimes need support.

Problem-Solving Therapy aims to reduce stress and associated mental health disorders and improve wellbeing by improving our ability to cope. PST is valuable in diverse clinical settings, ranging from depression to schizophrenia, with research suggesting it as a highly effective treatment for teaching coping strategies and reducing emotional distress.

Many PST techniques are available to help improve clients’ positive outlook on obstacles while reducing avoidance of problem situations and the tendency to be careless and impulsive.

The PST model typically assesses the client’s strengths, weaknesses, and coping strategies when facing problems before encouraging a healthy experience of and relationship with problem-solving.

Why not use this article to explore the theory behind PST and try out some of our powerful tools and interventions with your clients to help them with their decision-making, coping, and problem-solving?

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

  • Cuijpers, P., Wit, L., Kleiboer, A., Karyotaki, E., & Ebert, D. (2020). Problem-solving therapy for adult depression: An updated meta-analysis. European P sychiatry ,  48 (1), 27–37.
  • Dobson, K. S. (2011). Handbook of cognitive-behavioral therapies (3rd ed.). Guilford Press.
  • Dobson, K. S., & Dozois, D. J. A. (2021). Handbook of cognitive-behavioral therapies  (4th ed.). Guilford Press.
  • Eysenck, M. W., & Keane, M. T. (2015). Cognitive psychology: A student’s handbook . Psychology Press.
  • Nezu, A. M., & Nezu, C. M. (2009). Problem-solving therapy DVD . Retrieved September 13, 2021, from https://www.apa.org/pubs/videos/4310852
  • Nezu, A. M., & Nezu, C. M. (2018). Emotion-centered problem-solving therapy: Treatment guidelines. Springer.
  • Nezu, A. M., Nezu, C. M., & D’Zurilla, T. J. (2013). Problem-solving therapy: A treatment manual . Springer.

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Encyclopedia of Geropsychology pp 1874–1883 Cite as

Problem-Solving Therapy

  • Sherry A. Beaudreau 2 , 3 , 4 ,
  • Christine E. Gould 2 , 5 ,
  • Erin Sakai 6 &
  • J. W. Terri Huh 6 , 7  
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  • First Online: 01 January 2017

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Behavioral intervention; Skills-based therapy; Treatment

Problem-solving therapy (PST), developed by Nezu and colleagues, is a non-pharmacological, empirically supported cognitive-behavioral treatment (D’Zurilla and Nezu 2006 ; Nezu et al. 1989 ). The problem-solving framework draws from a stress-diathesis model, namely, that life stress interacts with an individual’s predisposition toward developing a psychiatric disorder. The driving model behind PST posits that individuals who experience difficulty solving life’s problems or coping with stressors of everyday living struggle with psychiatric symptoms more often than individuals considered as good problem solvers. This psychological treatment teaches a step-by-step approach to the process of identifying and implementing adaptive solutions for daily problems. By teaching individuals to solve their problems more effectively and efficiently, this model assumes that their stress and related psychiatric symptoms will...

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

  • Karolin R. Krause   ORCID: orcid.org/0000-0003-3914-7272 1 , 2 ,
  • Darren B. Courtney   ORCID: orcid.org/0000-0003-1491-0972 1 , 3 ,
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Problem-solving training is a common ingredient of evidence-based therapies for youth depression and has shown effectiveness as a versatile stand-alone intervention in adults. This scoping review provided a first overview of the evidence supporting problem solving as a mechanism for treating depression in youth aged 14 to 24 years.

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

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


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

Peer Review reports

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

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

figure 1

Dimensions of Problem-Solving (PS) Ability

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

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

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

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

Scoping review

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

Search strategy

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

Inclusion and exclusion criteria

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

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

figure 2

PRISMA Flow Chart of the Study Selection Process

Data extraction and synthesis

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

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

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

Exploratory Meta-analysis

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

Quality assessment

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

Statistical analysis

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

Selection and inclusion of studies

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

Clinical trials of PST

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

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

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

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

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

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

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

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

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

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

PS training in clinical practice guidelines

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

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


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

figure 3

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

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

Overall quality of the evidence

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

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

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

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

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

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

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

Strengths and limitations

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

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

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

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

Availability of data and materials

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


Avoidance style

Beck Depression Inventory

Centre for Addiction and Mental Health

Cognitive behavioural therapy

Children’s Depression Rating Scale—Revised

Center for Epidemiologic Studies Depression Scale

Clinical Global Impression Scale—Improvement

Cumulative Index to Nursing and Allied Health Literature

Clinical practice guideline

Adolescent Coping with Depression [intervention name]

Dialectical behaviour therapy

Grading of Recommendations Assessment, Development, and Evaluation

Impulsivity/Carelessness Style

Interpersonal psychotherapy

The Kiddie Schedule for Affective Disorders and Schizophrenia

Lifeskills training

Major depressive disorder

Medical Literature Analysis and Retrieval System Online

Negative problem orientation

Nondirective supportive therapy

Positive problem orientation

Preferred Reporting Items for Systematic Reviews and Meta-Analysis

  • Problem solving

Problem-solving training

Problem-Solving Therapy

Randomized controlled trial

Research ethics board

Risk of bias

Rational problem-solving style

Systemic Behaviour Family Therapy

Strengths and Difficulties Questionnaire

Solution-Focused Brief Therapy

Social Problem-Solving Inventory Revised

Selective serotonin reuptake inhibitors

Treatment for Adolescents with Depression Study

Treatment of Resistant Depression in Adolescents

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

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

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

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

Karolin R. Krause

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

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

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

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Correspondence to Karolin R. Krause .

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Supplementary Information

Additional file 1..

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

Additional file 2.

Search Strategy.

Additional file 3.

List of Studies Included in the Scoping Review.

Additional file 4.

Characteristics of Included Clinical Practice Guidelines.

Additional file 5.

Additional Data and Outputs from the Meta-Analysis.

Additional file 6.

Risk of Bias Assessment and GRADE Appraisal.

Additional file 7.

Illustration of Insights from the Consultation of Youth Advisors.

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

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Am Fam Physician. 2009;79(4):277-284

A more recent article on counseling patients in primary care is available.

Author disclosure: Nothing to disclose.

Although it is often unrecognized, family physicians provide a significant amount of mental health care in the United States. Time is one of the major obstacles to providing counseling in primary care. Counseling approaches developed specifically for ambulatory patients and traditional psychotherapies modified for primary care are efficient first-line treatments. For some clinical conditions, providing individualized feedback alone leads to improvement. The five A’s (ask, advise, assess, assist, arrange) and FRAMES (feedback about personal risk, responsibility of patient, advice to change, menu of strategies, empathetic style, promote self-efficacy) techniques are stepwise protocols that are effective for smoking cessation and reducing excessive alcohol consumption. These models can be adapted to address other problems, such as treatment nonadherence. Although both approaches are helpful to patients who are ready to change, they are less likely to be successful in patients who are ambivalent or who have broader psychosocial problems. For patients who are less committed to changing health risk behavior or increasing healthy behavior, the stages-of-change approach and motivational interviewing address barriers. Patients with psychiatric conditions and acute psychosocial stressors will likely respond to problem-solving therapy or the BATHE (background, affect, troubles, handling, empathy) technique. Although brief primary care counseling has been effective, patients who do not fully respond to the initial intervention should receive multimodal therapy or be referred to a mental health professional.

The primary care sector provides at least one half of all U.S. mental health services. 1 , 2 In the United States, 50 percent of patients treated for major depressive disorder are treated solely by primary care physicians, 3 and about 20 percent of psychotherapy sessions are provided in primary care. 4 However, family physicians often report time pressures and lack of knowledge as barriers to providing systematic counseling. Several models for brief counseling have been developed specifically for the outpatient primary care setting, and other problem-focused psychotherapies may be adapted for this setting.

Family physician counseling is an efficient and cost-effective initial intervention in a stepped-care approach. 5 – 7 As a first-line therapy, brief counseling is effective for many problems; is acceptable to most patients; and reduces the need for more time-intensive, costly treatment and referral for specialty care. 6 , 7 Evidence indicates that assessment and treatment overlap with many psychiatric conditions and health risk behaviors. Providing individualized feedback and recommendations about a patient’s alcohol consumption, 8 , 9 diet, 10 and mood disorders 11 often leads to at least short-term improvement without other therapies.

Patient responsiveness to physician education and direct advice is variable. Table 1 summarizes counseling approaches that address health risk behaviors or adherence problems, ambivalence to change, and broader psychosocial issues.

The Five A’s

The five A’s (ask, advise, assess, assist, arrange) 12 technique ( Table 2 13 , 14 ) is an efficient strategy for addressing health risk behaviors, such as smoking and alcohol use, and may be adapted to promoting healthy behaviors, including regular exercise. Asking questions presumptively (“How much do you smoke?”) may elicit more reliable information.

When advising patients, communication theory suggests that a defensive reaction is less likely if the physician begins with an “I” statement (“I recommend that you…”) rather than a “You” statement (“You need to...”). 15 , 16 Although educational handouts may augment the physician’s advice, printed material should not replace direct verbal recommendations.

Before developing a plan, it is necessary to assess the patient’s motivation for imminent change. After assisting the patient in developing concrete strategies for change, close follow-up should be arranged. For example, because nicotine withdrawal during smoking cessation includes unpleasant physical and emotional reactions, arranging supportive contact increases the likelihood of success. 13 Research including pregnant smokers found that the five A’s technique led to greater cessation rates than physician recommendations alone. 12 , 13

FRAMES Protocol

The FRAMES (feedback about personal risk, responsibility of patient, advice to change, menu of strategies, empathetic style, promote self-efficacy) protocol ( Table 3 14 , 17 ) also targets health risk behaviors. It begins with concrete, individualized patient feedback related to the behavior, 17 such as a CAGE questionnaire score for alcohol use, blood pressure, glucose levels, or A1C levels. The physician may also link a presenting complaint, such as sleep disturbance in a heavy drinker 18 or frequent respiratory infections in a long-term cannabis user, 19 to the under-lying substance abuse.

The physician directly or indirectly communicates the importance of the patient taking responsibility for change. Patient ambivalence should be briefly explored—if the patient appears ambivalent or is currently uninterested in addressing the issue, the physician should provide direct, succinct advice and indicate that it is an important future topic. Whenever feasible, the patient should receive a range of options to consider rather than a specific directive. By providing a menu of strategies, the physician communicates a willingness to collaborate while emphasizing that implementation is the patient’s responsibility. Communicating with empathy has been shown to increase patient satisfaction 20 and adherence. 21 The final step is promoting the patient’s sense of self-efficacy with an encouraging statement about the plan he or she has developed.

Stages of Change (Transtheoretical Model)

The transtheoretical model ( Table 4 14 , 22 , 23 ) assumes that health behavior changes in stages that reflect various levels of patient motivation and perceived self-efficacy (i.e., precontemplation, contemplation, preparation, action, and maintenance). 22 The physician asks targeted questions designed to increase patient motivation for change until motivation increases to the point of initiating action. The transtheoretical model, originally developed for smoking cessation, is supported by considerable research and appears to be effective for reducing other health risk behaviors 22 and for improving chronic disease self-management. 24 , 25 The model, using individualized patient feedback, is associated with improved adherence to a hypertensive regimen at 12 and 18 months. 24 With self-management of chronic diseases, such as type 2 diabetes, patients are likely to be at different stages for specific aspects of management (e.g., diet, activity level, blood glucose self-monitoring, taking medications). 25

During precontemplation and contemplation, patients are more likely to respond to a cognitive approach, such as discussing the benefits of habit change, possibly supported by written information. In the precontemplation stage, the patient perceives that the disadvantages of changing outweigh the benefits, whereas this pattern is reversed in the action stage. 23 Therefore, during precontemplation and contemplation, physicians should highlight the advantages of change. 23 , 26

In the preparation stage, the patient chooses a starting date and strategy for change. The action stage should target the behavioral skills and day-to-day challenges the patient encounters during his or her efforts to change. 23

During action and maintenance, brief lapses or more enduring relapses are common. 23 , 26 Physicians should praise and support the patient’s efforts to change and use statistical evidence to stress that episodes of relapse are normal. For example, only about 7 percent of persons initiating a smoking cessation attempt are abstinent after one year, 13 and multiple attempts are usually needed before achieving lifetime cessation.

Motivational Interviewing

Motivational interviewing ( Table 5 27 , 28 ) recognizes that patients may be ambivalent about change 27 and emphasizes patient autonomy, values, and collaboration with the physician. 28 The technique includes agenda setting, exploration, providing information, listening and summarizing, and generating options and contracting.

Beginning with agenda setting, the physician asks permission before discussing psychosocial conflicts, adherence, or health risk behavior. After eliciting permission, the physician then explores the topic with change-oriented queries focusing on the patient’s investment, urgency, perceived need, and reasons for considering change. 28 With an understanding of the patient’s motivation and values, factual information about the importance of change and treatment availability is presented in an emotionally neutral manner. This interpersonal style, which facilitates a partnership between patient and physician, 29 is in contrast to the “righting reflex” (in which the physician unilaterally presents the correct course of action). 28

Proponents of motivational interviewing believe that physician directiveness activates patient resistance. 27 , 28 However, using this technique, information is immediately followed by eliciting the patient’s reaction, which the physician then summarizes. In concluding the encounter, the patient is encouraged to consider treatment options and tentatively agrees to a specific plan with the physician (contracting). Evidence indicates that in primary care clinics, brief physician motivational interviewing has a positive effect on weight loss attempts, 30 exercise efforts, 31 decreased substance use, 32 and blood pressure control. 33

Problem-Solving Therapy

Problem-solving therapy ( Table 6 34 ) is a four-step approach (problem definition, generating alternative solutions, decision making, solution verification and implementation), which was developed from research comparing the problem-solving skills of clinical versus nonclinical populations. 34 , 35 Problem-solving therapy’s systematic framework begins with the physician asking questions to specifically define the problem using factual, concrete information. This method is particularly useful for patients exhibiting catastrophization, a cognitive and emotional escalation process in which life difficulties are exaggerated. 36 Diffusing concerns and targeting a specific, potentially modifiable feature is particularly important when addressing psychosocial crises.

While brainstorming for alternative solutions, the patient may indicate that the problem would be readily solved if someone else would change. When this occurs, physicians should redirect the patient to solutions that the patient can control to facilitate decision making and evaluation of possible consequences for each possible solution.

After the patient makes a decision, the physician verifies the solution by restating the plan and addressing any obstacles that might interfere with its execution. Lastly, the physician addresses the practical implementation of the plan. Research in health care settings supports the effectiveness of problem-solving therapy for a range of clinical problems, including major depressive disorder and nonadherence to a diabetes regimen. 37 – 39

The BATHE (background, affect, troubles, handling, empathy) technique, developed specifically for family physicians, is helpful for patients exhibiting psychiatric syndromes or a broad range of psychosocial problems. 40 The questions are almost always asked in the specific order listed in Table 7 . 14 , 40 , 41 The initial open-ended background question is a reminder to listen to the patient’s presenting narrative. Physicians are often concerned that initial open-ended questions will lead to overly long descriptions. However, most patients complete their answers in less than one minute, with 90 percent completing their answer in less than two minutes. 42 If the patient takes longer than a few minutes, keep the interview moving by politely interrupting and asking how the patient feels about his or her concerns. 41

Although the physician may briefly summarize the patient’s answer to the background question, the physician should quickly proceed to the “affect” question. Some patients have difficulty articulating feelings and continue to describe the problem, or they are simply unaware of their emotions. In response, the physician may repeat the question or suggest descriptors.

The “troubles” question provides a useful focus, particularly when the problem seems overwhelming. 40 , 41 Although the physician may believe that he or she knows what is most upsetting, the assumption may be incorrect. It may be tempting to recommend solutions, but handling the problem is the patient’s responsibility. However, the patient’s attempted solutions often cause more upheaval than the problem itself 43 —a point that the physician may reflect back to the patient. By focusing and labeling key dimensions, the physician’s questions facilitate the patient’s ability to generate realistic coping strategies.

Communicating empathy creates a physician-patient partnership and indicates that the physician is actively listening to the patient. If the visit is a follow-up, the opening question should target events in the time interval from the last visit. 41 Most BATHE interviews can be conducted in less than five minutes. 41

Approach to the Patient

In mental health settings, most evidence-based psychotherapies require a minimum of 10 to 15 sessions, 44 and approximately 50 percent of patients do not complete the treatment course. 3 Evidence-based reviews of primary care counseling indicate that brief approaches may lead to short-term reductions in psychosocial distress 45 , 46 and longer-term reductions in alcohol use 47 , 48 and depressive symptoms. 49 The models presented in this article may be implemented in approximately five to 10 minutes and can be integrated into most office visits. These strategies make up the first stage of a stepped-care approach 5 , 50 in which brief interventions, including providing patients with screening information, are the initial treatments. There are typically two options for patients who fail or incompletely respond to the initial intervention. For highly symptomatic patients or those with multiple high-risk behaviors, referral to a mental health specialist may be the next step. Alternatively, in less severe situations, the physician may add a second intervention, such as pharmacotherapy, more intensive education, or an additional counseling strategy. If problems persist, referral to a mental health or substance abuse specialist is recommended.

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Problem-Solving Therapy (PST)

(For resources, this is the publication date. For programs, this is the date posted.)


Visit the the  National Network of PST Clinicians, Trainers, & Researchers  for training options and resources. Also see the  archived NREPP listing .

Visit the the  National Network of PST Clinicians, Trainers, & Researchers .

Problem-Solving Therapy (PST) is a brief psychosocial treatment for patients experiencing depression and distress related to inefficient problem-solving skills. The PST model instructs patients on problem identification, efficient problem-solving, and managing associated depressive symptoms.

While there are different types of PST, they are all based on the same principle of resolving depression by re-engaging the client in active problem-solving and activities. In general, PST involves the following seven stages: (1) selecting and defining the problem, (2) establishing realistic and achievable goals for problem resolution, (3) generating alternative solutions, (4) implementing decision-making guidelines, (5) evaluation and choosing solutions, (6) implementing the preferred solutions, and (7) evaluating the outcome. A primary focus is learning and practicing PST skills, which are centered around empowering patients to learn to solve problems on their own.

Overall, the number of PST sessions may range from between 4 and 12. Individual sessions are, on average, 40 minutes long; however, group sessions can last up to 90 minutes. Each PST session follows a typical structure of agenda-setting, reviewing progress, engaging in the PST model problem-solving activities, reviewing action plans, and wrap-up.

PST can be used in wide range of settings and patient populations, including adaptations for those in primary care and those who are homebound, medically ill, and elderly. It can be delivered by a variety of providers, including mental health professionals, social workers, and health professionals, including primary care physicians and nurses.

Designation as a “Program with Evidence of Effectiveness”

SPRC designated this intervention as a “program with evidence of effectiveness” based on its inclusion in SAMHSA’s National Registry of Evidence-Based Programs and Practices (NREPP). 

Outcome(s) Reviewed (Evidence Rating)*

  • Suicidal Thoughts and Behaviors (Effective)
  • Depression and Depressive Symptoms (Effective)
  • Self-Concept (Effective)
  • Social Competence (Promising)
  • Self-Regulation (Promising)
  • Non-Specific Mental Health Disorders and Symptoms (Promising)
  • Physical Health Conditions and Symptoms (Ineffective)
  • General Functioning and Well-being (Ineffective)
  • Anxiety Disorders and Symptoms (Ineffective)

Read more about the  program’s ratings .


* NREPP changed its review criteria in 2015. This program was reviewed under the post-2015 criteria. To help practitioners find programs that fit their needs, NREPP reviews the evidence for specific outcomes, not overall programs. Each outcome was assigned an evidence rating of Effective, Promising, or Ineffective. A single program may have multiple outcomes with different ratings.  When considering programs, we recommend (a) assessing whether the specific outcomes achieved by the program are a fit for your needs; and (b) examining the strength of evidence for each outcome.

2012 NSSP Objectives Addressed: 

Objective 8.3: Promote timely access to assessment, intervention, and effective care for individuals with a heightened risk for suicide.

  • Study protocol
  • Open access
  • Published: 27 June 2013

The effectiveness of problem solving therapy for stroke patients: study protocol for a pragmatic randomized controlled trial

  • Marieke M Visser 1 , 2 ,
  • Majanka H Heijenbrok-Kal 1 , 2 ,
  • Adriaan van ’t Spijker 3 ,
  • Gerard M Ribbers 1 , 2 &
  • Jan JV Busschbach 3  

BMC Neurology volume  13 , Article number:  67 ( 2013 ) Cite this article

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Coping style is one of the determinants of health-related quality of life after stroke. Stroke patients make less use of active problem-oriented coping styles than other brain damaged patients. Coping styles can be influenced by means of intervention. The primary aim of this study is to investigate if Problem Solving Therapy is an effective group intervention for improving coping style and health-related quality of life in stroke patients. The secondary aim is to determine the effect of Problem Solving Therapy on depression, social participation, health care consumption, and to determine the cost-effectiveness of the intervention.


We strive to include 200 stroke patients in the outpatient phase of rehabilitation treatment, using a multicenter pragmatic randomized controlled trial with one year follow-up. Patients in the intervention group will receive Problem Solving Therapy in addition to the standard rehabilitation program. The intervention will be provided in an open group design, with a continuous flow of patients. Primary outcome measures are coping style and health-related quality of life. Secondary outcome measures are depression, social participation, health care consumption, and the cost-effectiveness of the intervention.

We designed our study as close to the implementation in practice as possible, using a pragmatic randomized trial and open group design, to represent a realistic estimate of the effectiveness of the intervention. If effective, Problem Solving Therapy is an inexpensive, deliverable and sustainable group intervention for stroke rehabilitation programs.

Trial registration

Nederlands Trial Register, NTR2509

Peer Review reports

Stroke is an increasing public health problem in the Netherlands: every year, 41,000 people suffer from stroke and over 3% of the total health care costs are related to the treatment of stroke and its consequences [ 1 ]. The mortality rate after stroke is 30% and is likely to decrease, which will cause an increase in morbidity [ 2 ]. Almost 50% of stroke survivors experience consequences in daily life that result in a lowered health-related quality of life (HR-QoL) [ 1 ]. The World Health Organization Quality of Life (WHOQOL) Group defines quality of life as “individuals’ perceptions of their position in life in the context of the culture and value systems in which they live and in relation to their goals, expectations, standards and concerns [ 3 ]. HR-QoL refers to the health-related aspects of quality of life. On average, utility scores of HR-QoL after stroke range from 0.47 to 0.68 (a utility score equal to death is 0.0 and full health 1.0), which is substantially lower than the value of a healthy reference population (utility score of 0.93) [ 4 , 5 ]. HR-QoL after stroke is predicted by functional constraints, age, gender, and psychosocial factors, like socioeconomic status, depression, and coping style [ 4 , 6 – 8 ]. Functional constraints, age, gender, and socioeconomic status cannot or are difficult to change, but coping style could be targeted. The question then becomes if HR-QoL after stroke could be improved through a coping style intervention. If this is possible, a secondary question would be how such improvement relates to depression, health care consumption, and costs.

A common definition of coping style is someone’s preferred way of dealing with different situations. Several coping styles can be distinguished, such as active, passive, and avoidant coping. Wolters (2010) shows that in traumatic brain-injured (TBI) patients, higher HR-QoL in the long term is predicted by an increase in active problem-focused coping style and a decrease in passive emotion-focused coping style. Unfortunately, in this population of TBI patients the active coping decreases over time, while passive coping increases [ 9 ]. This suggests that if the decrease of active coping can be stopped, there is room for improvement in HR-QoL. Stroke patients make even less use of active, problem-oriented coping styles compared to other brain damaged patients [ 10 ]. Furthermore, Darlington (2007) shows that in stroke patients, coping becomes more important in determining HR-QoL over time, while the importance of general functioning decreases [ 11 ]. This would mean that long term HR-QoL could benefit from improved coping.

Coping styles can be influenced by several interventions. Backhaus (2010) shows that an intervention aimed at changing maladaptive coping styles positively influenced psychosocial functioning of TBI patients [ 12 ]. However, HR-QoL was not measured in this study. No research is found that investigated an intervention aimed at improving HR-QoL through the change of maladaptive coping styles in stroke patients. We therefore set out to investigate whether Problem Solving Therapy (PST), which aims at active problem-focused coping, might improve HR-QoL in stroke patients. PST has been proved effective in other patient populations [ 13 , 14 ]. In stroke patients, PST has been shown successful for the prevention of post stroke depression [ 15 ]. Effects on coping style and HR-QoL have not been investigated yet.

The primary aim of this study is to investigate whether PST is an effective group intervention for improving active problem-focused coping style and HR-QoL in stroke patients. The secondary aim is to determine the effect of PST on depression, social participation, health care consumption, and the cost-effectiveness of the intervention. The effectiveness of the therapy will be investigated in an open group design, which has not been used in PST research before. PST will be added to the standard care just before the end of the rehabilitation program, as at this moment a relapse in HR-QoL is frequently observed, when patients cannot rely on their therapists anymore [ 16 ]. By teaching patients to actively cope with stressful situations, through adapting and realizing their goals, we expect that patients will use more effective coping styles, which consequently may prevent the relapse in HR-QoL, and possibly increase HR-QoL in the long term. With regard to the secondary aims of this study, we expect the incidence of depression to decrease, social participation to improve, and health care consumption to decrease, resulting in a favorable cost-effectiveness ratio for the intervention.

Study design and procedure

The effectiveness of PST for stroke patients will be evaluated in a multicenter pragmatic randomized controlled trial (RCT) with one year follow-up, with the intervention performed in the daily practice of a sub-acute outpatient stroke rehabilitation program. As such, the potential effects of the intervention have a good external validity, which allows us to calculate the cost-effectiveness of the therapy compared with standard care.

The study will be performed in Rijndam Rehabilitation Center in collaboration with Erasmus MC, both in the Netherlands, and in Ghent University Hospital in Belgium. Patients are invited by their rehabilitation physician to participate in the study. Before the start of the study, patients need to sign the informed consent form. Data will be collected at four time points by one of three research psychologists. T0 is the baseline measurement, performed within three weeks before the start of the intervention phase. T1 will be performed within ten days after the intervention phase, T2 six months and T3 twelve months after the intervention phase (Figure  1 ). The measurements will be performed in the rehabilitation center or at the patients’ home in a face-to-face interview. The study has been approved by the Medical Ethics Committee of Erasmus MC University Medical Center and the Ethics Committee of Ghent University Hospital.

figure 1

Design of the randomized controlled trial.

Study population

We strive to include 200 stroke patients. Inclusion criteria are: stroke (including subarachnoid hemorrhage), age between 18 and 75 years, being treated in the outpatient rehabilitation phase, and being able to participate in group therapy. Exclusion criteria are: progressive neurological disorders, life expectancy less than one year, insufficient understanding of the Dutch language, excessive drinking or drug abuse, subdural hematomas, moderate and severe aphasia. The same criteria would apply to the implementation of PST in practice, which stresses the pragmatic character of the trial. The inclusion of patients started March 2011 and will end August 2013. The one-year follow-up of all patients will be finished by September 2014.


Patients are randomized to the intervention- or control condition using a stratified block randomization procedure with a block size of four. To ensure comparability between the two groups, patients are stratified per rehabilitation center. A member of the research group, who is not involved in the collection of the data, prospectively allocates the patients to the intervention- or control condition in a one-to-one ratio using an online random-number generator. To allow blinded randomization, the allocation information will be put in separate sealed envelopes which are consecutively numbered. At the end of the baseline measurement, the investigator opens the numbered envelop and informs the patient about the condition he or she is assigned to. The research psychologists who perform the baseline and follow-up measurements are blinded for treatment condition. The therapists who provide the intervention are not involved in the collection of the data. The investigator who will analyze the data is not involved in the collection of the follow-up measurements.

Intervention: problem solving therapy

Patients who are assigned to the intervention condition will receive PST in addition to the standard rehabilitation program, which will start during the last eight weeks of outpatient treatment. PST is a widely used and practical intervention method, based on a general model of coping with stress [ 17 , 18 ]. The model states that having a chronic disease causes stressful daily problems, which increase the chance of experiencing psychological stress and depressive feelings. Therefore, the aim of PST is to improve the skills to cope with the stressful daily problems in life after stroke.

The intervention will be provided in an open group design, with a continuous flow of patients, which means that patients can enter the group every week and leave the group after eight sessions (Figure  2 ). The reason for this design is that it studies group therapy in its most feasible form, where patients start and end their programs at different time-points. If we had chosen to study the effect in closed groups, many patients in the similar stage of their programs are necessary. This would only be possible if patients are admitted to large scale rehabilitation centers, which is not the rehabilitation practice in The Netherlands, or patients would have to wait for a long time before entering the group. The open group design has some disadvantages. Patients may feel unsafe when they enter an already existing group. Furthermore, a continuous flow of patients is required to keep a balanced number of patients in the group. Therefore, interventions aimed at rare diseases cannot be studied with an open group design. However, for our population of stroke patients we do expect the design to be suitable and beneficial, because these patients are frequently seen in rehabilitation treatment. An open group design has several benefits as well. Advantages for the patients are that they do not have to wait until they can start with the intervention, they can share their experiences with other ‘experienced’ stroke patients, and there is room for interaction with many fellow patients. Other advantages are that the intervention is relatively easy to organize and implement in the daily practice of the rehabilitation center. This open group design has not been investigated in PST research yet.

figure 2

Patient flow in an open group therapy.

The intervention in this study consists of eight group sessions of 1,5 hours a week, with homework exercises after each session. The group consists of a minimum of three and a maximum of six participants. PST is provided by one to three trained neuropsychologists per rehabilitation center. Solving problems will be structured, by dividing the problem solving process in four steps:

Define problem and goal;

Generating multiple solutions;

Considering the possible consequences of the solutions systematically and select the best solution;

Implement the solution and evaluate.

Each session starts with the sharing of experiences from the past week. Then, the model of problem solving will be repeated and explained. If there are some participants who are in the group for a couple of weeks already, they will be asked to explain the model to other new participants. Subsequently, one step of the model will be highlighted every week. With emphasis on this specific step, the model will be applied to one or more examples from the participants. Finally, the participants will be asked to practice the specific step at home by making a homework assignment. During the sessions, inadequate and irrational thoughts will be challenged by common cognitive interventions. A unique aspect of the intervention is the focus on the definition of the problem in the first step of the model. A clear definition of the problem will lead to a better understanding and more solutions to it.

Control condition: standard care

Patients who are assigned to the control condition will receive the standard rehabilitation program, in order to be able to study the additional effect of the intervention to the standard rehabilitation program. This standard rehabilitation program consists of individualized amounts of treatment by a physical therapist, occupational therapist, speech therapist, psychologist, social worker, and rehabilitation physician, depending on the severity of stroke. On average, stroke patients in outpatient rehabilitation receive twelve hours of treatment a week during a nine week rehabilitation program.

Primary outcome measures are changes in task-oriented coping and psychosocial HR-QoL in patients in the intervention group in comparison with the control group. Coping style is measured using the Coping Inventory for Stressful Situations (CISS) and the short version of the Social Problem Solving Inventory-Revised (SPSI-R:SF). The CISS questionnaire consists of 48 questions and contains three subscales; Task-oriented coping, Emotion-oriented coping, and Avoidant coping. The subscale Avoidant coping consists of two subscales; Distraction and Social Diversion [ 18 , 19 ]. Because the PST aims at tasks, ‘Task-oriented coping’ is chosen as a primary endpoint; the other two subscales are used as secondary endpoints. The SPSI-R:SF questionnaire consists of ten questions about problem solving skills regarding daily situations. There are five subscales: Positive Problem Orientation, Rational Problem Solving, Negative Problem Orientation, Impulsivity/Carelessness Style, and Avoidance Style, and all are used as secondary endpoints in this trial [ 20 ].

HR-QoL is measured using the EuroQol (EQ-5D-5L) and the Stroke Specific Quality of Life Scale (SS-QoL-12). The EQ-5D is a generic questionnaire, and consists of five questions regarding mobility, self-care, daily activities, pain/complaints, mood, and a VAS scale. The five dimensions can be combined to one utility scale, representing the societal perspective of the general public [ 21 ]. The SS-QoL-12 is specifically developed for the population of stroke patients [ 22 ]. We will use the abbreviated version containing twelve items, which has been shown valid [ 23 ]. The questionnaire provides a total score and two sub scores: physical and psychosocial, of which the psychosocial sub-score is defined as the primary endpoint. The other HR-QoL scores are used as secondary endpoints.

Other secondary outcome measures are differences in depression, social participation, and health care consumption between patients in the intervention and control group. Additionally, the influence of cognitive functioning, personality characteristics, aphasia, type of stroke, side of stroke, level of functioning, and demographic characteristics on the outcomes will be assessed. Finally, the cost-effectiveness of the intervention will be calculated compared with standard care.

Depression is measured using the Center for Epidemiologic Studies Depression Scale (CES-D). This questionnaire consists of twenty items concerning depression, higher scores indicate more depressive symptoms [ 24 ].

Social participation is measured using the Impact on Participation and Autonomy (IPA). The questionnaire consists of five dimensions; Autonomy indoors, Family role, Autonomy outdoors, Social life and relationships, Work and education [ 25 ].

Health care consumption is measured using the Trimbos Questionnaire for Costs association with Psychiatric Illness (TiC-P). The questionnaire was developed for economic evaluation in mental health care, and measures health care consumption and productivity losses [ 26 ].

Sample size calculation

To determine the sample size for measuring differences between the intervention- and control group in coping style and HR-QoL, we searched for comparable effect sizes in the literature. With regard to coping style, there was no data available for this calculation. With regard to HR-QoL, Studenski (2005) measured an increase in HR-QoL after a physical therapy for stroke patients, with a long term effect size f ranging from 0.06 to 0.18 [ 27 ]. Because of the lack of more comparable data, we used this data and carefully estimated the effect size f to be 0.08. Considering the design of two groups and four repeated measurements, an expected correlation of 0.70, an alpha of 0.05, and a power of 0.80, we calculated a total required sample size of 132 patients based on the F-test. Because potential drop out is estimated at 0.30, we will strive to include 200 patients.

Statistical analyses

Demographic variables will be analyzed with an independent sample T-test for continuous variables, the Mann–Whitney U test for ordinal variables, and the chi-square test for categorical variables. Linear Mixed Models will be used to compare the repeated measurements between treatment groups, taking into account the correlation within and between subjects. We will create models for all the primary and secondary outcome variables, with time, group condition (intervention or control), and the interaction between these variables as predictors. Furthermore, we will control for variables that are accidentally not equally distributed between the two group conditions.

The cost-effectiveness of the intervention will be calculated by counting all the medical and non-medical costs, like productivity losses. The incremental cost-effectiveness ratio will be calculated by dividing the difference in total costs by the difference in quality-adjusted life years (QALYs). These QALYs will be calculated based on the EQ-5D questionnaire. The economic evaluation will be conducted according to the Dutch guidelines [ 28 ] and includes multivariate probabilistic sensitivity analyses. In the base case scenario the time horizon will be one year. If the effect is still present at one year follow up, a Markov model will be made to model a longer time horizon.

This study investigates the effect of PST on coping style and HR-QoL in stroke patients. In addition, the effect on depression, social participation, and health care consumption will be investigated, as well as the cost-effectiveness of the intervention. We will study the effectiveness of PST as close to the implementation in practice as possible, using a pragmatic trial design and an open group therapy. Any pragmatic trial has limitations; MacPherson (2004) argued that a pragmatic trial design cannot be used to determine the specific components of a treatment that caused an effect [ 29 ]. It may be possible that patients in the intervention group show improvement caused by the extra attention they receive and not so much by the assumed effective elements of the therapy; this attention effect may be considered a placebo effect. If we would like to distinguish between this ‘placebo effect’ and the effect of the specific treatment elements, the control group should have received a ‘sham therapy’. Such sham therapy would hinder the estimation of the effect of PST in practice, as in practice such additional effort would not take place. Therefore, one of the advantages of the pragmatic study design is that the external validity is better than using a sham-controlled design; the results will be generalizable to the normal rehabilitation setting [ 30 ]. The study population represents the normal stroke population in the outpatient phase of rehabilitation treatment, and the psychologists will provide the intervention to the patients just as they would do in practice. The results of a pragmatic trial are directly applicable to the usual care setting [ 31 ]. Moreover, if the intervention will prove effective, it will be easy to implement the intervention in the standard rehabilitation program, since it is already in use and the psychologists will already be trained. Other rehabilitation centers can use the therapy manual we developed.

We expect that patients who received PST will use more effective coping styles and experience a higher HR-QoL. Furthermore, we expect that patients after PST will show a decrease in depression score, an increase in social participation, and a decrease in health care consumption, which would lead to a reduction in the health care costs. We expect the intervention to be cost-effective, since the costs of the intervention are relatively low; one psychologist can train three to six patients at the same time. Darlington (2009) estimated the cost-effectiveness of an intervention aimed at coping strategies in stroke patients: the maximum costs for a single patient were 2500 euros, which will be lower if the therapy is provided in a group [ 32 ]. If PST will be proved effective for stroke patients in outpatient rehabilitation, the intervention will be an inexpensive, deliverable and sustainable group intervention that could be added to usual stroke rehabilitation programs.


Center for Epidemiologic Studies Depression Scale

Coping Inventory for Stressful Situations

  • Health-related quality of life

Impact on Participation and Autonomy

  • Problem Solving Therapy

Quality-adjusted life years

Randomized controlled trial

Social Problem Solving Inventory-Revised

Stroke Specific Quality of Life Scale

Traumatic brain-injured

Trimbos Questionnaire for Costs association with Psychiatric Illness

World Health Organization Quality of Life.

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This study is funded by the National Initiative Brain and Cognition (NIHC 056-11-010), Stichting Coolsingel, and Erasmus MC Cost-Effectiveness Research.

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All authors contributed to the development of the study protocol. AvtS adapted the PST-manual for the population of stroke patients. MMV implemented the therapy in the rehabilitation program. All authors read and corrected the draft version of this manuscript, and approved the final version.

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Visser, M.M., Heijenbrok-Kal, M.H., van ’t Spijker, A. et al. The effectiveness of problem solving therapy for stroke patients: study protocol for a pragmatic randomized controlled trial. BMC Neurol 13 , 67 (2013). https://doi.org/10.1186/1471-2377-13-67

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Cognitive Therapy for Suicidal Patients: Current Status

Suicide is the 10th leading cause of death in the United States, with more than 36,000 deaths by suicide per year ( Crosby, Ham, Ortega, Parks, & Gfroerer, 2011 ). The rate of completed suicides has increased steadily over the past decade, and the most recent statistics indicate that the rate of suicide has reached its highest level in the past 15 years ( Centers for Disease Control and Prevention [CDC], 2008 ). Despite the enduring public health significance of suicide, only recently has attention been given to the development of efficacious treatments to prevent suicidal behavior. Traditionally, the approach to treating suicidality was to address the patient’s depression ( Ellis, Allen, Woodson, Frueh, & Jobes, 2009 ; Linehan, 2000 ). However, this approach is limited because (a) it assumes that all suicidal patients are depressed, which is not always the case; (b) it does not necessarily address the unique psychological mechanisms at work leading up to or during suicidal behavior; (c) it does not necessarily address other modifiable risk factors for future suicidal behavior; (d) it does not necessarily allow for patients to develop strategies that they can use during a future suicidal crisis; and (e) there is no evidence that it is efficacious, as suicidal patients are almost always excluded from randomized controlled trials (RCTs) to evaluate treatments for depression. Thus, beginning in the late 1990s, pioneering work by Aaron T. Beck and Gregory K. Brown was initiated at the University of Pennsylvania to develop a cognitive therapy protocol that specifically targeted suicidal behavior.

This treatment protocol was first described in the mid-2000s ( Berk, Henriques, Warman, Brown, & Beck, 2004 ; Henriques, Beck, & Brown, 2003 ) and subsequently presented in greater detail in a full-length treatment manual ( Wenzel, Brown, & Beck, 2009 ). It was originally developed for patients who recently attempted suicide, but it can also be applied to patients who have experienced a recent episode of acute suicidal ideation that requires intervention. In this article, we view patients as being appropriate for this cognitive therapy protocol if they have experienced a recent suicidal crisis, which is defined as either a suicide attempt or acute suicidal ideation.

This treatment protocol’s central feature is that suicidal behavior is viewed as the primary problem rather than as a symptom of a psychiatric disorder. As such, it can be delivered to patients with a wide range of psychiatric disorders. Similar to cognitive therapy protocols for other problems, it targets unhelpful cognitions and maladaptive behavioral patterns, and in this case, the specific cognitions and behaviors that fuel suicidal behavior are the focus of treatment. This treatment protocol also shares many other features with other cognitive therapy protocols, such as an emphasis on problem solving in the here-and-now, collaboration between the patient and therapist, and an organized session structure. It was designed to be a brief intervention (i.e., approximately 10 sessions) that can be administered in concert with other relevant treatments, such as pharmacotherapy, drug and alcohol counseling, and/or group therapy. However, because many suicidal patients present with multiple life problems and chronic emotional distress, it is not expected that patients will no longer need therapy at the end of this brief intervention. Rather, treatment moves from an acute phase, in which the suicide prevention protocol described in this article is delivered, to a continuation phase, where other psychiatric disorders, Axis II clinical presentations, and/or life problems are addressed.

The following sections describe the acute phase of treatment for suicidal patients. First, we outline the cognitive model of suicidal behavior that forms the basis of treatment. Next, we describe specific therapeutic strategies that cognitive therapists implement in their sessions with suicidal patients. We also present the primary results from the RCT designed to evaluate the efficacy of this treatment protocol. Finally, we end by highlighting new developments in the field, which center mainly on the adaptation of the cognitive therapy treatment protocol for specific populations and settings.

Theoretical Framework

According to the cognitive theory that forms the basis of this treatment ( Wenzel et al., 2009 ), three sets of psychological processes make people vulnerable to engage in suicidal behavior. Dispositional vulnerability factors are long-standing psychological traits that (a) have the potential to increase life stress, (b) are associated with psychiatric disturbance (e.g., depressive symptoms), and (c) exacerbate affect dysregulation during suicidal crises. Examples of dispositional vulnerability factors include impulse aggression ( Brent & Melham, 2008 ), problem-solving deficits (e.g., Priester & Clum, 1993 ; Reinecke, 2006 ; Schotte & Clum, 1987 ), an overgeneral memory style ( Williams, Barnhoffer, Crane, & Duggan, 2006 ), and perfectionism ( Hewitt, Flett, Sherry, & Caelian, 2006 ).

The second set of processes associated with suicidal behavior comprises psychological variables associated with psychiatric disturbance, as over 90% of people who engage in suicidal behavior carry one or more psychiatric diagnoses ( Bertolote, Fleischmann, De Leo, & Wasserman, 2003 ), and nearly every psychiatric diagnosis is associated with increased suicide risk ( Harris & Barraclough, 1997 ). These psychological processes include unhelpful cognitive and behavioral patterns indicative of psychopathology (e.g., negative triad, inactivity). It is acknowledged that the presence of these cognitive and behavioral patterns does not guarantee that a person will engage in suicidal behavior, as most people who are diagnosed with a psychiatric disorder do not engage in suicidal behavior. According to our cognitive theory, suicide risk increases as the severity of a single psychiatric diagnosis increases and with comorbidity because these clinical presentations are most likely to activate suicide-relevant schemas (e.g., hopelessness, unbearability).

The third set of psychological processes associated with suicidal behavior involves suicide-relevant cognitive processes that become salient when a suicide-relevant schema is activated. These processes include attentional biases toward suicide-relevant stimuli (e.g., Becker, Strohbach, & Rinck, 1999 ; Cha, Naimi, Park, Finn, & Nock, 2010 ; Williams & Broadbent, 1986 ), the inability to disengage attention from suicide-relevant stimuli, and attentional fixation , or a preoccupation with suicide as the only solution to one’s problems. The model suggests that the threshold at which the cascade of suicide-relevant cognitive biases is activated depends on the person’s history of suicidal behavior; for example, those who have made previous attempts experience these suicide-relevant cognitive processes with less provocation than those who have never made a suicide attempt (cf. Joiner & Rudd, 2000 ).

Strategic Therapeutic Interventions

Cognitive therapy for suicidal patients proceeds from the theoretical framework described in the previous section and is divided into three phases: (a) an early phase (Sessions 1–3), (b) an intermediate phase (Sessions 4–7), and (c) a later phase (Sessions 8–10). Interventions that occur in each of these phases are described in this section.

Early Phase

The early phase of treatment is devoted to obtaining informed consent, engaging patients in treatment, conducting a suicide risk assessment, developing a safety plan, gathering information to facilitate a cognitive case conceptualization, and developing treatment goals. Although informed consent is an important feature in the delivery of any type of psychotherapy, it deserves special attention with suicidal patients to ensure that they clearly understand the goal of treatment (i.e., to prevent future suicidal behavior), learn about other evidence-based treatment options, and formulate realistic expectations for treatment (e.g., that participating in cognitive therapy for suicide prevention does not guarantee that the patient will not engage in suicidal behavior; Rudd et al., 2009 ). Thus, informed consent is a first step in engaging patients in treatment, as it orients them to the treatment that will be delivered. Other ways to engage patients in treatment include instilling hope, demonstrating confidence that their problems can be addressed using this framework, and showing a willingness to talk about suicide and other difficult issues that patients are experiencing.

Of course, with any suicidal patient, a comprehensive suicide risk assessment is in order at the beginning of treatment, and continued monitoring of suicide risk is indicated. In addition to assessing for suicidal ideation, intent, and plan, therapists can also identify whether suicidal patients report other psychological features of suicidality that have been demonstrated in the empirical literature to be associated with increased suicide risk. For example, therapists can ask patients to rate their wish to live and their wish to die, with the idea that high wish-to-die ratings accompanied by low wish-to-live ratings are especially potent risk factors for eventual suicide ( Brown, Steer, Henriques, & Beck, 2005 ). They can also ask patients who have attempted suicide about their reaction to their attempt, with the idea that patients who report regret that their attempt failed are at higher risk to eventually kill themselves than those who are glad to be alive or ambivalent ( Henriques, Wenzel, Brown, & Beck, 2005 ). Some research suggests that suicidal ideation at patients’ worst time in their lives is more predictive of suicidal behavior than current suicidal ideation ( Beck, Brown, Steer, Dahlsgaard, & Grisham, 1999 ); thus, therapists inquire about the characteristics of previous suicidal crises in addition to the current suicidal crisis that brought them into treatment. Other research has identified two cognitive factors that are particularly important in explaining suicidality—perceived burdensomeness to others and failed belongingness (e.g., Joiner et al., 2002 ; Van Orden et al., 2010 )—that can be monitored on an ongoing basis and that can eventually serve as targets in treatment.

On the basis of the suicide risk assessment, therapists work with their patients to develop a safety plan , which is a hierarchically arranged written list of tools for dealing with a suicidal crisis ( Stanley & Brown, 2011 ). The safety plan is not a contract that simply instructs patients not to attempt suicide; rather, it is guide for patients to consult in order to remember how not to attempt suicide. It is developed collaboratively by the patient and therapist in the first session, and it is modified in subsequent sessions on the basis of the cognitive and behavioral work that has taken place in session. Safety plans typically include six sections: (a) warning signs that a suicidal crisis is developing; (b) coping skills that patients can use on their own; (c) people with whom they can connect without talking in detail about the suicidal crisis; (d) people they can contact who can, specifically, help them manage the suicidal crisis; (e) contact information for treatment providers, hot-lines, and other emergency services; and (f) a plan for the removal of lethal means. Patients are instructed to consult their plan when they notice warning signs for a suicidal crisis and to implement coping skills on their own, with the notion that they will move onto the next step on the safety plan if the previous steps do not deescalate the crisis. The development of the safety plan is perhaps the single most important activity that occurs in the early sessions of treatment, as it is the first tangible tool that patients can take home that will help them to modify suicidal behavior.

During the early phase of treatment, cognitive therapists gather a great deal of information from the patient to develop a cognitive case conceptualization. Some of the information gathered pertains to the patient’s background, such as the dispositional vulnerabilities that play a role in the cognitive model of suicidal behavior described previously. However, a central goal of this information gathering is to paint a detailed picture of the situational, cognitive, emotional, and behavioral events that led up to the recent suicidal crisis that brought the patient into treatment, as well as the suicide-relevant cognitive processes that were at work during the crisis. Therapists encourage patients to “tell their story,” with the “story” beginning at any point in time that patients believe is relevant to understanding their suicidal crisis. As patients are describing these events, therapists take care to ask specifically about the psychological factors that contributed to the decision to make a suicide attempt (e.g., “What was running through your mind at that moment?” “When you had that thought, what did you do next?”). Therapists work with their patients to assimilate this information into a time line of events that led up to the suicidal crisis, with the goal of identifying multiple points on the time line that could serve as targets for later interventions (e.g., suicide-relevant cognitions, difficulty solving a problem).

As in most cognitive therapy protocols, a final activity that occurs in the early sessions of treatment is the development of specific and measurable treatment goals. In many instances, the development of treatment goals with suicidal patients is a daunting task, as they exhibit complex clinical presentations and report multiple life problems. Cognitive therapists who work with suicidal patients are mindful that the general goal of the acute phase of treatment is to reduce the likelihood of future suicidal behavior; thus, they use the cognitive case conceptualization that they have developed to work with their patients to identify specific goals that have the most promise in achieving this general aim. Goals pertaining to psychiatric disorders and other life problems can be developed when patients enter into the continuation phase of treatment.

Intermediate Phase

On the basis of the cognitive case conceptualization and the treatment goals, in the intermediate phase of treatment, therapists begin to apply cognitive therapy strategies to help patients acquire skills that will reduce the likelihood of future suicidal behavior. Some of these strategies take on a behavioral focus. For example, many cognitive therapists find that behavioral activation is indicated with suicidal patients in order for them to experience increased pleasure and meaning in their lives. In addition, because these patients typically receive a large number of services, cognitive therapists often work with patients to develop behavioral tools for increasing compliance with all aspects of their treatment. Other suicidal patients, such as those who are characterized by failed belongingness, have a limited or disrupted social support network. In these instances, cognitive therapists work with these patients to develop skills for strengthening their support network. At times, work on developing social support networks can take place in conjoint sessions so that the patient’s close others can learn how to provide the most effective support or to solve a problem in the relationship that was related to the recent suicidal crisis. Other behavioral tools that suicidal patients develop in cognitive therapy are those that promote affective self-soothing (e.g., behaviors that engage the five senses), such as those that are incorporated into dialectical behavior therapy (DBT; Linehan, 1993 ). All of these behavioral strategies are aimed at increasing the likelihood that patients emerge from a crisis without harming themselves, and their successful application begins to modify beliefs that their future is hopeless, that their current life situation is intolerable, and that there is no one to whom they can turn for support.

Because cognition plays a central role in the cognitive theory of suicidal behavior, most cognitive therapists find that incorporation of cognitive strategies into treatment has the potential to deescalate suicidal crises. Thus, cognitive therapists practice cognitive restructuring , or the systematic process of identifying, evaluating, and modifying unhelpful cognitions, with their patients in the intermediate phase of treatment. On the basis of the cognitive case conceptualization, they target the cognitions that are most directly related to the suicidal crises. These cognitions are usually associated with beliefs that the future will not get better (i.e., hopelessness), that one’s pain is intolerable (i.e., unbearability), and/or that one has no worth (i.e., worthlessness). Specific techniques that cognitive therapists use to address these cognitions include Socratic questioning (e.g., evidence for, evidence against), behavioral experiments, and future time-imaging (i.e., developing concrete mental images of the future 1, 5, and 10 years forward). The aim of cognitive restructuring is to modify suicide-relevant cognitions that are experienced during a suicidal crisis as well as unhelpful cognitions associated with psychiatric disturbance that have the potential to activate a suicide schema.

Although cognitive restructuring is often effective in modifying suicide-relevant cognitions in session, many patients report having difficulty applying these skills systematically during a suicidal crisis. This is especially true when patients are experiencing attentional fixation on suicide as the only solution to their problems. Thus, during times of agitation and emotional escalation, patients need quick and easily accessed reminders of the important work that they have done in therapy. One way for patients to be reminded of their adaptive responses to suicide-relevant cognitions is to consult a coping card , which is a small piece of paper (e.g., index card) that contains the fruits of the cognitive restructuring work done in session. Some coping cards contain questions patients can ask themselves to get distance from their cognitions; other coping cards contain adaptive, balanced responses that the patient developed in session when evaluating a suicide-relevant thought or belief; and still other coping cards contain a list of evidence in support of hope for the future, one’s ability to tolerate distress, or one’s worth.

A central activity in cognitive therapy for suicidal patients is the acknowledgment and development of reasons for living, as research has shown that few reasons for living increase the risk of suicidal behavior ( Jobes & Mann, 1999 ; Linehan, Goodstein, Nielsen, & Chiles, 1983 ). It is likely that few reasons for living exacerbate suicidal patients’ sense of hopelessness; thus, reminders of reasons for living can decrease the potency of a suicide schema and the resulting suicide-relevant cognitive processes experienced during a suicidal crisis. Coping cards can also be used as quick and accessible reminders of reasons for living. However, at times, the words written on a coping card are not powerful enough to deter a suicidal crisis. Some patients require more tangible and vivid reminders of reasons for living. As such, the construction of an individualized Hope Kit is often a central activity in cognitive therapy for suicidal patients. The Hope Kit comprises items that serve as visual and tactile reminders of reasons for living. For example, patients often use shoe boxes to house pictures of loved ones, letters from friends, inspirational music or poems, and/or prayer cards. The Hope Kit is then kept in an easily accessible place so that patients can utilize it in times of crisis. Many patients report that the construction of the Hope Kit is the most meaningful part of their experience with cognitive therapy.

In addition to the cognitive work aimed at modifying suicide-relevant cognitions, cognitive therapists also work with suicidal patients to enhance problem-solving skills, viewing suicidal behavior, itself, as evidence of a failure to solve a problem effectively (e.g., Reinecke, 2006 ). The goal of problem-solving training is to improve patients’ ability to cope with life stressors and engage in alternative solutions to suicidal behavior when faced with problems. Cognitive therapists systematically apply the steps to problem solving that are shared in many cognitive behavioral protocols, such as problem definition, generation of alternative solutions, decision making, and solution implementation and verification ( D’Zurilla & Nezu, 2007 ). Solutions that prove to be successful serve as corrective learning experiences that help patients adopt a more flexible approach to problem solving and modify beliefs that their problems are unsolvable or unbearable. Thus, the acquisition of problem-solving skills addresses both a dispositional vulnerability factor that puts people at risk for suicidal behavior as well as cognitive processes that are at work during suicidal crises, as it has the potential to reduce attentional fixation.

Because some research has found that impulsivity is associated with suicidal behavior ( Mann, Waternaux, Haas, & Malone, 1999 ; Michaelis et al., 2004 ), cognitive therapists who work with suicidal patients also target this construct. Although impulsivity is most evident in a person’s behavior, both behavioral and cognitive strategies can be used to reduce impulsivity. From a behavioral standpoint, patients are encouraged to use the coping strategies discussed throughout the course of treatment to help prevent impulsive suicidal behavior (e.g., consulting the safety plan, reaching out to someone in one’s social support network, engaging in self-soothing activities). From a cognitive standpoint, therapists can work with patients to evaluate the commonly held idea that suicidal crises will last indefinitely. Specifically, they can conceptualize suicidal crises as having “wave-like” properties, such that they ebb and flow rather than remaining consistent. Therapists can help patients to recognize that suicidal crises will eventually pass if they are willing to postpone self-harm while “riding the wave,” and they can encourage patients to conduct a behavioral experiment to “test” whether the wave will eventually recede. Therapists can also work with patients to conduct an advantages-disadvantages analysis (both short- and long-term) of acting impulsively on suicidal urges. With suicidal patients who are characterized by impulsivity, it is imperative to implement the long-term strategy of restricting means to suicide by working with patients to safeguard their environments early on in treatment to decrease the likelihood of impulsive suicidal behavior.

Later Phase

Once it is evident that patients have acquired the skills necessary to prevent or diffuse suicidal crises, treatment shifts to the later phase, which focuses largely on reviewing and applying specific skills to prevent future suicidal crises. There are four main components to the later phase of treatment: (a) reviewing and consolidating skills acquired during the intermediate phase; (b) conducting the relapse prevention protocol, in which patients apply these skills in guided imagery exercises; (c) reviewing gains and progress towards treatment goals; and (d) determining and preparing for disposition following treatment (i.e., continuation of treatment, referring for other treatment, or termination of treatment).

The consolidation of learning, review of progress toward treatment goals, and preparation for termination are activities in which cognitive therapists would engage in the later phase of most courses of cognitive therapy. In contrast, the relapse prevention protocol was developed specifically for suicidal patients to demonstrate to their therapist and to themselves that they can successfully apply the skills they have acquired in treatment. It is a series of guided imagery exercises in which patients visualize and systematically describe, in the present tense, the chain of events that led to the suicidal crisis that brought them into treatment. Particular emphasis is placed on the thoughts, emotions, and behaviors that contributed to the suicidal crisis. After engaging in a guided imagery exercise in which they describe the sequence of events that led to the suicidal crisis, patients are encouraged to go through the sequence again, this time describing in detail the manner in which they would implement skills to mitigate the suicidal crisis. Subsequently (and usually in the next session), patients use guided imagery to imagine the sequence of events that could lead to a future suicidal crisis, and, again, they describe in detail the manner in which they would apply the skills they acquired in treatment. Although this protocol powerfully consolidates learning and prepares patients for future crises, some patients find it daunting. Thus, therapists are mindful of spending sufficient time in preparation for the administration of this protocol (e.g., providing a clear rationale for the exercise, obtaining patients’ consent to engage in the exercise) and debriefing after the administration of this protocol (e.g., monitoring and addressing any residual suicidal ideation).

An important focus of the later phase of treatment is preparing patients for inevitable setbacks and challenges that may arise in the future, as well as focusing on identifying strategies to cope with these lapses. Some patients fall into the trap of dichotomous thinking, believing that they are “back at square one” if they experience another suicidal crisis. Thus, it is important to apply the cognitive restructuring skills acquired in the intermediate phase of treatment to help patients formulate accurate expectations about their symptoms, life problems, and unanticipated stressors following the acute phase of treatment. At the close of the later phase of treatment, therapists and patients can work collaboratively to decide whether to engage in a continuation phase of therapy, refer for other services, or taper sessions in anticipation of terminating treatment altogether.

In the past decade, many cognitive behavioral treatment protocols for suicidal behavior have been evaluated in RCTs (for a review, see Tarrier, Taylor, & Gooding, 2008 ). Overall, results from these studies support the efficacy of cognitive behavioral therapy (CBT), a term used interchangeably with cognitive therapy, for reducing suicidal ideation, suicidal behavior, and hopelessness relative to usual care. Furthermore, gains made in therapy are often maintained over time.

The specific cognitive therapy protocol described in this article was evaluated in an RCT by Brown et al. (2005) . In this study, 120 patients who had attempted suicide in the 48 hours prior to admission to an emergency department were randomly assigned to receive outpatient cognitive therapy plus usual care or usual care only. The only exclusion criterion was a medical disorder that would preclude participation in outpatient psychotherapy. At baseline, 77% were diagnosed with major depressive disorder, 68% were diagnosed with a substance use disorder, and 85% were diagnosed with more than one psychiatric disorder.

Patients completed assessments at baseline and 1, 3, 6, 12, and 18 months thereafter. The main outcome variable was a repeat suicide attempt. Between the baseline and 18-month assessments, approximately 24% of patients who received cognitive therapy and 42% of patients who received usual care made at least one subsequent suicide attempt, a difference that was statistically significant (Wald χ 2 = 3.9; p = .049). The hazard ratio was 0.51 (95% CI, 0.26 – 0.997), which indicates that patients who received cognitive therapy were approximately 50% less likely to reattempt suicide during the follow-up period than patients who received usual care. In addition, relative to patients who received usual care, patients who received cognitive therapy scored lower on the Beck Depression Inventory–Second Edition ( Beck, Steer, & Brown, 1996 ) at the 6-, 12-, and 18-month follow-up assessments and lower on the Beck Hopelessness Scale ( Beck & Steer, 1988 ) at the 6-month follow-up assessment.

New Developments

Since the publication of Brown et al.’s (2005) RCT, cognitive therapy for suicidal patients has been adapted for a number of different populations and settings, with many of these protocols using the term CBT. In this section, we briefly summarize recent developments in the application of CBT for suicidal adolescents and older men. We also discuss two brief, targeted interventions for suicidal patients in acute care settings: safety planning intervention and postadmission cognitive therapy.

Cognitive Behavioral Interventions for Suicidal Adolescents

According to the CDC (2008) , suicide is the third leading cause of death for children and adolescents between the ages of 10 and 19, with approximately 2,000 adolescent deaths by suicide each year. Two recent studies have significantly advanced the literature on the cognitive behavioral treatment of suicidal adolescents.

In the context of a multisite study (i.e., Treatment of Adolescent Suicide Attempters [TASA]), Stanley et al. (2009) developed a manual-based psychotherapy, Cognitive Behavioral Therapy–Suicide Prevention (CBT-SP), for reducing risk for future attempts in adolescents who recently attempted suicide. Therapy consists of acute and continuation phases, both of which last approximately 12 sessions. CBT-SP is both feasible and acceptable to patients, with over 70% of patients completing at least 12 sessions, and with 100% of a subgroup of patients who were interviewed about the treatment reporting that they found it to be helpful (Stanley et al.). Although TASA was initially designed to be an RCT comparing CBT-SP, medication management, and a combination of the two, difficulties in recruitment led the investigators to modify the design to allow participants to either choose a specific treatment or be randomized to a treatment, and most of the participants chose to receive combination treatment. Over a 6-month period, the full sample’s hazard ratios of experiencing a suicidal event (i.e., suicidal behavior, preparatory acts, or suicidal ideation) or a suicide attempt were 0.19 and 0.12, respectively, which compare favorably with hazard ratios ranging from 0.17 to 0.69 that have been reported by other research teams ( Brent et al., 2009 ). Of course, the nonrandomized design precludes definitive conclusions regarding the efficacy of CBT-SP in treating adolescents who recently attempted suicide. However, the TASA research team has made a notable contribution to the literature by manualizing an acceptable approach to treatment for a historically difficult-to-treat population and by demonstrating that retention rates and reductions in suicidal events are comparable, if not favorable, relative to other RCTs that have evaluated treatments for severely depressed, suicidal, and/or self-harming adolescents.

Esposito-Smythers, Spirito, Kahler, Hunt, and Monti (2011) recently conducted an RCT comparing an integrated outpatient CBT intervention (I-CBT) and enhanced usual care for adolescents who recently attempted suicide and who were diagnosed with a co-occurring substance use disorder. Results of this trial indicated that groups did not differ with regard to reductions in suicidal ideation. However, relative to enhanced usual care, I-CBT was associated with significantly less global impairment and fewer suicide attempts, inpatient psychiatric hospitalizations, visits to emergency departments, and arrests. In addition, relative to those who received enhanced usual care, those who received I-CBT reported significantly fewer days in which they engaged in heavy drinking or marijuana use. Overall, I-CBT appears to be an efficacious treatment for targeting both suicidal behavior and substance-use problems in dual-diagnosed adolescents.

Cognitive Therapy for Suicidal Older Adults

Compared to other age groups, older adults are disproportionately likely to die by suicide ( NIMH, 2007 ). Men account for approximately 85% of suicides in older adults ( CDC, 2008 ), suggesting the need for empirically supported treatments targeting suicidal older men. Brown and his colleagues at the University of Pennsylvania (personal communication, February 21, 2012) are in the process of completing a preliminary study to assess the feasibility and accessibility of a cognitive therapy protocol adapted for this demographic. In addition, the same researchers are currently conducting a fully powered RCT examining the efficacy of this intervention with suicidal older men.

Brief Cognitive Behavioral Intervention in Acute Care Settings

The standard of care for suicidal patients seen at emergency departments is to assess for risk of suicide and refer accordingly to appropriate level of care. However, despite the best efforts of emergency department staff, a significant portion of suicidal patients do not engage in treatment following emergency evaluation for a suicidal crisis (e.g., O’Brien, Holton, Hurren, & Watt, 1987 ). In response to this observation, Stanley and Brown (2011) designed a single-session, stand-alone brief intervention for emergency and acute care settings, known as the safety planning intervention (SPI). That is, they have developed the safety planning procedure from the protocol described in this article into a brief intervention unto itself. The aim is for patients to have a completed safety plan when they leave the emergency department so that some measure has been taken to reduce future suicidal behavior even if they do not have a single follow-up visit with a mental health professional. The efficacy of SPI is currently being evaluated in a national Department of Veteran Affairs clinical demonstration project, as well as in an urban emergency department ( Stanley & Brown, 2011 ).

Of course, patients determined to be at imminent risk for suicide by emergency staff are commonly admitted to inpatient units. However, there is a paucity of RCTs that have examined whether inpatient hospitalizations are actually effective in preventing future suicide attempts. In response to this concern, Ghahramanlou-Holloway, Cox, and Greene (2011) have adapted the cognitive therapy protocol described in this article into a targeted treatment for inpatients admitted due to a recent suicide attempt (i.e., postadmission cognitive therapy [PACT]). PACT consists of approximately six 60- to 90-minute individual sessions, preferably administered over the course of 3 consecutive days. This research team is in the process of pilot testing this treatment to assess the feasibility of its implementation in inpatient settings. Pending the results of this feasibility study, future RCTs will be conducted to determine the efficacy of this treatment.

The past decade has witnessed tremendous strides in the evidence-based treatment of suicidal patients, and the current decade promises to make significant advances in the adaptation of the evidence-based treatment to specific populations and settings. Cognitive therapy clearly reduces the frequency of repeat suicidal behavior in adult attempters relative to the care that these patients would typically receive. Mounting evidence suggests that it has great promise in reducing suicidal ideation and behavior in suicidal adolescents. The task for cognitive behavioral therapists in this organization is to disseminate this treatment so that suicidal individuals can get the targeted care that they need following a suicidal crisis.

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  • Study protocol
  • Open access
  • Published: 01 June 2020

Problem solving therapy (PST) tailored for intimate partner violence (IPV) versus standard PST and enhanced usual care for pregnant women experiencing IPV in rural Ethiopia: protocol for a randomised controlled feasibility trial

  • Roxanne C. Keynejad 1 ,
  • Tesera Bitew 2 , 3 ,
  • Katherine Sorsdahl 4 ,
  • Bronwyn Myers 5 , 6 ,
  • Simone Honikman 7 ,
  • Girmay Medhin 8 ,
  • Negussie Deyessa 9 ,
  • Nick Sevdalis 10 ,
  • Wietse A. Tol 11 , 12 ,
  • Louise Howard 1 &
  • Charlotte Hanlon   ORCID: orcid.org/0000-0002-7937-3226 13 , 14 , 15  

Trials volume  21 , Article number:  454 ( 2020 ) Cite this article

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In rural Ethiopia, 72% of women are exposed to lifetime intimate partner violence (IPV); IPV is most prevalent during pregnancy. As well as adversely affecting women’s physical and mental health, IPV also increases the risk of child morbidity and mortality associated with maternal depression, thus making antenatal care an important opportunity for intervention. Adapting generic, task-shared, brief psychological interventions for perinatal depression and anxiety to address the needs and experiences of women affected by IPV may improve acceptability to women and feasibility for health workers. This randomised controlled feasibility trial will compare brief problem solving therapy (PST) specifically adapted for pregnant women experiencing IPV (PST-IPV) with standard PST and enhanced usual care to determine the feasibility of a future fully powered randomised controlled trial.

Seventy-five pregnant women scoring five or more on the Patient Health Questionnaire, endorsing a tenth question about functional impact and reporting past-year IPV, will be recruited from antenatal care clinics in predominantly rural districts in Ethiopia. Consenting participants will be randomised to either four sessions of PST-IPV, four sessions of standard PST or information about sources of support (enhanced usual care) in a three-arm design. The interventions will be delivered by trained, supervised antenatal care staff using a task-sharing model. Assessments will be made at baseline and after 9 weeks by masked outcome assessors and will include measures of depression symptoms (primary outcome), post-traumatic stress, anxiety symptoms, functional impact, past-month IPV and hypothesised mediators (secondary outcomes). A mixed-method process evaluation will determine the feasibility of a future randomised controlled trial, assess the feasibility, acceptability, fidelity and quality of implementation of PST-IPV, generate testable hypotheses about causal mechanisms, and identify potential contextual factors influencing outcomes.

Despite mental health being a critical concern for women experiencing IPV, there is limited evidence for brief, task-shared psychological interventions adapted for their needs in low- and middle-income countries. Contextually tailored interventions for pregnant women experiencing IPV in low- and middle-income countries require development and process evaluation. This randomised controlled feasibility trial will yield results on the feasibility of conducting a fully powered trial, relevant to researchers, primary and antenatal care clinicians in resource-limited settings.

Trial registration

Pan-African clinical trials registry: PACTR202002513482084 . Prospectively registered on 13 December 2019.

Peer Review reports


Background and rationale.

Intimate partner violence (IPV) refers to behaviour by a partner or ex-partner that causes (or has the potential to cause) physical, sexual or psychological harm. IPV includes physical aggression, sexual coercion, psychological abuse and controlling activity [ 1 ]. It is highly prevalent worldwide [ 2 ] and an important social determinant of physical and mental health [ 3 , 4 ]. In response, the World Health Organization (WHO) [ 5 ], the United Nations [ 6 ] and the World Psychiatric Association [ 7 , 8 , 9 ] have prioritised interventions to prevent and address IPV and its health impacts.

The relationship between IPV and mental health is bidirectional, such that IPV increases a woman’s risk of mental disorders, which in turn increases a woman’s vulnerability to (further) IPV. For example, IPV is associated with subsequent depressive symptoms, suicide attempts [ 10 ] and alcohol use disorders [ 11 ], which increase women’s risk for IPV (re)victimisation. Exposure to IPV is rarely assessed in randomised controlled trials (RCTs) of psychological interventions [ 12 ], but some studies have found reduced IPV alongside improved mental health [ 13 ] and birth outcomes [ 14 ].

There is limited evidence on mental health interventions tailored to the needs of pregnant women experiencing IPV [ 15 ], especially in low- and middle-income countries (LMICs). In a rapid review of evidence, 33 studies were identified that reported mental health interventions for women affected by IPV [ 16 ]. In most of these studies, the interventions were group-delivered cognitive behavioural therapy (CBT)-informed interventions, mind–body interventions (such as mindfulness-based stress reduction, yogic techniques and biofeedback) or individually delivered, trauma-focused psychotherapeutic interventions. Although all the identified studies came from high-income countries, protocols from Tanzania [ 17 ] and South Africa [ 18 ] indicated growing research interest in the African region. For example, one RCT in Nairobi, Kenya, has shown that five sessions of the multicomponent behavioural treatment Problem Management Plus (PM+) delivered to women with a history of any gender-based violence are associated with improved psychological distress and post-traumatic stress symptoms at 3-month follow-up compared with enhanced usual care [ 19 ].

A recent systematic review confirmed the paucity of intervention research addressing the mental health of both survivors and perpetrators of IPV in LMICs [ 20 ]; no studies replicated evaluations of previously studied interventions and none were conducted in low-income countries. The authors recommended strengthening the theoretical underpinnings of mental health interventions for people experiencing or perpetrating IPV, testing their impacts on hypothesised mediators and improving IPV detection using continuous outcome measures and fully powered samples. Treating depression and post-traumatic stress disorder (PTSD) has the potential to reduce self-blame, low self-esteem, hopelessness and emotional numbing, and improve communication, stress coping and anger management skills among both survivors and perpetrators [ 20 ].

We recently investigated whether IPV exposure moderates the efficacy of generic psychological interventions in LMICs. Our meta-analysis of 15 studies that provided data showed that women reporting IPV demonstrated greater improvements in anxiety symptoms than women not reporting IPV following generic psychological interventions (difference in standardised mean differences, 0.31; 95% confidence interval 0.04–0.57; I 2  49.3%) and consistent but non-significant differences in PTSD, depression and psychological distress symptom improvements [ 21 ]. Our systematic review only identified two RCTs of psychological interventions for depression or anxiety in LMICs which were tailored for women experiencing IPV. In Pakistan, ten sessions of IPV-adapted group CBT were associated with improved depression and anxiety compared with CBT-based self-help groups [ 22 ]. In Iran, 10–12 sessions of IPV-tailored narrative exposure therapy were associated with improved PTSD and depression at 3- and 6-month follow-up compared with treatment as usual (life skills training and supportive counselling) [ 23 ]. These studies support the potential benefits of adapting psychological interventions for depression, anxiety or PTSD to meet the needs and experiences of women affected by IPV.

Although PM+ has been shown to be effective for women experiencing gender-based violence in Nairobi [ 19 ], delivering five 90-min sessions may not be feasible in primary care settings in low-income countries. Problem solving therapy (PST) is a brief psychological intervention that aims to improve coping with life problems by teaching problem solving skills. A meta-analysis of PST for depression found a standardised mean effect size of 0.34, but high heterogeneity among included studies indicated the need for research to determine the settings and patient groups for whom PST is most effective [ 24 ]. A meta-analysis of PST for any mental or physical health problem found that it was significantly more effective than no treatment, treatment as usual, and ‘attention placebo’ arms (controlling for non-specific effects of contact), moderated by the use of problem orientation training and homework assignments [ 25 ].

Several studies from LMICs suggest that PST can be effective for treating depression, anxiety and psychological distress. A 5-week pilot study of adapted PST in English, Xhosa and Afrikaans in South African township residents found that it was acceptable, feasible and associated with significant reductions in psychological distress [ 26 ]. An RCT of South African emergency department attendees found that substance use was significantly reduced at 3-month follow-up in participants who received five sessions of blended PST and motivational interviewing, compared to motivational interviewing alone or psychoeducation control [ 27 ]. In Zimbabwe, the ‘Friendship Bench’ intervention comprised six sessions of individual PST delivered by lay health workers, and an optional six-session peer support group [ 28 ]. In this 86% female sample, depression and psychological distress were significantly reduced following PST in comparison to enhanced usual care.

The importance of designing RCTs to evaluate mediators of treatment and mechanisms of change is widely supported [ 29 ]. However, despite evidence of efficacy, studies of how PST works are limited and contradictory. Hypothesised mechanisms have included improving mastery, self-control and the accuracy of perceived problem severity [ 30 ], problem solving skills [ 31 ], ‘life integration’ [ 32 ] and locus of control (the extent to which the individual attributes their experiences to internal or external factors) [ 33 ]. An RCT comparing online CBT, PST and waiting list control for depression found that the effects of both interventions were mediated by reduced dysfunctional attitudes, worry, negativity towards problems and increased mastery, with no difference in effect sizes between CBT and PST [ 34 ]. The authors postulated that both interventions increase expectations of self-efficacy, leading to greater commencement and continuation of coping behaviours [ 35 ]. Both mechanisms for improved mood might also influence the ability of women to respond to IPV.

Process evaluations of complex intervention feasibility studies are increasingly recognised as being vital to optimise the safety, efficiency and validity of subsequent RCTs [ 5 , 36 ]. Updated guidance [ 37 ] and growing consensus [ 38 ] support the need for studies to determine the feasibility of research methods used to study complex interventions before conducting definitive RCTs. Sociocultural, health system and economic factors affect the adaptation, translation, mechanisms, success and scale-up of interventions, so a mixed-method process evaluation [ 39 ] is crucial and helps to inform understanding of the context for future implementation [ 40 ].

In rural Ethiopia, 72% of women are exposed to lifetime IPV [ 41 ] and this is associated with emotional distress [ 42 ] and depression [ 43 ]. IPV in Ethiopia is most prevalent during pregnancy [ 44 ] and increases the risk of child morbidity and mortality associated with maternal depression [ 45 ]. Antenatal depression in Ethiopia is associated with increased emergency presentations in pregnancy [ 46 ], perinatal complications [ 47 ], prolonged labour [ 48 ] and use of emergency delivery care [ 49 ]. As pregnancy is the most common time for Ethiopian women to access health care [ 50 ], antenatal care offers an important opportunity to provide an intervention that addresses both IPV and depression.

The range of cultural, geographical, economic, linguistic, religious, socio-political, health system and other differences between rural Ethiopia and the largely middle-income settings of most RCTs published to date supports the need for research evaluating PST adapted for women experiencing IPV (PST-IPV) in this context.

In this randomised feasibility trial and process evaluation of perinatal PST-IPV in rural Ethiopia, we aim to determine the feasibility and acceptability of the intervention and study design to inform a future fully powered RCT. Specific objectives are to:

Determine whether the PST-IPV intervention and processes of recruitment, randomisation, follow-up and evaluation are feasible and acceptable to pregnant women and health workers in rural Ethiopia. This includes estimating parameters to inform the design of a future RCT.

Refine the PST-IPV intervention and study design in response to a mixed-method process evaluation, which assesses the feasibility, acceptability, fidelity and quality of the intervention, explores causal mechanisms, and identifies contextual factors that may influence outcomes [ 37 ].

Trial design

In this three-arm feasibility trial, we will randomise eligible women (with depressive symptoms, functional impact and past-year IPV) to PST-IPV, standard PST or enhanced usual care (information about relevant sources of support). All arms represent additions to standard clinical care, which does not currently provide any routine interventions for perinatal depression or IPV.

This study is linked to a two-arm feasibility trial that will randomise eligible women (with depressive symptoms and functional impact) to standard PST or information only, the protocol of which is reported separately (Bitew T, Keynejad RC, Honikman S, Sorsdahl K, Myers B, Fekadu A, et al. Brief problem-solving therapy for perinatal depression in rural Ethiopia: protocol for a randomised feasibility study.) (see Fig.  1 ).

figure 1

Flow diagram of problem solving therapy (PST) adapted for pregnant women experiencing intimate partner violence (IPV) feasibility trial procedure, indicating the relationship with a nested feasibility trial of standard PST in women not reporting past-year IPV (shaded grey). ANC antenatal care, HEW health extension worker, MINI Mini-International Neuropsychiatric Interview, PHQ-9 Nine-item Patient Health Questionnaire

Study setting

The study will be conducted in selected health facilities in the predominantly rural areas of Gurage zone (projected population 1,712,506) and Silt’e zone (projected population 1,043,242) in the Southern Nations, Nationalities, and Peoples’ Region of Ethiopia [ 51 ]. Primary health care is structured so that the nurse, midwife and health officer-run health centres (serving a population of 25,000–40,000) are linked to five community health posts (serving a population of 3000–5000) staffed by one or two health extension workers (HEWs) each, with access to a single primary hospital for more specialist care. HEWs, who have completed high school and received 1 year of undergraduate-level training [ 52 ], provide a first antenatal contact before referring women for further antenatal care (ANC) at a health centre or primary hospital and maintain contact with women during pregnancy.

This study builds on the programme for improving mental health care (PRIME) study [ 53 ], which integrated mental health into primary and maternal care in five LMICs, including the Gurage zone, Ethiopia [ 54 ]. In PRIME, a district-level mental health plan was developed in collaboration with key stakeholders and comprised interventions at the community, health facility and health system level. At the facility level, PRIME trained primary and maternal care staff using the mental health gap action programme (mhGAP) intervention guide of the WHO, which guides non-mental health specialists through clinical diagnostic and treatment algorithms for prioritised mental, neurological and substance use disorders [ 55 ]. The PRIME study investigators identified low detection rates of depression, which may be related in part to a lack of acceptable treatment options. Formative work was therefore conducted to inform adaptation of a brief psychological intervention for depression. In a nested study, PST was then adapted for antenatal women in this rural Ethiopian setting.

A systematic review and meta-analysis [ 21 ], further qualitative interviews and theory of change workshops (Bitew T, Keynejad RC, Honikman S, Sorsdahl K, Myers B, Fekadu A, et al. Brief psychological intervention for antenatal depression: a qualitative study.) (Keynejad RC, Bitew T, Mulushoa A, Tol W, Howard LM, Hanlon C. Adapting brief, task-shared problem-solving therapy for women experiencing intimate partner violence in rural Ethiopia: a qualitative study.) were then used to adapt this locally tailored PST intervention to address the needs and experiences of women affected by IPV. The preliminary theory of change visualises health worker perspectives on the components, hypothesised mediators, intermediate and long-term outcomes of PST-IPV intervention, and factors anticipated to influence the delivery and implementation of PST-IPV (see Supplementary file  1 ).

Adaptation for IPV focused on international guidelines [ 5 ], which recommend identifying women experiencing IPV, training health care providers about IPV, and providing woman-centred care and support when IPV is disclosed. PST-IPV will apply a PST approach in the context of IPV, enabling IPV-related problem solving and management of mental health-related symptoms.

Participant sample size

As a feasibility trial, this study is not powered to detect intervention efficacy, but rather to estimate feasibility parameters to inform a future RCT, and test intervention and research protocols. With a total sample size of 75 (25 participants randomised to PST-IPV, 25 to PST and 25 to enhanced usual care), a drop-out rate of 30% can be estimated to within a 95% confidence interval of ±3%. To estimate the standard deviation of the primary feasibility outcome measure to inform a future RCT sample size calculation, recommended feasibility trial sample sizes range between a total of 24 and 50 across two arms [ 56 , 57 ].

Participant recruitment

Research staff will consult health care workers based in primary hospitals and/or health centres in Gurage and Silt’e zones to identify potentially eligible women meeting those inclusion criteria about which information is held for screening. Potentially eligible women will be approached through ANC clinics and HEW home visits by research staff and provided with written and verbal information in Amharic, before being invited to give written, informed consent to initial screening. Non-literate women will signify their consent by finger print. A high school-educated assistant will act as a witness to confirm that the information sheet has been read aloud correctly to non-literate women. Women screened as eligible to participate in the randomised feasibility trial will then be invited to give written, informed consent to participate. As with screening, non-literate women will signify their consent to participate in the trial by witnessed finger print.

Due to potential risks of abusive partners learning of women’s involvement, information sheets, consent forms and other study paperwork will be kept in the locked research office after being read and signed but will be accessible to women at their request. Due to logistical challenges affecting women’s daily lives in this setting, it is not possible to give prospective participants 24 h to decide whether to take part. However, a minimum of 30 min will be allowed for the woman to make up her mind about participating in the study.

Participant screening

Consecutive, potentially eligible women who provide informed consent will be screened for depressive symptoms and a history of past-year IPV after their ANC appointment. Depressive symptoms will be screened for using the locally validated [ 58 ] nine-item Patient Health Questionnaire (PHQ-9) [ 59 ]. To screen for IPV exposure, research staff will first read the introductory paragraph of the Amharic translated [ 60 ] Conflict Tactics Scale [ 61 ] to potential participants (or they may read themselves, if literate) to ameliorate stigma they may feel towards disclosing IPV. A five-item ‘non-graphic language’ screening test previously used in this and other LMIC contexts and found to be a valid measure of IPV [ 62 ] will then be administered. Finally, items from the WHO multi-country study [ 42 ] of women’s health and domestic violence, previously used in this setting, will be used to ask about experiences of IPV in the past year.

All screened women scoring five or more on the PHQ-9 [ 63 , 64 ] and endorsing any functional impact of symptoms (the tenth item) will be invited to participate in the research study. Endorsement of the tenth item will be defined as answering “somewhat”, “very” or “extremely difficult” to the question “over the last two weeks, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?”.

Consenting women who disclose any past-year IPV during screening will be randomised to one of PST-IPV, standard PST or enhanced usual care, whereas consenting women reporting no IPV on baseline measurements will be randomised to one of standard PST or enhanced usual care for the separate, nested PST feasibility trial (see Fig. 1 ).

Participant recruitment procedures

All women screened as eligible to participate will be informed about the study and given the opportunity to ask questions before being invited to consent to participate in the randomised feasibility trial. Women consenting to participate will first receive their routine clinical care and then participate in a baseline interview using fully structured questionnaires. If screening or this assessment identify any sources of concern (e.g. suicidal ideation, risks to herself or others), the researcher will discuss these with the woman and explain the need to share them with her health care professional, before involving them. To be eligible to participate in the PST-IPV components of the overall study, women must meet the eligibility criteria (see below).

Participant eligibility criteria

Women can be included if they:

Speak Amharic (the official regional language)

Are aged 16 years or over

Are between 12 and 34 weeks gestation of pregnancy

Are intending to reside in the study area for the duration of the study

Score 5 or more on PHQ-9 with functional impairment (tenth question)

Report IPV in the past year (in a current or previous relationship) during screening

Consent to participate, including to accept enhanced usual care or to attend four sessions of PST-IPV or PST (if randomised to a treatment arm)

Women are required to speak Amharic, the official language of the region, so that they can access all translated study materials, verbally or in writing. Relationships are defined as any romantic or sexual interaction within or outside marriage.

PHQ-9 has been validated in the study area in both primary care [ 63 ] and ANC attendees (area under the receiver operating characteristic curve 0.91, 95% confidence interval 0.86–0.96) [ 64 ]. For primary care attendees a score of five or more was the optimal cut-off for identifying possible depressive disorder. For antenatal women, a cut-off of four or more was optimal. However, since at the optimal cut-offs the positive predictive value was less than 50%, in this study women scoring above the cut-off (five or more) will be included if they also report difficulty in their day-to-day activities (measured using the PHQ-9 tenth item).

Participant exclusion criteria

Women will be excluded if they:

Are acutely unwell

Require emergency treatment

Are identified by the ANC provider during pre-screening as having possible psychotic symptoms

Are unable to understand the interview (e.g. diagnosed with severe intellectual disability or dementia, or unable to speak Amharic)

Expect to move away from the study area before the study is completed

All women endorsing question nine of PHQ-9 about suicidal thoughts or self-harm behaviours will receive the Amharic [ 63 ] Mini-International Neuropsychiatric Interview suicidality scale [ 65 ]. Women scoring 17 or above on the Mini-International Neuropsychiatric Interview (indicating high suicide risk) will be excluded from participation as part of a stepped-care model [ 54 ]. They will be referred instead to a mental health-trained primary care worker who will employ mhGAP [ 55 ] criteria to assess for imminent risk of self-harm or suicide. Women assessed as being at imminent risk will be referred to a psychiatric nurse in the primary hospital for escalation of their care. The attendance of participants at referred appointments will be facilitated by the study, including any attendant transportation costs to access off-site services. Any psychotic symptoms and risks identified during the trial will be discussed with the project mental health professional and women will be referred for specialist mental health care if required. Women assessed as eligible to participate at the time of screening but who do not consent to take part will receive the same stepped mental health care model, depending on their symptoms and any imminent risks.

Otherwise eligible women reporting no past-year IPV exposure will be invited to participate in the separate, nested feasibility trial of standard PST for depression but will not be eligible for this study of PST-IPV.

Participant consent

Interested women who cannot read will be read aloud the information sheet. If unable to write, participants will record a thumb print, signed by a literate witness (a high school-educated assistant) after confirming that the information sheet has been read aloud correctly; otherwise, participants will provide written informed consent. Study documents will be kept in the locked research office but will be accessible to women at their request. The information sheet includes details of how participants can access compensation, if required.

Participant reimbursement

All participants will be reimbursed for their time attending research interviews in addition to transport costs and any additional expenses incurred. Participants will be reimbursed for transport costs to attend PST or PST-IPV sessions but will not be compensated for their time during these sessions. This is to determine the acceptability of psychological intervention sessions to women and enable calculation of drop-out rates. A fund will be available to assist participants disclosing IPV who wish to access support services (for example. to facilitate transport to a government social support office or police station).

Randomisation and allocation to trial arms

Research staff will telephone the Centre for Innovative Drug Development and Therapeutic Trials for Africa data manager, based at the College of Health Sciences, Addis Ababa University, Ethiopia, who is not otherwise involved in this study, to allocate each participant to a study arm (PST-IPV, standard PST or enhanced usual care) using a random number list generated by the trial statistician (GM), who is not otherwise involved in data collection processes. The data manager will telephone a separate member of research staff based in Silt’e, who will inform a clinician trained to deliver PST-IPV or standard PST when a new participant has been allocated to that trial arm. Research staff will provide participants with an unmarked card indicating their enrolment in the trial and agree a date and time to attend their first session of PST-IPV or standard PST. When they attend, they will be expected by their allocated clinician. For participants allocated to enhanced usual care, their antenatal care provider will provide them with information about sources of support and the research assistant will arrange a follow-up appointment 9 weeks later.

Women who do not attend their appointed date and time will be contacted using the telephone number (where applicable) and/or household details they have provided at trial enrolment or through their allocated HEW, up to a maximum of three attempts.

Given qualitative differences between PST and PST-IPV, clinicians delivering the intervention cannot be masked to participant allocation. To avoid contamination, PST-IPV, standard PST and enhanced usual care will be delivered by different practitioners who have either attended a PST-IPV or a standard PST training course, or received basic training to provide enhanced usual care. Post-intervention outcome assessments will be conducted by trained, independent assessors (working in separate offices from practitioners delivering interventions and not travelling together) masked to intervention allocation, with a minimum post-high school diploma level of education. Independent assessors will document any incidents of unmasking. Data analysts will also be masked to intervention allocation.

Intervention arms

Participants randomised to PST-IPV or standard PST will attend four intervention contacts within a maximum of 8 weeks. Where birth occurs before the end of treatment, the feasibility of continuing PST-IPV or standard PST post-natally will also be assessed.

Both manualised interventions will be delivered by trained health workers, such as nurses and midwives, supervised by Psychology Masters-level qualified research staff, with access to a project mental health professional for clinical concerns. Responses to concerns and risk incidents will follow standard operating procedures (SOPs). Government-employed health workers trained to deliver the interventions will be paid for their time.

Both PST-IPV and standard PST intervention arms follow the same structure of four sessions, based on the model successfully employed in South Africa and adapted for this rural Ethiopian setting [ 27 , 66 ]. Session 1 focuses on basic psychoeducation, introduction to PST, identifying the most important things in the woman’s life and categorising problems into three groups. Session 2 focuses on revising session 1, coping strategies for ‘group A’ problems (which are upsetting but do not influence the most important things in the woman’s life) and the six-step problem solving method for ‘group C’ problems (which are important and can be solved). Session 3 focuses on revising session 2, coping strategies for ‘group B’ problems (which are important but cannot be solved) and psychoeducation about the phases of coping with bereavement and loss. Session 4 focuses on revising session 3, using problem solving skills in everyday life and reviewing how the coping strategies worked in practice. All sessions involve assigning and reviewing take-home activities.

PST-IPV content and materials are adapted to address the needs and experiences of women affected by IPV, whilst standard PST content and materials are generic. Adaptations for women experiencing IPV include training staff using content and materials from the new WHO curriculum on caring for women subjected to violence [ 67 ], attention to safety and sensitivity where women list IPV-related problems during sessions (including training with worked examples of problem solving focused on IPV), and adaptation of PST case studies to reflect common problems associated with IPV.

Participants randomised to PST-IPV or standard PST will attend a total of six contacts: one baseline pre-intervention research assessment, four intervention contacts and a follow-up research assessment contact 9 weeks after recruitment. The feasibility of follow-up 9 weeks after recruitment will be assessed and may change, depending on gestation of pregnancy at the time of enrolment.

Enhanced usual care arm

One-third of participants will be randomised to information only about sources of support (enhanced usual care; see Supplementary file  2 ). They will attend two contacts: one pre-intervention assessment at which they are provided with information about relevant sources of support, and one follow-up assessment 9 weeks later.

In our meta-analysis we found that randomisation of control group participants with depression, anxiety, PTSD or psychological distress symptoms and IPV exposure to waiting list, treatment as usual, or enhanced usual care arms is widespread [ 21 ]. This, coupled with the lack of any standard intervention provision for perinatal depression and/or IPV in rural Ethiopia and the provision of safeguards in the study design, justify the use of a control arm, which comprises enhanced usual care (provision of information about sources of support).

Measurement: participants

Women will be assessed at baseline and then 9 weeks later in a private room of the health care facility at a time convenient to them (Fig.  2 ). During these assessments, fully structured measures will be administered to consenting participants in an interview format. The time taken to complete planned questionnaires will be tested prior to commencing the study. Where administration of study measures takes longer than 1 h per session or is experienced by research staff or participants as unduly burdensome, instruments will be removed from the assessment questionnaire. This information will contribute to the study’s process evaluation.

figure 2

Schedule of participant enrolment, interventions and assessments. CSRI client service receipt inventory, GAD-7 Generalised Anxiety Disorder 7 scale, IPV intimate partner violence, MINI Mini-International Neuropsychiatric Interview, OSSS-3 Oslo Social Support Scale 3, PCL-5 post-traumatic stress disorder checklist for Diagnostic and Statistical Manual version 5, PHQ-9 Nine-item Patient Health Questionnaire, PST problem solving therapy, PTSD post-traumatic stress disorder, WHO World Health Organization, WHODAS World Health Organization Disability Assessment Schedule

Primary participant outcome

At baseline and the independent, masked, 9-week follow-up interview, depression symptoms will be measured using the Amharic-translated PHQ-9 [ 59 ], a nine-item questionnaire asking about the presence of depressive symptoms in the preceding 2 weeks. Each item is rated according to persistence of the symptom (0 = not at all, 1 = several days, 2 = more than half of the days, 3 = nearly every day). PHQ-9 scores pre- and post-participation will be compared to calculate the mean difference in depression symptom reduction in PST-IPV, standard PST and enhanced usual care arms. Proportions of participants showing a treatment response, defined as a 50% reduction in PHQ-9 score, will also be calculated, although this feasibility trial will not be powered to detect treatment efficacy.

Secondary participant outcomes

At baseline and 9-week follow-up, the following will be measured using Amharic-translated scales. If scores are normally distributed, mean differences will be compared between arms using t tests and, if not normally distributed, median differences will be compared between arms using non-parametric statistical tests.

Post-traumatic stress symptoms using the PTSD checklist for the Diagnostic and Statistical Manual version 5 (PCL-5) [ 68 ] which has been adapted for a rural Ethiopian context

Anxiety symptoms using the Generalised Anxiety Disorder 7 (GAD-7) scale [ 69 ]

Disability using the 12-item Ethiopian adaptation [ 70 ] of the WHO Disability Assessment Schedule (WHODAS 2.0) [ 71 ]

IPV: participants will be asked about past-month IPV at baseline and 9-week follow-up to determine whether the frequency of different types of IPV (physical, sexual, psychological, coercive control) change during the study period

Self-efficacy using an adapted self-efficacy scale validated in Ethiopia for sexual health research [ 72 ]

Mastery (the extent to which the person considers themselves in control of forces affecting their lives in important ways [ 73 ]) using a 15-item multi-cultural mastery scale [ 74 ] adapted for rural, non-Western communities

Perceived social support using the Oslo Social Support Scale 3 (OSSS-3) [ 75 ] previously used in this region in a study of antenatal depressive symptoms [ 46 ]

Health care-seeking behaviour using the client service receipt inventory [ 76 ] adapted for Ethiopia [ 77 ] and modified to focus on the past month; the client service receipt inventory will be used to quantify the frequency of primary health care visits, inpatient admissions, private sector (including traditional healer) contacts, medications and investigations of women in each arm, in the past month, pre- and post-participation

Adverse events or unanticipated harms taking place during the study period

Obstetric and neonatal outcomes: HEWs, who maintain maternal care records, will report the location of birth and any stillbirths and early neonatal deaths among study participants, attendance at subsequent ANC appointments and medication prescriptions for physical and mental health, as they are not reliably self-reported [ 47 ]; where women attend ANC at a combination of HEW health posts, health centres and/or primary hospitals, antenatal contacts at all relevant services will be collected; the feasibility of collecting this data will be explored during analysis

Attitudes towards gender roles using the WHO Attitudes Towards Gender Roles questionnaire [ 42 ]

Measurement: process evaluation

Assessing parameters and feasibility for a future trial.

The mixed-method process evaluation will assess variables associated with intervention implementation processes. Recommended intervention process outcomes (for implementation) include acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration and sustainability [ 78 ]. In this feasibility trial, we will focus on evaluating:

Acceptability of PST-IPV and of the study design to women and health workers in terms of uptake, completion and drop-out rates

Adoption by health workers

Appropriateness from women and health workers’ perspectives

Feasibility in terms of practical organisation

Fidelity of delivery

The following administrative data will be collected, which will inform the feasibility outcome measures shown in brackets:

Screening rates and reasons for refusal (acceptability)

Recruitment rates (acceptability, feasibility)

Numbers of eligible women at each clinical site (appropriateness)

Proportions of eligible women agreeing to participate (acceptability)

Willingness to be randomised and comprehension by participants of randomisation (acceptability of allocation)

Session duration (appropriateness, feasibility, fidelity)

Take-home activity completion (acceptability, fidelity, appropriateness)

Drop-out rates (acceptability, feasibility)

Follow-up rates (feasibility of retention)

Research staff will document key site features to enable comparison of process data, and keep field journals noting:

Staff willingness to participate at each site and retention in the study (acceptability, adoption, appropriateness, feasibility)

Optimal recruitment procedures (feasibility)

Acceptance of randomisation at each site (acceptability, appropriateness, feasibility)

Qualitative interviews

The acceptability and burden on women and staff of the intervention itself (including which components are experienced as helpful or unhelpful), randomisation, outcome measures and follow-up will be assessed through qualitative interviews with a purposively sampled sub-group of approximately six women (three per intervention arm) and six staff (three per intervention arm). Interviews will also explore feasibility and acceptability of the study’s SOP, which dictates the management of safety, confidentiality and ethical concerns, risk disclosures during sessions and research contacts. Interviews will be conducted in Amharic by research staff who did not have extended contact with participants during the trial in a private location convenient to them. Participants will be compensated for their time, and interviews will be audio-recorded, transcribed and translated into English.

Intervention fidelity and supervision

Health workers trained to deliver PST-IPV and standard PST will receive monthly supervision with a local psychiatric nurse. Health workers will audio-record PST-IPV and standard PST sessions with the participant’s consent for review by their supervisor and to inform discussions of challenging cases during supervision sessions.

A random sample of these audio recordings will be evaluated using the ENACT scale [ 79 ] to assess therapist competence (quality) alongside supervisor observations and therapist logs. ENACT has been adapted for the Ethiopian context and has been shown to be reliably administered by trained clinicians [ 80 ].

Recordings will also be evaluated for intervention fidelity and session completion using a checklist of session components. Supervision records and therapist logs will also be reviewed for intervention fidelity and contamination between arms [ 27 ]. The frequency and duration of IPV-specific content during recorded sessions of both PST-IPV and standard PST documented in therapist logs will also be noted to determine the extent to which participants raise and explore IPV-related problems during sessions. The quality of therapist–client rapport will be assessed using the Amharic-translated helping alliance questionnaire [ 81 ], which has been tested in this setting [ 82 ].

Outcome assessors will receive supervision from a Psychology Masters-qualified supervisor. Supervision logs will include discussing any items which are poorly understood or completed, and reviewing the time taken for outcome assessment to assess its acceptability and feasibility.

Statistical analysis

We will follow the Consolidated Standards of Reporting Trials (CONSORT) extension to randomised pilot and feasibility trials [ 83 ].

We will review process evaluation data for indications of sub-group differences in uptake, recruitment and retention of participants by site, health worker, recruitment method/site, participant (age, education level, religion, parity) and health worker characteristics (age, profession, years of experience). Quantitative scale results will be analysed using STATA [ 84 ].

Feasibility studies are not powered to calculate effect sizes but standard deviations and drop-out rates will be calculated on the intention-to-treat sample (all women who were randomised, regardless of uptake of the intervention) to inform sample size calculation for a future RCT, for outcome measures, recruitment rates and drop-out rates. Quantitative process data will determine future RCT design improvements, such as session number and duration, recruitment, outcome measures, and strategies preventing contamination. The extent of missing data will be evaluated as part of the process evaluation. For clinical outcome measures, missing data will not be imputed. Rather, standard deviations will be calculated using data from participants for whom outcome measures are available.

We will apply the framework approach to thematic analysis of qualitative interviews [ 85 ] and triangulate the results with quantitative process data through researcher meetings. The full descriptive analysis will include contextual barriers and facilitators influencing study outcomes.

Ethical considerations

Strategies to ensure data protection, quality assurance and dissemination of results are outlined in Supplementary file  3 and data collection forms are provided in Supplementary file  4 . Ethical approval has been provided by the Institutional Review Board of the College of Health Sciences, Addis Ababa University, Ethiopia (protocol number: 032/19/CDT) and the Psychiatry, Nursing & Midwifery subcommittee of King’s College London’s College Research Ethics Committee, UK (reference: HR-18/19–9230); see Supplementary file  5 .

This study involves recruitment of potentially vulnerable women, disclosure of IPV, and detecting depression, anxiety and PTSD symptoms. The SOP therefore outlines actions to mitigate potential risks. If participants disclose current exposure to IPV, research staff will be trained to listen non-judgementally, offer privacy and confidentiality, and information about local agencies who can provide assistance (see Supplementary file  2 ) [ 42 ] in keeping with WHO guidelines, irrespective of the study arm.


Female research staff will be carefully selected with the sensitivity of subject matter in mind. Once recruited, they will receive locally tailored IPV training [ 44 ]. When approaching women, great sensitivity will be exercised. In all cases, care will be taken to ensure that women do not feel pressurised to participate. We will ensure anonymity of interview transcripts and any quotations used in publications or reports.

The SOP outlines measures to mitigate potential risks to participants, including abusive partners learning of their involvement. These include a protocol for responding to concerns or disclosures of risk, emergency contact information, conduct when communicating with vulnerable participants, documenting and responding to serious adverse events and reporting them to the King’s College London and Addis Ababa University institutional review boards which have provided ethical approval for this trial. Numbers of serious adverse events will be calculated per trial arm. A data monitoring committee will not be instituted due to the small sample size of this feasibility trial, which is not powered for interim analyses.

Risk of harm

The risk of harm to participants will be minimised by providing full information about the study prior to voluntary participation. Participants are free to withdraw from taking part at any time without needing to give a reason. Their individual data can be withdrawn from the randomised feasibility trial until the final data collection, at which point analysis will commence.

Some participants might become distressed when speaking about their mental health or experiences of IPV. Questions will be asked and worded sensitively to minimise this occurring during research assessments. During sessions of PST-IPV, the opportunity to express emotion about problems and difficulties may be therapeutic, however. Clinicians will be trained in responding to distress. Data collectors will be trained to be sensitive to signs of distress and when to suggest rescheduling or discontinuing an interview. If the participant remains distressed, the data collector will contact their supervisor and arrange appropriate support. If needed, women can be referred to their ANC provider, who has been trained in primary mental health care and the situation can be discussed with the project mental health professional.

Despite being an important social determinant of physical and mental health, there is limited evidence for brief, task-shared psychological interventions adapted to address the mental health needs of women experiencing IPV in LMICs. Interventions tailored to the specific LMIC context and adapted to address the experiences of women affected by IPV require development, evaluation and implementation. This randomised feasibility trial comparing PST-IPV with standard PST and enhanced usual care in rural Ethiopia and mixed-methods process evaluation will determine feasibility and acceptability to women and health workers to inform the design of a future RCT. It will generate hypotheses, explore causal mechanisms and contextual factors relevant to mental health clinicians, researchers and implementation scientists in primary care and ANC in LMICs, which can be investigated across contexts in a future, fully powered multi-centre RCT.

Strengths and challenges

This is the first study of its kind in this rural Ethiopian setting. Most research into psychological interventions for anxiety and depression in LMICs comes from urban or peri-urban areas of middle-income countries, and only two to date have been adapted for women experiencing IPV [ 22 , 23 ]. Neither of these interventions trialled a brief intervention, embedded within ANC in a rural, low-income country setting. The results will be informative to researchers developing brief psychological interventions adapted for this and other resource-restricted settings.

This three-arm randomised feasibility trial benefits from a shared control group with a separate, nested study of standard PST. The efficiency of shared control groups is well documented [ 86 ] and multi-arm trials are recognised for their simplicity, speed and reduced cost relative to two-arm trials [ 87 ]. The study focus on evaluating and refining the feasibility of both the PST-IPV intervention and the study design using a mixed-method process evaluation ensures that improvements will be made prior to a definitive RCT.

The sensitivity of discussing mental health and IPV, logistical challenges to women’s participation in research, limited education and literacy and competing priorities on ANC staff time are all anticipated challenges to the successful completion of this study. These will be mitigated by stringent ethical conduct emphasising confidentiality and supporting women at risk of IPV, supporting women to access intervention arms, adapting recruitment and intervention procedures to accommodate variable education and comprehensive training and supervision of health workers. However, unforeseen geopolitical eventualities may arise in rural, low-income settings which compromise the conduct and completion of this protocol as planned. The benefit of this feasibility trial is to identify study design problems as early as possible in order to mitigate their impact on the resultant research evidence.

Trial status

This is protocol version 1.0. This trial was prospectively registered on the Pan-African clinical trials registry (PACTR202002513482084) on 13 December 2019. Recruitment of participants has not yet commenced. Recruitment of participants is anticipated to complete by 31 December 2020. Any proposed changes to the protocol will be submitted to King’s College London and Addis Ababa University ethics review boards and updated on the pan-African clinical trials registry. Research staff will inform trial participants, where required, and changes will be discussed in the ultimate results publication. The trial sponsor is King’s College London, De Crespigny Park, Denmark Hill, London SE5 8AF, UK.

Availability of data and materials

The minimum dataset used to calculate the study findings will be included with the study’s resultant outcome reporting manuscript as a supplementary file. Additional datasets generated during this study will be available from the corresponding author upon reasonable request.


Antenatal care

Cognitive behavioural therapy

Health extension worker

  • Intimate partner violence
  • Low- and middle-income countries

Nine-item Patient Health Questionnaire

Programme for improving mental health care study

Problem solving therapy

Post-traumatic stress disorder

Randomised controlled trial

Standard operating procedure

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RCK, CH, LH and NS are supported by the National Institute of Health Research (NIHR) Global Health Research Unit on Health System Strengthening in sub-Saharan Africa (ASSET), King’s College London (GHRU 16/136/54) using UK aid from the UK Government. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. RCK is supported by a King’s Institute of Psychiatry, Psychology & Neuroscience Clinician Investigator Scholarship for her PhD. CH and KS receive additional support from AMARI as part of the DELTAS Africa Initiative (DEL-1501) funded by the Wellcome Trust. LH is in receipt of an NIHR Senior Investigator award. TB receives support from AMARI as part of the DELTAS Africa Initiative (DEL-1501) funded by the Wellcome Trust as part of his post-doctoral work. BM is supported through jointly funded research grant funding from the Department for International Development, the Economic and Social Research Council, and Wellcome Trust (MR/M014290/1; MR/M011464/1) as well as the South African Medical Research Council. SH is supported by research grant funding from Bill and Melinda Gates Foundation OPP1179252 through her contribution to the Kilkari Impact Evaluation Project in India. The research of NS is supported by the NIHR Applied Research Collaboration (ARC) South London at King’s College Hospital NHS Foundation Trust. NS is a member of King’s Improvement Science, which offers co-funding to the NIHR ARC South London and comprises a specialist team of improvement scientists and senior researchers based at King’s College London. Its work is funded by King’s Health Partners (Guy’s and St Thomas’ NHS Foundation Trust, King’s College Hospital NHS Foundation Trust, King’s College London and South London and Maudsley NHS Foundation Trust), Guy’s and St Thomas’ Charity and the Maudsley Charity. The research of NS is supported by the ASPIRES research programme in LMICs (Antibiotic use across Surgical Pathways—Investigating, Redesigning and Evaluating Systems), funded by the Economic and Social Research Council. RCK had full access to all the data in the study and had final responsibility for the decision to submit for publication. Funders played no role in the study design, data collection, data analysis, data interpretation, or report writing.

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Roxanne C. Keynejad & Louise Howard

College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

Tesera Bitew

Institute of Educational and Behavioural Science, Debre Markos University, Debre Markos, Ethiopia

Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa

Katherine Sorsdahl

Alcohol Tobacco and Other Drug Use Research Unit, South African Medical Research Council, Cape Town, South Africa

Bronwyn Myers

Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa

Perinatal Mental Health Project, Alan J. Flisher Centre for Public Mental Health, Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa

Simone Honikman

Aklilu-Lemma Institute of Pathobiology, Addis Ababa University, Addis Ababa, Ethiopia

Girmay Medhin

Negussie Deyessa

Centre for Implementation Science, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK

Nick Sevdalis

Department of Mental Health, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA

Wietse A. Tol

United States of America (USA) & Peter C. Alderman Program for Global Mental Health, HealthRight International, New York, New York, NY, USA

Centre for Global Mental Health, Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK

Charlotte Hanlon

World Health Organization Collaborating Centre for Mental Health Research and Capacity-Building, Department of Psychiatry, School of Medicine, College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

Centre for Innovative Drug Development and Therapeutic Trials for Africa (CDT-Africa), College of Health Sciences, Addis Ababa University, Addis Ababa, Ethiopia

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All authors contributed to the development of this protocol, reviewed drafts of this paper and approved the final manuscript. RCK led the conception, writing up and ethics applications for this study, which is a core part of her PhD research. TB collaborated on the study design process and led the conception of the linked, related feasibility trial described in this protocol, which is outlined in detail in a separate, linked protocol submission. KS collaborated on the adaptation of PST and its materials for perinatal depression in rural Ethiopia, and on the adaptation of PST for women experiencing IPV (PST-IPV). BM collaborated on the adaptation of PST and its materials for perinatal depression in rural Ethiopia, and on the adaptation of PST for women experiencing IPV (PST-IPV). SH commented on drafts of this protocol and suggested amendments to the study design. NS collaborated on the implementation of science elements of the study design process and commented on drafts of the protocol. GM commented on drafts of this protocol and suggested amendments to the study design. ND commented on drafts of this protocol and suggested amendments to the study design. LH supervised the development of this protocol, study design and ethics applications, commented on drafts and provided input to this study from its inception. CH supervised the development of this protocol, study design and ethics applications, commented on drafts and provided input to this study from its inception. WAT commented on drafts of this protocol and suggested amendments to the study design.

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Correspondence to Charlotte Hanlon .

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Ethical approval has been provided by the Institutional Review Board of the College of Health Sciences, Addis Ababa University, Ethiopia (protocol number: 032/19/CDT) and the Psychiatry, Nursing & Midwifery subcommittee of King’s College London’s College Research Ethics Committee, UK (reference: HR-18/19–9230); see Supplementary file  5 . Any protocol amendments will be communicated with both boards and updated on the pan-African clinical trials registry. Informed consent will be obtained from all study participants.

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Not applicable.

Competing interests

NS is the director of London Safety and Training Solutions, which provides advisory and training services in safety and quality improvement to hospitals and health care organisations globally on a consultancy basis. The remaining authors declare that they have no competing interests.

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Supplementary information

Additional file 1: supplementary file 1..

Provisional theory of change map for PST-IPV. Supplementary file 2. Example information sheet about local sources of support provided to all participants. Supplementary file 3. Data protection, quality assurance and dissemination plans. Supplementary file 4. Data collection forms. Supplementary file 5. Ethical approval. Supplementary file 6. (a) Participant information sheet. (b) Participant consent form. (c) Health worker information sheet and health worker consent form.

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Keynejad, R.C., Bitew, T., Sorsdahl, K. et al. Problem solving therapy (PST) tailored for intimate partner violence (IPV) versus standard PST and enhanced usual care for pregnant women experiencing IPV in rural Ethiopia: protocol for a randomised controlled feasibility trial. Trials 21 , 454 (2020). https://doi.org/10.1186/s13063-020-04331-0

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Received : 28 February 2020

Accepted : 19 April 2020

Published : 01 June 2020

DOI : https://doi.org/10.1186/s13063-020-04331-0

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