Problem-solving therapy

Problem-solving therapy (PST) is a short, practical kind of talk therapy. It teaches you a simple, step-by-step way to deal with the everyday problems that pile up and feed low mood. Instead of digging into the past, you work on what is bothering you right now.^6,8

PST has been tested often with older adults, including people with many health problems and people who live alone. It can be given by a counselor, a nurse in a doctor's office, or a trained coach who visits your home. This page explains what the research shows and walks you through the seven steps as a lesson you can try.

What problem-solving therapy is

When people feel depressed, problems can seem too big to start on. Small troubles, like an unpaid bill or a ride you need, can grow into a heavy fog. PST is built on the idea that solving even one concrete problem can lift mood and give you back a sense of control.^6,8

PST was first developed in Great Britain so that doctors and nurses in primary care could offer it. That version is called Problem-Solving Treatment for Primary Care, or PST-PC.⁸ It usually takes 6 to 10 sessions. The first visit is about an hour. Later visits are often about 30 minutes.⁸

Researchers group PST into three main forms:⁶

PST is close to cognitive behavioral therapy (CBT), but it spends less time on thoughts and more time on action. It is often paired with behavioral activation, which means planning pleasant, social and physical activities.^1,3

Who it may help

Most PST research is about depression. It also teaches skills for coping with everyday stress.⁶ PEARLS was tested in older adults living with many long-term illnesses.¹ See depression in older adults and coping skills for stress.

The developers of PST-PC say it is not meant to be the main treatment for some conditions. These include drug or alcohol problems, recent and severe PTSD, panic disorder, and new bipolar disorder or psychosis.⁸ Those need other care first.

What the research shows

Across all ages

A 2018 review pooled 30 randomized trials with 3,530 people who had depression.⁶ It found:

• PST worked better than no treatment or usual care. In the best-quality studies, the benefit was small.⁶
• PST worked about as well as other talk therapies.⁶
• In six trials that compared PST with antidepressant medicine, there was no clear difference.⁶
• Eight of the trials were in older adults. Results were not different for older adults than for younger people.⁶

The authors concluded PST is probably effective. They also noted that there were few high-quality studies and little long-term follow-up.⁶

In older adults: PEARLS

PEARLS stands for Program to Encourage Active, Rewarding Lives. It was designed in Seattle for older adults who had trouble getting depression care.^1,2

In the first trial, 138 adults aged 60 and older took part. They had milder or long-lasting low-grade depression. On average they had more than four long-term health conditions. About 7 in 10 lived alone, and more than half had very low incomes.¹

Half got PEARLS: eight home visits over about 19 weeks, then monthly phone calls. The visits combined PST with planning social and physical activities. The other half got usual care.¹

People in PEARLS also reported better daily functioning and emotional well-being.¹

What this means in daily life. Not everyone got better, but many more people improved with PEARLS than without it. These were people with real-life burdens, like chronic illness, money stress and living alone.

Later PEARLS studies tested the program in people with epilepsy and in programs focused on loneliness, with encouraging results.⁴ See loneliness in older adults.

In older adults with planning and organizing problems

Some older adults with depression also have trouble planning, organizing and switching tasks. Doctors call these skills executive function.

A trial at two sites tested a version of PST in adults aged 60 and older with major depression and these thinking problems. It was compared with supportive therapy, where a therapist listens and offers empathy. Each got 12 weekly sessions.⁵

By 12 weeks, more than half the PST group had a strong response. More than 45% reached remission. PST did better than supportive therapy, though supportive therapy helped many people too. The extra benefit of PST showed up in the second half of treatment, after about week 9.⁵

What this means for you. If you notice the steps feel slow at first, that is normal. The skills seem to build with practice.

In the doctor's office

In the large IMPACT study, 1,801 adults aged 60 and older with depression got care in primary care clinics. A depression care manager could offer PST-PC, usually about 6 to 8 sessions, as one choice next to medicine.⁷ About 3 in 10 people in the program received PST. Overall, 45% in the program had their symptoms cut at least in half, compared with 19% in usual care.⁷ That study tested the whole care program, not PST alone.

Where to get PST

• A therapist or counselor. Ask whether they offer problem-solving therapy or PST. See how to find a therapist and paying for therapy.
• Your doctor's office. Some primary care practices have a care manager or behavioral health staff trained in PST.^7,8
• PEARLS. Local senior service groups run it. Today it is usually 6 to 8 one-hour visits over 4 to 5 months, at home, in the community, or by phone or video.^2,3 You do not need a depression diagnosis. The program screens for symptoms.³ More than 12,800 older adults in 35 states and Washington, D.C. have taken part.² To ask about a program near you, email the PEARLS team at [email protected].³
• Veterans and service members. The VA and Department of Defense offer Moving Forward, a free online course on problem-solving skills. It has eight short modules and needs no sign-up.⁹

Lesson: the 7 steps of problem solving

PST programs teach the same basic path. You choose a problem, set a reasonable goal, weigh possible solutions, and build a plan you can carry out.³ Many programs break this into seven steps.³ Here is a plain version to practice. Use a notebook or a sheet of paper.

Why this matters

When you are low, problems blur together and everything feels urgent. Writing one problem down and working through it in order makes it smaller. Each small success gives you proof that you can still change things.

1. Name one problem. Pick something real and specific, not a vague feeling. "I have not seen my friends since my surgery" works better than "my life is bad." Start with a problem that is not the hardest one.
2. Set a realistic goal. Decide what "better" would look like within the next week or two. Keep it small and clear, such as "talk with one friend this week."
3. List possible solutions. Write down every idea you can think of, at least three. Do not judge them yet. Silly ideas can lead to good ones. Ask a family member for ideas if you get stuck.
4. Weigh the pros and cons. For each idea, write what is good and what is hard about it. Think about cost, energy, time and help needed.
5. Choose a solution. Pick the option with the best balance. It does not have to be perfect. It only has to be doable.
6. Make an action plan. Write exactly what you will do, when, and where. Include any help you need, such as a ride or a phone number. Break big tasks into small pieces.
7. Do it, then check how it went. After you try it, ask: Did it help? What got in the way? If it worked, move to the next problem. If not, go back to your list and try another idea.

An example worksheet

Common problems

I can't think of any solutions.

That is common with depression, which can slow thinking. Give yourself a time limit, like 10 minutes, and write anything at all. Ask someone you trust for one or two ideas. In therapy, the coach helps with this step, but you still choose.

My problem is too big to fix.

Some problems, like a serious illness or a loss, cannot be solved. You can still work on parts of them. Choose a smaller piece, such as getting a question answered by your doctor, finding a support group, or planning one restful hour a day. See coping with grief.

I tried my plan and it didn't work.

That is useful information, not failure. Look at what got in the way. Then pick the next idea from your list or make the plan smaller.

Can a family caregiver use these steps?

Yes. Caregivers face many practical problems, like scheduling, respite and paperwork. The same steps can help you sort through them one at a time. See caregiver stress.

Is self-help enough?

For mild, short-term stress, practicing the steps may be enough. For depression that lasts, a coach or therapist adds structure and support. The studies on this page tested PST with a trained person, not reading alone.^1,5,7

When to get help

See a doctor or therapist if low mood, loss of interest, or hopelessness lasts most days for two weeks or more. Get help sooner if you stop eating, cannot get out of bed, or cannot manage daily tasks. A doctor can also check for health causes of low mood. Read depression treatment to learn your options.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.