Table 1.

Step-by-step guide of PST-COA cultural modifications

PST task	Classic PST	PST-COA modification	Corresponding cultural theme	Category of modified treatment component
Establish relationship between therapist and client	Collaborative approach	Consider establishing hierarchical relationship, such that PST therapist is the authority figure and client is the learner	Hierarchy, authority, and respect in provider/client relationships	Core components: therapeutic framework
		Approach PST and the provider/client relationship with flexibility in structure, pace, content	Diverse psychosocial, socioeconomic, and linguistic needs of Chinese older adults may lead to varying needs of the client
Psychoeducation	The client is educated about depression as an illness linked to problems and mood or emotional problems	Use language consistent with client’s idiom of distress (e.g., refer to somatic rather than emotional symptoms)	Stigma and lack of familiarity with mental health heightens need for pre-therapy education and non-stigmatizing language	Peripheral components: Engagement, entry into and participation in treatment activities
	Physical symptoms are attributed to client’s emotions	Familiarize and introduce the client to the process of psychotherapy (e.g., PST may require work at home, this is a collaborative relationship, we will meet on an ongoing basis)
	Little mention of general education about the process of therapy, or inclusion of family members in the process	Provide family members with psychoeducation when appropriate	In collectivistic cultures, involving family in the therapy process can increase client engagement
Presenting the rationale for PST	Problems → deficient problem-solving skills → depressive symptoms → interference with problem-solving skills → more problems → worsened depression;	Problems → deficient problem-solving skills → deficiencies in health, wellness or low productivity	Stigma and lack of familiarity with mental health heightens need for pre-therapy education and non-stigmatizing language	Peripheral components: Engagement, entry into and participation in treatment activities
	Therefore: Effective problem-solving skills → fewer problems → improved mood and depressive symptoms	Therefore: Effective problem-solving skills → fewer problems → improved health, wellness, or productivity	Chinese older adults more likely to be oriented toward physical health, overall wellness, or productivity rather than depression and mood
Teaching and applying the 7 steps of PST with clients	Emphasis on client’s self-identified problems and self-generated solutions	Therapist takes more directive approach, demonstrating how to solve a first problem, incorporating case management in initial stages of treatment, or offering specific suggestions for solutions	Cultural expectation of a more directive approach and hierarchical relationship with the therapist	Core components: Problem-solving skill acquisition
		Client may need additional encouragement or even permission to self-generate solutions. Therapist may ask questions to stimulate ideas and solution generation
		Less acculturated clients may require therapist to teach them about locally accepted or feasible solutions	Less acculturated Chinese older adults may be less familiar with local systems and norms
Teach clients about pleasant activities	Emphasis on client’s self-generated pleasant activities	Therapist may guide client toward brainstorming and selecting pleasant activities if client is unfamiliar with local resources or norms	Cultural expectation of a more directive approach and hierarchical relationship with the therapist	Core components: Behavioral activation (pleasant activities)
Provide client with necessary paperwork to complete activities in session and as homework	After initially walking the client through the PST worksheet or materials, client is free to use the worksheet independently, as needed	Verbally present materials—walk clients through any written material	Chinese older adults may need visual aids and assistance in understanding worksheets that may contain unfamiliar wording	Peripheral components: Engagement, participation in treatment activities and completion of treatment
		Provide client with worksheets organized in binder
		Use PST worksheets translated into Chinese as needed	Presenting materials up-front in an organized and concrete format will contribute to the legitimacy of the treatment
Client tracks mood on a Likert scale (e.g., mood scale 1 to 10) to track progress in PST	Rating scales are presented on a numerical scale	Rating scales are presented with pictures to accompany any words or numbers	Chinese older adults may need visual aids and assistance in understanding outcome measures that are structured with unfamiliar Likert scales	Core components: Mood tracking

Note: PST-COA modifications are compared to classic PST and categorized by cultural theme and treatment component (therapeutic framework, core, or peripheral).