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Evidence-Based Practices: Shaping Mental Health Services Toward Recovery

Family Psychoeducation

Workbook
Chapter 7: An Introduction to Problem-Solving

The Problem-Solving Process

The problem-solving portion of the psychoeducational multifamily group is the essence of the process. Many individuals and families have expressed dissatisfaction with groups in general due to high degrees of emotion and low degrees of productivity. The problem-solving aspect of the multifamily group responds to those concerns. It is in this portion of the group that consumers, families and practitioners begin to make clear gains in dealing with symptoms of illness, in a planned and structured manner. It is our intention to present a method of defining and solving illness related issues to the group members. Our method for doing so is the psychoeducational multifamily group. The goal of the multifamily group process is not just to have the group’s help to solve these problems. Rather, it is to provide individuals and families with an on-going means to manage the symptoms of the illness beyond the multifamily group.

Each session of the multifamily group begins and ends with a period of purely social chat, facilitated by the practitioners. The purpose is to give the consumers and even some families the opportunity to recapture and practice any social skills they may have lost due to their long isolation and exposure to high levels of stress. Following the socializing, the practitioners specifically inquire as to the status of each family, offering advice based on the family guidelines or direct assistance, when it can be done readily. A single problem that has been identified by any one family is then selected and the group as a whole participates in problem-solving. This problem is the focus of an entire session, during which all members of the group contribute suggestions and ideas. The affected family then reviews all suggestions for their relative advantages and disadvantages, with some input from other families and practitioners. Typically, the most attractive of the proposed solutions is reformulated as an appropriate task for trying at home. An action plan is created and tasks are assigned to the consumer and family members. This step is then followed by another period of socializing. This format continues for most of the duration of the group, but is sometimes interspersed with visiting speakers, problem-solving focused on generic issues facing several families and/or consumers and celebrations of steps toward recovery, holidays and birthdays.

Structure of Psychoeducational Multifamily

Techniques for Formal Problem Solving

This six step approach helps breaks down problems into a manageable form, so that a solution can be implemented in easy-to-follow steps, usually with more success. Experiencing success in small steps gives families and consumers hope that change is possible. Often a small success will motivate families to apply the method to other aspects of their lives.

In formal problem-solving, one practitioner leads the group through the six steps. The other practitioner ensures group participation, monitors the overall process and suggests additional solutions. The practitioners choose someone to write down the six steps of the problem-solving process. This recorder can be a practitioner, a family member, or a consumer. The proceedings can be recorded on a chalkboard or a note pad or both. A pre-formatted worksheet can be used to make copies as needed. Whichever method of recording is selected, the practitioners and the family should have a copy to keep.

After a recorder is chosen, the practitioners follow each step of formal problem-solving, as shown here:

Steps of the Problem-Solving Process:

Step 1. Define the problem or goal.
Family, consumer & practitioners

Step 2. List all possible solutions.
All group members

Step 3. Discuss first advantages and then disadvantages of each in turn.
Family, consumer, and practitioners, group members

Step 4. Choose the solution that best fits the situation.
Consumer and family

Step 5. Plan how to carry out this solution by forming a detailed, written action plan.
Consumer, family & practitioners

Step 6. Review implementation.
Practitioners in concert with consumer and family

Tip: Solving long-standing problems
Many issues presented by the group members are perceived as not solvable. These are often longstanding problems that have resisted all attempts to make them better. Group members seldom have much hope that things will get dramatically better. With this in mind, facilitators should approach problem-solving based on the Family Guidelines: go slow; keep things cool; set limits; keep it simple and solve problems step-by-step. When things do indeed change, facilitators must help group members recognize the benefits of the MFamily PsychoeducationG process in resolving these issues.

Defining the Problem

Defining the problem, while sometimes viewed as a rather simple process, is often the most difficult step in the psychoeducational multifamily group process. If the problem is not properly defined, consumers, families and practitioners become frustrated and convinced that the problem cannot be solved. It is helpful if this information is shared with group members. Acknowledging that the process is not necessarily simple may alleviate some frustration later.

Some common difficulties that groups experience in this aspect of the process are:

• Choosing a problem that is too large or too general, [e.g. “I want to get a job”]
• The definitions of the problem by the facilitator and by the individual are different
• The problem is stated as “the person is the problem.”

Tip: Phrasing the problem
Remember, “The problem is the problem!” The person is never the problem.

Tip: Clarifying the problem
It is important for a practitioner to clarify what is written with the presenting individual. This step helps to avoid inaccurate perceptions/definitions.

The problem-solving process begins in the “go-around”. It is often helpful to write the query, “How have you been affected by the Illness since we last met?” on the top of the board or easel, giving the members a focus for their check-in and facilitating the problem definition process. As each person checks in, one of the facilitators should make a list of presented concerns for all to see. It is helpful to write problems on a flip chart or blackboard at this point.

The practitioners should address each issue presented individually, avoiding the temptation to combine similar concerns of group members. Each person will have his or her own perception of the problem and its resolution. Practitioners need to respect these individual perceptions. This approach also helps to keep the problem definitions simpler and more accurate.

After each person has had an opportunity to “check in” about their perceptions of difficulties with the illness, the practitioners review the issues presented to determine which will be the focus of the groups’ efforts. Once a problem has been defined in a way that is acceptable to each member of the family, one of the practitioners asks the recorder to write it down and read it back to the group.

Tip:
The practitioners decide the issue for the group to focus on. Group members benefit from hearing the practitioners discuss the issues presented. Listening to them “thinking out loud” and determining a problem to focus on for that particular group helps the group members learn how to simplify, clarify and prioritize concerns.

The practitioners need to consider carefully any report of actual or potential exacerbation of symptoms. Areas of particular significance are:

Safety: Safety is always of primary importance. As issues are reviewed, any that involve potential threats to personal safety should be addressed. An issue where safety is a factor should be clarified first. If, after clarifying, safety is not an issue, other concerns may be addressed. Safety issues may be addressed in front of the group provided the issues are not so emotionally charged as to disrupt the group. In many cases, these issues become a learning experience for the group.

Tip
There may be occasions when the best way to address a safety issue is apart from the group. This may be the case when emotionality or another persons’ confidentiality is a factor. It is helpful to inform the group that the issue will be addressed outside of the group because of “personal reasons” and that the group will be informed of the resolution as it occurs. It is important for the practitioners to discuss these plans, and the reasons, in as much detail as possible so that the group members have the best possible learning experience.

Family guidelines: When identifying and solving problems, practitioners should try to incorporate the Family Guidelines, as these will support the structure of the group. As issues are presented, it is helpful to refer to the guidelines whenever it is appropriate.

Medication issues and substance abuse: Issues concerning medications and substance use are of great importance. These are potentially emotional issues, so care should be taken to present or reframe the problem in “non-blaming” terms. Modeling this non-judgmental, non-blaming approach can often be a good learning opportunity for group members.

Life events: Sometimes, a major event occurs (e.g., divorce, death, marriage, graduation, birth of a child, etc.) in a family, which can be unsettling for the whole family and especially for someone with a severe mental illness. It is natural for the stress level to rise within the family at such times and it is important for the practitioners to listen carefully for signs of increased family stress, which may be connected, to the exacerbation of symptoms while providing education around managing stress. This may even occur with “good” stress.

Outside agency events: On occasion, changes occur within provider agencies, such as a move to another building or practitioners leave for various reasons. These changes maybe as distressing to a consumer and his/her family as other major life events and should be considered as such.

Disagreement among family members: It is natural for family members to disagree at times, but when the disagreement becomes intense, outside help may be necessary. The importance of keeping criticism and emotionality to a minimum cannot be stressed strongly enough. Sometimes, an issue surrounded by intense disagreement is better resolved in individual counseling and not in the group setting. This may be a time for the practitioners to suggest an outside meeting to help with the problem. However, if the disagreement is not extreme and especially if it is a consequence of the illness, it can be helpful for all family members to hear from other families and consumers. The problem-solving format of the group makes suggestions and feedback more pragmatic and less stressful. The approach used here is one of problem-solving the means for avoiding untoward consequences of the disagreement for the consumer. The problem definition takes the general form of “How can the Smith family manage their disagreements so that John will not be overwhelmed and relapse?”

In order to decide which problem to work on, the practitioners ask detailed questions to clarify the problem, such as:

• What is the current “undesired situation?”
• When was the problem first noticed?
• When does it occur? How often? In what situations?
• Has the problem, or its effect, changed in any way recently?
• Who is affected by the problem and how?
• With what activities does the problem interfere?
• What attempts have been tried to alleviate the problem? With what results?
• Who seems to have the most impact on the problem?

The scale of problems, at least in the first few months of the group, is also a factor in selecting the problem. For instance, long-standing or previously intractable problems should only be addressed if they can be broken down into more solvable sub-problems.

Tip
In the discussion of which issue to address, it is important to stress to the group that the goal is to teach a problem-definition/problem-solving skill and that, with practice, group members will refine that skill. It is also important to say something like, “Although the problem chosen may not currently be the problem of every individual or family, it is likely that this problem has been of concern to other members or will be experienced over the course of the group.” It is also important to say that, “Over the course of the group everyone’s issues will be addressed.”

Practitioners may choose to select simpler problems early in the group, so that the members learn the method, gain trust in each other and achieve a few successes. Often, the primary guideline for choosing an issue is “Upon which issue can we have the greatest chance of making a positive impact?”

It is important for practitioners to check in with the individual who raised this issue to be sure that the group truly understands their perception of the issue, including, “What will things look like when they are better?”

Generating Solutions

Each group member is asked to offer whatever solution they think may be helpful. Practitioners should stress that it is important to resist evaluating or discussing solutions, since doing so dramatically reduces the number of solutions presented.

Tip
It is often helpful to say to the group, “It has been our experience that it is difficult to resist discussing suggestions as they are generated. However, we have found that by discussing them as we go, some solutions are left unspoken. Therefore, we would like to help the group delay evaluating solutions until after all suggestions have been made.” This reminds the group that other groups and individuals have had similar experiences. It also sets the stage for the practitioners to intervene when members find it difficult to resist responding immediately to suggestions.

Tip
Take time to evaluate solutions. Some groups find that time is a factor and decide to streamline or eliminate the evaluation process. They simply move to presenting the solutions to the individual for their review and selection. There is some loss involved here since valid information as to the efficacy, or lack thereof, of certain solutions may not be presented.

Evaluation

After all solutions have been presented, facilitators invite group members to share their thoughts on the efficacy of each solution. Each solution is addressed individually, marking the “pros” [+] and “cons” [-] after each solution. This allows the group to become active in thinking about possible solutions, even when there are multiple solutions available.

Choose the Best solution

When faced with a difficult situation, many people find it helpful to make a list of possible solutions. Since this list is often quite large and can seem overwhelming, the individual quickly and arbitrarily reduces the solutions to the two that hold the most appeal. They then choose between these two. However, if the chosen solution does not provide satisfactory results, the individual often feels that the situation is hopeless. “I chose the best solution, [A was better than B], and it did not work, so nothing will.” They often forget that the choice was not just between “A” and “B,” there were numerous other solutions that were arbitrarily eliminated, one of which may be more helpful. This is the rationale for the problem-solving process. Reminding the group of this phenomenon may be helpful.

When all solutions have been evaluated, the practitioners review the list, stressing those with the most positive and fewest negative responses. The whole solution list is then discussed with the individual who provided the issue originally. They are asked which of the solutions they would like to test out for themselves and for the group over the next two weeks.

Tip
It is important to stress that testing solutions is for the benefit of both the individual and the group, as everyone is looking for things that work.

Tip
During the identification or solution stages, the individual and/or family who have identified the problem may begin to struggle with the process. If this happens, the practitioners should make sure the problem has been accurately defined and that the group is addressing the true problem.

Implementation

Once a solution has been selected, a very detailed plan is developed. Each step is discussed and a person is assigned responsibility for completion of each step. The greater the detail, the better.

Tip
Some groups offer the solutions to all group members to try, asking that the group be informed of their efforts, successes or lack of success, thus increasing the repertoire of knowledge of the group.

Review Implementation

The individual is reminded that the practitioners may call during the coming week to check on their progress and to offer assistance. The individual is also asked to report at the next psychoeducational multifamily group how successful they were and any obstacles they encountered.

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