Evidence-Based Practices:
Shaping Mental Health Services Toward Recovery
Family Psychoeducation
Workbook
Chapter 8: Problem Solutions from Actual Practice
Introduction
Formal problem-solving techniques should be used whenever the family encounters difficulties that cannot be solved by advice or action on the part of the practitioners or other families. We have compiled some case studies from actual multifamily groups. These examples may be helpful to practitioners who use this model, since they indicate the types of problems and solutions that have emerged in real groups in the past. The examples used here can also be used in single-family sessions, where formal problem-solving can be helpful.
Common categories of problems that occur:
- finding and keeping employment
- medication
- alcohol and substance abuse
- daily living skills
Since every group and family is unique, there is no one approach that will solve all families’ difficulties. Successful solutions must always be relevant to the individual family and acceptable to its members. In the case studies that follow, we have described the process in detail only in the first example. For all other examples, the problems will vary, but the problem-solving process will be the same.
Case Study Solutions
Solutions for Finding and Keeping Employment
Background for problem #1
Pedro is a man in his mid-30’s who has struggled with severe, persistent mental illness since his late teens. He has been able to maintain an apartment and stay on medication for years with minimal support, but has not worked since his teen years. Since he has not had much experience working with people or practicing social skills, he finds he is uncomfortable with co-workers. He is working closely with an occupational therapist and employment specialist to make his part-time job a success, but shares his concerns with the multifamily group.
Step 1: What is the problem?
“How can Pedro become more comfortable with his co-workers?”
In Step 1, the goal is to narrow the definition of the problem so that the group can achieve practical, concrete solutions. The practitioners return to the problem raised in the go-round. They gather information in order to reach a definition of the problem. The practitioners question family members, gathering relevant recent historical, social-contextual and clinical details. The practitioners ask additional questions about the situation from the perspective of how it relates to either relapse prevention or to the next step in the recovery process. Every family member present must agree with the definition of the problem. The more concrete and behavioral the definition, the more useful and focussed the solution-generating implementation-planning steps, and the more successful the overall outcome.
It is very helpful to ask each person’s view of the problem and what they desire as an outcome, in concrete terms.
The following questions are often helpful. Some may have been asked in the go-round.
- When did you first notice the problem?
- Is it related to biochemical factors, such as changes in medication or substance abuse?
- How often does it occur?
- Is it getting worse? At what rate?
- Does it occur with certain people or under certain conditions?
- Is it occurring more or less frequently than when it was first noted?
- Who is affected by the problem, and how?
- What has been tried to alleviate the problem in the past? What was helpful?
- With what activities does the problem interfere?
When a problem has been defined in a way that is acceptable to each member of the family, the practitioner asks the recorder to write it down and read it back to the group.
Here is the problem that was defined for the first example: “How can Pedro become more comfortable with his co-workers?”
Step 2: List all possible solutions.
When the problem has been defined, the practitioner asks the group members for suggestions. The purpose is to generate a lot of ideas about how to solve the problem or achieve the goal. The more possible the solutions, the more likely there will be one that adequately addresses the problem or goal. This step is open to all members of the group, and it is desirable for each family to contribute a possible solution.
The practitioners might begin by saying, “Now that we have defined the problem or goal, let’s hear from everyone in the group about possible solutions. This is a time for brainstorming. All ideas are taken seriously and recorded, even if a suggestion seems wild or a little silly; be as imaginative as possible. Then we will discuss the advantages and disadvantages of each one.” At this time, the recorder is asked to write down each suggestion, while one of the practitioners is writing down suggestions on a large pad or blackboard in front of the group.
The following is a list of possible solutions that might be generated for the problem defined in Step 1 above, “How can Pedro become more comfortable with his co-workers?”
- Tell yourself there’s no pressure to be friends, especially with everyone.
- Ask for support.
- Connect with people who do the same job.
- Do the best job you can.
- Plan pleasure/fun activities outside of work.
- Make small talk.
- Give compliments.
- Give yourself credit.
- Use humor.
- Join activities/lunch etc.
- Bring in food to share.
- Ask questions to get to know others – one question at a time.
Step 3: Discuss each possible solution, listing the advantages and disadvantages of each one.
After the possible solutions have been listed, the practitioners move on to first discuss the advantages and then the disadvantages of each solution. The practitioner asks the recorder to read each solution aloud, then asks the consumer, the involved family and the group, “What are the main advantages of this solution?” After the advantages are recorded, the practitioner then asks, “What are the disadvantages of this solution?” Advantages are always listed first, and there should be at least one advantage and at least one disadvantage for each solution.
Step 4: Choose the best solution or combination of solutions.
The practitioner asks the recorder to read each solution aloud, including the principle advantage and disadvantage. If the disadvantages strongly outweigh the advantages, the practitioner consults the family and, if they agree, asks the recorder to cross off that solution. If any family member, especially the consumer, is very opposed to that particular item, they are allowed to exercise a categorical veto. After more discussion of the solutions, the practitioner asks the family whose problem or goal is being worked on which solution or combination of solutions suits them best. Although the group does this part of the problem-solving process, it is the family with the specific problem or goal who is most involved and who carries out the solution.
Pedro chose the following solutions:
- Don’t feel you have to be good friends with everyone.
- Bring in food to share.
Step 5: Plan how to carry out the best solution.
The practitioners help the group break down the solution(s) into manageable, concrete, specific steps. The family and the consumer with the problem makes the final decisions, since ultimately, the family members and consumer are responsible for putting the solutions into action. However, group members often can be helpful in making reminder phone calls, giving rides, accompanying someone to an appointment, providing names of helpful agencies or people, etc. The practitioners help the group to be as specific as possible in each step of implementation, by asking such questions as:
- What needs to happen first?
- Who will be doing that step?
- When will that step happen?
- Where will people meet for that step?
The practitioners also help to anticipate things that might go wrong and formulate a backup plan. When the steps of implementation have been clarified as much as possible, the practitioners ask the recorder to read back the steps. The family and the practitioners both keep copies of the problem-solving worksheet. The practitioners should thank everyone in the group for their hard work and help.
Pedro’s action plan:
- Shop for apricot bread ingredients during the week:
- make a shopping list
- set aside grocery money
- Bake on Saturday afternoon.
- Bring bread to work on Sunday.
- Lower expectations of making friends quickly…go slow.
Step 6: Review implementation
In the go-round of the next group meeting, the practitioners ask how the implementation went. What steps did the family and the consumer complete? What went well? What did not go so well? The practitioners praise ALL efforts of the family, consumer, and any others involved, and point out any progress made. The practitioners might suggest how to continue with the implementation, how to use a back-up plan, or how to use an alternate solution. Sometimes, the practitioners might suggest “taking a break” from working on the particular problem, especially if implementation was not successful. If a decision is made to take a break, the practitioners might suggest that the consumer and family continue the problem-solving effort with them outside of group. If it seems appropriate, it is important to ask the other families if the solution or any of the suggestions would be, or have been, useful and effective for them. Group members may find it encouraging seeing completed solutions as potentially applicable in similar situations in each family. This generalizing will also help alleviate any sense that a particular family is uniquely deficient because they are having a particular type of difficulty.
Background for problem #2
Sharon is a 38-year-old woman who has schizoaffective disorder. Although she has had a diagnosed illness since her teens, she has worked hard to manage her illness. Her parents are in their mid-60s and attend the multifamily group regularly with her. She lives alone with her cat and works part-time (every morning for 4 hours) in the mailroom of a large insurance company. The bus stop to work is within easy walking distance of her apartment. She likes the routine of working every day, and has become quite efficient at her job, which does not vary too much from day-to-day. One challenge is that the company sometimes has bulk mailings that need to go out quickly, which means there is increased tension at the work site. Sharon finds it difficult to switch her pace and tasks at these times.
Step 1: What is the problem?
What can Sharon do to feel less overwhelmed at work when there are bulk mailings that need to go out quickly?
Step 2: List all possible solutions.
The group generated the following solutions:
- Quit.
- Talk to the supervisor.
- Set limits for you.
- Take more frequent breaks.
- Go to the gym to relieve tension.
- Get a massage - reward yourself for good efforts.
- Reduce your hours at those times.
- Scream into a pillow.
- Practice stress reduction techniques before and after work.
- Balance your life with a variety of activities.
- Clean your apartment.
- Seek out peer/mentor support.
Step 3: Discuss each possible solution.
The advantages of each suggestion were discussed first, then the disadvantages. Sharon decided she did not like #8 (scream into a pillow), so it was eliminated.
Step 4: Choose the best solution or combination of solutions.
Sharon chose the following solutions, and her parents agreed they were good ones to try:
- Talk to your supervisor.
- Practice stress reduction techniques before and after work.
- Balance life.
Step 5: Plan how to carry out the best solution.
With the practitioners’ help, Sharon and her family formed a plan during the multifamily group:
- Talk with supervisor tomorrow.
-
- Identify a good time to talk (break time?).
- Approach the supervisor first thing in the morning to request a meeting time.
- Try to “go slow”.
- Use stress reduction techniques.
- Identify 2 techniques to try.
- Identify what techniques you will try and how often (it may be helpful to record this on a calendar).
Step 6: Review implementation
At the next multifamily group, Sharon was asked how she had done with the action plan. She reported that she had been hesitant to talk with her supervisor, so had not approached him during the previous two weeks. She had been successful in identifying and trying one stress reduction technique, which she liked (listening to classical music with her headset). She also had tried some “self-talk” in order to go slow. When the practitioners questioned her about whether she would like more outside support in approaching her supervisor; she said yes. Her parents volunteered they did not want to appear as though they were taking control of this situation when they found out that she had felt uncomfortable approaching her supervisor. A discussion ensued about when family should offer more help and how to do that without appearing controlling. The practitioners volunteered that they wished they had called her during the 2-week period when there was no multifamily group, which demonstrated to Sharon and her parents that the practitioners were in partnership with them. The practitioners offered to continue the problem-solving process with Sharon and her family outside of the multifamily group.
Tip
The week following the problem-solving session, try to make brief contact with the consumer and family whose problem was solved to check in with their progress. This contact, no matter how brief, fosters a sense of “partnership” and provides an opportunity to brainstorm further solutions outside of the group if necessary.
Background to Problem #3
Rebecca is a woman in her mid-20s with a serious mental illness that is presently stable. She tries to take good care of herself and to stay on her medication regimen. Although she lives alone, her mother attends the multifamily group with her regularly. She has recently started working 20-hours a week as a caretaker for severely mentally retarded adults in a group home. So far, she likes the training and the work, but feels she cannot remember all of the information that she is receiving. This experience is starting to make her feel stressed and inadequate. Although she is working closely with an employment specialist, she does not want on-site supervision or to disclose her illness to her employer. She is wondering what she can do to feel less stressed and more in control of the situation while learning a new skill.
Step 1: What is the problem?
How can Rebecca receive support with her training and best approach her job in order to be successful?
Step 2: List all possible solutions.
The group generated the following suggestions:
- Review the written literature that the group home offers about specific tasks during the training period.
- Ask for a written job description.
- Speak to co-workers about what to expect on the job while training and shadowing.
- Don’t be afraid to ask questions.
- Ask for extra training if you feel you need it, and tell the employer that helps you learn the best.
- Know who to call for support.
- Make notes of questions to ask your supervisor and write down the answers.
- Make notes of tasks while being trained.
- Don’t be afraid to go to supervisor.
Step 3: Discuss each possible solution.
Rebecca decided she liked all of the suggestions and did not eliminate any during this section of the problem-solving process.
Step 4: Choose the best solution or combination of solutions.
Rebecca thought the following suggestions would be worth trying, and her mother agreed:
- Make notes of questions to ask your supervisor and write down the answers.
- Make notes of tasks while being trained.
- Speak to co-workers about what to expect on the job while training and shadowing.
- Bring a notebook and pen to work the first day and from then on keep it with you.
- Try to approach a co-worker who seems friendly and has worked there for awhile; ask that person about what you can do to make the learning process less stressful. They might share their own learning experiences and offer helpful tips!
Step 5: Plan how to carry out the best solution.
A Solution for a Medication Issue
Background for the problem
Darcy is a 29-year-old woman who has a severe mental illness with paranoid features. She is the mother of two young children. It is important to her to function well enough to care for her family, as well as to take one college-level course each semester as she works towards her undergraduate degree. Her family is very supportive of her efforts to stay stable.
Step 1: What is the problem?
What can Darcy do if she starts experiencing early warning signs of illness? (Warning signs include: sleeplessness, loss of appetite, stopping medication, restlessness, noticeable mood changes, and auditory hallucinations.)
Step 2: List all possible solutions.
- Call the doctor.
- Take more medication.
- Write down feelings or tell someone.
- Find out more information about the medication.
- Alert friends so they can give you feedback.
- Keep a diary about food intake to see if there is a change.
- Say a prayer.
- Talk to family and friends.
- Call the Hotline.
- Talk a walk.
Step 3: Discuss each possible solution.
What are the advantages of each solution for Darcy? Disadvantages? Neither she nor her husband asked to eliminate any of the suggestions.
Step 4: Choose the best solution or combination of solutions.
Darcy chose the following solutions:
- Take medication again, but call the doctor first.
- Say a prayer.
Step 5: Plan how to carry out the best solution.
Darcy and the group developed the following action plan:
- After talking with doctor, resume your daily strategy for remembering medications (e.g., set up pill caddy and put reminder sign on bathroom mirror).
- Tell family and friends that you are restarting medication, and ask for feedback as a way to monitor changes.
Step 6: Review implementation.
One of the practitioners who works closely with Darcy telephoned her the week prior to the multifamily group to see how she was doing and if she needed any help with the action plan. At that time, Darcy felt she was following through well with the suggested solutions, and that her family was quite supportive of her efforts. The following session, the practitioners “checked in” with Darcy to find out whether she had been able to continue to follow through with the action plan. She had been concerned that her doctor and treatment team would be angry with her, and had been relieved to find out that they were supportive of her restarting the medications without being angry. That had helped her to regain confidence in managing her treatment herself. Her family had also been able to provide feedback about the positive changes they were seeing in her behavior and mood.
Solutions Relating to Daily Living Skills
Background to problem #1
Sometimes several consumers are struggling with the same issue at the same time, and while it is usually preferable to focus on one person’s difficulty during a session, the group can benefit from solving a generic problem. A group of consumers in one particular multifamily group were having interpersonal problems with other residents during the same time period, so the practitioners opted to offer a “generic” question, which the group thought was helpful. Some of the interpersonal problems stemmed from other residents disobeying house rules.
Step 1: What is the problem?
What are some ways you can cope with (relate to) difficult people in your living situation?
Step 2: List all possible solutions.
The group generated the following list of suggestions:
- Don’t take it personally.
- Become angry.
- Use humor.
- Say “no” repeatedly if the other person isn’t listening.
- Explain your point of view (reasonably and calmly).
- Set clear limits about what you can deal with and what you can’t.
- Let them know you don’t like it.
- Walk away.
- Talk about consequences.
- Get out of the situation…get help!
- Use “I” sentences, not “you” sentences.
- Don’t accuse.
- Move!
Step 3: Discuss each possible solution.
The entire group reviewed each suggestion, starting with advantages of each and then exploring disadvantages. They did not eliminate any suggestions.
Step 4: Choose the best solution or combination of solutions.
The group as a whole narrowed down the list of suggestions to the following 4 that they wanted to start practicing:
- Say “no” repeatedly if the other person isn’t listening.
- Set clear limits.
- Talk about consequences.
- Get help.
.Step 5: Plan how to carry out the best solution.
- Set limits by nicely reminding the other person about the house rules, such as “no cigarette smoking in the house”.
- Repeat the reminder without accusing the other person.
- Be more firm each time.
- Write down an agreement and have each person sign it.
Step 6: Review implementation.
Each person in the group received a copy of the solutions and action plan. During the following group’s check-in, the practitioners reviewed each person’s experience with implementing the action plan. Some people needed further help outside of the group, while other people found they had been successful trying the action plan as well as some of the other suggested solutions.
Tip
Serious problems, such as substance abuse, should never be ignored and should be dealt with during the problem-solving session if the consumer will allow it.
Background to problem #2
Katrina is a 42 year-old woman with a history of schizophrenia and only a fair response to medication. She has been able to live alone in an apartment with her cats for the past 12 years, but receives significant support from community providers. She and her older siblings attend multifamily group on a regular basis. In the past 6 months, Katrina has developed a relationship with an older man who is transient, which frightens her family and friends. Katrina has difficulty staying away from this man, even though he forces her to do things she would prefer not to do, such as give him money. She would like to stay away from him, and her family would also like her not to see him any longer, but she has trouble saying “no” to his phone calls and ignoring the doorbell when he shows up in her apartment house. Recently, she has experienced more anxiety with this situation to the point that she sometimes feels unsafe in her own home. The police have intervened on her behalf several times, and her family finds they are becoming frustrated and angry. The primary difficulty seems to be Katrina’s increased feeling of discomfort in her own apartment.
Step 1: What is the problem?
What can Katrina do to feel safe in her own home?
Step 2: List all possible solutions.
Katrina was nervous about having the multifamily group focus on her group, but felt it might help her. She listened while other group members offered suggestions and asked her for more information during the brainstorming:
- Keep a cane or baseball bat near the bed for protection.
- Play soothing music.
- Get friendly with your neighbors…they could come if you called for help!
- Call the police if you feel you’re in danger.
- Check all windows to be sure they are down and locked.
- Call the landlord to put a lock on a window that doesn’t have one on it.
- Buy a whistle.
- Put bottles by the door and windows - soda cans with pennies in them to make noise.
- Ask someone to visit you each evening (for encouragement).
- Ask a friend to stay with you a while.
- Ask to stay with friends.
Step 3: Discuss each possible solution.
Katrina and her family participated in the review of the suggestions and did not eliminate any solutions.
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