Tag Archives: problem-solving

Cool Counseling, Counseling and Psychotherapy Theory and Practice, Suicide Assessment and Intervention, Therapy with Adolescents, Writing

A Sneak Peek at Our Upcoming Suicide Assessment and Treatment Book with the American Counseling Association

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Spring Sunrise and Hay

Rita and I are spending chunks of our social distancing time writing. In particular, we’ve signed a contract to write a professional book with American Counseling Association Publications on suicide assessment and treatment planning. We’ll be weaving a wellness and strength-oriented focus into strategies for assessing and treating suicidality.

Today, I’m working on Chapter 6, titled: The Cognitive Dimension. We open the chapter with a nice Aaron Beck quotation, and then discuss key cognitive issues to address with clients who are suicidal. These issues include: (a) hopelessness, (b) problem-solving impairments, (c) maladaptive thinking, and (d) negative core beliefs.

Then we shift to specific interventions that can be used to address the preceding cognitive issues. In the following excerpt, we focus on collaborative problem solving and illustrate the collaborative problem-solving process using a case example. As always, feel free to offer feedback on this draft content.

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Collaborative Problem-Solving

Though not a suicide-specific intervention, problem-solving therapy is an evidence-based approach to counseling and psychotherapy (Nezu, Nezu, & D’Zurilla, 2013). Components of problem-solving are useful for assessing and intervening with clients who are suicidal. As Reinecke (2006) noted, “From a problem-solving perspective, suicide reflects a breakdown in adaptive, rational problem solving. The suicidal individual is not able to generate, evaluate, and implement effective solutions and anticipates that his or her attempts will prove fruitless” (p. 240).

Extended Case Example: Sophia – Problem-Solving

In Chapter 5 we emphasized that clinicians should initially focus on and show empathy for clients’ excruciating distress and suicidal thoughts. However, there often comes a moment when a pivot toward the positive can occur. Questions that help with this pivot include:

  • What helps, even a tiny bit?
  • When you’ve felt bad in the past, what helped the most?
  • How have you been able to cope with your suicidal thoughts?

In response to these questions, clients who are suicidal often display symptoms of hopelessness, mental constriction, problems with information processing, or selective memory retrieval. Statements like, “I’ve tried everything,” “Nothing helps,” and “I can’t remember ever feeling good,” represent cognitive impairments. Even though your clients may think they’ve tried everything, the truth is that no one could possibly try everything. Similarly, although it’s possible that “nothing” your client does helps very much, it’s doubtful that all their efforts to feel better have been equally ineffective. These statements indicate black-white or polarized thinking, as well as hopelessness and memory impairments (Beck et al., 1979; Reinecke, 2006; Sommers-Flanagan & Sommers-Flanagan, 2018).

Pivoting to the Positive

Picking up from where we left off in Chapter 5, after exploring the distress linked to Sophia’s suicide ideation in the emotional dimension, the counselor (John) pivots to asking about the positive (“What helps?”) and then proceeds into a problem-solving assessment and intervention strategy. One clearly identified trigger for Sophia’s suicidal thinking is her parent’s fighting. She cannot directly do anything about their fights, but she can potentially do other things to shield herself from the downward cognitive and emotional spiral that parental fighting activates in her.

John: Let’s say your parents are fighting and you’re feeling suicidal. You’re in your room by yourself. What could you do that’s helpful in that moment? [The intent is to shift Sophia into active problem-solving.]

Sophia: I have a cat. His name is Douglas. Sometimes he makes me feel better. He’s diabetic, so I don’t think he’ll live much longer, but he’s comforting right now.

John: Nice. My memory’s not perfect, so is it okay with you if I write a list of all the things that help a little bit? Douglas helps you be in a better mood. What else is helpful?

Sophia: I like music. Blasting music makes me feel better. And I play the guitar, so sometimes that helps. And volleyball is a comfort, but I can’t play volleyball in my room.

John: Yeah. Great. Let me jot those down: music, guitar, volleyball, and being with your cat. And volleyball, but not in your room! I guess you can think about volleyball, right? And how about friends? Do you have friends who are positive supports in your life?

Although the fact that Douglas the cat has diabetes includes a depressive tone, the good news is that Sophia immediately engages in problem-solving. She’s able to identify Douglas and other things that help her feel better.

Throughout problem-solving, regularly repeating positive coping strategies back to the client is important. In this case, John summarizes Sophia’s positive ideas, and then asks about friends and social support—a very important dimension in overall suicide safety planning.

Sophia: Yeah, but we’re all busy. My friend Liz and I hang out quite a bit. I can walk into her house, and it will feel like my house. But we’re both in volleyball, so we’re both really busy. But our season will end soon. Hopefully that will help.

John: Ok, the list of things that seem to help, especially when you’re in a hard place with your parents fighting: Douglas the cat, music, guitar, and volleyball, and friends. Anything else to add?

Sophia:  I don’t think so.

Often, the next step in collaborative problem-solving is to ask clients for permission to add to the list, thus turning the process into a shared brain-storming session. At no time during the brainstorming should you criticize any client-generated alternatives, even if they’re dangerous or destructive. In contrast, clients will sometimes criticize your ideas. When clients criticize, just agree with a statement like, “Yeah, you’re probably right, but we’re just brainstorming. We can rank and rate these as good or bad ideas later.”

Overall, the goal is to use brainstorming to assess for and intervene with mental constriction. During brainstorming, Sophia and John generated 13 things Sophia could do to make herself feel better. Sophia’s ability to brainstorm in session is a positive indicator of her responsiveness to treatment.

 

Clinical Interviewing, Counseling and Psychotherapy Theory and Practice, Tough Kids Cool Counseling

A Bonus Counseling LAB Activity: Person-Centered Problem-Solving

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Riverbed and John

After having learned a bit about person-centered theory and therapy and then being exposed to behavior therapy, it makes sense to consider how you can combine the two. For me, the best first step is to integrate your person-centered attitude and skills into a behavioral problem-solving process.

 Person A: As usual, your job is to pretend that you’re a client who’s coming for counseling. You have a minor, but frustrating problem. It helps if the problem is concrete and best if you have a recent experience with it so you can describe it well.

When you sit down with your counselor, take about 5 minutes to describe your problem. Explain how bad it is, how difficult it is to change this problem, and share some of the strategies you’ve tried on your own. As the counselor listens and responds, do your best to respond genuinely back to the counselor and then go with the counseling flow.

Your counselor will engage you in a problem-solving process. Be yourself and participate as you would if you were with a “real” counselor.

Person B: You will be combining your person-centered attitudes and skills with a problem-solving approach. The basic steps to problem-solving [which you should always remember] are as follows:

  1. In collaboration with the client, identify the problem. When you do this, use your listening skills to try to operationalize it in a behaviorally specific way. Remember, you can ask questions, but if/when a person-centered counselor asks questions, the questions are centered on your client’s experiences and emotions. Remember also to avoid asking two questions in a row, because you need to paraphrase before moving to another question.
  2. Brainstorm (generate) a list of possible strategies that your client could use to solve or manage the problem that you’ve collaboratively identified. Remember to: (a) ask your client permission to start making the list, (b) tell your client that you’re only “making a list” to so that both of you can see all of what might be possible, and (c) therefore neither of you can criticize the alternatives/strategies on the list. In fact, you should let your client know that you’d also like to hear some bad ideas or strategies that have been tried, but that didn’t work perfectly.
  3. After you’ve generated 5-10 alternatives, share/show the list to your client and then ask if it would be okay to discuss the pros and cons and likely outcomes linked to each strategy. The purpose here is to collaboratively engage in a reflective process. You’ll want to know about obstacles that might make using some strategies more difficult and potential positive or negative outcomes/side-effects of each strategy. Explore your client’s thoughts, emotions, and reactions to each of the options, using your best listening skills. Behaviorists call this process “means-ends” thinking or “consequential thinking.” Engaging in this process can be naturally behaviorally inhibiting (meaning that it can decrease the chances of an impulsive behavioral response).
  4. Hand the list to your client. Ask something like, “Based on our discussion and on your feelings and thoughts, would you please rank these ideas from 1 to 8, with 1 being your first choice and 8 being your last choice (assuming there were 8 options).
  5. After your client has ranked the ideas, collaboratively make an implementation and evaluation plan. Your client might choose to use 1 or 2 or 3 different strategies. That’s fine. Ask questions like, “How will you remember to try this out?” and “How will you know if your strategy is successful?” You might need to help your client understand that the goal or outcome needs to be within your client’s circle of control. You also might need to provide psychoeducation on solutions often don’t fix things quickly and that it might take weeks to see progress. Let your client know that you’ll be checking in on progress at your next meeting and that although it would be very nice if the strategy has been implemented, it’s also a success to just be thinking about implementing the plan.

Close the session by thanking your client for engaging in this process with you.

Parenting

How Parents Can Use Problem-Solving Power

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Problem-solving power refers to a group of parent influence strategies designed to activate, within children or teenagers, a problem-solving or solution-focused mental state. This strategy is best illustrated with an example:

Sonya is busy at her laptop reading an online newspaper while her 6-year-old son plays in the living room. She notices her son working hard on a small puzzle and after he gets a piece into place, she says: “How did you figure out where that piece went?” Her son looks up and replies, “I don’t know. It just fit there.”

This interaction may seem trivial, but the mother, whether she knows it or not, is using problem-solving power to encourage her son to reflect on how he’s getting his puzzle together. This particular approach is based on constructive or solution-focused principles. The underlying belief is that the more we can get our children thinking about how to solve problems, the better they’ll become at problem-solving.  Further we are helping them become more optimistic, focusing on solutions and successes instead of pessimistically focusing on failures and problems.

The polar opposite of problem-solving power occurs when parents, in frustration, ask their child something like, “What’s wrong with you?” or after a sequence of misbehavior, “What were you thinking!?” When parents ask these problem-oriented questions, it encourages children to focus on their failures, what’s wrong with them, or on their negative thoughts and behaviors.

Just like solution-focused therapy, problem-solving power is indirect and leading (Murphy, 2008; Steenbarger, 2004). It’s also something we have to train ourselves to do.  For some reason, it seems more natural to ignore our children when they are behaving, and to give them attention when they are not.  Many parents remain silent and even detached while children play quietly (savoring the silence). This, of course, is the equivalent of ignoring good behavior, which we know from our basic behavioral principles is a great way to extinguish behavior.

The most common forms of problem-solving power are listed in the “How to Listen so Parents will Talk book (see: http://www.amazon.com/How-Listen-Parents-Will-Talk/dp/1118012968/ref=la_B0030LK6NM_1_5?ie=UTF8&qid=1351053762&sr=1-5)

Here’s one example of a problem-solving power strategy.

Child-Generated Rules

As noted in the “How to Listen. . .” book, parent-generated family rules are an example of direct power. In contrast, when using problem-solving power, parents try to hook their children into generating rules themselves. Interestingly, as family members discuss what they want for themselves and for the family, children often become motivated to contribute to very positive and reasonable family rules. Many authors have written about family meetings or the family council (Croake, 1983; Dreikurs, Gould, & Corsini, 1974).

Problem-solving power is an excellent way to help children reflect on and contribute to family solutions. It’s a method for helping children learn solutions and rules from the inside out—instead of the external or outside-in behavioral approach. Problem-solving power can be used liberally but sometimes parents need to take charge and solve family problems themselves. This is especially true with younger children. As family therapist Carl Whitaker once said (we’re paraphrasing), “Two-year-olds cannot take over leadership within a family unless they’re standing on the shoulders of a parent.” In the end, things go better if parents are the primary leaders in the home who not only allow their children to voice opinions, but also engage their children in the family problem-solving process.