Name of the Strategy or Intervention
Problem-Solving Training.
Synonyms
Introduction
Problem-solving training (PST*) is a central component of cognitive-behavioral couple therapy and featured prominently in behavioral marital therapy (BMT; also known as traditional behavioral couple therapy). PST* can be thought of as a specialized form of communication training that is specific to helping couples effectively navigate conflict around specific problematic behaviors or circumstances. PST* is aimed at developing the skills for distressed couples to collaborate on generating solutions to especially challenging problems in their relationship (e.g., how to divide financial responsibilities, how to manage in-laws at family dinners).
An important first emphasis in training couples in PST* is that this approach to problem-solving is not necessarily appropriate for all problems. Learning to make the distinction between what problems are and are not resolvable with PST* is an important skill for couples. Briefly, resolving feelings is not a primary goal of PST*, although emotions play a major role in couples’ arguments. Negative emotions that drive conflict are not easily solved with a structured, concrete, behavioral solution. However, conflicts related to discrete, problematic behaviors are appropriate for PST*. For PST* to be effective, partners must have volitional control over the behavior to be changed; for example, planning how to divide up certain household tasks or disagreements about parenting are excellent candidates for PST*.
After a problem is determined to be a good fit for PST*, the therapist helps the couple make a plan for problem-solving. Problem-solving typically occurs in a structured setting and includes an agenda that is set in advance. Discussion of a problem should occur for only brief chunks of time, and only one problem should be discussed in a given sitting. In the problem definition phase of PST*, the couple must agree what the problem to be solved is. Partners are instructed to begin with a positive statement, similar to communication skills training. They are then asked to be specific and behavioral in the description of the problem, take responsibility for their own role in the problem, and be succinct. In the problem solution phase, the couple works to generate potential solutions to their problem. In doing so, they are encouraged to brainstorm all possible solutions, regardless of the quality or feasibility. The emphasis in this step is for both partners to be generative and to feel comfortable doing so with one another. Partners are explicitly instructed to avoid judgment or comment on each other’s suggested solutions during this phase. The next step of PST* is joint evaluation of the possible solutions, with each partner providing feedback on potential solutions that feel unhelpful or unachievable, and both aiming to collaborate and compromise in selecting a solution. After the couple arrives at an agreed-upon solution, they make an action plan of behavioral steps each partner will take toward the solution. Therapists encourage couples to write out the agreed-upon solution, with the possibility of renegotiating it if the solution does not prove helpful.
Theoretical Framework
PST* is most often used in behavioral and cognitive-behavioral theories about relationship distress. It was first developed in the 1970s and used in BMT (Jacobson and Margolin 1979). Early treatment outcome research suggested that a significant proportion of couples (approximately half) did not respond to traditional behavioral couple therapy and an additional number of couples did not maintain gains made in behavioral couple therapy over time (e.g., Jacobson et al. 1987). In response to these findings, newer couple therapies were developed that focused on negative or difficult emotions that partners experience and their patterns of thinking. These next iterations of couple therapy sought to improve on the successes of behavioral couple therapy and retained the components of communication/skills/problem-solving training and behavior exchange.
However, how these communication skills are conceptualized and applied in more modern therapies differs somewhat from their original form. In integrative behavioral couple therapy (IBCT), the emphasis is on acceptance-based strategies for differences between partners that cannot change (Christensen et al. 2014; Jacobson and Christensen 1996). Within this approach, behavioral strategies and PST* are applied in ways that can augment emotional acceptance techniques. Similarly, in cognitive-behavioral couple therapy, these strategies are used alongside strategies to address distorted cognitions both partners engage in.
Finally, PST* and behavioral strategies have also formed the basis of couple-based interventions developed for couples where one partner has a specific form of psychopathology. For example, in cognitive-behavioral conjoint therapy for PTSD (Monson et al. 2012), problem-solving (and other traditional behavioral couple therapy strategies) is used in combination with techniques from cognitive processing therapy for PTSD. Through their application, this intervention aims to reduce relationship distress and symptoms of PTSD. Similarly, behavioral couple therapy (BCT) for substance use disorders, as well as a similar version developed for alcohol use disorders, incorporates PST* and other BMT techniques to reduce substance and alcohol use in couples while simultaneously promoting positive changes in their relationships. Within these interventions for a specific partner’s psychological distress, the role of behavioral strategies, including PST*, is to help improve relationship functioning alongside therapeutic strategies for the specific form of psychopathology. The theory behind this approach is based on basic science that suggests relationship distress can exacerbate or prolong individual psychological distress (e.g., Whisman and Baucom 2012). Thus, although PST* in its original form developed within BMT is practiced less often, the core technique and theoretical understanding of the strategy is still present in many modern evidence-based couple treatments.
Rationale for the Strategy or Intervention
Problem-solving techniques were originally developed as a component of behavioral couple therapy. Problem-solving techniques were included with other types of communication skills training to help couples better navigate problems or situations that evoked conflict. These were paired with behavioral exchange strategies designed to promote positive interactions within the couple. In conjunction, these two strategies (behavioral exchange and communication skills/problem-solving training) were thought to rectify behavioral skills deficits that distressed couples possessed. In theory, unhappy couples were experiencing significant relationship distress because they engaged in fewer positive interactions than satisfied couples and also lacked conflict resolution and problem-solving skills that increased the frequency and duration of negative interactions. Empirical research suggested that both components were effective at reducing relationship distress (Jacobson 1977a, 1979). However, follow-up analyses that attempted to identify which specific behavioral skills (including PST*) learned in therapy contributed to maintenance of relationship satisfaction over time were largely unsuccessful. As a whole, empirical literature and current manifestations of cognitive-behavioral couple therapy suggest that PST* is an important, but not wholly sufficient component of couple therapy on its own (e.g., Jacobson 1984; Hahlweg and Markman 1988).
Description of the Technique
PST* consists of four steps or phases the couple works through together. Ideally, these steps are first presented and practiced in session with the therapist prior to using them at home. They are then rehearsed and reviewed in sessions over time until the couple is comfortable using the technique independently. These steps are (1) define problem, (2) brainstorm solutions, (3) collaborate on a solution, and (4) reevaluate (Jacobson 1977b).
The couple must first define the problem to which they wish to apply PST*. The problem must be concrete and discrete, meaning that it is behaviorally definable and small enough that progress can be observed (e.g., “Be a better parent” is neither concrete nor small). Second, both partners suggest possible solutions to the problem. It is important that the therapist make it clear to the couple that during the brainstorming period, any and all solutions are accepted and written down. Evaluation of the solutions occurs later in a separate step to encourage couples to be as generative as possible when coming up with possible solutions. The therapist might also encourage the couple to include some implausible solutions to promote creativity in finding solutions (e.g., problem, “We both need to spend more time with the children”; possible solution, Husband and wife quit their jobs to spend more time at home). Third, the couple evaluates each solution, with each partner having the authority to negate solutions until an achievable and mutually agreed-upon solution is arrived at. The couple then develops a plan to work toward that solution (e.g., husband will try to come home early from work twice per week to spend time at night with the kids). Finally, the couple agrees to a date, time, and location to have a reevaluation meeting to assess progress on the plan. This step is critical for insuring that progress on the plan is monitored by both partners. At the reevaluation session, both partners evaluate whether progress has been made in enacting their agreed-upon plan.
It is important that the therapist emphasize for the couple that PST* is a special type of communication training. PST* is very structured and focused in its purpose. The intention is not to suggest to the couple that all discussions between them should occur in such a manner. PST* is reserved for a highly structured approach to solving a concrete problem for the couple. By reviewing the appropriate use of the technique through in-session practice combined with feedback, assignment for use at home, and then in-session assessment of the couple’s use of the skill at home, the therapist can both model the process of PST* and monitor progress toward its successful application for distressed couples. Ultimately, the therapist will work with the couple to reduce the therapist’s involvement in the couple’s use of the skill and promote autonomy in the couple using their own skills independently.
Case Example
Barbara and Ben were a couple who had been married for 13 years. Both partners were White, in their mid-30s, and this was the first marriage for both husband and wife. Barbara and Ben had two sons together, ages 5 and 7. They had briefly been in couple therapy previously, approximately 1 year before presenting to a departmental clinic specializing in IBCT. Relevant to the application of problem-solving strategies with this couple, Ben had been diagnosed with attention deficit hyperactivity disorder (ADHD) roughly 3 years prior and had been on stimulant medication (but not received psychotherapy) for his ADHD since his diagnosis. In their initial session, both husband and wife described feeling disconnected from another emotionally. In particular, Barbara noted that Ben had difficulty following through on household tasks and managing money well, which Barbara would react to by trying to control these aspects of their lives more closely. Both Barbara and Ben acknowledged that some of Ben’s difficulty in accomplishing these tasks was attributable to his ADHD. Both partners articulated wanting to feel closer to one another emotionally at the end of couple therapy, and Barbara also articulated hoping Ben would improve in managing household tasks and money without her monitoring them so closely.
Ben and Barbara’s therapist conceptualized their relationship distress by examining their individual differences, emotional vulnerabilities, external stressors, and their resulting pattern of interaction around issues that caused distress or conflict. Especially relevant for the application of PST* techniques for the couple, their therapist conceptualized some of their relationship distress as a consequence of Ben and Barbara’s individual differences in their ability to mentally organize and plan (i.e., as a function of Ben’s ADHD). In addition, Ben and Barbara had developed emotional sensitivities around these issues (e.g., Barbara having the belief that if she mattered more to Ben, he would remember things he needed to do at home better; Ben feeling condescended or inadequate when Barbara did things for him). Stressors the couple experienced (e.g., parenting, work-related stress) often exacerbated these issues. Finally, Ben and Barbara had developed a pattern of interaction where Barbara would ask Ben to complete a task at home and then repeatedly ask Ben if it had been done. Ben, in contrast, would try to avoid discussing the issue to prevent feeling criticized when Barbara found out he had not done the task.
Ben and Barbara’s therapist presented this conceptualization to them. Their therapist first used behavioral strategies to help the couple reduce their relationship distress and feel more connected around issues of daily household function given both partner’s focus on feeling the need for behavioral change. Ben and Barbara’s therapist presented the strategy of PST* to them in session.
First, the therapist explained the rationale behind PST*, as it applied to the couple’s conceptualization of their relationship distress.
- T :
I’m hearing that the specific problem you’re wanting to focus on is how you get the household organized for the week. It makes sense that this issue would bring up a lot of conflict for you since you both go about wanting to solve it in different ways. Ben, you’d prefer to “go with the flow” and take things day by day. Barbara, you’d prefer to plan things out when in advance.
- W :
That’s right.
- T :
For these types of specific problems, we can use a type of problem-solving that focuses on finding a time you’ll both be in a good mindset for dealing with it, come up with some possible solutions and then select the one that makes the most sense for you.
Next, the therapist outlined the concrete steps of PST* for the couple so that they were clear in their understanding of what the behavioral strategy involved.
- T :
To do this, you first want to pick a day and time you can set aside for a problem-solving meeting. This works best when you don’t have a lot of other distractions, like kids or work. First, you’ll want to decide on what the problem is very specifically, like we did here.
- H :
How we plan shopping and meals for the week.
- T :
That’s right. That type of problem is very specific and we can measure it. That way we know if you’re meeting the goal or making good progress toward it. After you both agree on the problem, you can shift to coming up with possible solutions. You both get to suggest solutions, and no one gets to say no to any possible solutions until you’re done coming up with them.
- W :
So there are no bad ideas in brainstorming.
- T :
Exactly! You’ll then go through each solution and evaluate it. You both have veto power here. Once you’ve agreed on a single solution, you can try it out over the upcoming week. The important final step is that you check-in about how that’s going the following week and tweak the plan if necessary.
The therapist then collaborated with the couple on a specific issue they might apply the strategy to, how they might apply it at home, and when they planned to do so. The therapist aimed to help the couple be as behaviorally specific as possible and practice PST* in session. The therapist provided corrective feedback along the way.
- T :
Let’s give this a try here today. Often these types of skills are easier said than done. This way I can provide some advice or help as you go along. We can start with the first step.
- H :
So the problem is how organized we both feel like being.
- T :
Let’s get really specific and zoom in on that.
- W :
Ok, so one problem related to that is how we plan our grocery shopping and meals for the week.
- T :
Great, that’s very specific. What’s next?
- H :
Solutions. So, we could sit down together every Sunday night and write it out.
- W :
That doesn’t seem very realistic.
- T :
Remember, here we’re just coming up with solutions.
- W :
Right, ok. We could do that. Or keep a list on the fridge.
- T :
Sometimes it helps to come up with really out there solutions to help you think outside the box. So, maybe you could each keep a meal plan and grocery list and call one another at work every time you change something on it.
- H:
Hmmm. We could make the meal plan for the week on Sunday morning after church and then have it in our email that we could both see.
- T :
So if you’re feeling like you have enough solutions on your list of possibilities, you want to shift to assessing each one.
- W :
I think we want it to be convenient but also reliable. I don’t think we’re ever going to remember to check the fridge each morning. I liked your email idea.
- T :
So let’s just review together so we’re all on the same page about what your plan is.
- H :
We’re going to sit down together Sunday morning after church and come up with a meal plan for the week and a grocery list that goes with it. Then we’ll e-mail it so we both have it handy separately and can check it for whoever is covering dinner that night.
- T :
That sounds really clear. I know this process can feel mechanical at first, but it did seem to help you arrive at solution that might work well for you both. I’ll be really curious to hear how that goes when we meet next week.
Finally, the therapist reviewed the couple’s use of the skill in a subsequent session to provide any additional feedback and support.
- T :
So I just wanted to check-in. How did your meal planning and email solution end up going last week?
- W :
Really well actually. We made the list and both had it handy. Doing that every week seems hard though. We might want to try and stretch it out to last every two weeks.
- T :
Well I’m glad you had some good success at the start! It sounds like you’re using your check-in time together to update the plan, which is great. And if it turns out you don’t need to check-in as much about the problem because the solution starts to work, that’s perfectly ok.
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Perry, N.S., Baucom, B.R.W. (2017). Problem Solving Skills Training in Couple and Family Therapy. In: Lebow, J., Chambers, A., Breunlin, D. (eds) Encyclopedia of Couple and Family Therapy. Springer, Cham. https://doi.org/10.1007/978-3-319-15877-8_92-1
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