































Graduate Student Journal of Psychology          Copyright 2012 by the Department of Counseling and Clinical Psychology 
2012, Vol. 14               Teachers College, Columbia University 

83 
 

 
Collaborative Problem Solving: Is Empathy the Active Ingredient? 

 
Kevin Ashworth, Sara Tapsak, & Susan Tinsley Li 
School of Professional Psychology, Pacific University 

 
Collaborative Problem Solving (CPS) is a cognitive-behavioral model that has gained popularity in 
the last decade as a promising treatment option for children with Oppositional Defiant Disorder-
type (ODD-type) behaviors and aggression.  Collaborative Problem Solving aims to help caregivers 
identify a child’s skill deficits, understand the role of triggers in maladaptive behaviors, and 
implement a framework for communicating with a child.  While multiple studies provide empirical 
support for the use of CPS in a variety of settings, only one experimental study has been conducted 
to date that compares CPS to a well-established parent-training program (Barkley’s Behavior 
Management Program; BBMP).  Furthermore, no studies have attempted to identify the 
mechanisms of change in CPS for ODD-type behaviors and aggression.  Based on current literature 
and clinical experience, the authors hypothesize that the effectiveness of CPS for ODD-type 
behaviors and aggression across a range of treatment settings is likely due to its focus on empathy.  
In the current article, the authors develop a conceptual model of empathy as a mechanism of 
change in CPS for ODD-type behaviors and aggression based on relevant literature on CPS and 
empathy as well as clinical illustrations.  Moreover, the authors present a design to empirically test 
this hypothesis.  
 

Collaborative Problem Solving (CPS) is a cognitive-
behavioral intervention for children with symptoms of 
Oppositional Defiant Disorder (ODD), such as defiance, 
disobedience, and hostility towards authority figures (Greene 
et al., 2004).  Collaborative Problem Solving is being 
increasingly recognized as an effective therapeutic modality 
for working with children with ODD-type behaviors and 
aggression.  Within the last decade CPS has emerged as a 
dominant treatment modality in residential, day-treatment, 
and inpatient psychiatric facilities throughout the United 
States to address these types of behaviors.  Research in 
several different settings supports CPS as an effective 
treatment option for children with ODD-type behaviors and 
aggression (Epstein & Saltzman-Benaiah, 2010; Greene et al., 
2004; Greene, Ablon, & Martin, 2006; Martin, Krieg, 
Esposito, Stubbe, & Cardona, 2008; Stewart, Rick, Currie, & 
Rielly, 2009).  However, despite the growing evidence for the 
effectiveness of CPS for children with ODD-type problems, 
there is currently a dearth of evidence elucidating the 
mechanisms of change in the CPS model, which limits the 
validity of the model as an efficacious treatment option.  To 
our knowledge, there is no formal model of change that 
explains the mechanisms of CPS, although some authors have 
theorized that “Plan B” conversations (described below) are 
essential (Greene & Ablon, 2006; Greene et al., 2004).  We 
hypothesize that the empirical support afforded to CPS is 
largely the result of a focus on empathy, accomplished 

                                                 
Kevin Ashworth, M.A., Sara Tapsak, M.S., and Susan Tinsley 

Li, Ph.D., School of Professional Psychology, Pacific University, 
Hillsboro, OR.  

Correspondence concerning this article should be addressed to: 
Sara Tapsak, Pacific University School of Professional Psychology, 
190 SE 8th Ave. Hillsboro, OR 97123. Email: 
sara.tapsak@pacificu.edu. 

 

through the identification of the child’s lagging skills and the 
use of empathic skills by adults.  This theoretical article 
investigates the use of empathy in CPS as a primary change 
mechanism, above and beyond the other components of the 
model (i.e., training of skill deficits and identifying triggers to 
problem behaviors), by providing a rationale for the role of 
empathy based on a literature review, as well as our clinical 
experience using the model.  To support our claim, we first 
introduce CPS, outline its principal components, and review 
current research that supports CPS’ effectiveness.  We then 
present our hypothesis for empathy as a mechanism of change 
within the model, as well as literature on the role of empathy 
in the therapeutic process, its influence on the parent-child 
relationship, impact on effective communication, and use by 
mental health staff.  Next, we provide clinical illustrations 
based on our clinical experiences, propose a model for 
empathy as a primary mechanism of change in CPS, and end 
with a discussion of the limitations of this paper. 

Fourth, there is the potential for benefits outside the 
realm of psychotherapy.  Specifically, knowing about the 
process by which maladaptive functioning changes into 
adaptive functioning may reflect upon the processes 
underlying different forms of psychopathology and healthy 
functioning in general. 

 
Collaborative Problem Solving 

 
Collaborative Problem Solving was developed over a 

decade ago and introduced in Ross Greene’s The Explosive 
Child, most recently published in 2010.  Greene highlighted 
the differences between CPS and traditional behavioral 
models for working with children who have ODD-type 
behaviors.  He emphasized the importance of recognizing 
these behaviors as secondary to skill deficits in different areas 
of ability.  He provided a collaborative method of 



ASHWORTH, TAPSAK, & TINSLEY LI 
 

84 
 

communication with children and understanding their 
concerns, based on a transactional model which posits that 
problem behaviors result from the incompatibility between 
characteristics of children and their adult caregivers, instead 
of employing conventional interventions for behavior change.  
Specifically, Greene (2010) shifted the emphasis in this 
treatment from reward and punishment strategies as 
contingencies in traditional behavioral therapies (Durlak, 
Fuhrman, & Lampman, 1991) to understanding the role of 
triggers in maladaptive behaviors (Greene, 2010).   

As part of this shift, a component of the model is to teach 
parents to think differently about their children’s behaviors 
through the identification of specific skill deficits in the areas 
of flexibility/adaptability, frustration tolerance, and problem 
solving, and therefore, viewing maladaptive behaviors as the 
byproduct of these lagging skills required for coping and 
problem solving (Greene & Ablon, 2006).  There are three 
identified goals of intervention in CPS: (1) to significantly 
reduce the frequency, intensity, and duration of problem 
behaviors; (2) to help adults have their expectations met; and 
(3) to teach cognitive skills that are lacking in the child 
(Green & Ablon, 2006).  The specific components of CPS 
employed to achieve these goals are described in detail 
below. 
 
Components of CPS 

While Greene (2010) described the two primary tenets of 
CPS as understanding lagging skills and solving problems 
collaboratively, we have identified three main components of 
the model: identifying lagging skills (i.e., skill deficits), 
identifying the triggers of problem behaviors, and 
implementing what the authors term the “plans framework” 
(see Figure 1).   

Identifying skill deficits is the first component and step 
of implementing CPS.  Skill deficits are assessed in the 
domains of executive skills, language-processing skills, 
emotion regulation skills, cognitive flexibility skills, and 
social skills.  The developers of CPS assert that this 
assessment helps caretakers understand that the child’s 
behavior is not intentional or purposeful.  Furthermore, this 
step identifies the skill deficits that need to be further 
developed in the child. After determining skill deficits, the 
second step of CPS is to identify the triggers and pathways of 
the problem behaviors.  In this way, CPS strongly focuses on 
the recognition of antecedents of behaviors and this is 
typically done using a pathway inventory (created by the 
developers of CPS) and situational analyses.  Identifying the 
pathways and triggers is a continuous and ongoing process in 
an effort to reveal the precipitating factors of current problem 
behaviors.  After the first two steps are completed, consensus 
is reached with the caretakers about the current understanding 
of the child’s skill deficits and the triggers of problem 
behaviors. 

The third step of CPS is implementing the plans 
framework.  According to the developers of CPS, adults have 
three basic, distinct options for how they choose to respond to 

problems or unmet expectations.  As described below, these 
problem solving strategies are termed Plan A, Plan B, and 
Plan C.  All three options can be effective responses 
depending on the adult’s goals and the needs and abilities of 
the child.  In understanding these options, the developers of 
CPS contend that adults can begin to categorize and 
understand their own behavior and reevaluate and prioritize 
expectations in aid of decreasing problem behaviors, 
improving interactions between the adult and child, and 
improving skill deficits.   

‘Plan A’ occurs when an adult imposes his or her will on 
a child, typified by such statements as, “Follow my directions 
or else” or “It’s my way or the highway” (Greene, 2010, p. 
43).  Greene and Ablon (2006) state that traditional parenting 
approaches usually operate from a Plan A perspective, often 
resulting in explosive behavior episodes and an escalation in 
parental intensity.  For children with ODD-type behaviors, 
this type of interaction typically leads to an episode in which 
the child can become defiant, hostile, and/or aggressive, 
potentially damaging the parent-child relationship.  It is 
important to note that Greene and Ablon (2006) support the 
use of Plan A in situations involving safety concerns.  This is 
in contrast to ‘Plan C,’ which involves the parent dropping his 
or her expectation temporarily, with the aim of decreasing the 
likelihood of explosive behavior in the moment.  Plan C is 
indicated when there is no time for confrontation or 
conversation; an additional goal of plan C is to reintroduce 
the dropped expectation at a later time.   

‘Plan B’ is the ideal problem solving strategy of CPS and 
is a proactive approach designed to assist a child in meeting 
an adult’s expectations (Greene & Ablon, 2006).  This is done 
when the child is less frustrated and ample time is available to 
figure out what got in the way of the child meeting the 
original expectation.  Plan B is divided into three steps: (1) 
empathy (plus reassurance); (2) definition of the problem; and 
(3) invitation to problem solve the issue.  The first step of 
empathy involves listening to the child’s concern, making the 
child feel understood, and acknowledging that the child has a 
legitimate concern.  This is generally done by making a 
neutral observation such as, “I noticed you didn’t do the 
dishes last night. What’s up?”  The neutral statement allows 
the child to feel less defensive and more open to a dialogue 
about why he or she was unable to meet the expectation. The 
empathy step requires the adult to listen to what the child has 
to say and show his or her understanding by repeating the 
child’s concern.  By listening and responding with empathy, 
the adult displays a willingness to understand the child’s 
perspective.  The emphasis on empathizing with the child’s 
experience is crucial and represents a shift away from 
traditional behavior modification approaches, as 
contingencies are not unilaterally employed (Greene, 2010). 

Collaborative Problem Solving also proposes that 
identified skill deficits are improved through Plan B 
conversations, which facilitate learning of cognitive skills 
through appropriate parent modeling (Green & Ablon, 2006).  



COLLABORATIVE PROBLEM SOLVING AND EMPATHY 
 

85 
 

The second step of Plan B is when the adult provides his 
or her concerns (i.e., expectations).  The problem is now 
considered defined, as both parties have presented their 
respective concerns.  The third and final step of Plan B 
consists of the adult inviting the child to collaboratively 
brainstorm solutions to the problem in a way that is possible 
and satisfactory to both people.  For example, the adult might 
ask the child, “So what is a way that you can watch your 
favorite show (child’s concern) and be able to complete your 
chores (adult’s concern)?”  A discussion then occurs until 
they reach a mutual solution that addresses both the child’s 
concern and the parent’s concern.  Although the basic tenets 

of CPS appear somewhat simple, implementing a Plan B 
conversation is complex.  The first two steps of a Plan B 
conversation focus on connecting with the child and 
understanding his or her concern.  Therefore, without the 
incorporation of empathic skills neither of these tasks could 
be successful, making the inclusion of empathy in the 
conversation seemingly essential. 

 
Empirical Support for CPS 

 
Evidence to support CPS as an effective model for working 
with aggression, explosiveness, depression, anxiety, and 

 
CPS Model 

 
Components 

 
 

Identify 
triggers to 
problem 

behaviors 

Plans 
Framework 

Identify 
lagging skills 

pathways 

 
 
 

Impose adult expectations 
("Do this or else") 

 
 

Outcomes: 
Avoid problem behavior, adult 

expectation not met 

 
 
 

Goal: 
Reduce problem behavior 

 
 
 

Drop expectations 
(For now) 

 
 
 

Goals: 
Impose adult will, child safety 

 
 

 
Outcome: 

Increase in problem behavior 

Plan A 

Executive 
skills 

deficits 

 
Problem 
behavior 

Adult 
response 

Social 
skills 

deficits 

Language 
processing 

deficitss 

Cognitive 
inflexibility 

Emotion 
regulation 

deficits 

Plan C 

Step 1. Empathy: Attempt to understand the child's concern 
by listening (e.g., “I see you just threw a chair, what's up?") 

and reflecting (e.g., "You're mad and frustrated, that sucks.") 

Step 2. Define the problem: Express adult concerns and 
restate child's concern (e.g., "Ok you're mad. My concern is 
that someone could get hurt when you throw the chair, and it 

scares me.") 

Outcomes: Decreased problem behavior,  
improved lagging skills, and met parent expectations  

(i.e., improved parent-child relationship). 

Step 3. Invitation: Invite the child to help develop solutions 
satisfactory to both parties (e.g., "So what's a way you can let 

me know you're mad and not scare me?") and choose a 
solution. 

 
Goal:  Reduce problem behaviors  

and teach skill deficits. 

Plan B 

Figure 1. CPS model components.  The three core components include identifying lagging skills pathways, identifying the triggers of 
problem behaviors, and implementing what the authors term the “plans framework” (Plans A, C, and B) 
 
 



ASHWORTH, TAPSAK, & TINSLEY LI 
 

86 
 

suicidality in children and adolescents is ample (Epstein & 
Saltzman-Benaiah, 2010; Greene et al., 2004, 2006; Martin et 
al., 2008; Stewart et al., 2009).  However, the mechanisms of 
change within it have yet to be defined (Callaghan, Follette, 
Ruckstuhl, & Linnerooth, 2008).  To our knowledge, only one 
experimental study (Greene et al., 2004) has shown CPS to be 
as effective as or more effective than Barkley’s Behavior 
Management Program (BBMP), a well-established parent-
training program (Barkley, 1997).  
 
Outpatient Studies   

Greene et al. (2004) provided support for the utility of 
CPS with an outpatient population, highlighting the model’s 
dual focus on parenting skills and cognitive deficits in 
children and comparing it to BBMP.  Outcomes were 
measured using the Parenting Stress Index (PSI; Abidin, 
1995), Parent-Child Relationship Inventory (PCRI; Gerard, 
1994), Clinical Global Impression (CGI; National Institute of 
Mental Health, 1985), and the Oppositional Defiant Disorder 
Rating Scale (ODDRS), an unpublished rating scale 
developed by Greene to measure parent-child conflict.  The 
CPS group demonstrated statistically significant improvement 
from pre-treatment to post-treatment on the PSI and PCRI.  
As the ODDRS is an unpublished rating scale, normative data 
are unavailable and therefore clinically significant change 
was used to measure outcomes.  The CPS group produced 
clinically significant change from pre-treatment to post-
treatment and at 4-month follow-up.  Additionally, scores on 
the CGI at post-treatment and at 4-month follow-up identified 
treatment group (CPS vs. BBMP) as a significant predictor, 
with the CPS group showing a significantly greater degree of 
improvement compared to the BBMP group.  

Epstein and Saltzman-Benaiah (2010) evaluated the 
feasibility and effectiveness of CPS among parents of 
children with both Tourette syndrome and ODD.  Following 
the implementation of CPS, significant changes were seen on 
the Eyberg Child Behavior Inventory (ECBI; Eyberg & 
Pincus, 1999), a parent rating scale that assesses the intensity 
and frequency of disruptive behaviors at home, indicating that 
parents reported fewer and less intense disruptive episodes, as 
well as a reduction in stress (Epstein & Saltzman-Benaiah, 
2010).  
 
Mixed Inpatient-Outpatient Study   

Stewart et al. (2009) demonstrated the effectiveness of 
CPS in reducing explosive behavior in a nine-bed residential 
treatment program.  Significant differences were seen in the 
number of “meltdowns,” as defined by scores on the Conners 
Parent Rating Scale (Conners, 1997), reported at pre- and 
post-treatment.  Furthermore, these improvements continued 
at 6-month follow-up.  Improvements in social skills were 
also seen post-treatment; however, they decreased at follow-
up, suggesting that these skills require more continuous 
reinforcement (Stewart et al., 2009).  These improvements 
mirror the philosophy of CPS, which is to improve the 
communication and relationship between parent and child.  
Stewart et al. (2009) contended that the changes observed in 

the study provide support for the effectiveness of CPS with a 
residential population.  Although significant changes were not 
found in all study domains (i.e., improved academic 
performance, enhanced community participation), those 
directly related to CPS (e.g., social skills, decreasing 
meltdowns, and parent stress) were positively impacted 
(Stewart et al., 2009).  
 
Inpatient Studies   

Greene and colleagues (2006) investigated the use of 
CPS in reducing seclusion and restraint incidents in a child 
inpatient psychiatric hospital.  The number of seclusions and 
restraints decreased significantly after its implementation.  In 
the nine months prior, the unit documented 281 episodes of 
restraints.  Following the 15-month CPS training period, the 
unit documented one incident of restraint. Because this was a 
quasi-experimental study, however, not all extraneous 
variables were controlled for.  Martin et al. (2008) attempted 
to replicate the aforementioned results by evaluating the 
effectiveness of CPS in reducing seclusion and restraint in a 
15-bed child psychiatric inpatient unit.  They collected data 
for three years prior to CPS implementation, six months 
during, and 18 months afterward.  After CPS implementation, 
the rate of restraint dropped from 263 incidents per year to 
seven incidents per year, with the mean duration of restraint 
decreasing from 41 to 18 minutes per incident.  Seclusion 
incidents decreased from 432 to 133 per year. 
 
Summary of Empirical Support for CPS 

The empirical support for CPS warrants 
acknowledgement within the field for its effectiveness in a 
wide range of treatment settings.  Within a relatively short 
time, the body of literature discussing CPS has grown and 
includes support for its use in both outpatient and inpatient 
settings.  Although initially developed to address explosive 
behavior in outpatient populations (Greene et al., 2004), it is 
becoming increasingly well known for its utility in reducing 
seclusion and restraint within inpatient populations (Greene et 
al., 2006; Martin et al., 2008), as well as an effective model 
for parenting programs (Epstein & Saltzman-Benaiah, 2010).   
 

Empathy as the Putative Mechanism of Change in CPS 
 
We believe it important, given the climate of evidenced 

based treatments, to attempt to understand the mechanisms of 
change underlying CPS in order to critically evaluate its 
effectiveness.  Empathy is clearly present in the 
implementation of CPS, both before and within a Plan B 
conversation.  Before a Plan B conversation can take place, 
the adult must examine what areas of cognitive ability are 
lagging for the child (the first component of CPS) by 
evaluating language processing, emotion regulation, cognitive 
flexibility, executive, and social skills.  With this examination 
and understanding, the adult is better able to develop empathy 
for the child and to view maladaptive behavior as the result of 
underdeveloped skills rather than malicious intent.  Inherent 
in identifying lagging skills, CPS allows adults to see 



COLLABORATIVE PROBLEM SOLVING AND EMPATHY 
 

87 
 

maladaptive behavior empathically (Greene & Ablon, 2006).  
For example, believing that a child is refusing to attend 
school due to his or her anxiety (i.e., a deficit in emotion 
regulation) is fundamentally different than assuming that he 
or she lacks motivation, is lazy, or is oppositional.  Given the 
latter assumption, the adult will probably attempt to 
‘motivate’ the oppositional child by invoking contingencies 
(i.e., “If you don’t do (X), then…”) to help precipitate the 
child’s return to school.  The former assumption requires 
adults to shift their understanding of the child, which will 
likely change how they approach the problem and includes 
the use of empathic skills (e.g., reflective listening, validation 
of child’s emotions, and perspective taking) during Plan B 
conversations. 

Although no research has been published on the 
mechanisms of change in CPS, we hypothesize that the focus 
on empathy is indeed the reason that CPS has gained both 
empirical and experiential support.  Specifically, we 
hypothesize that the creation of empathy through the 
identification of lagging skills and the explicit use of 
empathic skills by adults is responsible for improvements in 
the parent-child relationship and decreased problem 
behaviors, above and beyond the training of skill deficits and 
identifying triggers to problem behaviors.  This paper seeks to 
conceptualize the effectiveness of CPS in the context of its 
focus on empathy.  By examining the current literature on the 
construct of empathy, we believe that our conceptualization is 
plausible. 
 
Empathy in Psychotherapy 

Empathy can be defined as a shared understanding of 
thoughts and emotions between two people or groups of 
people (Pedersen, 2008).  As Carl Rogers stated, “Empathy is 
the therapist's sensitive ability and willingness to understand 
the client's thoughts, feelings, and struggles from the client's 
point of view… It is this ability to see completely through the 
client's eyes, to adopt his frame of reference” (Rogers, 1980, 
p. 85).  Empathy is essential in conveying caring and 
understanding to clients (Rogers, 1975) and has long been 
considered a necessary component for psychotherapy to be 
successful in most, if not all, therapeutic modalities 
(Anderson, Ogles, Patterson, Lambert, & Vermeersch, 2009; 
Rogers, 1975). Castonguay and Beutler (2006) echo Carl 
Rogers’ view that the fundamental tenets of empathy are 
positive regard, listening, and warmth, and see these as the 
bases of the therapeutic relationship.  The literature defining 
and exploring empathy in a therapeutic context is extensive 
(Greenberg, Watson, Elliott, & Bohart, 2001; Martin, Garske, 
& Davis, 2000; Preston & de Waal, 2002; Rameson & 
Lieberman, 2009), and therapeutic benefits are seen when 
empathic responses and empathic approaches to 
psychotherapy are utilized (Rogers, 1975).  

In a meta-analysis, Greenberg et al. (2001) found that 
empathy was the single best predictor of positive outcomes in 
therapy.  Further, they identified four factors that serve as 
mediators between empathy and positive therapeutic 
outcomes: (1) empathy as a relationship condition, in which 

feeling understood helps clients feel safe and increases client 
satisfaction; (2) empathy as a corrective emotional 
experience, in which an empathic relationship may help to 
strengthen the self; (3) empathy and cognitive-affective 
processing, in which empathy helps promote exploration and 
meaning and facilitates emotional reprocessing; and (4) 
empathy and the client as active self-healer, in which 
empathy helps engage the client and promotes active 
participation (Greenberg et al., 2001).  
 
Parental Empathy 

In addition to the general support for empathy as an 
important ingredient in psychotherapy, the presence of 
parental empathy has been implicated in positive outcomes 
for children.  Active listening and empathic responding by 
parents communicates to children a genuine valuing of and 
interest in their concerns (Kohut, 1977, 1984).  By developing 
a shared connection through empathy, it is possible that the 
child sees the adult as a collaborator in a shared valued 
outcome as opposed to a competitor for power (Pedersen, 
2008).  Trumpeter, Watson, O’Leary, and Weathington 
(2008) studied the relationship between perceived parental 
empathy and love-inconsistency, narcissism, self-esteem, and 
depression.  They found that perceived parental empathy was 
associated with healthy self-development and adaptive self-
functioning in young adults.  Schaffer, Clark, and Jeglic 
(2009) examined the relationship between empathy, 
parenting, and antisocial behavior in young adults.  Their 
results supported the conclusion that empathy was an 
important predictor of decreased antisocial behavior.   

Parental empathy has also been shown to be correlated 
with at least neutral or positive attitudes towards children 
(Moran & Diamond, 2008).  Goubert et al. (2005) defined 
two types of empathic responses in people who witness 
distress in others.  An empathic concern response is one in 
which the observer is focused on the distress of another 
person.  In contrast, an empathic distress response is one in 
which the observer is focused on his or her own experience of 
distress.  Both types of responses are associated with helping 
behavior; however, only the empathic concern response helps 
to comfort and calm the person in distress, whereas the 
empathic distress response serves to calm the observer 
(Goubert et al., 2005).  Penner et al. (2008) demonstrated the 
association between parental empathy and positive benefits 
for children undergoing oncology treatment.  They reported 
that increased parental empathic concern was associated with 
less pain and distress in children.  Utilizing empathic concern 
instead of empathic distress helped parents focus on the 
medical procedure and their child’s wellbeing rather than 
attending to potential complications and the invasiveness of 
the procedure.  In addition, the empathic concern response 
helped to ease parental anxiety and distress about the situation 
(Penner et al., 2008).  
 
Empathy and Parent-child Communication 

Parental reactions influence children’s emotional 
responses (Fabes, Leonard, Kupanoff, & Martin, 2001).  



ASHWORTH, TAPSAK, & TINSLEY LI 
 

88 
 

Additionally, disapproving parents likely teach their children 
that their feelings are wrong and invalid (Fabes et al., 2001).  
By providing empathic responses to a child’s distress, parents 
validate a child’s concerns and are better able to reduce the 
intensity of the distress experienced by the child.  In an 
attempt to understand the accuracy (or lack thereof) in 
empathic conversations between parents and adolescents, 
Sillars, Smith, and Koerner (2010) identified misattributions 
made between parents and teens when conversing.  They 
found that parents were more focused on the interaction 
process of the conversation and teens were more focused on 
the content of the discussion.  Furthermore, parents and teens 
were both unable to identify areas of similarity and difference 
with respect to positive and negative attributions toward one 
another when engaging in a heated discussion.  These 
findings provide support for the importance of finding 
common ground through empathic statements and validating 
comments.  Similarly, Sillars, Koerner, and Fitzpatrick (2005) 
reported that parents who were better able to understand their 
child’s self-concept (i.e., use empathy) were more likely to 
communicate openly and frequently with their child.  
Furthermore, high parent-child relationship satisfaction was 
associated with parental understanding of the child’s self-
concept (Sillars et al., 2005). 
 
Empathy and Mental Health Staff  

As parents are not the sole providers of care to children, 
especially in cases of significant behavior problems, it is 
worthwhile to explore the role of empathy in residential and 
psychiatric settings.  The use of empathy within these 
settings, specifically between staff members and their 
patients, is not well understood in the literature.  However, 
predictors of effective and positive psychiatric 
hospitalizations exist and follow a common theme.  Coleman, 
Paul, and Schatschneider (2007) reported that the amount of 
attention provided to patients on psychiatric units predicted 
better outcomes, such as lower chronicity of illness and 
patient effectiveness.  For the amount of attention provided to 
patients to impact outcomes, staff must be trained in “social-
learning procedures” (Coleman et al., 2007), which are likely 
to encompass skills such as effective communication and 
empathy.  The use of empathy, respect, and communication 
skills are paramount in the relationship between a psychiatric 
staff member (e.g., a social worker, nurse, or aide) and 
patient, particularly because of the power differential between 
the two parties (Holm, 2002).  One obstacle to empathy can 
be the lack of knowledge about rules for expressing feelings 
(Keefe, 1976; Strayer, 1987).  Keefe (1976) reported that one 
must permit oneself to be free from biases (i.e., stereotyping) 
that limit empathic responses, a skill that allows patients to 
elicit empathy from the psychiatric staff.  This skill is likely 
taught during academic training and may not be available to 
the untrained psychiatric staff member.  The delivery of 
empathy depends not only on the staff member’s ability to 
understand and acknowledge a patient’s feelings, but also on 
their motivation to be empathic (Holm, 2002; Suchman, 
Markakis, Beckman, & Frankel, 1997). 

Summary of Empathy 
The empirical literature on empathy is vast (Greenberg et 

al., 2001; Martin et al., 2000; Preston & de Waal, 2002; 
Rameson & Lieberman, 2009; Rogers, 1975).  It is clearly 
established that empathy is associated with positive outcomes 
in therapy (Angus & Kagan, 2007; Elliott, Bohart, Watson, & 
Greenberg, 2011).  Empathy is a necessary component of 
psychotherapy and has a greater influence on positive 
therapeutic outcomes than any other factor (Greenberg et al., 
2001).  It is often the first skill taught to new clinicians 
(Morrison, 1995), developed through training and practice, 
and is reported to be the core value to which therapists return 
when stuck or struggling with a difficult case (Holm, 2002; 
Waller, 2009).  For psychiatric staff, empathy is integral to a 
positive staff-patient relationship (Holm, 2002).  It is also 
associated with increased communication between parents 
and children (Sillars et al., 2005), healthy psychological 
development in children (Trumpeter et al., 2008), and overall 
changes in the ways in which parents interact with their 
children (Moran & Diamond, 2008; Sillars et al., 2005, 2010).  
In addition to mental health staff, parents are often involved 
in the treatment process with their children and effective 
communication between adult and child requires empathy 
through listening, respect, and understanding.  Unlike many 
traditional treatments for children, which primarily involve 
behavior modification techniques, CPS brings empathy to the 
forefront as an integral part of the intervention.  Through our 
clinical experiences, the positive impact of the creation of 
empathy and the use of empathic skills within CPS has been 
evident.  Therefore, two case vignettes are offered in the 
subsequent section.  
 
Clinical Illustrations 

Clinical practice often serves as the real-world test of the 
effectiveness of theories and interventions.  The following 
clinical examples, informed by the authors’ own experiences 
of working with the model, anecdotally illustrate the 
significance of empathic skills in the implementation of CPS.  
These two examples highlight the value of empathy within 
CPS in clinical practice. 

 
Vignette 1.  The following is a typical case of an 

adolescent on an inpatient psychiatric unit.  Prior to the 
implementation of CPS, the general staff consensus and goal 
was patient safety.  Historically, staff perceived safety as 
synonymous with control.  Therefore, when a patient was not 
following directions (such as being out of his or her room 
during “room time”), staff would subsequently demand that 
the youth comply and follow directions without protest.  On 
occasion, the redirection to return to his or her room would 
incite frustration in the youth, which would decrease the 
likelihood that he or she would comply with the request.  A 
conflict would often arise and the youth (who likely struggled 
with emotion regulation, as most patients on the unit do) 
would begin shouting, swearing, and/or crying.  In response, 
the staff would continue to direct the patient with verbal 
commands, elicit more staff, and if necessary physically 



COLLABORATIVE PROBLEM SOLVING AND EMPATHY 
 

89 
 

guide the youth back to his or her room.  Following the 
implementation of CPS through staff trainings and clinical 
supervision, however, staff began shifting their attitude about 
the meaning of safety, patient compliance, and empathy.  
Although patient safety continued to be a priority, it was no 
longer synonymous with control.  Thus, when a youth would 
exit their room during “room time,” a similar direction might 
be given, “Please stay in your room during room time.”  A 
typical response may have been, “No! Room time sucks!”  In 
accordance with the CPS model, the staff now responded 
with, “Room time sucks? How come?”  With the 
understanding that empathizing with the youth’s concern is 
paramount, in this case through reflective listening, the staff 
took time to listen to and understand the youth’s perspective.  
This approach decreased the youth’s frustration and increased 
the odds that he or she would engage in a dialogue with the 
staff member.  In the authors’ opinion, the use of empathic 
skills enabled staff to demonstrate understanding of the 
youth’s perspective regarding room time.  

 
Vignette 2.  A single mother who attended a CPS 

parenting class facilitated by one of the authors reported that 
she had struggled to find any help for her 12-year-old adopted 
son.  She described his behavior as violent and aggressive, 
explaining that she was victim to his abuse and that he had 
recently punched her in the face, resulting in a broken nose.  
The mother sat quietly through the hour and a half class 
taking notes.  At the end of the class she asked, “Do you think 
this would really work for my kid?”  The author 
recommended that she return the following week to learn 
more.  After five weeks of consistent attendance in the class, 
she reported improvement in her son’s behavior and 
specifically noted a decrease in his aggressive behavior.  Per 
her report, she had learned to set expectations while 
understanding her child’s abilities and most importantly had 
learned to inquire as to why a behavior occurred, instead of 
assuming she understood, suggesting an overall increase in 
empathy for her child.  She reported that she had learned to 
better understand her child and therefore had developed 
insight into his chronic frustration.  She reported that by 
attempting to understand his perspective she was able to 
ignore her own assumptions and connect with her son.  This 
understanding and communication style were the catalysts in 
helping her problem-solve with her child, while at the same 
time establishing a safe and consistent environment.  

In our experience, these two examples reflect common 
outcomes obtained by the implementation of CPS.  Amid 
learning the model, identifying lagging skills, and learning to 
collaboratively problem-solve, CPS fostered adults’ abilities 
to empathize with children and is arguably responsible for the 
shifts in their attitudes and behaviors.  Once parents and staff 
were able to view a child as frustrated, depressed, anxious, 
and/or confused (instead of manipulative, oppositional, 
defiant, or aggressive), they changed their interaction style, 
tone of voice, and assumptions about the child.  We believe 

that enhanced understanding and the use of these empathic 
skills are what increase an adult’s ability to effectively 
communicate and problem-solve with a child, subsequently 
promoting behavior changes in the child.  The next section 
proposes a conceptualization of empathy as a primary 
mechanism of change in CPS, as well as recommendations 
for how this assertion may be empirically tested.  
 

Proposed Mechanism of Change and Future Research 
 
As previously stated, CPS consists of three components 

(lagging skills assessment, triggers identification, and the 
plans framework; see Figure 1).  Despite empirical support on 
the utility of the model in various settings, there are currently 
no studies that have dismantled CPS, leaving the consumer 
unclear as to which components are necessary to effectively 
achieve desired outcomes (for example, a decrease in ODD-
type behaviors or an improvement in the parent-child 
relationship).  Based on our clinical experience working with 
the model in both inpatient and outpatient settings and our 
review of literature on empathy, we believe that a primary 
mechanism of change within CPS is empathy, which is 
created by having adults both understand the child’s lagging 
skills and utilize empathic skills.  

In CPS, empathy allows adults to better understand a 
child’s behavior and shift the way they think about them, 
consequently affecting how they respond to the child’s 
problem behaviors.  By identifying lagging skills in the child, 
adults are able to appreciate the skills necessary to be 
successful in life (e.g., social skills, ability to problem solve, 
frustration tolerance, etc.) and are less likely to view these 
issues as motivational in nature.  Thus, the understanding of 
lagging skills aids adults in developing empathy for children.  
With this understanding, adults are in turn more likely to 
respond to their child in empathic ways (i.e., employ 
empathic skills) by listening, reflecting back and validating 
the child’s concerns, and attempting to understand his or her 
perspective.  If this occurs, we argue that the child will feel 
understood, less defensive, and will therefore be more likely 
to follow adult directives.  Therefore, the identification of 
lagging skills (i.e., empathy through increased understanding 
of child’s lagging skills) in conjunction with adult 
implementation of empathic skills (e.g., reflective listening, 
validation of child’s emotions, and perspective taking), which 
is the first step in a Plan B conversation, accounts for the 
aforementioned desired outcomes (see Figure 2).  

In order to empirically evaluate the mechanisms of 
change in CPS, future research could dismantle CPS and 
examine isolated components.  We offer two avenues for 
doing this.  First, the following three treatment groups could 
be implemented: (1) CPS in its entirety; (2) CPS without Plan 
B’s empathy piece; and (3) CPS with only Plan B’s empathy 
piece.  Outcome measures could include frequency, intensity, 
and duration of problem behaviors, as well as ratings of 
parental stress to assess the parent-child relationship.   



ASHWORTH, TAPSAK, & TINSLEY LI 
 

90 
 

Additionally, a regression analysis could be run on the 
group implementing CPS in its entirety, examining outcome 
measures to determine to what extent various components of 
the model account for outcomes.  Isolating CPS components 
and evaluating outcome measures in this way could establish 
a clearer understanding of the role of empathy within the 
model. 

 
Limitations 

 
We have identified three important limitations to the claims 
presented in this paper.  First, our argument relies heavily on 
our clinical experiences working with the CPS model and on 
literature describing the positive impact of empathy more 
generally.  While clinical experience is important in 
furthering understanding, evaluating effectiveness, and 
inciting future research, it has the inherent limitation of lack 
of experimental control.  Consequently, our perceptions of the 
role of empathy as the change mechanism and literature 
asserting the value of empathy may have caused us to 
disregard other explanations of the positive outcomes we 
observed.  In addition, these outcomes were not validated by 
objective measures.  Despite this limitation, our clinical 
experiences raise the important question of what the role of 
empathy is in CPS.   

A second limitation is that although we argue that 
empathy is a primary mechanism of change and accounts for 
desired outcomes above and beyond the other components of 
CPS, we do not offer hypotheses as to the specific role 
empathy may play in the model (e.g., as a mediator, 
moderator, or the sole curative factor).  Expanding our 
hypothesis to account for the specific types of influence 
empathy may have would help to better direct future research.   

Finally, it is unlikely that empathy serves as a primary 
mechanism of change when the goal of CPS is to improve a 
child’s cognitive skills (Green & Ablon, 2006).  For example, 
the authors of CPS state that engaging in Plan B  
conversations improves skill deficits in the child through the 
experiences of articulating concerns, considering different 
solutions to problems, and reflecting on outcomes of solutions 
implemented (Green & Ablon, 2006).  We do not suggest that 
empathy components (such as understanding lagging skills 
and use of empathic skills) would explain improvement in 
cognitive skills and as such, our hypothesis is unlikely to 
explain this change.  However, this identifies another area of 
the CPS model that merits further investigation. 

 
Conclusion 

 
This article develops a rationale for empathy as a primary 

mechanism of change in CPS based on available literature on 
CPS and empathy in psychotherapy, as well as the authors’ 
clinical experiences.  The reviewed literature provides 
support for the promise of CPS as an effective treatment 
modality for ODD-type behaviors and aggression in a wide 
array of treatment settings.  Additionally, our clinical 
experiences have demonstrated that it can be an effective 

dyadic intervention for parent-child interactions, as well as an 
effective systemic model for creating change in residential 
and inpatient settings.  Collaborative Problem Solving 
engenders a climate of empathy by creating understanding 
within adults that lagging skills may be responsible for a 
child’s problem behaviors, and requires that adults utilize 
empathic skills to respond to a child’s behavior.  With this 
knowledge and skill set, adults can shift their expectations of 
interactions to understand what is going on for the child and 
respond in empathic ways, instead of attempting, often 
unsuccessfully, to control the child’s disruptive behaviors. 

Empathy in its own right has been shown to increase 
communication, change staff’s and parents’ interactions with 
children, and is associated with healthy psychological 
development (Moran & Diamond, 2008; Sillars et al., 2005, 
2010; Trumpeter et al., 2008).  It can change how adults 
interact with children and can increase the likelihood that 
children feel understood and supported by adults.  Given the 
overwhelming evidence of harsh parenting/discipline, low 
nurturance, and the use of punishment in the etiology of 
disruptive behavior disorders (Bailey, Hill, Oesterle, & 
Hawkins, 2009; Rothbaum & Weisz, 1994; Thompson, 
Hollis, & Richards, 2003), empathy may have a direct impact 
on improving parent-child relationships and subsequently 
increase behavioral compliance.   

 
Figure 2. Empathy (denoted by gray coloring) is represented 
within CPS through the identification of lagging skills and in the 
implementation of empathic skills. 
 

Executive 
skills  

deficits 

Identify lagging  
skills pathways

Problem 
behavior 

Adult 
response

Step 1. Empathic Skills: 
Adult attempts to understand the child's concern by listening (e.g., "I 

see you just threw a chair, what's up?") and expressing empathy 
(e.g., "You're mad and frustrated, that sucks.") 

 
Child believes adult understands them and cares. Child is more open 

to discussion. 

Social 
skills 

deficits 

Language 
processing 

deficits 

Cognitive 
inflexibility

Emotion 
regulation 

deficits 

Plan B 

Outcomes: Decreased problem behavior, met parent expectations 
(i.e., improved parent-child relationship) 

Increased adult 
understanding

Primary Mechanism of Change: 
Empathy Model 



COLLABORATIVE PROBLEM SOLVING AND EMPATHY 
 

91 
 

Collaborative Problem Solving reflects the value of 
empathy within its conceptualization of underdeveloped skills 
as the cause of problem behaviors and by having adults 
respond with empathic skills (Greene et al. 2004, 2006; 
Martin et al., 2008).  Therefore, the use of empathy arguably 
creates a fundamental shift in adults’ perceptions of children, 
leading to positive outcomes.  If the use of empathy is a 
primary mechanism of change within the model, then perhaps 
it is largely responsible for the success of CPS.  Collaborative 
Problem Solving is gaining empirical support and children, 
families, and organizations are benefitting from the 
implementation of this model.  Prudent scientific questioning 
would dictate, however, that understanding the mechanisms 
of change within the model is necessary for future replication, 
generalization, and implementation.  It is our hope that future 
research will seek to clarify the claims presented here.  

 
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