Solution Oriented Therapy

Watch: The Miracle Question & Its Use in Anger Management – Solution-Focused Therapy with Paul Grantham (38 minutes, Closed Captioned). A brief history of the development of the Miracle Question within Brief Solution Focused Therapy and demonstration of its use with a client with anger management and domestic violence problems:

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Solution-Focused Therapy (Ch 10)

Solution-focused practice is a short-term approach to intervention in which the social worker and client attend to solutions or exceptions to problems more so than to problems themselves (Franklin, Trepper, Gingerich, & McCollum, 2012; Elliott & Metcalf, 2009; Dejong & Berg, 2008; Corcoran, 2005). Its focus is on helping clients identify and amplify their strengths and resources toward the goal of finding solutions to presenting problems. Solution-focused therapy (SFT) is one of only two intervention approaches in this book that does not represent a single theoretical perspective (the other being motivational enhancement ther- apy), but is a model of practice that draws from theories in psychology, social work, and sociology. This model is clearly oriented toward the future, more so than most of the practice theories discussed so far. From a practice perspective, this shift in emphasis from problems to solutions is more radical than it might first appear.

ORIGINS AND SOCIAL CONTEXT

The principles underlying solution-focused therapy reflect a synthesis of ideas drawn from the systems, cognitive, communication, and crisis intervention theo- ries; the principles of brief therapy; and the social theory of constructivism. We will review each of these influences except for the last one, which is de- scribed in the context of narrative theory in Chapter 12. Family systems theory, discussed in Chapters 6 and 9, has great relevance to the solution-focused approach to practice (Andreae, 1996). It assumes that human behavior is less a function of the characteristics of individuals than of patterns of behavior they learn in their families of origin. General systems theory takes an even broader view, emphasizing the reciprocal influences between peo- ple and the environmental circumstances they encounter (Von Bertalanffy, 1968). Activity in any area of a system affects all other areas. The thoughts, feel- ings, and behaviors of individuals in a given system, then, are malleable and influenced by the behavior of other elements in the system. This is, of course, consistent with social work’s person-in-environment perspective. One important implication of systems thinking is that a client’s change efforts need not be directly related to a presenting problem. Because any change will affect the entire system, new actions will influence its elements in ways that cannot be predicted.

The social worker may thus consider creative strategies for change when work- ing with a client system. SFT was largely influenced by systems thinking as developed at the Mental Research Institute (MRI) in Palo Alto, California (Weakland & Jordan, 1992). The MRI brief therapy model views emotional and behavioral problems as de- veloping because people by nature develop a limited range of response patterns in relation to their life problems, some of which do not effectively resolve them. These patterns may include underreacting, overreacting, avoiding, denying, and even taking actions that worsen the situation. In a sense, the problem becomes the sum of failed solution efforts. MRI interventions represent efforts to identify and explore a client’s problem cycles and find new ways of interrupting them. The focus of this work is on presenting problems, not underlying issues. Cognitive theory has contributed to the development of solution-focused practice principles with its accounts of how people create unique meaning in their lives. The concept of schemas, described in Chapter 7, describes how we develop habits of thinking that should ideally be flexible but can at times become rigid, preventing us from assimilating new information that might enhance our creative adaptability to life challenges.

SFT can also be seen as an extension of the problem-solving process as outlined in cognitive theory. Communications theory and the study of language was of interest to the developers of solution-focused therapy with regard to the impact of the words people use about their attitudes toward the self and the world (de Shazer, 1994). SFT proceeds from the assumption that language shapes reality, and thus it em phasizes the importance of word clarity in intervention. Solution-focused practi tioners maintain a distrust of the abstractions found in many other practice theories. Such preoccupations are considered nonsensical and, worse, unproductive toward the goals of furthering a client’s welfare. The social worker tries hard to understand the specific nature of a client’s concerns and goals, and supports client initiatives toward change that are concrete as well. Crisis theory (described more fully in Chapter 13) developed as human service professionals in many settings faced demands to provide focused, effective interventions for people in need of immediate relief. Crises may be developmen- tal (leaving home, retirement), situational (natural disasters, death of a loved one, loss of a job), or existential (meaning-of-life issues). Caplan (1990, 1989) devel- oped one widely respected model of crisis theory, defining a crisis as a disruption in a person’s physical or emotional equilibrium due to a hazardous event that poses an obstacle to the fulfillment of important needs or life goals.

Crises are characterized by a person’s need to resolve problems while feeling overwhelmed. Crisis intervention must be short term because, with its associated debilitating physical effects, a crisis can persist for only four to eight weeks. All interventions are time-limited, have a here-and-now focus, rely on tasks to facilitate change, and feature a high level of practitioner activity (Gilliland & James, 2005). Like systems theory, crisis theory recognizes that the environmental context influences the severity of distress, as well as the availability of resources to meet its demands. A final, more general influence on the development of solution-focused practice was the proliferation of brief therapy models that emerged within the human service professions in the 1980s (Corwin, 2002). Some of these ap- proaches did not result from an evolution of ideas about appropriate practice but were a reaction to external pressures, including the need to manage long waiting lists in agencies and reduced insurance coverage for clinical services. Still, it was discovered that these methods are effective, sometimes more so than longer-term interventions. Brief treatment models have emerged within most practice theoretical frameworks and tend to share the following elements: A narrow focus on the client’s most pressing concerns A belief that not all of a client’s presenting concerns need to be addressed A focus on change, not a “cure” An assumption that the origins of a client’s problems need not be understood in order to help the client Clients should lead the process of problem formulation, goal setting, and intervention Intervention should have a strengths orientation Solution-focused therapy is distinct from some brief therapies in its strategies for assessment, goal setting, and intervention, as we will see.

MAJOR CONCEPTS

Despite its roots in other theories, solution-focused therapy has become recognized as a unique approach in direct practice. Its major principles are described below. “Grand theories” of human development—those that emphasize similarity across populations and cultures—are no longer relevant to the world of social work practice. For example, not all children and adolescents progress through the same stages of cognitive, moral, and social development. This principle is shared with most other practice approaches that have emerged in the past several decades.

Language is powerful in shaping one’s sense of reality. The words we use to define ourselves and our situations influence the conclusions that we draw about those situations. A drug abuser who “buys into” the language of addiction may define himself as “diseased,” and thus less functional by nature than many other people. Social workers need to be attuned to how clients use language to define their challenges and their functioning. Is their language constructive or destruc tive? Interestingly, social workers may be tied to a professional language that stigmatizes clients. If I use the language of the Diagnostic and Statistical Manual of Mental Disorders (DSM; “major depression”), for example, I may conclude that my client has a limited capacity to alleviate her depression without medications.

Social workers must de-emphasize problem talk in an effort to shift the intervention focus away from a search for the causes of a client’s difficulties. An emphasis on solution talk represents a means of helping clients focus on solutions to problems and to act or think differently than they normally do. This includes the social worker’s cultivating an atmosphere in which strengths and resources are highlighted. It is important to emphasize again that solutions do not need to be directly related to a client’s presenting problem; a client’s decisions to act differently in the future may emerge independently of any problem talk. This idea is consistent with the systems perspective that any change reverberates through a system, affecting every other element. The social worker thus does not need to feel con- strained by “linear” thinking about problems and solutions. This non-linear perspective is quite different from that espoused in many other practice theories and models, where it is assumed that there is a logical, systematic relationship between problems and solutions, and that a solution should be directly related to the nature of a problem. For example, a cognitive practitioner might conclude that a client’s ongoing depression is a consequence of negative self-talk, and that the solution to this problem should include changes in specific types of self-talk. A solution- focused practitioner would be more open to a range of client-generated solutions.

Problems are real, but often not so ubiquitous in the lives of clients as they may assume. It is through habits of selective attention that clients become preoccu-pied with the negative aspects of their lives. An adolescent girl who feels hopeless about her ongoing social rejection at school may benefit from recognizing more clearly when this problem is not happening in her life—for example, when she is participating in youth groups at church. The social worker’s role in a client’s goal achievement is made more constructive with an exploration of problem excep- tions (times when it is not happening).

THE NATURE OF PROBLEMS AND CHANGE

As we have seen, the solution-focused perspective includes few assumptions about human nature. This supports its focus on the future and its de-emphasis of lengthy assessment protocols. The perspective does assume, however, that people want to change, are suggestible, and have the capability to develop new and existing resources to solve their problems. The nature of problems in SFT can be summarized through several principles (O’Connell, 2005). Many problems result from patterns of behavior that have been reinforced. Our rigid beliefs, assumptions, and attitudes prevent us from noticing new information in the environment that can provide solutions to our problems. That is, we are often constrained from change by our habitual, narrow views of situations. There is in fact no “correct” way to view any problem or solution. Significant change can be achieved for most problems that clients present to social workers in a relatively brief period of time (Elliott & Metcalf, 2009). This is largely because change is constant in our lives—it is always happening, whether we recognize it or not. There is no difference in SFT between symptomatic and underlying change—all change is equally significant. Small changes are important because they set ongoing change processes in motion in any system. The process of change is facilitated in our favor by our learning to reinterpret existing challenging situations and acquire new ideas and information about them. The goals of intervention in solution-focused therapy are for clients to focus on concrete solutions to their problems or challenges, discover exceptions to their problems (times when they are not happening), become more aware of their strengths and resources, and learn to act and think differently.

ASSESSMENT AND INTERVENTION

The Social Worker/Client Relationship During the engagement stage, the social worker attempts to build an alliance by accepting, without interpreting or reformulating, the client’s perspective on the presenting problem in the client’s own language. The worker promotes a collaborative relationship by communicating that he or she does not possess “special” knowledge about problem solving, but is eager to work with the client on de- sired solutions. The practitioner builds positive feelings and hope within the client with future-oriented questions, such as “What will be different for you when our time here has been successful?” With its emphasis on short-term intervention and a rapid focus on client goals, solution-focused therapy is sometimes criticized for not adequately attending to the development of a positive worker/client relationship (Coyne, 1994). That is, the rapid application of techniques may prohibit the development of a sound working relationship, which in turn might decrease the effectiveness of the intervention. In response to this concern, one study compared client perceptions of the “working alliance” at a university counseling center when receiving either solution-focused or brief interpersonal therapy (Wettersten, Lichtenberg, & Mallinckrodt, 2005). The working alliance was assessed after each session with respect to the client’s sense of bonding, shared tasks, and shared goals.

With approximately 30 clients in each treatment group, it was found that SFT practitioners indeed develop a working alliance with their clients, although it is not perceived as such by clients early in treatment. Assessment and Intervention Strategies

Before beginning the discussion of the particulars of solution-focused thereapy, we will outline the process as follows:

Problem articulation, including the client’s beliefs about the source of the problem, how it affects the client, how the client has coped so far, and what solutions the client has tried already

Developing goals within the client’s frame of reference

Then, during each session, the social worker:

Explores for exceptions

Participates in task development (jointly designed by the social worker)

Provides end-of-session feedback Evaluates client progress

One of the unique characteristics of solution-focused therapy is the lack of a major distinction between the assessment and intervention stages. Although a cli- ent’s presenting issue does need to be investigated, many of the social worker’s questions and comments made during that stage are intended to initiate change processes. The reader should keep in mind, then, that distinctions between “stages” of therapy are somewhat artificial. All of the techniques presented below are drawn from Elliott and Metcalf (2009), DeJong and Berg (2008), Quick (2008), Corcoran (2005), and de Shazer (1994, 1985).

The assessment stage is intended to gather information directly related to the client’s presenting problem. The social worker also evaluates the client’s level of motivation by discussing the value of resolving the problem. This can be done informally with a scaling exercise, whereby the social worker asks the client to rate his or her willingness to invest effort into problem resolution on a l-to-10 scale. If the client’s motivation is low, the social worker raises the dilemma with the client about how the problem situation can improve in that context. Of course, there are several ways to formulate or partialize any problem, and the client may be motivated to address some aspects more than others.

Parents of an acting-out adolescent, for example, may be more highly motivated to change his school behavior than his related playground behavior. Through refraining comments and actions, the social worker gives the client credit for the positive aspects of his or her behavior relative to the presenting problem. This strategy also introduces clients to new ways of looking at some aspect of themselves or the problem. For example, a client who feels so stressed about a family issue that he is unable to sleep or work can be credited with car ing so much that he is willing to sacrifice his own well-being. The social worker might also suggest that the client is working too hard on the problem, and might consider sharing responsibility for problem resolution with other family members.

The social worker’s goal is not to be deceptive, but to help the client feel less overwhelmed and more capable of managing the issue. The practitioner must be careful not to falsify the client’s reality through the use of exaggerated compliments and reframes. Rather, he or she identifies genuine qualities of which the client may be unaware but can realistically bring to bear on the problem situation. The social worker asks strengths-reinforcing coping questions during the initial session, such as “How have you been able to manage the problem thus far?” or “What have you done recently that has been helpful?” Another pre-session change question asks the client, “Has anything changed about the problem between the time you made this appointment and now?” Questions designed for clients who seem to be stuck in a pessimistic stance might be formulated as: “It sounds like the problem is serious. Why is it not worse? What are you (or your family) doing to keep things from getting worse?” If appropriate, the social worker asks questions about the desired behavior of other persons in the client’s life who are connected to the problem, such as: “What will your son be doing when you are no longer concerned about his behavior on the weekends?” If the client is reluctant to participate in the assessment, the social worker asks questions that serve to promote collaboration, such as: “Whose idea was it that you come here? What do they need to see to know that you don’t have to come anymore? How can we work together to bring this about? Can you describe yourself from the perspective of the person who referred you here?” The social worker thus attempts to engage the client by join- ing with him or her against the external coercive source.

During exploration the practitioner externalizes the client’s problem, making it something apart from, rather than within, the person. This gives the client a reduced sense of pathology, and a greater sense of control. For example, with depression, the practitioner focuses on aspects of the environment that create or sustain the client’s negative feelings.

In situations where the client must cope with a physical illness or disability, the worker focuses on aspects of the environment that inhibit his or her ability to cope. The social worker often personifies the problem (“How closely does depression follow you around? Does depression stay with you all day long? Does it ever leave you alone?”), is reinforcing the idea that it is an entity separate from the essence of the person. The practitioner then explores exceptions to the client’s presenting problems. This is in keeping with the assumption in solution-focused practice that problems are not so ubiquitous as clients tend to assume. These questions initiate the intervention stage as they bring ideas for solutions to the client’s attention. The questions help clients identify their strengths, and the practitioner will often prescribe that the client do more of what he or she does during these “exception” periods. Exploring for recent exceptions is recommended, as these will be more salient to the client’s sense of competence.

The following types of questions seek exceptions: “What was different in the past when the problem wasn’t a problem?” “Are there times when you have been able to stand up to, or not be dominated by, the problem? How did you make that happen? What were you thinking? When did it happen? Where did it happen? Who was there? How did they have a part in creating that? What did you think and feel as a result of doing that?”

“What are you doing when the symptom isn’t happening?”

“What do you want to continue to happen?”

The client is encouraged to define his or her goals, and from that starting point, the practitioner collaborates with the client to achieve them. The social worker may present alternative perspectives regarding goals that are intended to free the client from habitual patterns of thinking and consider new ideas. For example, if a client wishes to “feel less depressed” or “experience more happy moods,” the social worker might clarify that the client “wants to spend more time with his interests” (if these have been identified as strengths) or “join the civic association” (if that has been articulated as a possibility). All goals must be articulated in ways that are concrete so that the client and practitioner will know when they have been met. It is important for the social worker to partialize goals, or break them down into discrete units that can be actively and specifically addressed. For each identified goal the client is asked to scale its importance with regard to his or her well-being in general and relative to the other goals.

If the client has difficulty specifying the problem or any exceptions, intervention tasks may be developed following responses to the miracle question (Dejong & Berg, 2008). The client is asked to imagine that, during the night while asleep, the presenting problem went away, but he or she did not know that it had. What, then, would the client notice as he or she got up and went through the next day that would provide evidence of problem resolution? The social worker helps the client report specific observations of what would be different, not settling for such global comments as “I would be happy” or “My wife would love me again.” The client might reply that his wife greeted him warmly, and that he got through breakfast without an argument with his spouse and child.

It is important to emphasize here that at no time does the social worker suggest specific tasks for the client to enact between sessions. The client always has the responsibility for doing so. The social worker helps the client formulate task ideas and alternatives, and supports certain tasks as appropriate, but it is always left to the client to choose a task. This is an empowering process for the client and is a core principle of the model.

The client’s answers to the “miracle question” (if utilized) provide indicators of change that can be incorporated into tasks intended to bring about those indicators in real life. These tasks can relate to the client’s personal functioning, interactions with others, or interactions with resource systems.

They are based on existing strengths, or new strengths and resources that the client can develop. Often, the client is encouraged to do more of what he or she was doing when the problem was not happening. In every task assignment, the social worker predicts potential failures and setbacks because these are always possible, are a part of life in the best of circumstances, and should not be taken as indications of total client failure. All task interventions are intended to encourage the client to think and behave differently with regard to the presenting problem than has been typical in the past.

Clients may still rely on their existing resources to a large degree, but they will use them in new ways. It may seem paradoxical to note that in many cases, the social worker encourages easier alternatives to prior attempts at problem resolution. This is not to minimize the seriousness of the problems people face, but to emphasize that people commonly react to failed problem resolution ideas by applying the same (failed) ideas more intensively. For exam- ple, a couple who argues each evening at home may decide, with the social worker’s support, to take a walk through the neighborhood after supper, with no expectation that they address their family concerns. Their rationale may be that spending quiet time alone doing something new will reconnect them in an important way. Before ending this review of intervention strategies, two other techniques need to be highlighted.

First, the formula first-session task is an assignment given to the client at the end of the initial visit. The social worker states: “Between now and the next time we meet, I’d like you to observe things happening in your life that you would like to see continue, and then tell me about them.” This is an invitation to clients to act in a forward-looking manner, and the task may also influence the client’s thinking about exceptions.

Second, the surprise task is an assignment (not necessarily limited to the intial session) whereby a client is asked to do something before the next session that will “surprise” another person connected with the problem (spouse, friend, child, other relative, employer, teacher, etc.) in a positive way. The social worker leaves the nature of the sur- prise up to the client. The rationale behind this technique is that whatever the client does will “shake up” the client system from its routine, and perhaps initiate new, more positive behavior patterns within the system. Each session includes a segment in which the practitioner and client review therapy developments and task outcomes.