Solution Focused Therapy

Many are stubborn in the pursuit of the path they have chosen, few in the pursuit of the goal - Nietzche

Solution Focused Therapy (SFT) is sometimes linked to general Brief Therapy, Problem-Focused Therapy, and Possibility Therapy…. All share some common points of focus:

• Traditional therapy goes wrong by focusing on the cause of problems, the details of how they play out, the ways these events deviate from "normal" or the way couples are "supposed" to work, and having couples passively accept the expert therapists' explanations of "what is wrong" with them. Doing this gets clients stuck in a passive and helpless role, locked into a problem narrative they rehearse over and over again
• A better approach moves client focus off of what's wrong and onto what's right, stresses the resources and skills clients have, and helps them take the role of expert (which they hold anyway) and take responsibility from there for setting their own goals and reaching them. It's not about what's missing and causes woe, but what's present and can lead to happiness
• Solution building is the goal, and as you change the language that shapes how you think about the problem, you change the language that shapes how you think about the solution
• There is no theory behind this, and you need not fully understand the problem to fix it. The solution may not even look like it will fit or resolve the problem, and that's fine - a small enough change will nudge the system in a different direction and that may be all that's needed
• Therapists maintain a future focus, with language like "when this is fixed…" "notice when this problem doesn't happen this week…" "write down what your partner does to fix the problem this week…"
• Rather than summing up what the therapist thinks the clients is saying, the therapist asks questions to focus and direct the client's thinking and view

Basic Theory

de Shazer and Insoo Kim Berg developed this approach based on Milton Erickson and MRI models, and by watching what seemed to happen to families and couples right before they reported having had some break-through moment. This is key, as many studies of what works in therapy have been based on therapists views. When studies are done comparing therapist and client views of what happened in session and what was helpful… well, they disagree.

Metcalfe and Thomas (1994) did a study asking some SFT therapists and patients the same questions. Here's what they found:

What's the role of the therapist?
Therapists Say Consultant Ask scaling questions Paraphrase Look for strengths and resources Listen, give ideas	Clients Say Mediator Friend Sounding board Made suggestions Savior
Why did you seek therapy?
Therapists Say There was a divorce, multiple relationships, a death, mother worried about how the death impacted the son Depressive symptoms, panic disorder, marital discord She said both children were hyperactive, boyfriend, anger problems	Clients Say It was emergency treatment for me when I brought my son in, I was concerned about his out of control behavior Panic, family stressors, my son's problems A lot of negative people in our relationships, anger and temper problems
Why did you end therapy?
Therapists Say I suggested they take a break over summer since it was a school issue, she agreed, she called later about another issue that was not therapy related We agreed she had made significant progress. I asked if she wanted to end, she agreed They decided they didn't need to come back, they thought they could do it on their own Things were a 9 for her and an 8.5 for him. They felt things were resolved	Clients Say It was the therapist's decision… I was torn… I wanted my son to have someone to talk to… I still have difficulties with him He said if I passed my driver's license I wouldn't need to come back… I was elated but also felt he pushed me out of the nest We had limited visits, he said the problem was not severe, we didn't come to the last session and he didn't call us I had to stop because I changed jobs and the insurance dropped
What helped the most?
Therapists Say I validated mother's feelings… helped her figure out her goals… empowered her I found strengths and resources I gave her credit for all the changes I looked for differences that made a difference I asked them to notice what was right, what should continue, scaling questions	Clients Say The team told us positive things, reminded us of things we had forgotten about ourselves She mixed things up and asked "Why?" and helped us be less "perfect," told us about herself Dumping it out in the open helped, the therapist's self-disclosure… she asked what's better, focused on what I did right She pointed out things in a different way She helped us see we got along better than we thought, gave us a neutral place to come

So, sometimes SFT and client's agree, sometimes not, but as to what worked… they agreed fairly well there.

Whereas MRI focuses on what you are doing wrong (more of the same) and how to change that, SFT focuses on exceptions to the problem, thinking that a change in behavior will naturally develop then. It's sort of insight-oriented, but not in traditional ways, since it is future focused, and doesn't get too deep into one member's "pathology," but rather focuses on what the system can do to adapt to it, and let's the couple decide if that "pathology" is a problem or not…

Sessions last about an hour, include a short break, and are loosely scheduled, meaning couples may have 1 or more sessions, with the average being 3-4 sessions. What you do depends on the couple members' status when they come in. The theory itself has been applied to variety of settings, from therapy with individual experts, to school prevention programs with parent-school-teen teams as the experts, to substance abuse treatment with abusers and sponsors. It's been used with psychiatric populations (Bozeman, 1999), couples (Lambert, 1998, and Zimmerman et al, 1997), elderly (Dahl, 2001), youth offenders (Seagram, 1997), school-aged children (Corcoran, 2000), and children with LD (Franklin et al, 2001), all with success.

Research has been generally supportive in the 30 or so studies done on SFT. Effectiveness rates range from 65% (MacDonald, 1994, and Lee, 1997) to 82% (Beyebach, 2000) improvement in treatment groups with short follow-ups. Recidivism in a prison population dropped 23% in one study (Lindfross, 1997), and youth studies show the same for re-arrest and run-aways. Some medium effect sizes have been found, and one or two have been above 1.00. However, most studies haven't reported effect sizes at all, and many suffer from significant design flaws such as

• failure to collect pre-test scores
• treatment and control therapists who knew the purpose of the study and their groups
• poorly defined treatment models (textbook SFT or "real world" SFT)
• failure to randomly assign or match subjects
• over-reliance on self-report methods for gauging positive outcomes
• no comparison group of other treatment types

Further, there have been no dismantling studies, or studies on therapist variables or client variables to maximize effectiveness. A few studies (Littrell et al, 1995, and Sundman, 1997) showed no difference between SFT and control groups, but most show some benefit from SFT.

Couple Member Status

Couples who seek SFT are classified as one of three types:

• Visitor - "I don't need any help since I'm not the problem." Confronting them on their lack of responsibility is easy, but not very helpful. They need compliments for coming in and to get them to come back and be more active
• Complainant - "We need help and are suffering but, someone else is responsible for fixing it." They need compliments to come back, and homework to focus their attention on things they control that impact the other's behavior, especially before "good" interactions
• Customer - "We need help. We are both part of the problem, and we are both here to fix it but don't know what to do." Compliment them for coming, then give homework to shift their attention away from problems and on to exceptions and strengths

Steps in Therapy

Pre-Session

• Skeleton Key Question - "Between now and when we meet, I would like you to pick one thing in your relationship you definitely want to keep happening"
• Some clients report that this actually helped them the most, and therapy built on this exercise. I know… It sounds a bit like Oprah's Gratitude Journals, but there's some research to support it

Session

Sessions have key stages the therapist follows:

Stage 1 - Socializing and Joining

• I think this borrows from Minuchin a lot, as joining is becoming a part of the system for a short time, learning their language, and accommodating the therapist's views to the client world
• The point is to create an environment where you can host a productive conversation. Question the couple - "What brings you here today?" "How can I be helpful to you?" "What have you noticed since you made the call to come in?" "What needs to happen today so that when you leave you'll think 'This was a good session!'"?
• If they've been in couples therapy before, ask things like - "What did the last therapist miss that I should know about?" "What are the mistakes the last therapist made?" "On the way in, what were you most worried I would do? What would 'screw things up worse'?" "Where would the perfect therapist start with a couple like you two? What would they do?"

Stage 2 - Describing the Problem

• Miracle Question
  • Suppose one night, while you are asleep, a miracle happened and fixed this problem. Only you are asleep, so you don't know it happened. What would be different? How would you know a miracle happened?
  • You can get very concrete here, with what they would notice first, and then what would happen, and then what would happen, and then… You can ask, "If I videotaped you after the miracle, and showed the tape to people who knew you, what would they immediately notice was different from usual? What would they notice next?" Flesh out their answer with details… Create a "good story" which is inspiring to the listener and teller. The key with this question, and others, is not to "find out the truth" (which you are really going to help them create later on), but rather to refocus their attention on the elements they need to construct a new and positive story of how their life is going
  • Another point for success is that questions are designed to help them get to a new spot, not for you to dig for something (affairs, drinking, parenting problems…) You really do want to avoid the "Why?" and "If…?" questions, which typically provoke blaming and problem discussion, and focus on questions like "How…?" and "When…?" that elicit future, solution focus.
  • Change what you talk about by shifting from what's missing to what's present, so
    • "Tyrone is worthless with the checkbook" becomes "Tyrone has to double-check the checkbook"
    • "Sue can't control her temper" becomes "Sue is looking for ways to express anger productively"
    • "Eddie withdraws during fights and drives Jeannie crazy" becomes "Eddie becomes introspective during heated conversations, and Jeannie would like to respond to him supportively more often"
  • Therapists report the Miracle Question helps them the most (Skidmore, 1993) in refocusing from traditional ways of thinking to the SFT way
  • Sometimes clients answer with, "I don't know." There's a couple of ways to respond - "How would your life be better if you did know?" Or with five seconds of silence, as if you see the "I don't know" as filler. Or "It's a hard question, and I wouldn't think you would immediately know the answer, but think about it for a moment." "Take a guess; I won't hold you to it." Or "What would your best friend say if they were here?"
  • Exception, and Agency and Coping Questions
    • This is the point where the therapist refocuses the couple's attention off of the problem story to the details
    • "When was the last time this was not a problem?" or "Tell me about a time when you avoided this?" (not "Was there a time when…?" or "Has there ever been a time when…?") followed up with questions like "What was that like?", "Wow! How did you do that?", and "What were you doing differently?"
    • "How have you kept this from getting to be a bigger problem?" followed up with "Good idea, but I'm curious how you knew that would help?" and "How did you decide to do that?" "What did you notice about the times when this problem could have developed, but didn't?" (not "Are there any times when this problem …?")
    • "What have you noticed is better when this problem doesn't develop?" followed by "What needs to occur first before that can happen again?" and "What would your partner say you could do to encourage them more along these lines?"
  • Scaling
    • Scaling allows clients to take a stand on where they are about things, and communicate possibly negative things in a positive method. It can be a way you shift them from problem-talking to solution-talking. Ask clients to rate on a scale of 1 to 10 with 1 being horrible and 10 being perfect. Ask how committed/motivated they are to fixing this problem, how confident/hopeful they are that this problem can be fixed, and how much progress they have made.
    • You then ask clients what will move them one or two points at most, and get more concrete from there. You can compare them, with focus on one being more hopeful/motivated, rather than one being less so.
  • When progress is not shifting from its original position, this is often a sign of resistance, which is a client message that what you are doing is not working for them, not that the couple is a "problem" couple or is engaging in self-defeating behavior. You can deal with resistance by asking things like:
    • "What should we be working on that we aren't?" "What do we need to be working on for you to feel the situation will improve?" "It seems like we might be on the wrong track. How do we get back on the right track?"
    • Clients report this helps them the most (de Shazer, 1991).

  Stage 3 - Goaling

  • Keep treatment goals small, concrete, and objective if possible. "What specifically would show you progress on this goal?" "How will you know if things are better?"
  • Use solution building vocabulary
    • respect, nurture, honor, appreciate…..
    • empower, facilitate, collaborate, expand….
    • forward, create, possibility, grow
  • Make sure they involve what the individual will do, not just what the other person is expected to do. "What would progress look like to you? To your partner? To your friends/kids/extended family?" "Once you partner has made some changes, what will they notice that's different about you to let them know they are on-track?" "How will your partner know things are better? What should s/he be looking for?"
  • Word them with the client's goals and language, making them salient to the clients, and if there are competing goals, you can still work on both or ask for them to find somewhere they both agree on to start with, or if one goal can be worked on first and then you'll come back to the other one. Focus not on eliminating or ending something, but on instituting or beginning something new.
  • Future Oriented Questions
    • These questions focus on the future explicitly and stir a little observing ego. "What does this say about you as a couple?" "How will doing this make you happier?" "What will be better for you after this progress becomes common for you?"
    • "What do you see down the road for yourselves after this is resolved?" "How will you let your partner know you see things getting better and are happier?" "How will your partner let you they see things getting better and they are happier?" "How does your partner know you love them?"

  Stage 4 - Break

  • This allows time for the therapist to consult with the team or supervisor. Send clients out (5 minutes) to reflect on the session, what's been helpful, or what's been missed

  Stage 5 - Ending

  • This is the time the therapist offers feedback on their view of the couple, and a suggestion for an experiment or homework. Three sayings guide this:
    • if it ain't broke, don't fix it
    • if you know it works, do it again
    • if it doesn't work, do something different

  There is usually one suggestion given at the end of the first session, called the Formula First Session Task. de Shazer reports that up to 90% of clients report things are better at their second session. Gottman might offer that this is a short-lived improvement, and many clients experience such improvement simply by coming to therapy, voicing their problems, and having someone normalize them… but these improvements do not last. However, SFT therapists would offer that such early gains are not obtained through SFT, and do not last because they are "less of the same" instead of "more of something different." The refocusing of the couple is a significant intervention, not a short-term pause in their complaining.

  Ending session feedback looks a lot like reframing, and can be conceptualized as having 5 parts (Campbell et al, 1999):

  • Normalizing - this normalizes the couples' experience to help them see themselves as not "crazy"
    • "First of all, it makes sense for you to be feeling the way you've been feeling. You've been through a lot, including….. No wonder you've been stressed and depressed…"
  • Restructuring - this reconceptualizes a problem as a short-term issue, like "we're stuck" becomes a "transitional life experience," "a decisional crossroad," or an effort to "find balance in your lives"
    • "You said you've been arguing about whether or not the two of you can support one of you going back to school. That makes sense, since changing careers is such a big decision, one that alters your future income, work schedule, and retirement plans… this is a big decision point in your lives."
  • Affirmation - reinforcement for drawing on strengths
    • "We're/I'm most impressed by the fact that…"
    • This is a good time to be checking on their comments and body language to make sure they agree with your reframe before moving to the bridging statement
  • Bridging - this connects the conceptualization you've offered to the homework or experiment you are about to suggest
    • "You are basically a xxxx person, and we like xxxx people, and we want to find a way to use the xxxxiness in a way that will be helpful"
    • "You are a couple who divide up everything, a couple that is very good at splitting up difficult or unpleasant tasks into smaller portions. You make sure each has a share that they are not only willing to do, but also are likely have some skill to do well."
  • Homework - Homework or experiments are suggestions for them to try, not assignments they are commanded to do. They should be suggestions that flow from where they are to where they want to be.
    • for visitors , make sure they are very very simple and very very likely to succeed, like
      • "Notice when you are thinking you could make a change in things…" "Notice when you're partner is a little nicer than they have been and what went better for you as a result…" "I think I understand things better now, and I agree that this is complicated. So, I'm hoping you will come back next week so we can take a more focused look at how to fix this."
    • for complainants , offer ways to discover strengths, like
      • "This week pay attention to all the times you could have argued, but were able not to, and write down one thing about each time that helped you not argue." "When this could have happened but didn't, watch for things you think your partner did that were especially helpful." "When you find yourself in this spot again, do something different. Anything different could work. What are some things you can come up with now that might be different?"
      • "Pay attention this week to the signs that tell you that this problem can be solved." "Pick a day and, without telling your partner, act 'as if' the miracle happened. Do exactly what you would do if everything was going wonderfully."
    • for customers , offer ways to find their own strengths and monitor their own progress, like, "Pay attention to the things that help you keep on track, head off problems productively, and feel like progress is being made." "Since you can't decide which approach to take to this problem, and I don't know which one will work the best either, we should do an experiment. Each day flip a quarter, heads it's Solution A, tails it's Solution B, and just for that day, try the Solution picked and put in your absolute best effort. Take notes about how well it worked, paying attention to what went especially well, and then bring your notes in next time and we'll figure out which Solution works best."
  • Use a "So the next step/task/objective/goal is for…" (rather than a "So the problem/mistake/conflict/weakness is…") statement that fits their goals, followed by how hopeful you are that they can do that. For hesitant clients, suggest they do it for a week and then you can review it to see if they like the progress they are making, or if they have a better idea that this might help them generate… it's not a permanent solution, but rather something different to try…
  • One way to think about a good homework assignment is that it should address change at four levels
    • behavioral - what will you do?
    • cognitive - how do you have choice? how are you not a victim to this problem?
    • experiential - how will it look, feel, and be different when you know you are doing it?
    • systemic - how can this be used in resolving other problems?
    You might do the first three a lot, cycling back and forth between them. As for compliments, make them personal, but don't overdo it and start gushing with praise. The couple will tune you out.

  You can borrow from other schools of therapy -

  • Cognitive - role plays to practice re-focused attention, skills building around communication (specific complaints, action statements, smaller goals…), schema exploration (to find the meaning of some behavior for a client), daily logs documenting what went right, or predicting whether tomorrow will be a good or bad day, and then reviewing that prediction
  • Bowenian - solution focused genograms - what did you learn from family, what strengths are passed down, keep it calm to avoid a conflict-focus in the session
  • Rogerian - empathy and reflection, genuineness, humor and kindness
  • Gottman - NSO and PSO conceptualizations, Fondness and Admiration, Rituals of Connection, Dreams within Conflict
  • Strategic - prescribe continuing the problem and doing things differently, go slow prescriptions, "as if" days

  Return Sessions

  These are marked by EARS - elicit exceptions, amplify the details, reinforce what worked, and start again in a new line of inquiry
  • Sometimes the therapist will share stories, sometimes self-disclosing ones, that are designed to highlight the couple needs and efforts
  • At some point the therapist has to ask, "What would need to happen so you did not need to come back anymore?" or "How will you know when you are ready to 'go it on your own' without coming to therapy?"

  Does this really work?

  If this bothers you a bit because it seems to ignore negative emotions… you are not alone. Miller et al (2000) respond to this criticism and explain their view of emotions in SFT. They quote Harre (1986): "There has been a tendency among philosophers and psychologists to abstract an entity--call it 'anger', 'love', 'grief', 'anxiety'--and to try to study it. But there are angry people, upsetting scenes, sentimental episodes, grieving families and funerals, anxious parents pacing at midnight, and so on. There is a concrete world of contexts and activities. We reify and abstract from that concreteness at our peril."

  They basically argue language is a game that allows us, through words, silences, gestures… to "create" and communicate about second order constructs (the label "sadness" or "happiness") which represent first order constructs or the actual internal emotions we feel. However, signs we interpret as indications of these second order constructs (e.g., tears indicating "sadness") can indicate other emotions or mixes of emotions (e.g., sadness, or anger and anxiety at the same time). So… when we say "I yell because I'm angry" is it true that yelling results from anger? Does anger lead to other responses? Does yelling result from other emotions? In other words, does language reflect "objective truth" or first order constructs that these second order constructs supposedly represent? Or does language reflect something that is "true enough for our purposes"?

  This is like Rational Emotive Therapy (RET) in a way. When a client says, "I couldn't survive that!" we say, "Couldn't you? It might be hard, or stressful, and challenging, but would it really kill you?" If we changed the way we spoke, could we change the "true enough" reality? In SFT, we aren't aiming to remove the underlying experience, just find a solution to the problems that sometimes do (and sometimes don't) result. Emotions are the engine, cognitions the steering wheel, and language paves a new road. By offering different ways to talk about experiences and problems, we are trying to offer couples an alternative set of beliefs about themselves. These might offer other options for to how to feel, react, and cope that they may not have been able to realize using the "true enough" reality as their starting point.

  One difference between SFT and Possibility Therapy (as proposed by O'Hanlon) is that Possibility Therapy combines a Rogerian approach to dealing with emotions with the SFT approach. The idea is that sometimes people need to have their problems spoken, the emotional pressure behind their misery voiced and validated, before they can move on to dealing with it. However, another response to critics of SFT is that follow-up studies with clients of SFT indicate the clients felt understood and validated… so SFT therapists might be doing some humanistic type stuff, just not articulating it as important or recognizing it as a key element of change.

  Resources

  • Campbell, J., Elder, J., Gallagher, D. Simon, J., & Taylor, A (1999). Crafting the 'tap on the shoulder': A compliment template for solution focused therapy. American Journal of Family Therapy, 27(1), 35 - 47.
  • Gingerich, W. J. & Eisengart, S, (2000). Solution-Focused Brief Therapy: A Review of the Outcome Research. Family Process, 39(4), 477-498.
  • Hoyt, M. F. Solution-focused couple therapy. In Alan S. Gurman and Neil S. Jacobson (eds), Clinical Handbook of Couple Therapy (3rd Edition) 2002. New York: Guildford Press.
  • Lethem, J (2002). Brief Solution Focused Therapy. Child and Adolescent Mental Health, 7(4), 189-192.
  • Metcalf, L., & Thomas, F. (1994). Client and therapist perceptions of solution focused brief therapy: A qualitative analysis. Journal of Family Psychotherapy, 5(4),49–66.
  • Miller, G. & Shazer, S. (2000). Emotions in Solution-Focused Therapy: A Re-examination. Family Process, 39(1), 5-23.
  • Zimmerman, T. S., Prest, L. A., & Wetzel, B. E. (1997). Solution-focused Couples Therapy Groups: An Empirical Study. Journal of Family Therapy, 19(2), 125-144.