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Sunday, April 14, 2013

Theories of Change: Solution-Focused Brief Therapy


The solution-focused approach lends itself toward rapid change of individual issues. Individual issues are isolated and the focus is placed on making a solution to the problem happen. Solution-focused brief treatment aims to motivate and empower clients who require intervention in a specific area. The approach implies that change can occur quicklly, often in less than 10 sessions. Traditional therapeutic activities such as processing feelings and extensively mapping out a client's developmental history are not used. The focus is on "the here and the now." Solution-focused brief therapy has many components, and there is not a solid consensus regarding which components are necessary and which are not. Thus, all research on is considered preliminary because of the large amout of variation among agencies using the approach.

This common assumption in solution-focused brief therapy is that clients have the capacity to change their situation, and have untapped resources which will allow them to solve their problems. The main job of the professional is to assist client in removing self-defeating thoughts, beliefs, and behaviors, then help clients brainstorm new or modified ways of getting their needs met. The client and social worker collaborate to identify possible solutions and prioritize them. The client is generally not given the opportunity to envision a world in which the problem cannot be solved, or that it will be solved in the future. Thus, an underlying ideology of the approach is that change can happen quickly (Hepworth et al, 2006).

An early form of solution-focused brief therapy in a mental health clinic was described by Weakland, Fisch, Watzlawick & Bodin (1974). Treatment goals were identified by the clients in the beginning sessions, and therapy focused primarily on how the client could work to solve their problems. Problems were viewed in the specific contexts in which they developed, to keep clients thinking concretely. Considerable focus was placed on the client's individual characteristics and self-described motivators.

The clinicians served a mixed group of clients, from families with adolescents to severely mentally ill individuals, for an average of 7 sessions, and a maximum of 10 sessions. Success was measure by whether the client met their treatment goal or goals. The clinic experienced a success rate in 40% of clients, and a significant improvement in 32% of clients over the course of the study.

Most researchers consider the beginning of the solution-focused approach to be in the work of clinicians at Brief Family Therapy Center in Milwaukee, Wisconsin. This approach was reported to have originated in the 1980s. The view of the clinicians there was that clients already had sufficient knowledge to solve their problems, and the clinician's role was to help clients in accessing that knowledge. Over time, solution-focused approaches have come to accept that while clients may have some of the needed information to find solutions to their problems, and most of the resources to solve them, the clinician still has a role of educIssues exist with studies of solution-focused brief therapy, due to the fact that a truly standardized approach is has not been established. Necessary parts of a solution-focused approach for one agency may be unnecessary for another agency, and visa-versa. All of the studies reviewed in this article called for an integration of the various solution-focused approaches, so that true efficacy can be established.ating the client, in appropriate situations (Iveson, 2002).

Another primary belief in the beginning of the solution-focused approach was that the psychological origins of problems need not be fully investigated in order for psychological problems to be solved (Kim, 2008). This belief has changed over the years, as many solution-focused clinicians now use psychodynamic or family systems approaches in conjunction with solution-focused methods (Iveson, 2002). Hepworth et al (2006) describes how a 1996 study by McQuaid found that using psychodynamic and cognitive behavioral approaches to identify a client's problem history, then using solution focused work to move forward, was successful in changing clients' emotional states.

Overall, research is unclear as to whether using solution-focused methods in conjunction with more traditional ones actually lends itself to significantly better outcomes (Roberts, 2005). In a meta-analysis of 15 solution-focused brief therapy outcome studies, researches found that the tendency was for solution-focused approaches to work significantly better than no treatment or standard institutional services. The research was inconclusive as to how solution-focused brief therapy would compare to other psychotherapeutic approaches because other therapies were not controlled for or used in any of the studies (Gingerich & Eisengart, 2000).

Another meta-analysis examined 22 studies on the effectiveness of solution-focused brief therapy (Kim, 2008). The meta-analysis revealed that solution-focused brief therapy did well at addressing depression, anxiety, self-concept, and self-esteem issues, but was less effective with hyperactivity, conduct disorders, aggression, family, and relationship problems. The approach was significantly effective with these all of these areas, but much less with the areas noted. Researchers noted that some of the differences may have been attributable to the fact that half of the studies used in the meta-analysis were unpublished dissertations, and that considerable differences in the components of solution-focused approaches were present across agencies.

Issues exist with studies of solution-focused brief therapy, due to the fact that a truly standardized approach is has not been established. Necessary parts of a solution-focused approach for one agency may be unnecessary for another agency, and visa-versa. All of the studies reviewed in this article called for an integration of the various solution-focused approaches, so that true efficacy can be established (Gingerich & Eisengart, 2000).

The belief that change can happen soon, despite the past, is common in solution-focused treatment. This belief often empowers clients because conventional wisdom says that change happens slowly. Some researchers and clinicians argue that it is the belief that change takes time that causes change to take time (Hepworth, 2006).

Coinciding with this belief of rapid change is the inherent method of focusing on the solution. It is not a problem-focused approach. Work with clients may begin by identifying problems and prioritizing them. However the focus of language and interactions are the client's strengths and how strengths can be used decrease undesired symptoms and behaviors. Problems are only used briefly as a stepping stone to looking at the solution. A solid body of research shows that the shift of focusing on the problem to looking at the solution is more effective for positive client outcomes, and helps increase motivation. Solution focused work removes the enmeshment with problems (Hepworth, 2006).

Inherent in this approach is the assumption that language influences and is a factor in the creation of a person's reality. Language is thought of as an extension of cognition. Cognition in turn drives language and behavior. This is a possible explanation for how using solution-focused language can help change behavior.

Critics argue that solution-focused therapies aren't cognizant enough of diversity. At the same time, the approach has been used in many diverse settings with good results. It is likely if the clinician is aware of diversity issues and keeps the focus on the things that are within clients' power to change, the approach can still work (Hepworth, 2006). A clinician who is not attuned to diversity will have difficulty using any theoretical approach, however, so it may not be fair to criticize solution-focused brief therapy on these grounds (Roberts, 2005).

Another part of the approach that most agencies employ is the engagement of the client in the treatment planning process. Clients are not simply assessed and given a treatment plan by the clinician; clients identify their own goals and tasks, and for the most part the treatment team simply supports the clients meeting those goals. When working with involuntary clients, the clinician may need to redirect the client from blaming to a solution focus, but inevitably the client will have goals that involve being free of some of the problems which prompted treatment.
questions:

Hepworth (2006) identifies four types of questions which guide solution-focused work: scaling, coping, expectations, and miracle questions. Scaling questions are involve rating something using a scale, for example, "On a scale of 1 to 10, how likely is X scenario?" These types of questions are helpful to the ongoing assessment and treatment planning process. They help to evaluate progress. Also these questions can be used to identify how ready the client is to move to a lower level of care, or terminate treatment.

Coping questions seek out the ways in which clients have already coped with similar situations in the past. For example, a treatment provider might ask, “What did you used to do when this happened?” or, “What would somebody else do in this situation?” The focus is placed on the client's strengths and the things that are within the client's power to change.

Exception questions move the focus from the problem to the solution. These questions are helpful for externalizing the problem, so that the problem is not seen as part of the client, but as part of the world or the situation. The aim of an exception question is to remove self-defeating thoughts and language. Clients may be asked to remember a time when the problem did not exist.

Miracle questions call on the client's creativity in envisioning that the problem has been removed quickly. Examples are, "If you had your choice, how would your life look right now?" or, “What would things be like if you woke up this morning and the thing were are here to discuss was no longer an issue?” Considerable guidance by the therapist may be needed to redirect the client from self-defeating thoughts, or feeling stuck because the world without the problem is far off. The goal of asking a miracle question is to help the client formulate a picture of what things would look like if the problem were solved. The client then may feel more motivated to work because their perspective has been lifted from the gloominess of the present situation to a more enlightened outlook.

Tasks play an important role in solution-focused work. Tasks are individual actions to be taken on part of the client which help to accomplish the client's goals (Hepworth, 2006). Task identification is a process which can be employed to help clients plan out the required tasks to accomplish their treatment goals, or make their miracle world a reality (Roberts, 2005). Engaging in this process helps clients to see that their goals are within reach, and takes away some of the apprehension that may be present because the road to the goal has been illuminated.

Finally, practicality is an underlying theme of solution-focused brief therapy. Hepworth (2006) notes that though there are exceptions, solution-focused brief therapy continues to gain support as an empirically-backed approach. Areas where success with the approach has been most evident are in family therapy, in schools, and with involuntary clients. A study at a brief family therapy clinic found that about two-thirds of families achieved their treatment goals in 5.5 sessions when working with a therapist using a solution-focused approach (Lee, 1997). Involuntary clients are proposed to do well in solution-focused therapy because it heavily supports the client's perspective, encourages positive interactions between clients and social workers, and because emphasis on the solution instead of the problem is empowering (Hepworth, 2006).

My field placement is at Turning Point's Crisis Residential Program (CRP). The clientele at the CRP are primarily homeless or very low socio-economic status. They have recently experienced a mental health emergency and are still in crisis. To facilitate a smooth and successful transition back into the community, as well as keep overall medical spending lower, the clients are referred to the CRP. Our main focus is to put out the fires, so to speak, in clients' lives that are keeping them in crisis and directly impacting their ability to function. If there are specific obstacles that are unresolved and keeping clients from being relatively self-sufficient, we empower clients to resolve those things as well. In many cases there is childhood trauma or deep-seeded psychological unrest that would require longterm therapy and cognitive restructuring to resolve. However our focus is specifically on getting clients to a level of functioning that is acceptable to them, and link them to appropriate mental health services to address non-immediate issues.

Taking a solution-focused approach with the CRP's clients is probably the best suited approach to accomplish the program's treatment mandate. Treatment is brief, at an average of 9 to 14 days, and at the longest 30 days. Treatment is specific to those things which impede the individual's ability to function and stay out of crisis. Since solution-focused treatment aims to empower clients and engage them in being the driving force behind their wellness, this approach is a perfect fit for the agency. Clients are asked to brainstorm with their primary service coordinator about which aspects of their life have led them to crisis and to identify solutions to each detrimental factor. The job of the treatment team at the CRP is to give each client just enough in order to accomplish their goals, leaving as mucTaking a solution-focused approach with the CRP's clients is probably the best suited approach to accomplish the program's treatment mandate. Treatment is brief, at an average of 9 to 14 days, and at the longest 30 days. Treatment is specific to those things which impede the individual's ability to function and stay out of crisis. Since solution-focused treatment aims to empower clients and engage them in being the driving force behind their wellness, it is a perfect fit. Clients are asked to brainstorm with their primary service coordinator about which aspects of their life have led them to crisis and to identify solutions to each detrimental factor. The job of the treatment team at the CRP is to give each client just enough in order to accomplish their goals, leaving as much as possible up to the client to carry out. Heavy emphasis is placed on on the solution and the strengths of each client, and how their individual strengths can be used to solve the pressing problems. This matches the solution-focused approach outlined previously in the present article.h as possible up to the client to carry out. Heavy emphasis is placed on on the solution and the strengths of each client, and how their individual strengths can be used to solve the pressing problems. This matches the solution-focused approach outlined previously in the present article.

Additional aspects of the solution-focused approach that are present at the CRP are the use of scaling and miracle questions. Miracle questions, or asking clients to imagine that the presenting problems have been removed, are asked during the intake and biopsychosocial assessment phase of treatment. Scaling questions are employed at the beginning of each of the three daily group counseling sessions, where clients are asked to rate how they are feeling on a scale of 1 to 10. Client strengths are acknowledged often, and are required to be reported in each progress note written about the client. This incorporation of strengths into progress notes helps ensure that the assigned service coordinator is actively staying aware of and focusing on a client's strengths.

Any longer term theories than solution-focused brief therapy would not be appropriate as primary treatment approaches in the CRP, for a few reasons. First of all, clients simply do not have enough time to go through longterm therapy, as the program cannot last for more than 30 days. Secondly, nearly all of the clients were able to function in the community without addressing these issues. They may have experienced deficits and setbacks due to their deeper unresolved issues, and may have been at a lower level of functioning that they were capable of being at, but nonetheless were able to function out of crisis. If a client is not is crisis, they are not an appropriate fit for the CRP. Finally, the staff of the program is not equipped to handle intense psychotherapy and other extensive services to resolve the issues. Licensed clinicians are in management positions, and rarely interact with clients. The only doctorate level clinician is the staff psychiatrist who is availabe three days per week for about 3 hours per day. Clients tend to meet with the psychiatrist about two times during their stay, and at most can meet three times per week. To employ the advanced level of clinicians needed to perform the needed treatment, the program would need to be fundamentally restructured, and in doing so, the operating cost for the program would likely be, at minimum, twice as high.

Shorter term theories may superficially appear to meet clients' needs, but with the amount of problems these clients have, shorter term approaches would result in a quick return to treatment. In fact, the Crisis Residential Program and others like it were started because short-term crisis intervention and task-oriented treatments were putting bandages on the problems and not providing enough of a solution for clients to stay out of treatment. The majority of the referrals are from county emergency mental health treatment, and are clients who are not in emergency but are still in crisis upon discharge. They will likely not be successful because multiple interacting factors are impeding their functioning. At the CRP, clients are supported in finding adequate solutions to their problems, so that they can function and not need a return to more treatment. The solutions that clients are encouraged to find enable them to maintain functioning, in theory, for the remainder of their lives. In practice, some clients do return to inpatient treatment, but the goal is always to enable clients to utilize only outpatient services.

I was privileged to be able to see a client successfully transition from a crisis state to fully functioning in the community. Assigned as his primary service coordinator, I was supported by the rest of the CRP treatment team in using solution-focused techniques to help this man meet his needs. Early in treatment, particularly during the assessment and treatment planning phase, he was experiencing a high level of cognitive distortions and depressive symptoms, exacerbated by hallucinations of his deceased mother belittling him. He reported feeling hopeless because he was homeless, had a broken arm, and was experiencing many suicidal thoughts.

To combat his symptoms, we employed a solution-focused approach. We supported him putting together a treatment plan which included advocating for his needs to the psychiatrist, finding permanent housing, arranging an outpatient mental health link, obtaining financial and medical behefits, and negotiating troublesome relationships. When the client was experiencing symptoms, his strengths were emphasized and the focused was placed on the things that were within his power to change. This approach was very helpful in removing the depressive symptoms. After about 12 days, he reported that his depression and suicidal thoughts were manageable. Hallucinations were still occurring, but he reported feeling more empowered, because of the environment, to engage in activities that took the focus away from the hallucinations. Medication was likely helpful in mangaging the hallucinations as well.

When the client graduated from the program, all of his needs had been successfully arranged. Additionally, the client recognized that he would benefit from attendance at 12 step meetings and regular contacts with a church. He was supported by the treatment team in obtaining transportation to these places after he was discharge. Many small tasks were completed while in treatment to meet his goals. These tasks were identified in a collaborative process between the treatment team and client, and completed alone by the client whenever possible.

Solution-focused brief therapy is a process that lends itself to rapid, specific change using positive client-centered interactions between with treatment providers. While research on the efficacy is to be considered preliminary, it appears that the approach is more effective than no treatment and works adequately when combined with other approaches, such as psychodynamic theory. I have experienced success with clients using solution-focused treatment, and will continue to use it in the future, when appropriate.




References

Gingerich, W. J., & Eisengart, S. (2000). Solution-focused brief therapy: a review of the               outcome research. Family Process, 39(4), 477-498.
Hepworth, D. H., Rooney, R. H., Rooney, G. D., Gottfried, K. S., & Larsen, J. (2006). Direct               social work practice: Theory and skills (8th ed.). Belmont, CA: Brooks/Cole, Cengage               Learning.
Iveson, C. (2002). Solution-focused brief therapy. Advances in Psychiatric Treatment, 8, 149-157.
Kim, J. S. (2008). Examining the effectiveness of solution-focused brief therapy: a meta-              analysis. Research on Social Work Practice, 18(2), 107-116.
Lee, M. Y. (2007). A study of solution-focused brief family therapy: outcomes and issues. The American Journal of Family Therapy, 25(1), 3-17.
Roberts, A. A. (Ed.). (2005). Crisis intervention handbook assessment, treatment, and research (3rd ed.). Oxford: Oxford UP.
Weakland, J. H., Fisch, R., Watzlawick, P., & Bodin, A. M. (1974). Brief therapy: focused               problem resolution. Family Process, 13(2), 141-168.

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