Solution-Focused Brief Practice with Long-Term Clients in Mental Health Services

"I Am More Than My Label"

Joel K. Simon, Thorana S. Nelson

• Publisher: Routledge
• Year: 2012
• eBook ISBN: 9781136863523
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Valuable patient-centered ideas for treating mental illness

Traditional forms of mental health care can often center more on simply avoiding hospitalization than on promoting wellness by focusing on a patient's personal feelings and hopes. In fact, these established methods can even have a dehumanizing and devaluing effect on a patient. Solution-Focused Brief Practice with Long-Term Clients in Mental Health Services is a practical introduction and guide that provides practitioners an alternative way of thinking about and working with individuals who have been long-term users of the mental health system. Through interviews, case studies, and actual client testimony, this valuable text demonstrates the most effective ways to establish patient-centered conversations that forge collaborative relationships, realize strengths, and use them to move toward healing.

Solution-Focused Brief Practice with Long-Term Clients in Mental Health Services is a strength-based approach that utilizes a client's personal and social resources to help them find a satisfactory solution to the sources of their need for professional help. This book offers a unique approach that can be applied to those who have been in the mental health system for many years and may remain so. Accessible and useable, this guide explores the meaning of conventional diagnosis and treatment and how both can actually reinforce the client's disability, chronicity, and sense of helplessness as a person.

Topics Solution-Focused Brief Practice with Long-Term Clients in Mental Health Services covers include:

• the tools of solution-focused brief practice
• working with borderline personality disorder
• adaptability and application to different contexts
• reading the client during discussion sessions
• emphasizing an individual's healthy parts
• the role of community support
• rethinking the medical model
• implementing solution-focused practices in agencies and hospitals
• poststructuralism, social constructionism, and language games
• and many more!

Solution-Focused Brief Practice with Long-Term Clients in Mental Health Services is extensively referenced with a detailed bibliography. It is an essential resource for psychiatrists, social workers, psychologists, family therapists, counselors, nurse practitioners, and schools of social work and family therapy training programs. Staff of inpatient psychiatric hospitals, psycho-social clubs, and community mental health clinics will also benefit from this indispensable text.

Chapter 1

Introduction

In July 1988, Joel was offered a newly created position, Intensive Case Manager (ICM), with a local agency in Orange County, New York. New York State had initiated the ICM program to reduce the total inpatient hospitalizations among those who had been designated as seriously and persistently mentally ill (SPMI) by providing trained clinicians who, in effect, acted as ombudsmen for a limited caseload of clients¹ with high inpatient psychiatric admissions.

Orange County was one of a select number of counties in New York State chosen to test the ICM program. Joel was one of the first ICMs in New York and the first in Orange County. Selecting a suitable caseload was relatively simple: obtain a computer printout of the 10 highest inpatient recidivists in the local state psychiatric hospital and work with them. These were to be Joel’s clients. He provided case management services, transportation, and direct clinical services when no other providers were involved.

Joel worked with his clients in their life spaces, often visiting them in their homes. Very often, individuals ancillary to the client also were involved with the mental health system² as caretakers. The major thrust of maintaining stability within the client’s social system mandated that Joel also include these significant others in his work with the client. Joel had free access to the state psychiatric hospital, which allowed him to continue to work with clients who were hospitalized.

During the course of Joel’s work with the clients, he came to know each one of them individually beyond their diagnoses and their roles as “mental health patients.” In addition, working within the local mental health system, he gained insights into patterns of interventions that were helpful, and many that were not. The lessons learned in this position and subsequent positions led to insights that were reinforced when Joel finally came in contact with the ideas of solution-focused brief practice (SFBP)³ in the early 1990s.

The first lesson—and probably the one that had the most impact— was that although these were clients with the highest number of annual hospitalizations, there were periods—some longer than others— when most people enjoyed relatively stable functioning. Joel quickly learned to suspend his role as expert and listen to what the clients had to say about what it was that helped them stay out of the hospital or helped them get discharged more quickly when they were hospitalized. The role of the ICM became much simpler: rather than dictate certain things as “best,” Joel would find out what clients did that helped them stay out of the hospital, encourage them in these practices, and help them do more of them. The aim of the ICM was not to “cure,” but (1) to help clients function as well as they possibly could, and (2) to minimize psychiatric hospitalizations.

Despite their long-term patient status and the expectations that accompany this status, many of the clients courageously and persistently maintained a sense that they were somehow more than their diagnoses or their patient status. One client was an inventor who had one invention highlighted in Popular Mechanics magazine. Another had been a jazz pianist who, when he had the opportunity to play, exhibited an amazing transformation from psychiatric patient to creative and competent artist. When asked, clients were able to talk about their interests, hopes, aspirations, internal and external resources, strengths, and competencies.

Dr. Gale Miller (personal communication, July 15, 1997), professor of sociology at Marquette University in Milwaukee, Wisconsin, reflected that doing SFBP requires the ability to notice the extraordinary things that individuals do in their ordinary lives. The clients that Joel worked with illustrate Miller’s observation. Throughout their difficult lives, they somehow maintained courage and strength that helped them preserve a spark of hope for a better future and a sense of possibilities.

During the course of Joel’s tenure as an ICM, he observed conversations that the clients had with mental health professionals. Contacts usually were brief and centered on whether the individual was “compliant” with the prescribed course of treatment. Clients often were admonished that they needed to take their medications and see their therapists regularly or suffer the risk of hospitalization.

Conversations with doctors focused on compliance, and physicians instructed clients that they had a disease similar to diabetes that needed to be managed. Clients who told their doctors about any future aspirations or hopes were advised that they needed to keep the amount of stress in their lives within manageable levels and therefore needed to have more realistic goals for the future. It was not surprising that for some clients, these conversations served to dampen their hopes and reinforce their beliefs of incompetence and hopelessness about themselves.

In a moving speech, Dr. Patricia Deegan (1993) reflected on her experiences as an adolescent when she was first diagnosed with major mental illness:

I was thinking about my first couple of hospitalizations when I was first diagnosed with schizophrenia, and three months later, at my second hospital admission, I was labeled with chronic schizophrenia. I was told I had a disease that was like diabetes, and if I continued to take neuroleptic medications for the rest of my life and avoided stress, that I might be able to cope. (p. 2)

She continued, talking about the effect that this conversation had on her:

And I remember that as these words were spoken to me by my psychiatrist, it felt as if my whole world began to crumble and shatter. My teenage world in which I aspired to dreams of being a valued person in valued roles—of playing lacrosse for the U.S. Women’s Team or maybe joining the Peace Corps—I felt these parts of my identity being stripped from me. I felt myself beginning to undergo that radically dehumanizing and devaluing transformation from being a person to being an illness: from being Pat Deegan to being “a schizophrenic.” (p. 2)

Other clients fought bravely against the “radically dehumanizing and devaluating transformation,” and it is not surprising that those clients who struggled to maintain some modicum of self beyond their diagnoses stopped going to the clinic and avoided the conversations. They also had been prescribed medications that often had side effects such as stiffness, restlessness, and what clients usually identified as “a drugged out feeling” that limited their abilities to work, play, and love. The professionals then gave additional labels to clients who avoided treatment: noncompliant and resistant. When they did go to see their doctors or therapists, they were warned that if they continued avoiding treatment they would once again find themselves in the state hospital, all too often a self-fulfilling prophesy.

After his time as an ICM, Joel was hired as director of a community mental health clinic licensed by the New York State Office of Mental Health. Typical of such clinics, it served a wide range of clients, especially those from a lower socioeconomic stratum. In this new setting, Joel continued working with those clients who had been long-term users of the mental health system. As he incorporated the solution-focused approach in his practice as both a supervisor and clinician, he once again became interested and curious about what individuals do on a day-to-day basis that helps them live satisfying lives.

Joel’s next experience was as a treatment coordinator for a private psychiatric hospital, which provided him additional insights into the effects of the medical model within a psychiatric system. Despite the often frustrating sense that the application of the medical model to clinical treatment is akin to fitting the proverbial square peg into a round hole, the actual day-to-day solution-focused work with clients afforded additional evidence that SFBP provides a set of tools that can be very effectively applied to working with clients within a psychiatric system. This book is about how we can better listen to clients, and in so doing, learn how to co-construct more useful conversations about clients’ goals, resources, strengths, and possibilities.

One of the most difficult tasks we faced in writing this book was how we would refer to the individuals about whom we are writing. Two major considerations needed to be made: The first is the lesson we have learned (whether as clinicians, ICMs, clinic directors, SFBP trainers, or university professors) that no matter what the label, it can serve only to limit our ability to experience another individual holisti-cally; labels are reductionistic and necessarily omit much information. Metaphorically, they are only snapshots of an individual’s behavior at a specific time in a specific place. The second consideration regards the scope of the topic. Long-term users of the mental health system do not include just those who are psychiatrically diagnosed, but those who have permanent physical challenges as well and who frequently utilize the services of mental health professionals.

Many clinicians seem to believe that SFBP is not appropriate for “real,” “hard,” or “serious” situations. They especially seem to believe that SFBP cannot be helpful for situations that include behaviors, symptoms, and diagnoses that are considered permanent or incurable. These people often are called “chronic users” of services and are unable to benefit from therapy except for “managing” their “illnesses.” We prefer to think of them as people—people who may have biological, physiological, or psychological conditions that limit their abilities to function as well as many other people, but people who most likely have more potential than most would think. We believe that SFBP is uniquely helpful to those clients who may need intermittent support for long periods or for most of their lives, and who are more than their diagnosis. Thus, we refer to these clients as long-term users of services rather than as chronically mentally ill or something else. These clients may need frequent or infrequent services, for very short or longer periods in each occurrence, and for very short or longer sessions of conversation.

Joel recalls one of his clients who, after years of therapy and several diagnoses, declared that he realized one day that he was more than his label. We thought that this was an especially good starting point for the book and, in its simplest and most elegant form, why we thought that it was time for a book about solution-focused work with long-term users of the mental health system. Our review of the applicable literature highlighted the paucity of information regarding the application of SFBP to individuals who too often become victims of a system that confers labels that serve to limit their possibilities.

This book holds in common with solution-focused literature the general principle of finding out what works and doing more of it. In this regard, it would be appropriate to conclude our introduction with an applicable quote from Dr. Deegan:

You see, I would argue that until the fundamental relationship between people who have been psychiatrically labeled and those who have not changes, until the radical power imbalance between us is at least equalized, until our relationships are marked by true mutuality, and until we recognize the common ground of our shared humanity and stop the spirit-breaking effects of dehumanization in the mental health system, then that gaping hole will continue to sink the best of our efforts. (1993, p. 2)

We write this book for those clinicians and clients who are able to see beyond psychiatric labels, beyond symptoms and limitations, and beyond the limitations of those who assign labels into futures of possibilities and hope for better lives.

The purpose of the book is to provide students and providers who may not be conversant with solution-focused ideas an opportunity to understand and explore this very different way of working with those who may be considered as suffering from severe or chronic psychological problems or mental illnesses. Readers of Chapter 2 will enjoy definitions and descriptions of the basic assumptions, concepts, and practices of the approach. Subsequent chapters will illustrate ideas for working with clients who were diagnosed with various mental illnesses and who have long histories of psychiatric treatment. Three chapters describe first the ways that SFBP is different from a medical model for understanding the problems people bring to us, views from four psychiatrists who use SFBP in their practices, and ways that solution-focused perspectives can be helpful for establishing SFB practices in agencies and hospitals. We conclude with a chapter on the philosophies that guide our thinking about SFBP.

Notes

1. We use the term client in this book to denote a professional and contractual relationship between a user of mental health services and a provider.

2. It seems contradictory to the authors to call something mental health when the system focuses on mental illness. However, for the sake of convention, we use the term mental health.

3. The original solution-focused work was centered on therapy. Today, solution-focused ideas are used in a variety of contexts, including social services, corrections, and even business. Steve de Shazer suggested the concept of solution-focused brief practice. Therefore, we use the acronym SFBP.

Chapter 2

Tools of Solution-Focused Brief Practice

The solution-focused brief practice approach is, above all, an approach, a stance, or a perspective. It is not a Theory of how people develop, how people change, or how therapy should be conducted. One could say, we suppose, that “one theory” (note the small t) is that a solution-focused approach in therapy helps clients make the changes they wish to make because they focus on what they want rather than on what they do not want. This is as far as the approach goes, in terms of theory, however. In Chapter 9, the philosophies that inform our understanding of the approach will be explained in terms of post-structuralism, social constructionism, and language games. In this chapter we describe some of the basic elements of the SFBP stance: assumptions, concepts, and practices.

Stance

During the 2002 European Brief Therapy Association conference in Cardiff, Wales, a question was asked: “When did you realize that you became solution-focused?” Joel’s response was that he had originally learned to ask questions to which he would probably know the answer. SFBP takes a very different stance: practitioners ask questions only the client can answer. Joel answered that he became solution-focused when his questions became driven by his curiosity about clients’ responses.

One of the chief elements of SFBP is a stance of curiosity. That is, the therapist does not “know” what is happening with the client or what course of action clients should take to better their circumstances. When a client says he or she is “bipolar,” or a referring person states that the client is “schizophrenic,” the SFB therapist does not pretend to know what this means in the particular situation. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994) lists criteria for various diagnoses; these criteria are not all present, however, in every case. Neither are they present all of the time or with the same severity all of the time. Also, these behaviors are not the only behaviors or characteristics of the client.

Finally, no two situations have the exact same contextual factors. No two people have the same family, friends, work or school situation, resources, or stressors. Especially, no two people experience these contextual and cultural factors, their own characteristics, their symptoms, or the interactions of people around them in the same way. Therefore, it is important for the therapist to be curious about the client’s unique situation.

Similarly, no two people or situations will require or find suitable the same solutions. What works for one person or family in one situation/context may or may not be helpful to another situation or person. Therefore, again, the SFB therapist maintains a sense of profound curiosity about what will be helpful to each unique client.

The SFB therapist does not maintain a stance of diagnosing, hypothesizing, or attempting to discover underlying causes or dysfunctions related to the symptom. This nonpathologizing aspect of the SFBP stance is very important. Using DSM criteria to diagnose and then develop treatment plans based on theoretical underlying problems and treatments is not helpful in this work. Maintaining an abiding faith in the nonpathology of all persons is very important. It is tempting ...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright
• Dedication
• About the Authors
• Contents
• Foreword
• Acknowledgments
• Chapter 1. Introduction
• Chapter 2. Tools of Solution-Focused Brief Practice
• Chapter 3. Mary “The Borderline”
• Chapter 4. “I Have More of a Sound Mind Now”
• Chapter 5. “Agoraphobia” and “Me” Are Not Synonymous
• Chapter 6. Rethinking the Medical Model
• Chapter 7. Psychiatry Should Be a Parenthesis in People’s Lives
• Chapter 8. Meta-Systemic Considerations of the Solution-Focused Brief Approach: Using the Ideas to Implement Solution-Focused Practices in Agencies and Hospitals
• Chapter 9. Philosophies that Inform Solution-Focused Brief Practice: Poststructuralism, Social Constructionism, and Language Games
• Epilogue
• References
• Index