The Next Generation of Solution Focused Practice

Stretching the World for New Opportunities and Progress

Mark McKergow

• Publisher: Routledge
• Year: 2021
• eBook ISBN:
  9781000376753
• Subtopic: Cognitive Psychology & Cognition

The Next Generation of Solution Focused Practice shows how practitioners help create change by 'stretching the world' of their clients.

The book brings new ideas from enactive cognition which show how skilled attention on the client and their words is important both practically and conceptually. It provides both a summary of the development of Solution Focused Brief Therapy (SFBT) over time and how the latest developments form a newly coherent form of practice based on developing descriptions. The author has structured the book using simple and easy to understand metaphors to paint a rich, creative, and visual picture of therapy for the reader, which makes it an accessible read.

This book will be of interest to a wide range of SF practitioners internationally, as well as to those involved in coaching, counselling, family therapy, education, social work, healthcare and organisational change.

Chapter 1
Introduction

Change is happening all the time … the simple way to change is to notice useful change and amplify it.

American futurist Buckminster Fuller wrote: ‘You never change things by fighting the existing reality. To change something, build a new model that makes the existing model obsolete’ (Sieden, 2011, p. 358). This book sets out to show how, in the world of mental illness and personal change, there is already such a new model. It doesn’t rely on diagnosis. It doesn’t rely on a conventional therapeutic alliance between practitioner and client. It appears to be effective across cultures, class and social hierarchies. It has been extensively researched, though sometimes not in ways which satisfy the old model. And, in the latest evolutions, it complements a new picture of mental wellbeing based on the integrative paradigm of enactive cognition. It is the next generation of Solution Focused Brief Therapy (SFBT) and, more broadly, Solution Focused (SF) practice.

SFBT has had an interesting and distinctive evolution. Arriving as a distinct form of practice in the late 1980s, it has in many ways seen a meteoric rise. From roots in the interactional brief and family therapy tradition, the approach has found enthusiastic adoption in myriad fields including social work, education, coaching, organisational development and public service. It is in use around the world, with more and more national associations appearing every year. The results and research are very positive – successful outcomes for most clients are built consistently and rapidly, with long-term sustainability and customer satisfaction. This huge international impact from tiny beginnings in a maverick therapy project in Milwaukee, Wisconsin is in many ways a runaway success.

And yet … SFBT has operated, and continues to operate, largely outside the mainstream of mental health work. Other practices such as Cognitive Behavioural Therapy (CBT) are often presented as a default choice by providers, while older traditions rooted in the work of Sigmund Freud and Carl Gustav Jung still hold considerable sway in some circles. In some ways this is not surprising – new ideas have always had to struggle against the forces of conservatism to gain a foothold. There are few sightings of SFBT in academic settings (with a few honourable and growing exceptions), perhaps because it has been practitioner-led and empirically developed.

It seems to me that the lack of headway for SFBT in the ‘establishment’ (as opposed to with individual practitioners) is more fundamental than this. Bluntly, SFBT challenges some fundamental assumptions in the field of mental health. To take it seriously would be to undermine many decades of established wisdom. SFBT practitioners have been eloquent in showing what we do, but less convincing in being able to talk about what we do (as opposed to how we do it) to other professionals, academics and service commissioners.

The purpose of this book is therefore threefold:

• To bring together developments in the field of SFBT and of SF practice more generally over the past three decades into a coherent starting point for the next generation of practitioners and researchers
• To connect this emerging practice with the emerging theory of enactive cognition, a field rich in possibilities which resonates well with theoretical positions taken by SFBT co-founder Steve de Shazer and others, and
• To combine these two positions to show how SFBT, particularly in the latest developments, ‘stretches the world’ of the client – giving a theory of change, a look at why SFBT might be effective, and ultimately a new view on how we look at mental illness which is applicable across the board – providing a potential new agenda for practitioners and researchers alike.

We will look at established practices in new ways, gain novel understandings of how they work, how they contribute to effectiveness and how they might be further developed in future.

A bold ambition

This is, I admit, a bold ambition. It is no less bold than the ambition of Steve de Shazer, Insoo Kim Berg and others when set up their Brief Family Therapy Centre (BFTC) in Milwaukee, Wisconsin in 1978. Not long before her death, Insoo told me (and the audience at the SOLWorld 2006 conference in Vienna, Austria) that their original impetus had been to further develop Brief Therapy methods, as a response to the long-term therapy methods which still held sway at that time.

Now, in the 21st century, that struggle against long-term therapy (at least in its 20-years-on-the-couch form) seems to be largely won. People are more interested in efficiency, resources are limited, there is increased awareness of the need for informed choice and involvement for patients and clients rather than simply handing all power to the all-knowing professional. However, some of the assumptions of long-term therapy still hold considerable sway. Longer treatments must be ‘better’. Rapid progress is to be distrusted as a ‘flight to health’. Expectations of progress are ‘putting pressure on the client’, and so on.

In this book I will be presenting a view of how we as humans operate which shows how such assumptions are misguided. We are now in a position to reshape not just practice but the very paradigm of what it means to live well. The practice can be subtle, and there will be some fine distinctions to be made. They will make better sense, however, in this framework of ‘stretching the world’.

A tradition of outsider perspectives

de Shazer and Berg were both ‘outsiders’ in their chosen field. de Shazer was a professional saxophonist with a fine arts degree and a master’s in social work before he found his place as a therapist. Berg trained in pharmacy studies in South Korea before getting bachelor and master’s degrees in science in the USA. They chose to work with colleagues from a variety of fields – ‘philosophers, educators, sociologists, physicians, linguists, even engineers, along with usual mental health professionals’ as Insoo recalled (Berg, 2007).

I too am an outsider in the world of brief therapy, albeit one with a longstanding interest. My original doctorate was in nuclear physics, and my first job was at a nuclear power plant. (I now say, half-jokingly, that I am a ‘recovering physicist’ – an allusion to the famous Alcoholics Anonymous phrase. It is only half a joke though – I am still a committed scientist too.) By strange coincidence, I too played the saxophone at professional level for a while. Working with people as a management consultant, trainer, coach and facilitator, I have spent the best part of three decades working with SF therapists and practitioners learning, writing, teaching, developing, experimenting and arguing about it. Perhaps it is easier for an outsider to see what’s happening, and what else might happen.

Why is SFBT so interesting?

Why have I, this recovering-physicist management consultant outsider, spent so much time learning, using and sharing SFBT-related methods? What makes this field so worthy of interest and exploration? I like to sum it up in five headings:

• Effective
• Efficient
• Ethical and respectful
• Energising
• Elegant

Effective

The first question is, naturally, ‘does it work?’. The answer is a resounding yes, with the caveat that in the field of therapy and human relations nothing seems to ‘work’ all the time. Readers will no doubt be aware of the common factors research from Bruce Wampold and others (for example, Wampold & Imel, 2015) which suggests that the specific techniques and models used by the practitioner only have a small effect on overall outcomes; more important are factors common to effective therapy including alliance, empathy, expectations and cultural adaptation (all of which appear strongly in SF practice). From this perspective, most therapies are effective in the range of 60–70% of cases.

In recent years there has been a shift towards looking at the effectiveness of individual practitioners rather than models. Scott Miller has long been an advocate of this approach (see Miller, Hubble & Chow, 2020), making use of brief client questionnaires, focused reflections and assessments to help practitioners keep track of their own results. This is laudable, a welcome progression from traditional views like the model being more important than the client, and ‘the longer the treatment the better’.

SFBT, as part of the brief therapy tradition, has always been interested in outcomes. Steve de Shazer and Insoo Kim Berg kept records from the start, and also carried out follow-ups on clients. Over the past 30 years a large evidence base has grown, catalogued for much of that time by psychiatrist Dr Alasdair Macdonald (Macdonald, 2011, 2017). By 2017 the list had grown to include ten meta-analyses; seven systematic reviews; 325 relevant outcome studies, including 143 randomised controlled trials showing benefit from solution-focused approaches, with 92 showing benefit over existing treatments. Of 100 comparison studies found, 71 favoured SFBT. Effectiveness data was also available from over 9000 cases with a success rate exceeding 60%; requiring an average of 3–6.5 sessions of therapy time.

This looks to me like an impressive track record. It is deemed somewhat less impressive by some in the academic world (and indeed in the medical field) who point to the lack of psychiatric diagnoses in most of this work. As SFBT is not a diagnostic approach, this ‘lack’ is in fact a boon. It’s like early research on air travel being discounted because the number and size of the horses used was not recorded (the horses being historically normal to transport, but irrelevant). Some of this research comes from areas such as nursing and occupational therapy, which have historically been regarded as ‘lower class’ by doctors and scientists. For whatever reason, these results have not led to breakthrough interest in SFBT by the academic world. I hope to offer new routes to mutual interest and co-operation.

Efficient

Efficiency is surely the great ignored parameter in therapy studies. Decades of intensive work has gone into attempting to measure the effectiveness both of talking therapies in general and of specific modes of such practice. By contrast hardly any effort has been given to how quickly these methods work. This may be because of a clash of priorities; half a century ago it might be a badge of honour for both practitioner and client that the issues being dealt with were so complex that years of treatment were necessary. There is an important difference, of course, between such lengthy treatment being really necessary (needed, with no alternative) and being applied anyway in a kind of mutually agreed complicity by people who are both very comfortable to carry on, with at least one of them earning good money to do so. I will return to the ethics of such situations in the next section.

SFBT, by contrast, has always been part of a wider brief therapy tradition. This is so little known to the public that I am sometimes understood to be talking about ‘grief therapy’ at first hearing. As we will see in the next chapters, it links back to the Brief Therapy project at the Mental Research Institute, Palo Alto, started in the 1960s (see Weakland, Fisch, Watzlawick & Bodin, 1974). This kind of work has always held efficiency as a hallmark – it’s not satisfactory that clients simply get better, they should preferably get better quickly. This meant, broadly, single figures of sessions. This is not to be confused with a ‘brief’ psychodynamic therapy tradition, which works in terms of some 50 sessions. (SFBT, like other interactional brief therapies, is not time limited – the expectation of progress within a few sessions is a norm, not a rule.)

In a world where most therapies are viewed as being effective, it is puzzling why relative efficiencies are not of wider interest. There are strong ethical, practical and societal reasons for preferring treatments to be brief. We do not have the right to waste our clients’ time. We certainly do not have the right to waste our clients’ time while charging them money for the privilege. As long as they are effective, shorter treatments are preferable to clients (who can get back on with their lives), their families (who don’t have to worry as much or for as long), their workplaces (who get back to having productive staff) and those who have to pay (be that the clients themselves, insurance companies, national schemes or whatever).

Ethical and respectful

Of course, practitioners of all talking therapies would say that their work is ethical and respectful – even those tiny minority of practices which deliberately set out to discomfort the client (for example Farrelly & Brandsma, 1989) would say they are doing it in the client’s long-term interest.

Many of these practices, however, revolve around practitioners forming a view of what their clients need to do, and then having them do it. Moreover, the practitioners will have their own special language about their clients’ disorders and problems, which they will use to interpret the client’s situation. In some cases they may even insist that the client learns to speak in their way, so as to show they, the client, have really ‘understood’ what’s going on.

With SFBT the ethical stance is more straightforward. We work with clients towards their own best hopes, goals and desired outcomes as described by them, and we do it using their own language as the starting point. There is no need for elaborate interpretations of dreams, revelations of unconscious thoughts, establishment of root causes, working through of negative emotions – all of these from an SFBT perspective are the practitioner privileging their own understanding over the client’s understanding of themselves.

We seek instead to privilege the client’s experience of their own lives, their networks of support and most of all their language. The words chosen by the client matter, and we will seek to use them as starting points rather than substituting our own (perhaps more technical and professionally impressive) language. As we will see as this book unfolds, the practitioner’s role is not one of clever interpretation, it is more like a physiotherapist exercising muscles which were always there but have been neglected for a while.

In practice this means listening very hard to the client and the words they are using, and the cultivation of a slightly detached position where we are interested in the client’s progress but do not feel primarily responsible for it. The client will succeed through their own efforts – and while we are there to help, our work is in supporting the client, not doing the work for them. This looks somewhat like a ‘coaching’ role, and the success of SF in the coaching field is surely not coincidental.

The client sets the agenda, taking account of their own contexts and lives (including the legitimate interests of others). Their words lead the process. As practitioners we will be very interested in what they are hoping for from their lives, what’s working for them and how they are making progress already in what may be very difficult and challenging situations. This is usually experienced as a respectful relationship – partly because of the cent...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Contents
• Acknowledgements
• 1 Introduction
• SECTION A Development of Solution Focused Brief Therapy
• SECTION B Building descriptions, stretching worlds
• SECTION C Next generation Solution Focused practice
• SECTION D A Solution Focused aesthetic
• Index