Solution-Focused Therapy

SAGE Publications Ltd, Bill O′Connell

• Publisher: SAGE Publications Ltd
• Year: 2012
• Print ISBN: 9780857024152, 9780857024145
• eBook ISBN: 9781446290934
• Edition: 3
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Struggling with the intricacies of Solution-Focused theory, skills or practice? Wanting to learn more about providing brief, practically-based solution-focused interventions across many therapeutic settings? As part of the popular Brief Therapies Series, this long awaited third edition will tell you all you need to know about Solution-Focused Therapy (SFT) and more!

This popular introduction takes you step-by-step through the counselling process, providing insight into how to structure and manage your therapeutic work in ways that are grounded in Solution-Focused principles.

This book includes:

- a detailed introduction to the theory and practice of ?brief? therapy

- a discussion of the foundations of SFT

- exercises to use with clients and/or trainees

- brand new case examples relating theory directly to practice

- an insightful reflection on the journey of the practitioner

From leading Solution-Focused expert Bill O?Connell, this book will not only provide practical guidelines and theoretical background for the beginner but support and inspiration for the more experienced.

Bill O?Connell is Director of Training for Focus on Solutions Limited in Birmingham. He was previously Head of the Counselling Department at Westhill College of Higher Education, Birmingham, and is co-editor of Handbook of Solution-Focused Therapy (SAGE, 2003).

1

Brief Therapy

 

The unique feature of Brief Solution-Focused Therapy (BSFT) is that it focuses on solutions, not problems. It aims to help clients achieve their preferred outcomes by evoking and co-constructing solutions to their problems (O’Connell, 2001). It emerged in the 1980s as a form of brief therapy, with its origins in the work of Steve de Shazer, Kim Insoo Berg and their team at the Brief Family Therapy Center in Milwaukee, USA. To understand its context, it is helpful to be aware of the brief therapy tradition.

The fact that many brief therapy models come from within the main schools of therapy (psychodynamic and cognitive behaviour in particular) may give the impression that this kind of therapy is derived from long-term therapy (Feltham, 1997). However, this is not the case. Bloom (1992) lists a large number of case studies over the past eighty years in which patients report significant changes in their lives as a result of brief therapy. As far back as 1925, eminent therapists, such as Ferenczi and Rank, argued against the assumption that analysis had to be lengthy. They advocated that the therapist should adopt an active empathic stance in making interpretations, promoting transference and keeping the emotional temperature high. Rank also emphasised the importance of a client’s motivation to engage in a process of change, the need to set an end to the treatment, and the necessity of paying more attention to the client’s current experiences rather than having them relive the past. However, the psychoanalytic community remained defensive and hostile to the idea that therapy which was not lengthy and ‘deep’ could be of any lasting value. Alexander and French (1946) provoked considerable uproar when they wrote about the ‘almost superstitious belief among psychoanalysts that quick therapeutic results cannot be genuine’. They had recommended using weekly rather than daily sessions in order to enable clients to put into practice what they had learned in therapy.

Malan’s influential (1963, 1976) studies demonstrated the efficacy of short-term dynamic therapy. He highlighted the need for careful assessments and retaining a therapeutic focus for the work. From the 1960s until the 1980s the works of Malan, Mann (1973), Sifneos (1979) and Davanloo (1980), became the driving force that propelled the case for brief dynamic casework. Since then, the increasing body of research demonstrating that brief therapy is just as effective as the long-term (summarised in Koss and Butcher, 1986), and that brief therapy is the expectation and preference for more than 70 per cent of clients (Pekarik, 1991; Garfield and Bergin, 1994), has been a powerful market force. Frances et al. (1984) found that a wide range of practitioners – marital therapists, sex therapists, family therapists, crisis therapists and cognitive-behavioural therapists – all claimed to work within a short period of time and that their actual practice bore this out. One study of a counselling centre in the UK (Brech and Agulnik, 1996) reported that approximately 40 per cent of clients had between one and four sessions, a further 40 per cent between five and 20, and 20 per cent had therapy contracts extending beyond six months. The study also found that by introducing a four-session model for clients on the waiting list, the number of people waiting was reduced, and that this in turn reduced the waiting time for all clients, even those who had not accepted the offer of the four sessions and had chosen to wait for more open-ended therapy. The majority of studies over recent decades have shown that the median length of treatment (of whatever orientation) ranges from four to eight sessions, with clustering at around six (Koss and Butcher, 1986; Garfield and Bergin, 1994). Koss and Butcher (1986) conclude that ‘almost all psychotherapy is brief.’

There are differences however in defining what constitutes brief therapy. Eckert (1993) stated this was ‘any psychological intervention intended to produce change as quickly as possible whether or not a specific time limit is set in advance’. Malan (1976), coming from a psychodynamic tradition, used the term to mean between four and 50 sessions; Mann (1973), from the same tradition, set a fixed number of 12; while Ryle’s (1991) cognitive-analytic model used 16. Talmon (1990) and Manthei (1996) argued the case for single-session therapy. While some models will set fixed limits, others are brief within flexible parameters (Steenbarger, 1994). Budman and Gurman (1988) prefer the term ‘time-sensitive therapy’, which they feel highlights the necessity of the therapist making the maximum impact within a rationed amount of time. Although major differences exist between brief therapists, there is still a degree of consensus here that brief therapy means fewer than 20 sessions.

There is considerable agreement in the literature about the main characteristics of planned brief therapy. These features are also prominent in solution-focused brief therapy. Barret-Kruse (1994) summarises them as follows:

• The view that yourself and others are essentially able.
• The acceptance of the client’s definition of the problem.
• The formation of the therapeutic alliance.
• Crediting the client with the success.
• The therapist learning from the client.
• The avoidance of a power struggle with the client.
• The objectification, rather than the personalisation, of the client’s behaviour.

She asserts that in brief therapy the therapist needs to join with the client in creating an expectancy of change. In her view, this requires a degree of directiveness from the therapist in order to form a working relationship as quickly as possible. It is equally important to identify the problem and the goal(s) clearly and develop appropriate action plans that will be evaluated carefully. In brief therapy, the client defines the problem. Wells and Gianetti (1993) argue that a collaborative and effective relationship can be established more quickly if clients receive as much information as possible about the problem and the therapy.

Koss and Butcher (1986) summarise the research by describing the main features of brief therapy as follows:

• a focus on the here and now;
• clear, specific and attainable goals achievable in the time available;
• the establishment of a good working relationship as soon as possible;
• a projection of the therapist as competent, hopeful and confident;
• the therapist being active and openly influential.

By contrast, Hoyt (1995) identifies a number of beliefs that underpin long-term therapy:

 

• damaging early experiences must be slowly and fully uncovered;
• the therapeutic alliance must form gradually;
• the client must be allowed to regress;
• transference takes a long time to develop and must not be interpreted too early;
• the consolidation of any gains will require a lengthy period of working through.

Effectiveness

The research evidence for the effectiveness of brief therapy is impressive. In 1990 Talmon published his influential study on single-session therapy. He researched over 10,000 outpatients of a psychiatric hospital who had received psychotherapy. He discovered that the most frequent length of therapy was one session and that 30 per cent of all patients chose to come for only one session in a period of a year, irrespective of the theoretical orientation of the therapist. Moreover, in a follow-up study of 200 of his own clients, 78 per cent said that they had received what they had wanted from a single session. In another study of planned single-session therapy he found that 88 per cent of clients reported that they had improved since the first session and 79 per cent thought that the single session had been enough. His study challenged the view that clients who leave therapy early are failed dropouts. He claimed that his research indicated brief therapy was the preferred choice of many clients and more therapy need not necessarily mean more effective therapy. As Hoyt (1995: 144) has put it, ‘More is not necessarily better. Better is better’.

Kogan (1957) followed up clients three and 12 months after they had received a single session of therapy. Approximately two-thirds felt that they had been helped. He concluded that, in cases with unplanned endings, therapists consistently underestimated the help clients had received. Malan et al. (1975), in a study of 45 clients, two to eight years after they had received a single session of therapy, found that a quarter had improved symptomatically and another quarter had also improved in dynamic terms. Smith (1980) found that the major impact of therapy occurred in the first six to eight sessions, followed by a continuing but decreasing positive impact for approximately the next ten sessions. Howard et al. (1986), in a meta-study, found that 15 per cent of clients improved before the first session, 50 per cent by the eighth, 75 per cent by the twenty-sixth, and 83 per cent by the fifty-second. Stern (1993) suggests that those who stay longer are those who do not feel that they have made enough progress. Brech and Agulnik (1996) found that, of clients who received four planned sessions of therapy in a setting that used psychodynamic methods, 25 per cent found it useful and sufficient and, for a further 50 per cent, it was a useful beginning that helped them to plan the possibility of further long-term work. Bloom (1992) concluded that short-term psychotherapies were equally effective as time-unlimited psychotherapy.

Howard et al.’s (1986) meta-study suggests that while the frequency of sessions was not related to improvement, the structuring of the therapy was indeed important because clients could use regular sessions as organising factors in their lives. It can be helpful to have special times assigned for oneself and, in addition, there must be a degree of intensity in the sessions for change to take place.

It is not clear whether therapy is brief because it works or it works because it is brief. Perry (1987) suggests that the effectiveness of brief therapies may be due to the techniques used, rather than the short duration of the therapy itself.

Solution-Focused Therapy Research

A comprehensive and up-to-date list of all the studies on SFT can be found on Alasdair Macdonald’s website (www.solutionsdoc.co.uk). According to Macdonald (2011) the research on the solution-focused approach (not exclusively in a therapy context) consists of 103 relevant studies: two meta-analyses; and 18 randomised controlled trials showing the benefit from solution-focused brief therapy, with nine showing the benefit over existing methods. Of 39 comparison studies, 30 of these favour SFT. Effectiveness data are available from more than 4000 cases with a success rate exceeding 60 per cent; requiring an average of three to five sessions of therapy time.

Kiser’s (1988) and De Jong and Hopwood’s (1996) studies of the Brief Family Therapy Centre in Milwaukee (de Shazer’s team) found that:

• more than three-quarters of clients fully met their treatment goals or made progress towards them;
• the average number of sessions was 3.0;
• the counselling was equally effective with a diversity of clients and did not vary according to the client-counsellor gender or racial mix;
• the same therapeutic procedures were effective across a wide range of client-identified problems.

In the UK, Macdonald (1994) researched patients from a psychiatric outpatient department in which all the counsellors had received solution-focused training. In a follow-up study one year after treatment a positive outcome was self-reported in 70 per cent of patients (71 per cent by their GPs) while 10 per cent reported a negative outcome. There was a significant correlation between a positive outcome and length of treatment. The mean number of sessions for the improved group was 5.47 and, for the unimproved, 3.71. Long-standing problems did slightly less well. Those in the group who deteriorated were younger and all were female. Social class was not a factor, perhaps suggesting that brief therapy is accessible to a wide range of people and may be effective for those groups thought to be apprehensive of traditional forms of therapy.

There is anecdotal evidence that the model brings about change in clients, but limited published research that is acceptable to the academic community. The development of a Europe-wide SFT research group will hopefully remedy this deficiency.

Consumer preference

Intermittent therapy – which is analogous to our visiting the doctor from time to time as and when we need to – is more in tune with how people currently live their lives than traditional forms of therapy. Cummings and Sayama (1995) argue for intermittent therapy throughout the lifecycle. In their opinion brief focused therapy, which can be accessed at points of crisis during a person’s life, is more effective than other models. There is evidence, as we have seen, that brief therapy is the therapy of choice for consumers. According to Pekarik and Wierzbicki’s (1986) research, 65 per cent of therapists preferred to deliver long-term therapy (i.e., more than 15 sessions), whereas only 20 per cent of their clients expected it. This may suggest that clients do not see themselves as being entitled to lengthy therapy, although that may be their preference, or it might point to clients not wanting to be in therapy and instead choosing to go through it as quickly as possible. There is some evidence that clients opt for brief therapy even when they are entitled to lengthier periods of therapy at no cost to themselves (Hoyt, 1995). Such findings have clear implications for the just distribution of scarce therapy resources.

Clients’ and therapists’ understandings of the therapeutic process are very different. Llewelyn (1988) found that clients were motivated to find a solution to their problems and to feel better, whereas therapists prioritised the search for explanations for problems and their transformation by means of insight. There is also some evidence that clients’ expectations about outcomes will differ from those of many therapists. Warner (1996) suggested that counsellors find it difficult to believe that clients have benefited from brief interventions. According to Beutler and Crago (1987), the majority of clients are hoping for symptom relief whereas therapists plan to achieve character changes in their clients.

In short, we need to recognise that brief therapy does not mean less of the same, as if it were a bargain basement offering, but that it has its own unique structure and process that will require different values and skills from the therapist (Barkham, 1993).

Practice points

 

• Use every session with a client, including the first, as if it were the last.
• Project confidence and hope that much can be achieved in limited time.
• Stay close to the client’s agenda.
• Trust your client’s competence and keep out of his or her way.
• Ask yourself what difference it would make to your practice if you really believed that, ‘More is not better, better is better’.
• Consider ways of evaluating the effectiveness of your work.

2

Foundations of SFT

When the invention of the steam engine was first announced in the last century, a distinguished scientist and wit is reported to have remarked: ‘It works in practice, but does it work in theory?’

(quoted in O’Hanlon and Wilk, 1987)

Lipchik et al. (2011) give a fascinating account of how Solution-Focused Therapy (SFT) developed from the work of the team at the Brief Family Therapy Center (BFTC) in Milwaukee USA. They state that the model evolved from clinical practice (de Shazer et al., 1986) and emerged from many thousands of hours of observation from behind a screen and lengthy discussions among the team of observers. They discovered that clients made progress by talking about their preferred futures without analysing their ‘problem-laden’ histories. They felt empowered as they described what they wanted to happen in their lives (solutions). These ‘solutions’ were more than just the absence of their problems, they embraced many aspects of clients’ lives. The use of what came to be known as The First Formula Session Task, where clients were asked ‘to notice and remember things that happened this week that they would like to see continue’, produced such positive results that it became the launch pad for a fully blown solution-focused approach (de Jong and Berg, 2008). The clinical team learnt that ‘solutions’ did not have to fit with ‘problems’ – they had to fit with the clients. They also found that by means of a questioning process, they could elicit clear ideas about change from clients. These questions, described by de Shazer (1985) as ‘skeleton keys’, invited clients to:

• become more aware of exceptions – those times when they succeeded in overcoming their problems;
• utilise their personal and social resources;
• imagine their preferred future – the miracle question;
• take small steps forward.

These questions were strongly orientated towards the future and not the past on the basis that ‘the future does not exist and cannot be predicted. It must be imagined and invented’ (Gelatt, 1989). To some extent the future is less contentious than the past – at the very least it opens up new possibilities of things b...

Table of contents

• Cover Page
• Title
• Copyright
• Dedication
• Contents
• About the Author
• Foreword by Harvey Ratner
• Foreword by Alasdair J. Macdonald
• Preface to the Third Edition
• Acknowledgements
• 1 Brief Therapy
• 2 Foundations of SFT
• 3 Overview of the Model
• 4 The First Session
• 5 The Second Session and Beyond: Keeping the Focus on Solutions
• 6 The SF Journey
• 7 SF Supervision
• 8 Frequently Asked Questions About SFT
• 9 An Integrative SF Approach
• 10 Tips and Exercises for using the SF Approach
• Appendix: Solution-Focused Resources
• Bibliography
• Index