Solution-focused brief therapy
Solution-focused (brief) therapy (SFBT) is a goal-directed collaborative approach to psychotherapeutic change that is conducted through direct observation of clients' responses to a series of precisely constructed questions. Based upon social constructionist thinking and Wittgensteinian philosophy, SFBT focuses on addressing what clients want to achieve without exploring the history and provenance of problem(s). SF therapy sessions typically focus on the present and future, focusing on the past only to the degree necessary for communicating empathy and accurate understanding of the client's concerns.
The solution-focused brief therapy approach grew from the work of American social workers Steve de Shazer, Insoo Kim Berg, and their team at the Milwaukee Brief Family Therapy Center (BFTC) in Milwaukee, Wisconsin. A private training and therapy institute, BFTC was started by dissatisfied former staff members from a Milwaukee agency who were interested in exploring brief therapy approaches then being developed at the Mental Research Institute (MRI) in Palo Alto, CA. The initial group included married partners, Steve de Shazer, Insoo Berg, Jim Derks, Elam Nunnally, Marilyn La Court and Eve Lipchik. Their students included John Walter, Jane Peller, Michele Weiner-Davis and Yvonne Dolan. Steve de Shazer and Berg, primary developers of the approach, co-authored an update of SFBT in 2007, shortly before their respective deaths.
The solution-focused approach was developed inductively rather than deductively; Berg, de Shazer and their team spent thousands of hours carefully observing live and recorded therapy sessions. Any behaviors or words on the part of the therapist that reliably led to positive therapeutic change on the part of the clients were painstakingly noted and incorporated into the SFBT approach. In most traditional psychotherapeutic approaches starting with Freud, practitioners assumed that it was necessary to make an extensive analysis of the history and cause of their clients' problems before attempting to develop any sort of solution. Solution-focused therapists see the therapeutic change process quite differently. Informed by the observations of Steve de Shazer, recognizing that although "causes of problems may be extremely complex, their solutions do not necessarily need to be".
Questions and compliments are the primary tools of the solution-focused approach. SF therapists and counselors deliberately refrain from making interpretations and rarely confront their clients. Instead, they focus on identifying the client's goals, generating a detailed description of what life will be like when the goal is accomplished and the problem is either gone or coped with satisfactorily. In order to develop effective solutions, they search diligently through the client's life experiences for "exceptions", e.g. times when some aspect of the client's goal was already happening to some degree, utilizing these to co-construct uniquely appropriate and effective solutions.
SF therapists typically begin the therapeutic process by joining with client competencies. As early in the interview as respectfully possible to do so, SF therapist/counselors invite the client to envision their preferred future by describing what their life will be like when the problem is either gone or being coped with so satisfactorily that it no longer constitutes a problem. The therapist and client then pay particular attention to any behaviors on the client's part that contribute to moving in the direction of the client's goal, whether these are small increments or larger changes. To support this approach, detailed questions are asked about how the client managed to achieve or maintain the current level of progress, any recent positive changes and how the client developed new and existing strengths, resources, and positive traits; and especially, about any exceptions to client-perceived problems.
Solution-focused therapists believe personal change is already constant. By helping people identify positive directions for change in their life and to attend to changes currently in process they wish to continue, SFBT therapists help clients construct a concrete vision of a preferred future for themselves.
SFBT therapists support clients to identify times in their life when things matched more closely with the future they prefer. Differences and similarities between the two occasions are examined. By bringing small successes to awareness, and supporting clients to repeat their successful choices and behaviors, when the problem is not there or less severe, therapist facilitate client movement towards goals and preferred futures they have identified.
One way of understanding the practice of SFBT is displayed through the acronym MECSTAT, which stands for Miracle questions, Exception questions, Coping questions, Scaling questions, Time-out, Accolades and Task.
Evidence based status
SFBT has been examined in two meta-analyses and is supported as evidenced-based by numerous federal and state agencies and institutions, such as SAMHSA's National Registry of Evidence-Based Programs & Practices (NREPP). To briefly summarize:
- There have been 77 empirical studies on the effectiveness of SFBT,
- There have been 2 meta-analyses (Kim, 2008; Stams, et al, 2006), 2 systematic reviews.
- There is a combined effectiveness data from over 2800 cases.
- Research was all done in "real world" settings ("effectiveness" vs. "efficacy" studies), so the results are more generalizable.
- SFBT is equally effective for all social classes.
- Effect-sizes are in the low to moderate range, the same that are found in meta-analyses for other evidence-based practices, such as CBT and IPT. Overall success rate average 60% in 3–5 sessions
- The conclusion of the two meta-analyses and the systematic reviews, and the over-all conclusion of the most recent scholarly work on SFBT, is that solution-focused brief therapy is an effective approach to the treatment of psychological problems, with effect sizes similar to other evidenced-based approaches, such as CBT and IPT, but that these effects are found in fewer average sessions, and using an approach style that is more benign (Gingerich et al, 2012; Trepper & Franklin, 2012). That is, the more collegial and collaborative approach of SFBT does not involve confrontation or interpretation, nor does it even require the acceptance of the underlying tenets, as do most other models of psychotherapy. Given its equivalent effectiveness, shorter duration, and more benign approach, SFBT is considered to be an excellent first-choice evidenced-based psychotherapy approach for most psychological, behavioral, and relational problems.
The miracle question
The miracle question or "problem is gone" question is a method of questioning that a coach, therapist, or counselor can utilize to invite the client to envision and describe in detail how the future will be different when the problem is no longer present.
A traditional version of the miracle question would go like this:
- "I am going to ask you a rather strange question [pause]. The strange question is this: [pause] After we talk, you will go back to your work (home, school) and you will do whatever you need to do the rest of today, such as taking care of the children, cooking dinner, watching TV, giving the children a bath, and so on. It will be time to go to bed. Everybody in your household is quiet, and you are sleeping in peace. In the middle of the night, a miracle happens and the problem that prompted you to talk to me today is solved! But because this happens while you are sleeping, you have no way of knowing that there was an overnight miracle that solved the problem. [pause] So, when you wake up tomorrow morning, what might be the small change that will make you say to yourself, 'Wow, something must have happened—the problem is gone!'"?
Whilst relatively easy to state, the miracle question requires considerable skill to ask well. The question must be asked slowly with close attention to the person's non-verbal communication to ensure that the pace matches the person's ability to follow the question. Initial responses frequently include a sense of "I don't know." To ask the question well this should be met with respectful silence to give the person time to fully absorb the question.
Once the miracle day has been thoroughly explored the worker can follow this with scales, on a scale where 0 = worst things have ever been and 10 = the miracle day, with questions such as: Where are you now? Where would things need to be for you to know that you didn't need to see me any more? What will be the first things that will let you know you are 1 point higher? In this way the miracle question is not so much a question as a series of questions.
There are many different versions of the miracle question depending on the context and the client.
In a specific situation, the counselor may ask,
- "If you woke up tomorrow, and a miracle happened so that you no longer easily lost your temper, what would you see differently?" "What would the first signs be that the miracle occurred?"
The client, in this example, (a child) may respond by saying,
- "I would not get upset when somebody calls me names."
The counselor wants the client to develop positive goals, or what they will do—rather than what they will not do—to better ensure success. So, the counselor may ask the client, "What will you be doing instead when someone calls you names?"
Scaling questions invite clients to employ measuring and tracking of their own experience, in a non-threatening way. Scaling and measuring are useful tools to identify differences for clients. Goals and progress towards goals are often facilitated by subjective measuring and scaling.
SFBT is famous for inviting clients to get very specific about such subjective measuring and scaling; for example, by asking questions that invite clients to establish their own polarity; and then, measure their progress—forwards and backwards—towards the more desirable pole. SFBT innovated language to make this invitation to more internal rigor sound natural to clients: What is "the worst the problem has ever been?" (zero or one). What is "the best things could ever possibly be?" (ten). The client is asked to rate their current position on their own scale. Questions are used to elicit useful details of behavior to measure by, resources and support (e.g. "what's stopping you from slipping one point lower down the scale?"). Clients are then invited to calibrate their own progress precisely (e.g. "on a day when you are one point higher on the scale, what tells you this is a 'one point higher' day?"). Similarly preferred futures can be discussed in light of the client's own scale (e.g. "where on the scale would be good enough? What would a day at that point on the scale feel like; what would you do differently?")
Proponents of SFBT insist there are always times when the identified problem is less severe or absent for clients. The counselor seeks to encourage the client to identify these occurrences and maximize their frequency. What happened that was different? What did you do that was different? The goal is for clients to repeat what has worked in the past, and support confidence in taking more and more "baby steps" towards their ideal scenes. This concept and practice was influenced by Milton Erickson.
Coping questions are designed to elicit information about client resources that will have gone unnoticed by them. Even the most hopeless story has within it examples of coping that can be drawn out: "I can see how things have been really difficult for you, yet I am struck by the fact you get up each morning and do everything necessary to get the kids off to school. How do you do that?" Genuine curiosity and admiration can help to highlight strengths without appearing to contradict the client's perception of the problem. An initial summary "I can see how things have been really difficult for you" is for them true and validates their story. The second part "you manage to get up each morning etc.", is also a truism, but one that counters the problem-focused narrative. Undeniably, they cope and coping questions start to gently and supportively challenge the problem-focused narrative.
Solution-focused therapists attempt to create a judgement-free zone for clients where what is going well, what areas of life are problem-free are discussed. Problem-free talk can be useful for uncovering hidden resources, to help the person relax, or become more naturally pro-active, for example. Solution-focused therapists may talk about seemingly irrelevant life experiences such as leisure activities, meeting with friends, relaxing and managing conflict. This often uncovers client values, beliefs and strengths. From this discussion the therapist can use these strengths and resources to move the therapy forward. For example; if a client wants to be more assertive it may be that under certain life situations they are assertive. This strength from one part of their life can then be transferred-generalized to another area where new behavior is desired. Perhaps a client is struggling with their child because the child gets aggressive and calls the parent names. If the parent continually retaliates and also gets angry, perhaps they can recall another area of their life where they remain calm even under pressure; or maybe, they have trained a dog successfully who now behaves and can identify how kindness, patience and consistency were keys to eliciting the dog's good behavior. This could lead to discussion of using kindness, patience and consistency to create healthy boundaries the child might cooperate with.
Dan Jones, in his Becoming a Brief Therapist book writes:
'...it is in the problem free areas you find most of the resources to help the client. It also relaxes them and helps build rapport, and it can give you ideas to use for treatment...Everybody has natural resources that can be utilised. These might be events...or talk about friends or family...The idea behind accessing resources is that it gives you something to work with that you can use to help the client to achieve their goal...Even negative beliefs and opinions can be utilised as resources'.
A key task in SFBT is supporting clients to identify and attend to their own internal competencies, skills and resources; as well as their immediate support systems and supportive social networks. This focus helps the client construct narratives as internally competent and externally supported. Expanding language here often identifies new ways to bring existing resources to bear upon present problems. Therapists empower clients to identify their own resources by way of scaling questions, problem-free talk, and during exception-seeking.
Resources can be Internal: the client's skills, strengths, qualities, beliefs that are useful to them and their capacities, or External: supportive relationships such as, partners, family, friends, faith or religious groups and also support groups.
Solution-focused brief therapy is one of a family of approaches, known as systems therapies, that have been developed over the past 50 years or so, first in the US, and eventually evolving around the world, including Europe. The title SFBT, and the specific steps involved in its practice, are attributed to husband and wife Steve de Shazer and Insoo Kim Berg, two American social workers, and their team at The Brief Family Therapy Center in Milwaukee, USA. Core members of this team were Eve Lipchik, Wallace Gingerich, Elam Nunnally, Alex Molnar, and Michele Weiner-Davis. Their work in the early 1980s built on that of a number of other innovators, among them Milton Erickson, and the group at the Mental Research Institute at Palo Alto – Gregory Bateson, Donald deAvila Jackson, Paul Watzlawick, John Weakland, Virginia Satir, Jay Haley, Richard Fisch, Janet Beavin Bavelas and others.
Many of the concepts of brief therapy were independently discovered by several therapists, in their own practices, over several decades in the 1950s (notably Milton Erickson), as described by authors such as Haley, and became popularized in the 1960s and 1970s.
Solution-focused brief therapy has branched out in numerous spectrums – indeed, the approach is now known in other fields as simply solution focus or solutions-oriented therapy. Most notably, the field of addiction counseling has taken up SFBT as one of the most cost-effective means to treat problem drinking. Johns Hopkins University, the Center for Solutions in Cando, ND, and notable others, have implemented SFBT as part of their program, where they use it as part of a partial hospitalization and in residential treatment facility for both adolescents and adults.
The field of Christian pastoral counseling has also seen solution-focused brief therapy make inroads into its practices where it is referred to as solution-focused pastoral counseling or brief pastoral counseling.
Example solution-focused coaching prompts include:
- What are grounds for optimism?
- 0–10, what would be different at +1 on your scale?
- What would others notice at +1?
- When does your perfect future happen, even a little bit?
- How did you make that happen?
- Where in your life have you overcome similar problems?
- Who believes you could do this?
- What other resources do you have that can help?
- Supposed the problem went away overnight: How would you know?
- What would you notice was different?
- Describe concrete observable behaviours – from different points of view: boss, colleagues, friends, computer?
- What else? What else? What else?
- What would you like to happen?
- How will you know you've achieved it?
- What was the best you ever did (at this thing)?
- What will be the first signs that you're getting better?
- What would your family, your partner, your friends and strangers notice is different about you?
- What will be difference since your last catch up with me?
Solution-focused counseling is a solution-focused brief therapy model. Various similar, yet distinct, models have been referred to as solution-focused counseling. For example, Jeffrey Guterman developed a solution-focused approach to counseling in the 1990s. This model is an integration of solution-focused principles and techniques, postmodern theories, and a strategic approach to eclecticism. Guterman describes the theory and practice of solution-focused counseling in a book he authored, Mastering the Art of Solution-Focused Counseling. The Journal of Marital and Family Therapy reviewed Guterman's counseling model, stating that he "clearly demonstrates and stresses the adaptability of this model as well as its usefulness for the client and therapist."
Solution-focused consulting is an approach to organizational change management that is built upon the principles and practices of solution-focused therapy. While therapy is for individuals and families, solution-focused consulting is being used as a change process for organizational groups of every size, from small teams to large business units.
A contemporary therapy linking the solution-focused brief therapy model back to the hypnotherapy of Milton H Erickson, the hypnotherapist who inspired Steve de Shazer and Insoo Kim Berg. Solution-focused hypnotherapy (SFH) adopts practical, modern strategies that include the best of solution-focused brief therapy (SFBT), cognitive behavioural therapy (CBT), neuro-linguistic programming (NLP) and direct hypnosis.
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