Guest Anne Bodmer Lutz, B.S.N., M.D. discusses Solution Focused Therapy and Intensive Home-Based Treatment (IHBT). She is the Director of The Institute for Solution-Focused Therapy and is the author of Learning Solution-Focused Therapy: an Illustrated Guide, published by American Psychiatric Association Press.
What is Solution-Focused Therapy?
Solution-Focused Brief Therapy (SFBT), also called Solution-Focused Therapy, Solution-Building Practice therapy was developed by Steve de Shazer (1940-2005), and Insoo Kim Berg (1934-2007) and their colleagues beginning in the late 1970’s in Milwaukee, Wisconsin. As the name suggests, SFBT is future-focused, goal-directed, and focuses on solutions, rather than on the problems that brought clients to seek therapy.
The entire solution-focused approach was developed inductively in an inner city outpatient mental health service setting in which clients were accepted without previous screening. The developers of SFBT spent hundreds of hours observing therapy sessions over the course several years, carefully noting the therapists’ questions, behaviors, and emotions that occurred during the session and how the various activities of the therapists affected the clients and the therapeutic outcome of the sessions. Questions and activities related to clients’ report of progress were preserved and incorporated into the SFBT approach.
Since that early development, SFBT has not only become one of the leading schools of brief therapy, it has become a major influence in such diverse fields as business, social policy, education, and criminal justice services, child welfare, domestic violence offenders treatment. Described as a practical, goal-driven model, a hallmark of SFBT is its emphasis on clear, concise, realistic goal negotiations. The SFBT approach assumes that all clients have some knowledge of what would make their life better, even though they may need some (at times, considerable) help describing the details of their better life and that everyone who seeks help already possesses at least the minimal skills necessary to create solutions.
Key Concepts and Tools
All therapy is a form of specialized conversations. With SFBT, the conversation is directed toward developing and achieving the client’s vision of solutions. The following techniques and questions help clarify those solutions and the means of achieving them.
Looking for previous solutions
SF therapists have learned that most people have previously solved many, many problems and probably have some ideas of how to solve the current problem. To help clients see these potential solutions they may ask, “Are there times when this has been less of a problem?” or “What did you (or others) do that was helpful?”
Looking for exceptions
Even when a client does not have a previous solution that can be repeated, most have recent examples of exceptions to their problem. These are times when a problem could occur, but does not. The difference between a previous solution and an exception is small, but significant. A previous solution is something that the family has tried on their own that has worked, but later discontinued. An exception is something that happens instead of the problem, often spontaneously and without conscious intention. SF therapists may help clients identify these exceptions by asking, “What is different about the times when this is less of a problem?”
Present and future-focused questions vs. past-oriented focus
The questions asked by SF therapists are usually focused on the present or on the future. This reflects the basic belief that problems are best solved by focusing on what is already working, and how a client would like their life to be, rather than focusing on the past and the origin of problems. For example, they may ask, “What will you be doing in the next week that would indicate to you that you are continuing to make progress?”
Compliments are another essential part of solution focused brief therapy. Validating what clients are already doing well, and acknowledging how difficult their problems are encourages the client to change while giving the message that the therapist has been listening (i.e., understands) and cares. Compliments in therapy sessions can help to punctuate what the client is doing that is working. In SF therapy, compliments are often conveyed in the form of appreciatively toned questions of “How did you do that?” that invite the client to self-compliment by virtue of answering the question.
Inviting the clients to do more of what is working.
Once SF therapists have created a positive frame via compliments and then discovered some previous solutions and exceptions to the problem, they gently invite the client to do more of what has previously worked, or to try changes they have brought up which they would like to try – frequently called “an experiment.”
Miracle Question (MQ)
This unusual sounding tool is a powerful in generating the first small steps of ‘solution states’ by helping clients to describe small, realistic, and doable steps they can take as soon as the next day. The miracle question developed out of desperation with a suicidal woman with an alcoholic husband and four “wild” children who gave her nothing but grief. She was desperate for a solution, but that she might need a ‘miracle’ to get her life in order. Since the development of this technique, the MQ has been tested numerous times in many different cultures. The most recent version is as follows:
T: I am going to ask you a rather strange question . . . that requires some imagination on your part . . . do you have good imagination?
C: I think so, I will try my best.
T: Good. The strange question is this; After we talk, you go home (go back to work), and you still have lots of work to do yet for the rest of today (list usual tasks here). And it is time to go to bed . . . and everybody in your household are sound asleep and the house is very quiet . . . and in the middle of the night, there is a miracle and the problem that brought you to talk to me about is all solved . But because this happens when you are sleeping, you have no idea that there was a miracle and the problems is solved . . . so when you are slowly coming out of your sound sleep . . .what would be the first small sign that will make you wonder . . .there must’ve been a miracle . . .the problem is all gone! How would you discover this?
C: I suppose I will feel like getting up and facing the day, instead of wanting to cover my head under the blanket and just hide there.
T: Suppose you do, get up and face the day, what would be the small thing you would do that you didn’t do this morning?
C: I suppose I will say good morning to my kids in a cheerful voice, instead of screaming at them like I do now.
T: What would your children do in response to your cheerful “good morning?”
C: They will be surprised at first to hear me talk to them in a cheerful voice, and then they will calm down, be relaxed. God, it’s been a long time that happened.
T: So, what would you do then that you did not do this morning?
C: I will crack a joke and put them in a better mood.
These small steps become the building block of an entirely different kind of day as clients may begin to implement some of the behavioral changes they just envisioned. This is the longest question asked in SFBT and it has a hypnotic quality to it. Most clients visibly change in their demeanor and some even break out in smiles as they describe their solutions. The next step is to identify the most recent times when the client has had small pieces of miracles (called exceptions) and get them to repeat these forgotten experiences.
Scaling questions (SQ) can be used when there is not enough time to use the MQ and it is also useful in helping clients to assess their own situations, track their own progress, or evaluate how others might rate them on a scale of 0 to 10. It is used in many ways, including with children and clients who are not verbal or who have impaired verbal skills. One can ask about clients’ motivation, hopefulness, depression, confidence, and progress they made, or a host of other topics that can be used to track their performance and what might be the next small steps.
The couple in the following example sought help to decide whether their marriage can survive or they should get divorced. They reported they have fought for 10 years of their 20 years of marriage and they could not fight anymore.
T: Since you two know your marriage better than anybody does, suppose I ask you this way. On a number of 1 to 10, where 10 stands for you have every confidence that this marriage will make it and 1 stands for the opposite, that we might just as well walk away right now and it’s not going to work. What number would you give your marriage? (After a pause, the husband speaks first.)
H: I would give it a 7. (the wife flinches as she hears this)
T: (To the wife) What about you? What number would you give it?
W: (she thinks about it a long time) I would say I am at 1.1.
T: (Surprised) So, what makes it a 1.1?
W: I guess it’s because we are both here tonight.
This question is a powerful reminder that all clients engage in many useful things even in times of overwhelming difficulties. Even in the midst of despair, many clients do manage to get out of bed, get dressed, feed their children, and do many other things that require major effort. Coping questions such as “How have you managed to carry on?” or “How have you managed to prevent things from becoming worse?” open up a different way of looking at client’s resiliency and determination.
Consultation Break and Invitation to Add Further Information
Solution focused therapists traditionally take a brief consultation break during the 2nd half of each therapy session during which the therapist reflects carefully on what has occurred in the session. Some time prior to the break, the client is asked “Is there anything that I did not ask that you think it would be important for me to know?” During the break, the therapist or the therapist and a team reflect carefully on all that has occurred in the session. Following that, the client is complimented and usually offered a therapeutic message based on the client’s stated goal. Usually this takes the form of an invitation for the client to observe and experiment with behaviors that result in positive movement in the direction of the client’s identified goal.
Even though it is an inductively developed model, from its earliest beginnings there has been consistent interest in assessing SFBT’s effectiveness. Given the clinical philosophy behind the SFBT approach, it is not surprising that the initial research efforts relied primarily on client self reports. Since then, an increasing number of studies have been generated, many with randomized comparison groups, such as that of Lindforss and Magnusson who studied the effects of SFBT on the prison recidivism in Hageby Prison in Stockholm, Sweden. Their randomized study compared those clients who received average of five SFBT sessions and those who received their usual available services. Clients were followed at 12 and 16 months after discharge from prison. The SFBT group consistently did better than the control group.
A number of researchers have reviewed studies conducted in a variety of settings and geographical locations, with a range of clients. Based on the reviews of these outcome studies, Gingerich and Eisengrat concluded that the studies offered preliminary support that the SFBT approach could be beneficial to clients. However, more microanalysis research into the co-construction process in solution-focused conversation is needed to develop additional understanding of how clients change through participating in these conversations.
About the Presenter
Anne Bodmer Lutz, B.S.N., M.D. is the Director of The Institute for Solution-Focused Therapy. Anne is a board certified Adult, Child and Adolescent Psychiatrist, and was a nurse prior to becoming a physician. She was trained by the founders of Solution-Focused Therapy, Insoo Kim Berg and Steve de Shazer. She is the author of Learning Solution-Focused Therapy: an Illustrated Guide, published by American Psychiatric Association Press.
Anne is an assistant professor in psychiatry at the University of Massachusetts in Worcester MA, and Visiting Professor at Framingham State University. Anne worked for many years in community mental health and as a consulting psychiatrist for a residential treatment center for adolescent girls coping with substance use disorders and co-occurring disorders, integrating Solution-Focused approaches within their treatment setting.
She consults with community mental health agencies integrating Solution-Focused approaches. She provides direct clinical supervision, teaching and training to psychiatric residents, psychology interns and workshops for community based treatment organizations. Anne currently has a private practice in West Boylston Massachusetts where she sees children and families providing Solution-Focused psychiatric treatment. She received a Course of Distinction Award in 2016 through the Massachusetts College Online (MCO) recognizing her for an online and blended learning course in Solution-Focused Fundamentals and Practice.