What is the role of pathology in solution-focused family therapy
Solution-Focused Brief Therapy (SFBT) is one of the world’s most widely used therapeutic treatments (De Shazer, 2007, Hsu, 2011). Unlike traditional forms of therapy that take time to analyze problems, pathology, and past life events, SFBT concentrates on finding solutions in the present and exploring one’s hope for the future in order to find a quick and pragmatic resolution of one’s problems. This method takes the approach that you know what you need to do to improve your own life and, with the appropriate coaching and questioning, are capable of finding the best solutions.
SFBT was developed by Insoo Kim Berg, Steve de Shazer, and their colleagues in the late 1970s. Disillusioned by the results of traditional psychoanalysis, Berg and de Shazer wanted to create a new type of therapy that dealt less with the “why” behind challenges patients face, and more with the “how” of treating them. Originally begun out of Berg’s living room, the group went on to found the Milwaukee Brief Family Therapy Center in the early 1980s.
A review of 43 studies on SFBT found that there was “strong evidence that Solution-Focused Brief Therapy was an effective treatment for a wide variety of behavioral and psychological outcomes.”
SFBT has become particularly popular in non-Western countries, another study showed. Though the treatment started in North America, since 2013 the amount of research on SFBT in non-Western countries is twice that of Western countries.
The approach is particularly popular in Asia. In the 1980s, Berg was invited to speak and give workshops on the technique in Hong Kong. The treatment received attention and study, and soon after reached Mainland China.
Researchers suggest that the efficacy, practicality, and optimistic nature of the treatment translate well across cultures, and that the approach allows patients to maintain familial relations and personal dignity while addressing mental health issues.
Key Concepts and Tools
Almost all psychotherapy is language-based and each utilizes its own form of specialized conversations. With SFBT, the conversation is directed toward developing and achieving the client’s envisioned solutions. The following techniques and questions help clarify those solutions and the means of achieving them.
Goal Development Questions
SF therapists variously begin a first session with one or more goal development question. These might variously include asking clients to describe their best hope for what will be different as a result of coming to therapy, what needs to happen as a result of coming in so that afterwards the client (and/or a person who cares about them) will be able to look back and think that it had been a good idea to come, or what needs to happen so that clients would be able to say afterwards that coming was not a waste of their time.
Once a goal has been identified, SF therapists ask their clients questions designed to generate a detailed description of what the client’s life will be like when the goal has been achieved. In some cases, this may include the SF Miracle Question (see below). Once a detailed description has been developed of how the client’s life will be different after the goal has been achieved, the therapist and client begin searching through the client’s life experiences and behavioral repertoire for exceptions, e.g. times when in at least some parts of the goal have already happened.
Pre-Session Change Question
In first sessions, once a client has identified a goal, a SF therapist usually asks some version of the following question: We have learned over the years that sometimes in between making an appointment and coming in, something happens to make things better. Did anything think like that happen in your case?
If the client answers no, the SF therapist simply moves on, however in the event that the client answers in the affirmative, it may likely be that the solution-development process has already begun in which case the SF therapist follows up with questions about the details of how, when and where things have begun to get better and how this might possibly continue.
Looking for previous solutions
As illustrated above, SF therapists have learned that most people have previously solved many, many problems and may likely have some ideas of how to solve the current problem. To help clients discover these potential solution ingredients, they may ask, “Are there times when this has been less of a problem?” or “What did you (or others) do that was helpful?” Or “When was the last time when something like this (client’s goal description) perhaps happened, even a little bit?”
Looking for exceptions
Even when a client does not have a fully developed previous solution that can be readily repeated, most have recent examples of at least partial exceptions to their problem; no problem happens to the same degree all the time. There are for example, times when a problem could occur, but does not.
The difference between a previous solution and an exception is small, but potentially significant. A previous solution is something that clients previously that worked, but was perhaps later discontinued. An exception, on the other hand, is something that happens instead of the problem, sometimes 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?”
Direct and indirect compliments based on careful observation of positive things the client has done or said are an essential part of solution focused brief therapy and are used throughout the therapeutic process. 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 serve to punctuate and validate what the client is doing that is working. In SF therapy, indirect 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 and their clients have identified some previous solutions and exceptions to the problem, the therapists gently invite the clients 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” or a “homework experiment.”
Miracle Question (MQ)
The Solution-Focused Miracle Question is oftentimes used as a vehicle for clients identifying the unique details of the first small behavioral steps that gradually lead towards a viable solution in the context of their everyday life. Here is an example of the Miracle Question:
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 is 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 blocks of an entirely different kind of day as clients may begin to implement some of the behavioral changes they just envisioned.
Most clients visibly change in their demeanor and some even break out in smiles as they describe their solutions in the context of the Miracle Question.The next step is to invite clients to identify the most recent times when the have experienced some aspect (even the smallest pieces) of their miracle description (exceptions) and invite them to experiment with replicating these in the context of their everyday life.
Scaling questions simultaneously allow both client and therapist to assess the client’s situation, identify their current distance from the goal, what it will to maintain their current level of progress and move forward. Clients can variously be invited to rate their level of motivation, confidence, as well as identifying what specifically helps them progress on the scale in the direction of their goal, “best hope,” or “miracle.”
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. That’s at least a beginning.
The Miracle 10 Question
A hybrid of the Miracle Question and Scaling, the Miracle 10 Question is worded as follows: Imagine a 0-10 scale in which 10 represents that you have now fully achieved your goal and 0 represents the exact opposite. Let’s suppose that tonight while you are sleeping somethings shifts during the night and when you wake up tomorrow you are suddenly at a 10. But since you were asleep when it happened, you don’t initially realize it. What will be the first differences(s) that you or people around you begin to notice about you that begins to give you (and/or them) the idea that something has changed, that in fact you are a 10 now?
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 clients to observe and experiment with behaviors that help maintain or result in further positive movement in the direction of their identified goal.
Solution-focused brief therapy is an evidenced-based psychotherapy approach. There have been close to 150 randomized clinical control studies with different control populations in different clinical settings in multiple countries, almost all showing positive benefit of SFBT. There have also been eight meta-analyses on a range of outcome studies with an overall effect size ranging from small to large, for child, adolescent, and adult populations, for presenting problems such as depression, stress, anxiety, behavioral problems, parenting, and psychosocial and interpersonal problems (Kim et al, 2010; 2019). Click Here for more about the research in SFBT.
Suggested Readings and References
Berg, I.K. & Dolan, Y. (2001). Tales of solution: A collection of hope inspiring stories. New York: W.W. Norton.
Berg, I. K., & de Shazer, S. (1993). Making numbers talk: Language in therapy. In S. Friedman (Ed.), The new language of change: Constructive collaboration in psychotherapy. New York: Guilford.
De Jong, P., & Berg, I. K. (2012). Interviewing for solutions. Nelson Education.
De Shazer, S. (1984). The death of resistance. Family Process, 23, 79-93.
De Shazer, S. & Dolan, Y., Korman, H, Trepper, T. S., McCollom, E., Berg, I. K. (2007). More Than Miracles: The State of the Art of Solution-Focused Brief Therapy. New York: Routledge.
Franklin, C., Trepper, T. S., McCollum, E. E., & Gingerich, W. J. (Eds.). (2012). Solution-focused brief therapy: A handbook of evidence-based practice. Oxford University Press.
Froerer, A.S., Von Cziffra-Bergs, J., Kim, J & Connie, E. (Eds.) (2018). Solution-focused Brief Therapy With Clients Managing Trauma. New York: Oxford Press.
Gingerich, W., & Eisengrat, S. (2000). Solution-Focused brief therapy: A review of the outcome research. Family Process, 39, 477-498.
Kim, J., Jordan, S. S., Franklin, C., & Froerer, A. (2019). Is solution-focused brief therapy evidence-based? An update 10 years later. Families in Society, 100(2), 127-138.
Kim, J. S., Smock, S., Trepper, T. S., McCollum, E. E., & Franklin, C. (2010). Is solution-focused brief therapy evidence-based?. Families in society, 91(3), 300-306.
Lutz, A. B. (2013). Learning solution-focused therapy: An illustrated guide. American Psychiatric Pub.