Brief Direct Practice
Solutions Or Not?

Contents

Introduction

This paper will provide an opportunity to consider some aspects of Brief Solution Focussed Therapy (BSFT) and its relationship to ‘what works’ in direct practice. It argues that BSFT techniques may have something to offer in terms of their relationship to positive outcomes in direct practice. With this in mind the aspects of BSFT that relate to goal formation, client / practitioner collaboration and empowerment are worth considering adding to the ‘tool box’ of the eclectic practitioner.

The Evolution Of Brief Therapies

A Summary Of The History And Context Of Brief Therapy

Developing from the convergence of the work of Erickson (1954) as well as Systems (Bertalanffy, 1968), Communications (Bateson, 1973) and Cybernetic theories, 50’s through 70’s, it can be seen that there were some very rapid if not radical developments in the thinking about problems, their development, maintenance and management. This initial perspective to working with human problems represented a major advance because it no longer viewed troubled people as morally deficient, and it gave us a common vocabulary - codified in the Diagnostic and Statistical Manual - for describing human problems. But focussed so heavily on pathology that it skewed our view of human nature (O’Hanlon, 1994:22).

Following the Freudian movement though not replacing it came the problem focussed interventions. The view of these approaches was that one could influence an aspect of the system and as a result change the system on the whole. Movement could include personal characteristics that may once have been seen as unchangeable. These approaches to direct practice were generally represented by the cognitive and behavioural schools of thought and were typically focussed on smaller systems such as the family (O’Hanlon, 1994:23).

O’Hanlon goes on to describe what he calls ‘the third wave’ of therapies. In the early 1980s some therapists began adopting what might be called a precursor to the third wave - competence based therapies of which Brief Solution Focussed Therapy (BSFT) is one. We believe that the focus of the problem often obscures the resources and solutions residing within clients (O’Hanlon, 1994:23). These approaches also considered that the client carried with them the solutions to their problems and the practitioner was no longer the ‘expert’ and the source of the solutions. These developments were largely influenced by the work of Milton Erickson and were focussed on solution exploration as opposed to problem development. These approaches considered unhelpful communication styles almost as ‘systems failure’ that resulted in the problem continuing. The fundamental view was that a little change could result in significant differences, however they were still limited to smaller interactional systems.

The third wave coming to the fore in the 1990s draws upon far larger systems including cultures, schools, newspapers and television, experts family and friends to name a few. All those sources of information that tells us how to think and how to be. (O’Hanlon, 1994:23). The view is that there are so many of these messages that we begin to think of them as ourselves. These messages can be very disempowering and destructive. There is a focus on narratives and language in addressing these imbalances. The underpinning philosophy of the narrative approach is that the person is never the problem the problem is the problem.

From the pioneering work done in theory development during the 50s to 70s particularly, many practitioners began to develop differing ideological frameworks for practice. A number of models of brief family therapy developed drawing upon the theoretical base of either psychodynamic or systems theory. These include; Psychodynamic, Structural, Systemic and Strategic Brief Family Therapy models (Kosmas, Smyrnios and Kirkby, 1992:119-127).

The Growing Discontent

Over the past 30 years there has been a notable increase in the number of models of relating to direct practice from 60 to more than 400. From the years of outcome studies available researchers have not found any one theory, model, method or package of techniques to be reliably better than any other. In fact, virtually all of the available data indicate that the different therapy models, from psychodynamic and client-centred approaches to marriage and family therapies, work equally as well (Miller, Hubble and Duncan, 1995:53-54).

There is no evidence that any particular approach or model exclusively works more effectively than another across the range of presenting issues. Lambert (1992:112) suggests that the newer qualitative reviews based on meta analysis have been more likely to reflect small differential outcomes, albeit with little consistency. Add to this the view that brief therapy is no more brief than any other approach and given the proliferation of approaches in recent decades it would seem improbable that all of these approaches have something unique to offer the field of psychotherapy (Miller, Hubble and Duncan ,1995). In fact Miller et al. (1995) suggest that the research evidence to date indicates the similarities rather than the differences between models account for most of the change that clients experience across therapies.

This underlying criticism of direct intervention models has grown into a trend towards questioning the unquestioned application of any particular approach or school of thought. (Goldfried, 1980). We seem to be entering a period of self examination, with therapists beginning to ask themselves such questions as, where does our approach fail? What are the limits of our paradigm? Do other approaches have something to offer? (Goldfried, 1980). This comment by Goldfried in 1980 compares to the comments made in later years by Miller et al. (1995) in the Third Wave Article.

A Move Towards Eclectic Practice

The eclectic approaches to direct care set out to identify the common elements of practice across varied approaches and to achieve recognition of these commonalities in terms of their active ingredients. Eclectic practitioners’ are relatively atheoretical and draw upon a range of empirically tested techniques in their practice (Orlinsky and Howard, 1987:6-7; Lambert, 1992:95). The constructionist/ post modern movement may learn a lot from the eclectic thinkers. The constructionists may have developed a unique stance on considering what the client says from within that context however, it can be argued that the constructionists move away from what is historically a key component of our intervention, that is, independent rationale and experience. Eclectic practitioners’ suggest that aspects of these approaches are useful though would also offer strategies to clients that have been demonstrated as effective. Eclectic practice may be developing as a challenger to the trendy narrative/ post structuralist approaches of the 90s.

The ‘What Works’ Relationship To BSFT

Read more about "What Works" in Psychotherapy.

The Client/Practitioner Relationship

Psychotherapy research consistently supports the BSFT view of the therapeutic relationship. Positive treatment outcomes are linked to therapists developing warm relationships with clients, working to accomplish the clients goals (rather than the therapists’ agendas), listening to clients, and collaborating with clients regarding significant decisions about their treatment (such as what topics will be discussed, when treatment will end, and so on) (McKeel, 1996:261).

I would like to take the opportunity to discuss some aspects of the client/ practitioner relationship that attracts much discussion daily in the social work profession , these being the notions of (1) empowerment and collaboration with respect to the goals of the intervention and (2) feedback on which to take further action. Empowerment for this paper should be considered as being the clients felt and actual ability to be actively involved in the process they are undertaking. Involvement includes a say in the process, content and outcome or goals of the intervention.

Empowerment, Self Efficacy and Collaboration

The concept of empowerment has many aspects, two of which are the concepts of self efficacy and collaboration. The literature suggests a clients sense of collaboration with the therapist is linked to session effectiveness, the client continuing treatment and positive therapeutic outcomes (McKeel, 1996:255; Miller, 1995). Self-efficacy is concerned with judgements and beliefs a person has about their ability to act in a given situation (Bandura, 1997).

BSFT as it indicates in the name endeavours to focus on solutions to peoples problems rather than the problem itself. Remembering the underlying idea that the client and therapist co-create solutions as a result of the relationship, there have been a number of thoughts on empowerment and self-efficacy. In the book ‘Interviewing for Solutions’ there is the argument made that traditionally authors have placed an emphasis on clients problems and expert solutions (DeJong and Berg, 1998:10) and in fact this might be far from the mark. The post structuralists’ would certainly think so.

Egan (1986) describes a number of thoughts on empowering relationships including the practitioner as expert ie, the more knowing participant in the relationship. He outlines the role of the helper as consultant versus helpers as agents of social influence. Egan suggests that if client self-responsibility and self-efficacy are important values, then helpers can be viewed as consultants hired by clients to help them more effectively face problems in living (Egan, 1986:23). Bandura (1997:2) suggests with respect to self-efficacy that the more people bring their influences to bear on events in their lives, the more they can shape them to their liking. By selecting and creating environmental supports for what they want to become, they contribute to the direction their lives take.......... (t)he environmental supports for valued life paths, therefore, are created both individually and in concert with others.

Empowering clients for the social worker working from a post-structuralist perspective suggests that the therapeutic relationship should strive to enhance the clients existing competence in a way that the client can recognise and make use of in the future. Saleebey (1992:8) suggest that empowerment means helping people discover the considerable power within themselves, their families and their neighbourhoods. Saleebey calls this view of empowerment the strengths perspective. I like Saleebeys inclusion of the term neighbours in his definition as it has the potential to include a broader social work rather than psychotherapy context in which to consider BSFT. It is also interesting to note in the literature the shift in the emphasis of BSFT to considering broader cultural and demographic considerations (Berg and Ruess, 1998; DeJong and Berg, 1998; Miller et al. 1996; deShazer, 1985, 1988) Saleebey indicates that the clients frame of reference and their perceptions about what might be useful is as useful as the scientific evaluation of the problem and the solutions (Saleebey, 1992).

So, if it is generally felt in the literature that empowerment and self-efficacy is an important aspect of the client / practitioner relationship and that this relationship is an important aspect of successful outcomes, What has BSFT got to offer the professional relationship in terms of developing client empowerment and self-efficacy?

DeShazer writes ...therapy is a conversation between at least two people (minimally one therapist and one client) about reaching the client’s goal. When as a result of this conversation clients begin to have doubts about their immutable framing of their troublesome situation, the door to change and solution has been opened. This is the essence of brief therapy deShazer (1990:98). This view is endorsed by Bandura (1997:101) who says ...social persuasion serves as a further means of strengthening people’s beliefs that they posses the capabilities to achieve what they seek. It is easier to sustain a sense of efficacy, especially when struggling with difficulties, if significant others express faith in one’s capabilities than if they convey doubts. In order to open this ‘door’ the therapist has a number of techniques available that allow for the introduction of a challenge to the all or nothing perspective that the client is assumed to bring to the session. The practitioner is listening to the clients concerns while simultaneously challenging the all or nothing rule and potentially developing a new perspective.

There is a focus throughout the contact on what has worked previously for the client and as little attention as possible is placed on a discussion of the disempowering problem. Hepworth and Larsen (1993) point out that a major source of gain in the helping process is an increased sense of self efficacy. Self-efficacy is the expectation or belief that one can successfully accomplish tasks or perform behaviours associated with specific goals. Performing behaviours that are foundations to achieving goals are instrumental in actually achieving these negotiated goals and a subsequent increase in self-efficacy and more successful outcomes. The context in which the client is empowered enough to act is obviously necessary for change.

Here primacy is given to the clients competence and unique knowledge of their environment needed to facilitate change noting the session is client driven. In this view there is evident a significant amount of unconditional positive regard and support and respect for the clients gains. The therapist responsibility is to identify what the client wants to achieve in therapy and can offer the observation and reflection not the answers.

BSFT has a variety of techniques that assist the client in noticing differences and making change in their situation. Namely the use of clearly defined goals, pre-suppositional questions (questions assuming that competence to change exists), solution talk, a formula ‘first session task’ (homework) and a focus innate in this process of developing productive client\ practitioner collaboration (Miller et al. 1996). Solution focussed interviews are unique with regards to the concrete and clearly identifiable questions asked: the miracle question (for amplifying client goals), relationship questions (for drawing out alternatives and contextualising client perceptions, exception questions (for uncovering client successes and strengths), scaling questions (for measuring client progress and in general, helping client render vague perceptions more concrete and identifiable) (Berg and DeJong, 1996:377).

These questions may appear unique to solution focussed interviews in terms of their deliberate and reinforced use, however a review of any general counselling text suggests that establishing an understanding of what the client has already tried to do about their situation, establishing some goals for the intervention ie, a significant aspect of the counselling contract and understanding the context of action are fundamental to successful a intervention (Shulman, 1991; Hepworth and Larsen, 1993).

Goal Formation and the Expectancy For Change

Mutually developing a contract is vital as it helps in the process of empowering the client and developing a collaborative relationship, it also allows the client to consider what is realistic from the experience. The practitioner has the responsibility of selecting and supporting the implementation of interventions that are directly related to the problem and the goals (Hepworth and Larsen, 1993:30). Practitioners working from a post structuralist perspective would not consider that they have the responsibility for selecting interventions related to goals individually but rather create goals through narrative, co-creating interventions and goals with the client. Solution focussed practitioners will commence by asking the client ‘what is important for you to talk about today?’. From this point naturally enough, information would come forward from the client about the situation. In terms of developing goals that are concrete the counsellor would enquire as to when the presenting issue has not occurred or at least been less effective in impacting negatively on the clients life. The client would be asked to identify some of these differences that have been co-created in the discussion and to scale the effect of these differences from say 1 to 10. Developing an understanding of how these differences may have occurred allows for a discussion on how they might occur more. The counsellor is building on the competence of the client and the concerns that they presented with. Goals are developed by asking questions such as, What is different from the time we made this appointment until now? This question pre-supposes that the client has some competence that can aid in the development of solutions. It allows the practitioner and client to examine changes that may have already occurred but may have gone un-noticed. Other questions may include, What would it be like when this issue no longer a problem? How will you know when you have got closer to (the solution)? What will you notice about yourself at this time? What will others notice about you when you are more in control? The responses to these questions are sought in great detail and from this conversation concrete, behavioural and measurable goals are set incrementally and aimed at achieving the final goal as negotiated with the client. The client is at the centre of the goal development and actively involved in the process.

A study on the BSFT relationship (Beyebach et al. 1996: 314-329) considered the aspect of expectancies including such variables as:

  1. Internal locus of control expectancies ie clients being convinced that their goal achievement is dependent upon their actual behaviour,
  2. Self-efficacy expectancies ie. the belief that certain actions can be operationalised and,
  3. Success expectancies relating to the belief outcomes will be possible in the probability.

This study found that there was a positive correlation between pre-treatment change, generalised locus of control and self-efficacy. The results provided for some empirical evidence in support of some of the assumptions of BSFT. Particularly pointing to the positive correlation between pre-treatment changes, clear goals and outcomes. (Beyebach 1996). Several process studies have suggested that clients can make some to significant improvement in their situations before attending the first session. This has ranged from 15 to 40% of clients studied (Allgood, Parham, Salts and Smith, 1995; Howard et al, 1986).

Also the research suggested negotiating well formed goals should be thought of as a process that occurs when clients feel that solving their problems will depend on themselves, and when they have high hopes that their problem will be solved (Beyebach, 1996:323). The clients belief that their goals will be achieved as a direct consequence of their own behaviour was found to be a significantly influential factor relating to successful outcomes.

Kiser (1988) and Kiser and Nonally (1990) found an 80% success rate (65.5% of clients met their goals while 14.7% made a significant improvement) with an average of 4.6 sessions. When contacted 18 months later the success rates had increased to 86%. (de Shazer, 1991:162)

DeJong and Berg (1988) suggest that 26% of clients only attend one session and more than 80% came for four or fewer sessions. The overall results following a follow up telephone survey indicated that 45% of clients said there goals were met, 32% said there goals were not met but there had been some improvement and 25% said there had been no progress made. (DeJong and Berg, 1988: 192-193)

In addition to a need for well formed goals identified in the Beyebach (1996) study, pre-treatment change was found to also positively correlate with successful completion of therapy (Beyebach, 1996). This may well relate to the clients internal locus of control. It may be argued that if a client has a view that their behaviour has a direct relationship to the outcome then by simply making the appointment to commence work may have a positive enough effect that they can then consider making changes themselves. This shift may be intentional or otherwise. The BSF practitioners, on the initial contact phone call will often ask a question around noticing changes between the initial call and the first appointment.

This research however limited largely to client feedback confirming pre-session change when responding to pre-suppositional questions, would suggest that the task of the solution focussed therapist is to collaboratively increase the clients expectation in their ability to make changes in their situations. The intervention process reinforces this thinking in that it encourages clients to consider or co-create examples of positive change, and subsequent actions that have been successful though possibly unrecognised through the use of exceptions questions.. In addition, pre-suppositional questions allow the practitioner to highlight in the client a sense of possibility and client strengths through the questioning process. Pre-suppositional questions assume competence or strength in the client. A pre-suppositional question typically looks like this, ‘How is it that you were able to do this?’ Pre-suppositional question couched as a difference question can assist in building on client strengths. Building on a clients weak belief that they can make a change may assist in negating the more probable negative experiences and lead to more successful outcomes (Bandura, 1997).

It may be that the benefit of a Solution Focussed approach is not in discovering what it is that works but rather a discovery that one can make it work (Beyebach, 1996). Subject to much more research, it might be that BSFT techniques have something to offer practitioners in terms of addressing and utilising pre-session change as a therapeutic device. The theoretical justifications for BSFT have undergone some revision in relation to the developing thoughts of post structuralist writers, however the techniques have remained the same.

Conclusion

The BSFT movement is continuing to undergo change at least in terms of its definition of terminology as a result of the continued development of post structuralist theory.

BSFT initially developed during a time of increased interest in exploring new approaches to therapy and has been demonstrated to having developed from the same theoretical base as a number of other practice approaches. This paper argues that the generation of ‘new’ forms of therapy are predominantly an exercise in marketing. BSFT has provided little evidence of being more effective than any other approach in the general therapeutic relationship. On the other hand evidence of what works in practice across a wide range of approaches lends itself favourably to the aspects of BSFT that assist in developing a collaborative therapeutic relationship and well formed goals. BSFT may offer valuable contributions to the knowledge base of eclectic practitioners by adding to the view of ‘what works’ generally. The focus of BSFT in this area as well as areas of professional supervision might well be something that it has to offer the field of social work.

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