Solution-Focused Therapy Gains Adherents

The purpose of psychotherapy is to "become unstuck," an expert contends.

Solution-focused clinical practice — brief therapy aimed at achieving behavioral changes in the future rather than resolving problems of the past — continues to gain adherents as its efficiency becomes apparent, according to Joseph Steiner, professor emeritus at Syracuse University.

Rather than operating from a whole therapeutic framework or philosophy, solution-focused practice looks for methods that are swift and inexpensive, said Steiner in workshops at NASW's fall 1999 regional conferences in Los Angeles and New Orleans.

Many clients are stuck, mired in feelings of powerlessness over mental health and substance abuse problems. They need help to muster the energy and vision to begin to become unstuck. This comes not through talking about the past, which Steiner calls "problem-focused practice," but through getting clients to imagine what their future will look like without their problem, their "area of stuckness," he said. "The purpose of psychotherapy is to become unstuck."

With new clients in solution-focused therapy, a small fraction of the first session is spent acknowledging the person and his or her pain, but not in prolonged discussion of etiology and pathology. Then the therapist asks how he or she can be helpful and begins to construct goals and roles with the client.

Several techniques are employed to nudge clients away from areas where they are stuck. One is the "miracle question," said Steiner. Clients are asked to imagine that they went to sleep one night and when they awoke, the problem that brought them into therapy had vanished. How would they first know that something was different? What would others notice about them that would indicate the problem was gone? How would they act differently in the absence of the problem?

As clients construct an alternative reality for themselves, it energizes them, begins to erode their feelings of being a victim and becomes a script for what they do, said Steiner.

When clients come up with a clear list of ways life would be changed without their problem, the items on the list become their goals. Their assignments between sessions consist of trying to make some of the behavioral changes on the list — to live as if their problems didn't exist. "The first change is hardest; later changes are easier," said Steiner.

Therapy doesn't occur when clients experience changed feelings or insights in therapists' offices, but when they make positive changes in their everyday lives, he said.

Another technique to achieve this result is called "scaling." Clients are presented with a scale on which 100 represents the ideal person and 0 the worst. They are asked where they are on the scale. If they say 30, they are asked for details of what 40 would be like, then 50, and so on.

In giving details of how they envision steps up the scale, clients are setting goals and scripts for change. "Clients can't answer the questions without feelings of efficacy, empowerment and hope," said Steiner.

Later therapy sessions are devoted to discussing progress toward goals and encouraging clients as they make changes.

The biggest obstacle to effective practice is the attitude of practitioners who assume that clients will resist change, he said. Solution-focused therapists assume clients have the resources to change and to better their lives. "When you assume they will fight to get and keep unstuck, that's what you tend to see," he said.

The methods are quick, efficient and work for all clients, including those with serious psychiatric diagnoses like schizophrenia and bipolar disease, said Steiner. Research has shown the effectiveness of solution-focused therapy for all age groups, all diagnoses, and for individuals and couples.

In his own solution-focused practice, Steiner said "what took the longest was to truly have faith that seriously ill people have the resources in them to better their lives."

"Isn't that what we're all doing, deciding how we want to play out our lives — sick or well, diagnosed or undiagnosed — recognize our strengths and resources, fight those areas of stuckness where we feel those around us are victimizing us?" he asked. "The essence of life itself is to find those areas where we can become unstuck and move toward a better tomorrow."

Brief therapy methods like solution-focused practice are valuable in a managed care environment because of their efficiency, Steiner said. While some managed care companies act as obstacles to care, many are "truly looking for ways to save money and get people the things they need."

Managed behavioral health care is a response to agencies and practitioners who came to believe that the therapeutic relationship needed to be an end in itself to be effective, and would keep providing services as long as the clients would come back, he said.

Research shows that more people come to therapy for one session than for any other number, yet there is little research at schools of social work or elsewhere on efficiency of one-treatment therapy.

Much of the research in solution-focused therapy has been done at the Brief Family Therapy Center in Milwaukee. Books about the method have been available since the late 1980s, and have become plentiful in the last four or five years, said Steiner.

Some books mentioned in the workshop bibliography include Working with the Problem Drinker by I. Berg and S. Miller, Clues: Investigating Solutions in Brief Therapy by S. de Shazer and A Guide to Possibility Land and Fifty-one Ways of Doing Brief Respectful Therapy by B. O'Hanlon and S. Beadle.

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Copyright NASW Press, 1998