Solution-focused brief therapy
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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.
SFBT is future-oriented and goal-oriented interviewing technique that helps clients "build solutions." Elliot Connie defines solution building as "a collaborative language process between the client(s) and the therapist that develops a detailed description of the client(s)' preferred future/goals and identifies exceptions and past successes". By doing so, SFBT focuses on clients' strengths and resilience.
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 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. SFBT is what evolved from the Brief Therapy that was practiced at MRI.
SFBT might be best defined by what it does not do because SFBT presents an innovative and radically different approach from traditional psychotherapy. Traditional psychotherapy looks at how problems happen, manifest, and resolve. 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. he problem-solving approach is influenced by the medical model, where the symptoms are assessed to diagnose and treat the malady. Outside of SFBT, the almost universal belief is that the clinician must define and understand the problem to help. To do this, the practitioner must develop some information about the nature of problems that they will help resolve and ask questions about the client's symptoms. The more common problem-solving approach includes a description of the problem, an assessment of the problem, and plan and execute interventions to resolve or mitigate the impact of the problem. This is followed by an evaluation determining the success of the intervention and follow-up if necessary.
Solution-focused therapists see the therapeutic change process radically differently. SFBT posits that a therapist can help clients resolve their problems without identifying the details or source problem and completely avoids exploring the details and context of the problem. SFBT believes that an assessment of the problem is entirely unnecessary. Focusing on the problem actually may serve to shift the client away from the solution. This is because SFBT fundamentally believes that the nature of the solution can be completely different from the problem. So instead, SFBT focuses on building solutions by conceptualizing a preferred future with clients. SFBT is all about finding alternatives to the problem, not identifying and eliminating the problem.
SFBT is strengths-based and supports clients' self-determination. Using the client's language, SFBT uses the client's perspective and fosters cooperation. The focus on the strengths and resources of clients is a factor in why some social workers choose SFBT.
SFBT is designed to help people change their lives in the fastest way possible. By finding and amplifying exceptions, change is efficient and effective. Treatment usually lasts less than six sessions, and it can work in about two sessions. Its brevity and its flexibility have made SFBT the choice of intervention for many health care settings. Interventions in a medical setting many times need to be brief. Agencies also choose SFBT because its efficiency translates into monetary savings.
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. The initial group included married partners, Steve de Shazer, Insoo Berg, Wallace Gingerich, Alex Molnar, 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. 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.
In the 1970s, Steve de Shazer, Insoo Kim Berg, and colleagues conducted Brief Family Therapy at a community agency and installed one-way mirrors to observe sessions with clients to study which activities were most beneficial for the clients. When the administration disallowed the one-way mirrors, Steve de Shazer, Insoo Kim Berg put together a team of practitioners and students and founded the Brief Family Therapy Center in Milwaukee, Wisconsin, to continue their work. The result was the eventual development of SFBT.
In 1982 there was the watershed moment where the founders of SFBT, Insoo Kim Berg, Steve de Shazer, and their team transformed their Brief Therapy practice to become Solution-Focused. A family came to be treated at the Milwaukee Brief Family Therapy. During the assessment, the family provided a list of 27 problems. The team was at a loss as to what to suggest the family try to do differently. They suggested that the family come back with a list of things they want to continue to happen. The remarkable effectiveness of this spontaneous intervention led to the understanding that the solution is not necessarily related to the problem. This was the beginning of Solution-Focused Brief Therapy.
SFBT practice began to be popularized starting in the late 1980s and experienced tremendous growth in its first 15-20 years. In the late 1980s Evan George, Chris Iveson and Harvey Ratner founded Brief Therapy Practice (now called BRIEF), the first clinic to practice SFBT in the UK. SFBT gained tremendous popularity in the UK in the late 1990s and the 2000s. At that time, it also spread worldwide to be a leading brief therapy, with many agencies adopting SFBT as their only modality. It is now one of the most popular psychotherapeutic modalities globally. SFBT respects the clients' strengths and right to self-determination, which are important social work values making SFBT an ideal intervention for social workers.
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.
In SFBT, the questions themselves are the intervention. SFBT practitioners use conversational skills to evoke a discussion about solutions, also known as "solution talk", which is very different from "problem talk". SFBT questions help clients think about their situation in a solution-focused way. They attach new meaning to their experiences, noticing change potential where they might not have noticed it before. The questions focus the client to a conversation that creates and fosters a change-inducing mindset and decreasing negative feelings.
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 questions ask a client to talk about their preferred future. They are asked to describe what would be different when the problem is solved or managed. For example, "What would you notice that lets you know that the problem that brought you to see me is solved?" SFBT posits that change happens when people focus and flesh out details of their preferred future. One SFBT practitioners' tool to help the client describe their preferred future is the "miracle question." This question asks the client to imagine that the problem was miraculously solved without their knowledge. It then asks, "What would be some of the first clues they let you know your problem is solved?".
The therapist also asks questions that focus on looking at previous solutions or "exceptions" to the problem. In SFBT, "Exceptions" in SFBT are the times that the problem is smaller or is coped with better and SFBT believes that every problem has exceptions. 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;Finding exceptions helps build solutions by helping find what is working in the clients' lives. By finding and amplifying minor exceptions to the problem, they explore what is already working and orient the client to do more of what already is working.
When looking for exceptions, the practitioner does not try to convince the client that the exceptions are significant. That would go against the SFBT stance that sees the clients as the expert of their life. Instead, the therapist maintains a genuine, curious stance and asks the client to tell them how they interpret the significance of the exception. The therapist needs to maintain a not-knowing stance which can be challenging for emerging SFBT practitioners.
One tool that SFBT practitioners use to help find exceptions to ask start sessions (other than the first) with the question "What's been better since we last talked?". This question reframes the clients perspective to look for exceptions i.e. the areas that are better. Another tool practitioners use is "scaling questions." A scale is used to measure where the client rates themselves in achieving their goal. They are then asked what they notice is working that makes them rate themselves as they do and not lower. They also are asked for details about the times when the problem is less. Then, "how are you doing it?" or "how did you do it?". Exceptions can also take the form of coping, so a SFBT practitioner can ask "coping questions" to find exceptions. For example, "It sounds like a lot is going on… how are you managing?". When a client identifies behaviors that work for them, they are encouraged to continue those behaviors.
With SFBT, the session is very structured. There is a particular way to conduct a session, and there are formulated interviewing techniques used. Compliments are one of the primary tools of the solution-focused approach. 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. Practitioners report that fidelity to the philosophy is more important than fidelity to the techniques.
SFBT is radically simple and looks easy to do, but in truth SFBT is very hard to learn. SFBT requires a very disciplined practice. Because of this, many practitioners end up using components of SFBT and not practicing pure SFBT. This is often done because it can be challenging for a practitioner to change from a problem-focused stance. On the side of the coin, many new SFBT trainees struggle with being overly optimistic and with not truly validating clients' pain. This might be because the focus necessary to apply their newly learned SFBT skills and techniques take the focus away from being 'with' the client. Authentic SFBT practice requires the therapist to be very attuned to the clients' verbal and non-verbal communication and adapt the questions to meet and better understand the client's perspective.
Tenets and Assumptions of SFBT
A SFBT practitioner has to carry several assumptions to carry into the session to truly and effectively engage in authentic SFBT practice. One core SFBT assumption is that clients are the experts in their lives and know what is best for them and how to achieve their goals. This is the essential assumption that defines SFBT. With authentic SFBT practice, there is no such thing as resistance. The therapist is only the expert on the questions that will evoke the change process. SFBT assumes that the clients have all they need to build a solution; they do not need the therapist to teach them skills or tell them what to do. The stance of curiosity and not knowing is essential for SFBT.
Another overarching tenet of SFBT is the idiom "If it isn't broken, don't fix it". This means that if the client feels that things are working, the therapist shouldn't encourage therapy.
In SFBT the therapist assumes that every client is motivated to change. The therapist's job is to uncover what it is that the client is motivated for.
SFBT assumes that it's not necessary to understand the problem to be able to build a solution. The problem and solution are not even necessarily related. 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".
SFBT assumes that small changes can be the catalyst for big change.
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'.
Evidence based status
Several meta-analyses show SFBT to be effective with internalizing issues. SFBT has a robust, broad, and growing evidence base and is recommended for use when deemed a good fit for the client and their problem.
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 cognitive behavior therapy and interpersonal psychotherapy. 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.
Applications of SFBT
SFBT is very adaptable to many settings because it helps the clients create custom-made interventions for themselves, and the client is always considered to be the expert. Even the practitioner's language is taken from the words the client uses to describe their life and preferred future. The result is that SFBT provides interventions that are perfectly matched with the clients' way of understanding and acting. Techniques such as the miracle question can be adapted to make them more culturally relevant and come across in ways more empathetic and supportive based on the culture and needs of the population being served. It is no surprise that SFBT can be and has been used in a wide variety of settings, populations, and problems.
SFBT works well with children and families and can be applied to many family-related situations. It is effective with adolescents, pregnant and postpartum women, couples, and parents. SFBT was shown to be effective for families in the child welfare system, with case management in social welfare programs, financial counseling, and with therapy groups.
SFBT has been applied to many settings, including education and business settings. It is effective in schools and with college students. It was successfully used with populations in jails, inpatient addiction rehab centers, inpatient psychiatric facilities, and in a wide range of medical settings. It has been helpful with treating family members of patients with serious illnesses.
SFBT works in treating people who experienced trauma. It has been suggested to use with patients that are suicidal or in crisis, families coping with suicide, and patients with eating disorders substance use disorders, and obesity. It was also suggested as a promising intervention for individuals with a brain injury and was helpful with those with intellectual disabilities. It has even been documented to have been successfully used with a patient in a psychotic crisis.
Workers with child protective services report in a qualitative study that SFBT training and supervision was helpful for them to work in a more cooperative and strength-based way and improved the overall mood and atmosphere of their encounters. There are models designed for child protection services that incorporate aspects of SFBT because SFBT alone cannot be used for child protective services because a more authoritative approach is necessary.
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 behaviors – 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.
Elements of solution-focused brief therapy resemble 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.
Critique of SFBT
SFBT has been criticized because it does not include discussions about how the client feels. However, good SFBT practice does just that while still staying true to SFBT principles. The emotions that the client brings up are never ignored or minimized. At the beginning of the session, the client is asked, "How can I help?", "What is important for me to know?". The client will generally talk about the problem, and the social worker will engage in active listening and show genuine empathy. The critical difference is that in SFBT this is done out of respect for what the client feels is important and demonstrates genuine care for the client. "Problem talk" is never done as a primary therapeutic technique or a way to conduct an assessment. So SFBT does validate the clients' negative feelings and elicit positive emotions. However, ultimately SFBT believes that change primarily occurs with creating solutions, not bettering emotions.
Critics say the SFBT does not always give clients what they need. Some clients need a more significant focus on emotional support and a robust empathic relationship with the therapist. Other clients might clients need medication or other external help.  However, SFBT does not claim to be the only thing that the client would need. In fact, the foundation of SFBT is to ask the client what they want and to trust what they say they need to achieve their goals. SFBT will support the client in finding what works for them.
In the early days of the model, critics often said that SFBT does not have enough research. In 2000 a review of SFBT research just showed that SFBT only had preliminary evidence of efficacy. However, in 2010 the SFBT research grew to a level where the evidence was promising. As mentioned above, today several meta-analyses show that SFBT is effective and SFBT now has a robust, broad, and growing evidence base.
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