A 3000 word reflective account of Solution Focused Brief Therapy within a practice placement setting
This assignment is a personal reflective account on the use of solution focused brief therapy (SFBT) carried out during a practice placement within a Crisis and Home Treatment Team (CRHT). This assignment aims to discuss the importance of the 10 Essential Shared Capabilities, introduce clear definitions of SFBT, evaluate current research of SFBT, and provide an evaluation of the key principles of SFBT. I will make a brief comparison of SFBT and traditional psychotherapy.
I will utilise aspects of Gibb’s Model of Reflection (1988) when discussing my own thoughts and feelings in order to critically analyse and evaluate two key features of SFBT interventions used in practice. This will allow me to identify positive aspects of my practice as well as highlighting aspects which need further development. Finally, I will evaluate the theoretical framework underpinning its relevance in current and future practice. De Shazer & Dolan (2007) defined SFBT as “a future focused, goal orientated approach to brief therapy”. Iveson (2002) proposes that SFBT focuses on “solution building rather than problem solving”.
As such, SFBT does not require a detailed history of the past or problem due to its solution focused nature. The client is believed to have the necessary resources to implement changes. Furthermore, Macdonald (2007, p. 7) stipulates that the client has the capacity to use these resources to set their own goals for therapy. In a general sense, psychotherapy aims to aid clients to reach their full potential or to develop better coping mechanisms to deal with their problems. During psychotherapy a client will develop skills to become self aware, change their unhelpful cognitive schemas, and develop insight and empathy (O’Connell, 2005).
Additionally, psychotherapy assumes that, with guidance, each client has the capacity to overcome their discomfort or distress. There is considerable agreement in literature regarding the main characteristics of SFBT (De Shazer & Dolan, 2007; O’Connell, 2005; Lethem, 2002; George, Iveson & Ratner, 1990; Sharry, Darmody & Madden, 2002). It is believed that therapy must convert from focusing on the presenting problem and move towards looking for solutions (O’Connell, 2005). Therefore, the therapist must consider the client’s subjective, individual interpretations of the given problem.
O’Connell (2005) reports that this phenomenon is a result of social constructionism. Social constructionism proposes that client’s theories are created as a result of social interaction and negotiations with peers. As result these theories are fluid, constantly changing with knowledge, and therefore move away from any certainty (McNamee, 2010). For example, Walter & Peller (1994, p. 14) reported that if a therapist was to lead from behind, by allowing a client to talk about their experiences, this would encourage the client to become increasingly aware of aspects of the perceived problem that had previously been disregarded.
Rosenbaum, Hoyt & Talmon (1990) theorised that improvements can be achieved by the change of the smallest aspect in the client’s life, and that it is this smallest, positive, initial step that will inevitably lead to greater improvements for the client. Furthermore, Sharry et al (2002) highlight that it is not possible for a client to experience one emotion all of the time, and that there must be times when the problematic emotion is more or less intense. They stipulate that it is the therapists’ role to determine when the emotion is less severe and encourage the client to do more of these behaviours.
In addition to this, Sharry et al (2002) advise that the therapist should not focus failed solutions or advise the client to continue with behaviours that are problematic. Clients are advocated to actualize their preferred future by implementing small changes that have proved to be positive solutions. The idea of a preferred future is dominant with the SFBT approach. This is seen throughout a SFBT session, from the initial clarification of the client’s goals for therapy to the client being encouraged to describe in detail what their future without their problem would look like by use of the miracle question (De Shazer & Dolan, 2007).
De Shazer & Molnar (1984) advise that is important to be mindful that clients may think they have to do something which they feel is expected of them by the therapist, even though this may not necessarily be right for them. As such, I feel that asking about the client’s preferred future can be a high risk strategy for vulnerable clients as it may initiate a negative response and prolong feelings of hopelessness. There are many similarities of the underlying assumptions of SFBT and other psychotherapies.
For example, the goals for therapy are chosen by the client (O’Connell, 2005). In addition to this, all psychotherapy assumes that the client has the resources they need to implement change (Macdonald, 2007, p. 7). However, the main differences between SFBT and other psychotherapies are that a detailed history is not needed, the perceived problem is not analysed, the treatment process begins within the first session of therapy and that SFBT does not believe a person’s perception is maladjusted or in need of change (O’Connell, 2005).
It is evident that SFBT draws upon numerous therapeutic approaches. I believe SFBT shared a number of theoretical principals with person-centred therapy. Rogers (1951) hypothesised that human’s have an intrinsic ability to self-actualise, which can be seen explicitly in SFBT in identifying the clients strengths and resources (Saunders 1998). In terms of person-centred counselling, the way SFBT highlights these factors is directly facilitating the self- actualization of the client. Furthermore, both theories take an eclectic approach to the client’s situation.
For example, the importance of the whole person in person-centred counselling is associated with the interest in the whole context of a person’s life in SFBT (Iveson, 2002). Hales (1999) describes how person-centred therapy believes that the client is in control of the counselling process and makes judgements about their decisions and experiences; this is seen much more overtly in SFBT as the clients are asked directly their goals for therapy and how they would know that therapy had been worthwhile.
Both approaches provide client-orientated counselling which aims to promote self esteem and coping strategies for the client (Hales, 1999). By employing the underlying principals of SFBT into future training, my practice will remain aligned with the Ten Essential Shared Capabilities (Department of Health, 2004). In particular, SFBT focuses on ‘working in partnership’, ‘identifying people’s needs and strengths’, providing service user care’ and promoting safety and positive risk taking’ (Department of Health, 2004, p.4).
In a literature review, Ferraz & Wellman (2008) emphasise that it is possible to incorporate these essential capabilities into SFBT techniques in current practice. They suggest that SFBT is particularly appropriate when staff have relatively brief contact with clients. SFBT is congruent with these essential capabilities, enabling nurses to develop improved therapeutic relationships with clients, improved communication skills, and a goal orientated approach to recovery (De Shazer & Dolan, 2007).
Whilst there is limited research surrounding SFBT in comparison to other psychotherapies, the evidence base has developed in recent years (Gingerich & Eisengart, 2000). However, much of the initial research was conducted by the pioneers of SFBT, e. g. De Shazer & Molnar (1984) and Kiser (1988), and is therefore likely to be in favour of SFBT. In terms of success rate, Kiser (1988) and Kiser & Nunnally (1990) conducted six month follow up studies which showed an 80% success rate of clients who had received SFBT.
However, these studies can be criticised as only 14.7% clients reported considerable improvements beyond meeting their treatment goals. Much research into the effectiveness of SFBT concludes a success rate which is calculated by a combination of clients who achieved their goals and clients who made significant improvements. Further to this, Macdonald (1994; 1997) argued success rates of 64% at a three year follow up. Moreover, DeJong & Berg (1998) report that SFBT achieves 70% or more success rates for multitude of social and mental health issues, including depression, suicidal ideation, relationship difficulties, domestic violence, and self-esteem.
As such, the underlying principals of SFBT can be applied to the Seven Stage Crisis Intervention Model (R-SSCIM; Roberts, 1991). For example, stage 3 of Roberts’ model (1991) help clients to identify their strengths, resources and past coping skills. This can be achieved through the use of exception and coping questions (O’Connell, 2005). De Shazer & Dolan (2007) expand on this by advising that identifying strengths and resources can help build rapport and trust with the client as the focus is shifted away from short-comings and towards complimenting the client.
During Stages 4 & 5, feelings and emotions are explored, and alternatives are generated and explored (Roberts, 1991). SFBT utilises these stages by acknowledge client’s current experiences and aiding them to create an action plan. The client I chose to utilise SFBT techniques with had an extensive mental health history. He has been known to community services for the past 5 years, and has a diagnosis of major depression. He had been referred to CRHT following deterioration in mood and was expressing suicidal ideation. The client had consented to me using SFBT techniques during a home treatment visit.
I utilised several assessment tools of SFBT including pre-session changes, goal setting, exception seeking and coping questions, miracle question, scaling question, and task setting. I have chosen to reflect on the use of scaling questions and exception seeking questions. O’Connell (2005, p. 35) stipulates that scaling is a technique whereby the therapist asks the client to rate on a scale of zero to ten, where zero is the worst they have felt recently and ten is the best they have felt recently, for a particular issue.
O’Connell (2005, p. 35) goes on to state that scaling can be used to set treatment goals, measure progress, establish priorities, rate the clients motivation, and discover the client’s confidence in resolving their issues. I have chosen to reflect on scaling techniques as I felt confident and noticed my personal strengths but also identified some areas for development. I first introduced scaling with my client when asking about pre-session changes.
I explained the scale to him and asked where he would place himself today and if this was any different from when he had contacted CRHT. I reassured the client by complimenting him for contacting CRHT regarding his mental health. The second time I used scaling questions was following the miracle question. This was to assess whether the client had shown any sessional changes from the score he reported earlier. Finally, I used scaling when amplifying homework tasks. This was to assess whether the client was motivated and confident in achieving these tasks, and whether these tasks would improve the client’s depressive symptoms.
Throughout the home visit, I felt extremely nervous, tense and pressurised because I was also being assessed by my mentor as part of the Direct Observation of a Nursing Activity. I was also aware that the client was at crisis point and was somewhat volatile in mental state. This made me feel inexperienced and very aware that I had limited training in SFBT. Initially, I felt apprehensive at making a mistake or asking the wrong question, and this was clear to the client when I had perplexed the explanation of the scale.
Upon reflection, my emotions affected my performance throughout the intervention; for example, as I became more relaxed I gave a more apparent explanation of the scale for confidence in completing homework tasks. My strengths were that I was able to obtain a baseline of the client’s rating of their mood, affirm sessional changes to mood, and attain a rating of the client’s motivation and confidence in achieving set tasks. I felt the client responded well to the scaling questions as it did not involve him explaining in depth his feelings, but rather focused on how to resolve his current crisis state (De Shazer & Dolan, 2007).
However, I feel my weaknesses lie in the timing of the scaling questions. For example, I introduced the scale near to the start of the home visit and then a further two times during the visit. As a result I felt I had to explain the scale each time I used it. I feel this made the intervention slightly disordered and therefore illogical to the client.
The use of scaling questions following the miracle question was partially inappropriate as the client stated that he had just answered questions regarding his preferred future (i. e. where the client would like to be on the scale) when amplifying the miracle question. In hindsight, I feel that these questions were somewhat unnecessary. In contrast to this, De Shazer & Dolan (2007) stipulate in their G. E. M. S approach that scaling questions should follow the miracle question due to its effectiveness in obtaining measures of where clients would rate themselves today, and their preferred future. Furthermore, O’Connell (2005, p. 52) describes the importance of scaling questions with regard to communication with a client.
He advises that it gives the opportunity for the client to express how they are feeling and eliminates the therapist making assumptions. He argues that scaling provides a comprehensive interpretation of the client’s feelings on a particular issue, with limited scope for individual interpretation. However, there is much research (Chant, Jenkinson, Randle & Russell, 2002; Sumner, 2001) to suggest that communication and interpretation of a client’s feelings is eclectically gained through the practitioner’s emotions, personal development, perception of others, and the circumstances of the interaction.
I feel this is particularly relevant to my performance since my communication was adversely affected initially due to my anxieties and the circumstances of being assessed. This therapeutic intervention provided me with first hand experience of these barriers to communication (Sumner, 2001) and as such I am aware of how my communication is affected by anxiety which in turn impacted on the scaling technique I was using. This issue could be resolved through the use of further reflections and SFBT with other clients.
I feel that utilising SFBT techniques in my future practice will improve my confidence and my ability to concisely deliver explanations of scaling questions as I will no longer feel like a novice. I have also chosen to reflect on the use of exception questions with the client as I feel that I need to expand my current knowledge base of how to carry out these questions effectively in order to develop my skills in SFBT. Macdonald (2007, p. 15) advises that exception seeking questions are particularly useful when clients are feeling hopeless.
I feel this was very relevant to my client as he was somewhat resistant to change initially. However, through the use of these questions my client identified small exceptions where he was able to control improve his low mood, which in turn improved his motivation and confidence in setting small tasks. In this instance, I used exception questions with the intention of demonstrating to the client that his low mood was not occurring all of the time. However, my client was vague and negative in his response. I intended to demonstrate previous enjoyment to the client by focusing on spending time with his family.
I felt very inexperienced and incompetent when using this technique as I struggled initially to achieve my intentions. As a result, I felt very aware that I was being assessed by my mentor, which added to my anxieties. I felt frustrated that my client was unable to identify any positive aspects in his life, but began to relax when he described the pleasure he gains from spending time with his children. I felt positive and confident when my client became facially bright and was laughing when telling personal anecdotes.
De Shazer & Dolan (2007) highlight the difference between previous solutions and exceptions, with exceptions being times when the problem could have occurred but did not. In hindsight, I feel I was searching for previous solutions rather than exceptions. Furthermore, they go to theorise that the role of the therapist to recognise opportunity for exceptions during the session rather than actively seek out opportunities to utilise this technique. Therefore, as a skilled therapist I should be seeking opportunities to amplify exceptions rather than explicitly questioning the client in this way.
Due to my limited training in SFBT I felt like a novice and did not utilise the true nature of exception seeking questions. Following this reflection I am now more aware of the difference between previous solutions and exceptions that De Shazer & Dolan (2007) hypothesised, and how they can both influence the therapeutic intervention. As I gain experience and further develop my knowledge base of SFBT, I feel that I will be able to use exception questions when required rather than expectantly.
In my future practice as a registered mental health nurse, I plan to utilise SFBT techniques with service users, particularly those experiencing relapse, as the use of these tools can provide immediate improvements and allows for a future focused approach rather than problem orientated. I must remain mindful of the barriers that exist in communication (Kiser, Piercy & Lipchink, 1993) and apply this when delivering SFBT techniques. However, De Shazer & Dolan (2007) theorise that scaling is a very effective tool for the client to verbalise their emotions.
Therefore, this could be used in my future practice, particularly when building a therapeutic relationship with clients. In terms of current practice, I have effectively demonstrated the scaling technique within cognitive behavioural therapy; however, I am aware that these two therapies use the scale in different ways. To conclude, this assignment has allowed me to develop my knowledge of the key principals of SFBT, the practical applications, and the limitations of my inexperience when utilising SFBT assessment tools.
I believe SFBT shares many fundamental assumptions with person centred therapy. The underpinning principals are apt for contemporary nursing, particularly as it fits wells with the Ten Essential Shared Capabilities (DoH, 2004). There are some limitations to this approach, such as lack of extensive research (Gingerich & Eisengart, 2000). However, I feel that this approach is appropriate to use with clients who are experiencing mental health difficulties.