You were provided with literature on Solution-Focused Brief Therapy with the case of Jim. You will write 5 pages in the APA 7th

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Chapter 9 Solution-Focused Brief Therapy: The Case of Jim

Philip Miller

Introduction to Solution-Focused Brief Therapy

Two frameworks are used in this case. The first framework is the solution-focused brief therapy (SFBT) clinical approach, and the second framework is the behavioral health in primary care model. The SFBT framework is a therapeutic approach that emphasizes client strengths, construction of solutions rather than solving problems, and the development of personalized goals to produce change as quickly as possible (Gingerich & Eisengart, 2000; O’Hanlon & Weiner-Davis, 1989; Rothwell, 2005). The behavioral health in primary care framework provides guidance integrating behavioral health services into the primary care setting (Robinson & Strosahl, 2009). To comprehend the intricacies of this case, the SFBT clinical approach must be examined in the context of the primary care model.

Solution-Focused Brief Therapy Framework

Development of the solution-focused brief therapy approach originated from clini- cal practice within the Brief Family Therapy Center in Milwaukee, Wisconsin in 1980 and, a short time later in 1982, this new therapeutic approach was officially named solution-focused brief therapy (de Shazer & Berg, 1997; Gingerich & Eisengart, 2000). The SFBT approach quickly became popular because of its appli- cability in a variety of settings with a diverse clientele. SFBT is now used world- wide (Franklin, 2015). Professionals from diverse disciplines and work settings have broadly applied SFBT to include physicians and nurses in health care settings, teachers to creatively engage with students and families, mental health providers to

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facilitate individual, group, and family therapy, and businesses to better equip man- agement by integrating SFBT into coaching strategies (Franklin, 2015; Redpath & Harker, 1999; Shilts & Thomas, 2005; Stevenson, Jackson, & Barker, 2003). Ongoing research on SFBT has further reinforced its popularity by favoring SFBT as an effective approach to quickly produce sustainable behavior changes (Corcoran, 2016; Franklin, Zhang, Froerer, & Johnson, 2016; Gingerich & Eisengart, 2000; Macdonald, 1997; Rothwell, 2005).

The SFBT approach challenges the traditional structure of mental health services in a variety of ways and may cause dissonance with new SFBT practitioners. As a result, clinical knowledge and beliefs may need to be restructured and familiar clini- cal methods modified. SFBT is not a series of easily applied techniques but a way of thinking about the process of therapy and how change occurs. Without under- standing the assumptions and underlying beliefs of SFBT, techniques will be mini- mally effective. Learning the SFBT approach is an ongoing process and requires openness, training, observation, mentoring, and practice (Froerer & Connie, 2016; Lee, 2011; Shilts & Thomas, 2005).

A critical element to the success of SFBT is the therapist’s belief about the pro- cess of change. Beliefs regarding change need to be critically examined because the SFBT approach assumes that change can and does occur quickly without exploring history, diagnosing, and offering ongoing intervention (O’Hanlon & Weiner-Davis, 1989; Reiter, 2010). In contrast, traditional clinical approaches are problem and complaint focused, rely on finding a cause for the presenting problem, emphasize advice-giving, and oriented toward establishing a diagnosis (Froerer & Connie, 2016; Gingerich & Eisengart, 2000; O’Hanlon & Weiner-Davis, 1989; Rothwell, 2005). SFBT is based on empowering the client by drawing on strengths and abili- ties to construct solutions, rather than the therapist emphasizing the resolution of problems (Gingerich & Eisengart, 2000; Rothwell, 2005; Stevenson et al., 2003). SFBT practitioners also believe that client life struggles and presenting problems are not due to pathology but originate from the patient being overwhelmed and los- ing sight of their ability to solve problems and mobilize their existing strengths and resources. SFBT practitioners assume clients want to change, have the ability to change, and are already taking steps to change. Therefore, within the treatment structure of six sessions or less, a core duty of the therapist is to amplify change, create hope and expectancy, and co-create a path to change through a collaborative process (Franklin, 2015; Franklin et  al., 2016; Gingerich & Eisengart, 2000; O’Hanlon & Weiner-Davis, 1989).

The delivery of the SFBT approach requires specific language skills designed to create hope and expectancy and empower clients to realize inherent solutions (Franklin, 2015). The hope of successful outcomes leads to positive change and the expectation that this will happen is created by the therapist (Reiter, 2010). It is the responsibility of the therapist to shift the client’s problem-focused thinking and speech to solution talk and future-oriented thinking. Solution-focused language is carefully used throughout treatment to promote the realization of positive outcome possibilities and ensure clients link their actions to treatment progress and success (Froerer & Connie, 2016; Reiter, 2010; Taylor, 2005). The use of presuppositions is

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embedded in SFBT language and permeates all SFBT techniques. The use of pre- sumptive language is a type of strategic communication that infers something with- out saying it directly and is a way to introduce change and promote client acceptance that change is occurring (O’Hanlon & Weiner-Davis, 1989). For example, asking the client “What is better?” instead of “Is anything better?” assumes improvements were made and emphasizes change.

The first session involves developing a strong therapeutic relationship and uses the initial assessment as an intervention. SFBT is a collaborative process and prac- titioners rely on the expertise of the client. Therefore, a healthy therapeutic relation- ship is critical for success. Initial engagement requires SFBT practitioners to adopt the language of the client, accept the client’s perspective, understand the context of their identified problem, and intentionally reduce the pathology of the presenting problem by normalizing their concerns (Corcoran, 2016). The initial assessment in SFBT is used as an intervention by immediately engaging the client in the process of change. This may differ from traditional binary assessment models where first the objective is to obtain an elaborate history to understand the client’s presenting com- plaint and to develop a diagnosis, and then move forward with the treatment process (Lee, 2011).

At the beginning of the first session, the SFBT practitioner asks the client, “Please tell me what brought you in today.” However, after this opening statement, the first session becomes an open and fluid exchange that doesn’t follow a rigid protocol (Lee, 2011). Taylor (2005) developed a helpful guide for trainees learning how to implement SFBT for the first session that includes five areas of inquiry. The five areas of inquiry include the major focal points of client engagement with accompanying SFBT techniques. The five areas of inquiry include the client’s: (1) awareness of what improvement will look like; (2) recognition of improvements already occurring; (3) acknowledging actions leading to improvements; (4) expand- ing possible solutions; and (5) establishment of goals.

The first area of inquiry from Taylor’s (2005) work is associated with specific SFBT techniques such as exploration of pre-session change, the miracle question, and identification of what improvement will look like. This line of inquiry occurs at the beginning of the first session and challenges the idea that a client’s situation is defined by a “problem.” Often, exploring pre-session change occurs immediately following asking the client what brought them into treatment. The practitioner may simply ask the client, “What is better since you made the appointment?”. Exploration of pre-session change assumes that positive changes have likely occurred between the time of making the appointment and the first session. The focus of pre-session change creates hope and expectancy that change can occur and attributes the change to the client’s actions (O’Hanlon & Weiner-Davis, 1989; Taylor, 2005). The miracle question is often asked to promote a future-oriented focus and produce images of living without the expressed problem. The miracle question may be phrased, “What if you wake up tomorrow and the problem is solved, what would that look like?” Asking the client to describe the future without the problem provides insight into potential solutions and can oftentimes be the spark to move toward change (de Shazer & Berg, 1997; O’Hanlon & Weiner-Davis, 1989; Reiter, 2010). Following

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the client’s response to the miracle question, the therapist asks, “What aspects of this miracle are already occurring?”. Further intentional questioning can elicit how the client sees themselves behaving or thinking differently without the problem, who will be the first to notice the miraculous changes, and how their life will be different (Franklin et al., 2016; O’Hanlon & Weiner-Davis, 1989).

The second area of inquiry focuses on recognizing when improvements have occurred and exploring what was different or better during these moments (Taylor, 2005). The SFBT practitioner assumes there are always times, places, and circum- stances when the expressed problem doesn’t occur. Using exception questions examines the times when the problem doesn’t occur and elucidates possibilities to solve the problem. A simple exception question is, “What is different during the times when you are not as stressed?”. As a reminder, the therapist doesn’t ask “Have there been times you have not been as stressed?”. As the therapist, you are implying there must be times when the client is feeling less stressed (Franklin et al., 2016; O’Hanlon & Weiner-Davis, 1989; Reiter, 2010).

The third area of inquiry from Taylor (2005) amplifies what the client is doing to create identified improvements to ensure they take credit for the positive changes. When the client provides an exception to their expressed problem, a quick follow- up question is, “How did you make that happen?”. The therapist may have to be persistent and insist that the client must have done something to create the excep- tion, no matter how small. Additional questions can include, “What did you do dif- ferently?”, or “How is what you did different from the way you might have responded 1 month ago?”. The underlying assumption of this line of inquiry is once the client recognizes their part in creating the exception, increased self-confidence will occur to do more of the same (Corcoran, 2016; O’Hanlon & Weiner-Davis, 1989; Reiter, 2010).

According to Taylor (2005), the fourth line of inquiry directs the client to acknowledge the positive results from their actions and explore how other areas of their life are impacted. Targeted questions are used to expand potential solutions and explore what occurred following their action. For example, the SFBT practitio- ner may ask a range of question to include “Who else notices when you do______ (insert behavior)?”, “How do people react differently to you?”, “If you were to do _______ repeatedly over the next month, how would it impact your life?”, “How is your day different when you_______?”, or “What will have to happen for you to do it that same way more often?”. Using this line of questioning can expand clients’ narrow view of their problem and prompt them to not overlook the positive impact one small exception can have in their lives (Franklin et  al., 2016; Lee, 2011; O’Hanlon & Weiner-Davis, 1989; Reiter, 2010).

The fifth and final area of inquiry from Taylor (2005) occurs toward the end of the first session and is focused on the future and the establishment of achievable goals. Collaborative goal setting, scaling questions, and compliments are techniques typically used. Collaborative goal setting involves questioning allowing the client to define treatment goals that drive the trajectory of treatment. Questions such as, “What will indicate to you that your situation is improving?”, and “What will indi- cate to you that things are continuing to improve?” can facilitate the identification

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of concrete and achievable goals (Bodenheimer & Handley, 2009; O’Hanlon & Weiner-Davis, 1989). Scaling questions are an important technique that can facili- tate the identification of specific observable goals that are meaningful to the client. For example, the client may be asked, “On a scale from 1 to 10 where would you place your stress?” An immediate follow-up question might be, “You chose a #6, what would a #8 look like?”, and “What will it take for you to reach a #8?” (de Shazer & Berg, 1997; Lee, 2011; O’Hanlon & Weiner-Davis, 1989; Reiter, 2010). Additional scaling questions can focus on the client’s level of confidence to achieve a higher number on the scale. The therapist can ask, “On a scale of 1–10, how con- fident are you that you can reach a #8?”, and “What would it take for your confi- dence to be higher? (Taylor, 2005). The goals identified through scaling questions can also be used for follow-up appointments to monitor progress.

The SFBT practitioner concludes the first session by offering authentic compli- ments to reinforce successful actions by the client to correct the presenting concern. Compliments accentuate client strengths and should be based on the conversation that occurred during the session. A compliment can be stated as “I appreciate your willingness to seek help. I think you are a person that doesn’t give up easily and you are already using this strength to create change.” Also, no-fail homework is assigned such as, “Observe the times you feel less stressed” (de Shazer & Berg, 1997; Lee, 2011; Macdonald, 1997; O’Hanlon & Weiner-Davis, 1989; Reiter, 2010; Rothwell, 2005).

Behavioral Health in Primary Care Framework

Early models of behavioral health in primary care began to surface in the 1960s (Robinson & Strosahl, 2009), but complex issues of funding, reimbursement, and the challenges of integrating two different treatment models representing the medi- cal and behavioral health fields have stunted the growth of this innovative approach (Pomerantz, Corson, & Detzer, 2009; Robinson & Strosahl, 2009). The foundation of behavioral health services in primary care is a population health management paradigm. This paradigm is identified by Bryan, Morrow, and Appalonio (2009) as either having a horizontal or vertical structure. The horizontal structure emphasizes providing care to the entire population of primary care patients to better manage the needs of the primary care patient to improve overall health and well-being. In con- trast, the vertical structure provides targeted specialty care to a select few of the general primary care population (Bryan et al., 2009). Within the horizontal or verti- cal structure of population health management, the level of actual integration into primary care exists on a continuum (see Fig. 9.1). On one end of the continuum is coordinated care with primary care that resembles traditional mental health care with a reciprocal referral process in place. In the middle is a co-location model where the behavioral health specialist has a physical presence in primary care, mostly keeps autonomy over the treatment, and has occasional engagement with the primary care team. On the opposite end of the continuum, the behavioral health

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Coordinated Co-Located

Levels of Behavioral Health Integration into Primary Care

Practitioner: Practitioner: Practitioner: Is not located in primary care

Has office in primary care Is a consultant to PCP

Provides frequent feedback to PCP

Is part of the PCP team

Collaborative decision- making

Uses brief/targeted treatment

Yields autonomy to PCP

Occasionally consults & collaborates with PCP

Has separate schedule

Is semi-autonomous with treatment goals

Uses brief & traditional treatment modalities

Provides no consultation to PCP

Has full autonomy with treatment

Provides traditional mental health care

Uses traditional referral process

Fully Integrated

Fig. 9.1 Continuum of Primary Care Integration

specialist is fully integrated into the primary care team, acts as a consultant to the primary care physician, frequently communicates with the entire primary care team, and provides brief and targeted interventions (Bryan et  al., 2009; Mauer, 2003; Robinson & Strosahl, 2009).

Integrating mental health services into primary care improves access to care, provides an opportunity for prevention and education, lessens the stigma of seeking mental health care, reduces demand on the primary care provider, and patients can receive short-term and more precise care (Miller & Malik, 2009; Pomerantz et al., 2009; World Health Organization, 2008). According to the National Council for Community Behavioral Healthcare (2002), about 30% of primary care office visits are mental health in nature. Furthermore, 50–80% of people that have a common mental health issue are treated in primary care (Bryan et  al., 2009; Mauer, 2003;Miller & Malik, 2009; World Health Organization, 2008). Consequently, pri- mary care providers may not be adequately trained and can feel overwhelmed treat- ing mental health issues and often don’t have the time to adequately address these types of patient concerns (Robinson & Strosahl, 2009). However, when patients have direct access to a mental health professional to address their concerns, they can be treated earlier with targeted care and will require fewer medical-related appoint- ments creating less demand on the primary care provider (Miller & Malik, 2009; World Health Organization, 2008). According to Mauer (2003), patients prefer to have mental health care coordinated within primary care because it is more efficient and also reduces the stigma of seeking mental health services. During a medical appointment, a medical provider can accompany a patient down the hall to connect with a mental health provider for a drop-in session. This type of in-house coordina- tion helps to overcome the 30–40% rate of “no-shows” for follow-up appointments when patients are referred to mental health services outside the primary care clinic (Miller & Malik, 2009; National Council for Community Behavioral Healthcare, 2002).

Interventions offered by the mental health specialist complement the care pro- vided by the primary care physician because the mental health specialist can address

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a wide spectrum of disease management or lifestyle concerns. Moving beyond the biomedical approach and drawing on psychosocial factors of patients, mental health specialist can offer effective health education and utilization of functional interven- tions to assist patients to adapt to an illness, be compliant with medication or diet, learn stress-management techniques, improve sleep hygiene, and practice improved self-care that impacts the overall quality of life (Mauer, 2003; Miller & Malik, 2009; Pomerantz et al., 2009; Population Health Support Division Air Force Medical Support Agency, 2006). Furthermore, patient outcomes are positive when mental health issues are addressed in primary care. In as few as one to three, 30-min ses- sions, improvements in symptom reduction, behavioral change, sense of well-being, and improved life functioning can be achieved (Bryan et al., 2009; Cape, Whittington, Buszewicz, Wallace, & Underwood, 2010; Miller & Malik, 2009; Pomerantz et al., 2009; Robinson & Strosahl, 2009).

Introduction to the Case of Jim

In the context of this case, the SFBT practitioner’s integration into primary care at the free medical clinic aligns with the horizontal framework as described by Bryan et al. (2009), where the entire primary care population is available for a referral. The level of integration in the clinic includes characteristics of being both co-located and fully integrated. The SFBT practitioner’s office is physically located in primary care but full integration into the primary care team is not evident. Referrals are received from the physicians and consultation will occasionally occur to clarify the referral details. Appointment schedules between the SFBT practitioner and physi- cian are not fully coordinated and the SFBT retains significant autonomy with treat- ment protocol and goals. When appointment schedules do overlap, the primary care physicians can do an on-site referral, and the patient is seen as a walk-in. Behavioral health appointment slots are 30 min in length which follows the brief therapy model.

Jim is a pseudonym to protect his identity. The identifiers of this case have been changed to maintain the confidentiality of the client. Jim was referred by one of the free medical clinic physicians after disclosing his pattern of substance use. Jim was scheduled within a week, and at the time of the appointment, the SFBT practitioner had minimal history about Jim’s substance use because there was no access to records and the referring physician did not provide details regarding Jim’s substance use. The physician wants Jim assessed and his substance use addressed in treatment.

Jim, a 57-year-old black, divorced, male, presents with an extensive substance use history. On two occasions, Jim has been voluntarily admitted into an inpatient substance abuse treatment facility and has engaged with outpatient counseling on several occasions. However, he has not had any type of mental health treatment for the past 6–7  years. Jim drinks beer daily to help him sleep and he is frequently exposed to drugs because he allows prostitutes to smoke crack in his trailer in exchange for occasional sexual activities. Jim reports using crack cocaine one or two times a week 2 years ago, but he has tried to quit and now uses it about two or

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three times a month. Specific details about past mental health diagnosis and medical history are insufficient due to his limited recall ability and sparse medical records. However, through the free medical clinic, Jim is being treated for high blood pres- sure and ongoing headaches. He does not report any current or past legal issues. His education level is a high school diploma. Jim grew up in the south and currently resides in a southern state. He lives alone in a run-down rental trailer, isolated on a dead-end street in an extremely rural part of the county. The street where he lives contains a pocket of small houses consisting mainly of low-income, black individu- als and families. Jim describes his neighbors as acquaintances versus friends, but reports they keep an eye out for each other. Details regarding his divorce are unclear but he does not have any contact with his ex-wife. However, he sees his adult daugh- ter and her 13-year-old child about once every 3–4 months. Jim has a sister that tries to be supportive and occasionally provides him rides to medical appointments. Both his sister and adult daughter live approximately 30 miles away which limits their contact. The relationships with his sister and daughter are very meaningful to Jim. He expresses guilt regarding his history with substances that have interfered with developing a deeper relationship with his daughter and grandchild. Jim does not identify with any religion and does not indicate spirituality is integrated into his life. Jim has not worked consistently in the last few years and has primarily worked manual labor jobs. Jim doesn’t own any type of transportation which increases his sense of isolation. He relies on friends to take him to work odd jobs and to obtain food at the nearby country store.

Theoretical Integration

SFBT is an excellent fit to use in primary care and is compatible with population health management goals to better manage mental health-related issues commonly seen in primary care such as medication compliance, anxiety, depression, stress management, sleep hygiene, and substance use (Khatri & Mays, 2011). The core tasks of the SFBT approach are consistent with brief healthcare goals to provide patient-centered care while targeting specific behavior change using goal-driven, time-limited solution-focused strategies, follow-up, and support (Bodenheimer & Handley, 2009; Flemming & Manwell, 1999; Khatri & Mays, 2011; National Council for Community Behavioral Healthcare, 2002; Rothwell, 2005).

Providing services in primary care requires flexibility to accommodate characteris- tics associated with the primary care environment and discard many of the traditional mental health practices. For example, to manage time efficiently to stay within a 15- to 30-min time limit, a more active and directive approach with patients is required. This may be uncomfortable for traditionally trained mental health clinicians. Delicately balancing being empathic and directive without compromising the critical develop- ment of the therapeutic relationship is a developed skill. Accomplishing this balance can be facilitated by using the assessment process as an intervention during the first session. Even during a 15–30 min initial session, Taylor’s (2005) areas of inquiry can be applied to join with the client, explore exceptions, set goals, and provide homework.

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Joining: (10 min) includes being genuine and authentic while engaging in small- talk to quickly connect with the patient. Attention to the development of the helping relationship occurs immediately and undergirds all treatment activities. The role of the clinician and structure of the first session is quickly explained to the client. The clinician inquires if the patient understands the process and asks if they are willing to continue. Open-ended and presuppositional questions are used throughout the session, and thoughts and feelings are validated to normalize their concerns.

The moment Jim is called back to the behavioral health office, efforts begin immediately to positively connect with him to develop the helping relationship and initiate the assessment. Jim’s frail physical structure and his slightly disheveled appearance are immediately noticed. Jim slowly walks down the hallway toward the office with an imbalanced gait. Jim has a noticeable smile, friendly disposition, and steady eye contact. Once in the office, Jim is engaged in small talk which involves joint laughter at some of his responses. His sincerity about attending the appoint- ment stood out, but he could only articulate a minimal understanding as to why his medical provider referred him. Uncertainty existed about why Jim believed to be at this appointment. Regardless, careful attention is given to responding to Jim so that he does not feel alienated due to the details of the referral being unclear. Jim is dif- ficult to understand at times because he sometimes mumbles, speaks in generalities, and has several front teeth missing. As a result, a cognitive impairment (substance- induced or biological), or Jim being currently impaired by a substance is immedi- ately considered. The SFBT practitioner speaks slowly and is mindful to keep speech simple and asks specific, clarifying questions that seem to work well with Jim. An explanation is quickly given to Jim outlining limits of confidentiality, the goal of the first session, and the role of the SFBT practitioner being a consultant to his primary care provider. There is a moment of silence to see if Jim wanted to respond, then Jim is asked, “Do you understand what was just explained?” He responds by nodding and mumbling “Yes, I understand.” Permission to continue with the session is asked to reinforce his voice in the process. Jim agreed to continue.

Due to the paucity of Jim’s responses, the SFBT practitioner recognizes staying within the 30-min allotted time is going to be difficult. Fortunately, there are no patients scheduled immediately following Jim so a little more time can be spent with him. With experience, the SFBT practitioner has learned that being flexible to take advantage of the time with …