The Institute for Solution-Focused Therapy is privileged to have provided Solution-Focused Brief Therapy training with an amazing group of clinicians within Crescentcare Health Center in New Orleans, Louisiana. In this interview with Lucy Cordts, the Director of Behavioral Health, she shares what she is most proud of within her organization and her experience with Solution-Focused training. Crescentcare is a unique organization that provides a broad range of integrated care from frontline primary care providers to a full range of mental health services. They are especially proud of their work providing high-quality care to the transgender and gender non-conforming population. They have found Solution-Focused Brief Therapy and Practices a safe, trauma-informed approach that can help engage clients who have experienced significant adversity and complex trauma. They have appreciated the flexibility, culturally sensitive, and client-centered approach of SFBT and how the training structure has enabled staff to feel more effective and competent with the clients they serve. Crescentcare describes the SFBT approach as being their “go-to” approach for all levels of practitioners, from primary care providers, nurse practitioners, social workers, licensed mental health practitioners, and all professionals across disciplines within their organization. Lucy describes how there has been a noticeable shift in more solution-focused documentation and more positive staff consultations following the training. Please enjoy this video with Lucy Cordt, one of the many wonderful colleagues we have been privileged to work with and learn from!

Behavioral health workforce shortages and increased demand for services have required mental health professionals and organizations to devise innovative service delivery and training strategies. Solution-focused brief therapy (SFBT) is an evidence-based approach that can assist clinicians, and behavioral health organizations manage long waitlists increasing access to treatment for more clients.  Solution-focused brief therapy can provide a solution to open up enrollments assisting clients in “graduating” from discrete treatment episodes. SFBT can help clinicians and mental health organizations manage surging caseloads, staff retention and burnout, and increasingly complex client needs that have only worsened with the mental health COVID pandemic.

The United States Surgeon General Vivek H. Murthy came out with a 53-page advisory panel on December 7th, 2021, regarding the mental health challenges in children and stated the situation is dire (Protecting Youth Mental Health: The US Surgeon General’s Advisory, 2021).  A Surgeon General’s Advisory is a public statement that calls the American people’s attention to an urgent public health issue and provides recommendations for how it should be addressed. Advisories are reserved for significant public health challenges that need immediate awareness and action.

“Mental health challenges in children, adolescents, and young adults are real and widespread. Most importantly, they are treatable and often preventable. Combined with an uptick in gun violence, a reckoning on racial justice, a climate emergency, and a divisive political landscape, the coronavirus-related hardships have taken a toll on young Americans’ mental health at a time when it was already in decline. More people seeking help have strained the ability of practitioners to provide treatment, underscoring, experts say, the need to radically change how mental health is addressed in the United States. ” (Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory).

Doctor Vivek Murphy further writes:

“Our obligation to act is not just medical—it’s moral. I believe that coming out of the COVID-19 pandemic, we have an unprecedented opportunity as a country to rebuild in a way that refocuses our identity and common values, puts people first and strengthens our connections to each other.  If we seize this moment, step up for our children and their families in their moment of need, and lead with inclusion, kindness, and respect, we can lay the foundation for a healthier, more resilient, and more fulfilled nation.”

The advisory acknowledges that our healthcare system is ill-equipped to support the mental health and wellbeing of our children and youth. The advisory exhorts us to reimagine addressing, managing and preventing mental health challenges. It urges recognizing the need for trauma-informed care and youth facing adversity and educating a wide range of professionals who work with children such as schools, child care, justice, social services, and public health sectors.

The SF clinician believes in client resilience, which has the added benefit of clinicians experiencing “vicarious resilience” instead of “vicarious trauma”. The SF clinician remains disciplined in the quest for client resources throughout the therapeutic process. The types of questions combined with the language of empathy and taking the lead from the client all enhance the client’s sense of choice and control. Amid a traumatic event, the client’s sense of control and choice is often lost. Guiding the conversation with questions, remaining attuned to the client’s need for empathy, focusing on positive differences, and conveying a belief in the client all facilitate and are congruent with a trauma-informed approach.

The mental health of children and youth is closely linked to the well-being of their families. SFBT broadens the definition of“who” the client is to include their unique social context. The solution-focused practitioner assesses the client’s social text by learning “who” are the most important relationships in their lives, their VIPs. Mapping out a client’s social context is essential in understanding and assisting clients in building solutions from often underutilized and unacknowledged relational resources. Asking clients who the most important people are in their life assesses, from their perspective, who will be most helpful in determining when their problem is solved. These relationships are often obscured, especially when people are in the depths of their crisis.  Knowing who the client’s stated VIPs are, assists the SF therapist in negotiating goals and evaluating treatment progress from the client’s distinctive social context. Meaningful relationships often provide clients with a reason for living. Asking clients who are experiencing suicidal thoughts what stopped them from acting on their impulses often reveals essential relationships. Activating a client’s relationship resources can be life-saving.

Caring for the mental health workforce is a critical component of the quality, access, and cost of mental health care. Solution-Focused Brief Therapy is an approach that has been applied successfully across a wide range of professions and fields, in a transdisciplinary way,  and for a broad range of mental health conditions (Beyebech, M. et al., 2021). Clinicians, business people, educators, social service workers, case managers, in-home therapists, paraprofessionals, medical professionals, to name a few, have applied this approach successfully.  Solution-focused techniques can be practiced within any conversation, dissolving conventional disciplines’ boundaries. The client and the clinician work together to create an innovative plan that enhances agency and hope.

Solution-Focused Brief Therapy and Practices can be applied across disciplines enhancing collaboration and integration for the benefit of clients and their families. The Substance Abuse and Mental Health Services Administration (SAMHSA) has included psychiatry, clinical psychology, clinical social work, advanced practice psychiatric nursing, marriage and family therapy, substance abuse counseling, psychosocial rehabilitation, school psychology, and pastoral counseling (Bagalman, E., The Mental Health Workforce: A Primer, 2015). Many others are also involved in caring for people with mental health conditions, such as teachers, para-professionals, nurses, primary care physicians, pediatricians, and residential care staff.

The Solution-Focused Brief Therapy approach, which co-discovers clients’ resources and details what they want, is much less burdensome for the clinician. Instead of the clinician worrying that every detail of their client’s problem and trauma is fully explored, the solution-focused practitioner listens resolutely for past moments when things were even a little bit more bearable, discovers what clients know about their condition and how they have managed to lessen or tolerate their difficult situation even a little bit.   In this way, the clinician experiences vicarious resilience rather than vicarious trauma.

One component of caring for the mental health workforce is providing high-quality training programs. Effective training includes equipping medical and mental health professionals with brief, practical tools that clinicians can apply right away. Despite the acute need for evidenced-based brief and practical therapeutic approaches, often these are not extensively taught in training programs.  Solution-focused brief therapy is an evidenced-based, hopeful, pragmatic approach that quickly engages with clients and assists them in developing a plan of action, harnessing often unrecognized resources both individually and within their social context. SFBT empowers both clinicians and clients to navigate purposeful conversations to assist clients in reaching their targeted goals. 

SFBT starts by revealing a detailed understanding of the client’s best hope for their future and collaboratively looks for client-related resources and actions that build this outlook. The focus is on detailing what a client will be doing when their problem is solved, rather than diagnosis and symptom exploration. Based on the premise that people have the necessary resources to solve their problems, SFBT amplifies these strengths and abilities by building a shared dialect that focuses on what has worked and is working in a client’s life.  

Solution-Focused Brief Therapy is intended to be pragmatic and based on the clients’ presenting concerns focusing on what the client has already done to cope and what the client wants, rather than exploring history or theories about root causes. The goal is for the client to leave with a plan and know they have the skills and resources available to move forward in a good enough way.  SFBT harnesses hope pragmatically, assisting clients in developing a concrete plan with targeted goals while simultaneously strengthening agency thinking through the use of solution-focused questions. For example, the indirect compliment; how did you initiate doing something kind for yourself today? The SF practitioner frames goals as challenges and negotiates with clients to determine an optimal level of challenge. SF interventions focus on concrete behavioral endpoints through the use of scaling questions. The client’s language serves as the compass for formulating the next question or response. Goals are intrinsically reinforced, acknowledged, celebrated, and noticed with others, strengthening a positive feedback loop. These techniques are very client-centered and maintain attunement to what the client wants,  incorporating their social and cultural context. 

The practitioner interested in making the best use of the therapeutic encounter harnesses the initial period while encouraging clients to return for brief treatment episodes if needed. Planned short-term brief psychotherapy is designed to be intermittent – multiple brief treatment episodes within an ongoing therapeutic relationship. Practitioners of brief therapy view every interaction and encounter as its own intervention. These encounters are intensely focused on the client’s goals and may be good enough, so additional sessions are unnecessary.

Clinicians who practice brief psychotherapy believe that clients can be helped and helped relatively quickly. They take a generally more active role in the therapy process assisting their clients in establishing their goals and bringing therapy to an agreed-upon conclusion celebrating their graduation from treatment.

Brief psychotherapies emphasize the time between sessions as valuable opportunities for clients to practice the solutions discovered within the therapeutic encounter purposely. The small changes started within the therapeutic encounter may be all that is needed for the client to make significant and long-lasting improvements.

SFBT focuses intensely on the client’s goals and whether they are achieved in a good enough way. It is essential to set reasonable expectations from the onset of treatment. Some clinicians are limited to a brief number of sessions. Harnessing strengths early on and setting the stage for treatment completion may be accomplished by asking the client’s best hopes for treatment within the boundaries of available resources. For example:

What are your best hopes in the next four sessions that will tell you that this treatment episode was helpful and worth your time?

What will you be doing after the next four sessions that will tell you that you have the necessary skills to manage in a good enough way?

What will your VIPs notice you doing after the next four sessions that will tell them you are managing in a good enough way and ready for graduation?

SF conversations embed client feedback throughout the conversation and at the end of the session through scaling questions. Scaling questions are ideal in assessing whether the client is confident in their skills to graduate from treatment. When clients rate their number as good enough, it is important to list all the skills co-discovered in their treatment episode and celebrate their accomplishments. Depending on the client’s treatment goals, many areas of function can be easily and quickly assessed.

Scaling clients’ skills from the perspective of those most important in their lives, their VIPs affirm their readiness from those most critical in their social context to celebrate their graduation from treatment. Scaling how confident they are that they will maintain the skills they gained during their treatment episode and working the scale reinforces and solidifies their strengths and abilities. 

For some clients, it may be challenging to graduate from treatment. Reinforcing the skills they learned, and providing them the analogy of not wanting to be held back in school several years in a row, can assist them in appreciating the progress they have made.  Solution-focused practitioners encourage clients to consider how their current treatment episode is one chapter of their life and appreciate the privilege of playing even a small part in assisting them in moving towards a more satisfying life. The SF practitioner reminds clients that they can return for another discrete treatment episode if they need a booster session to help them navigate another challenging issue. 

How confident are you that you have the necessary skills from 1-10 to graduate from treatment?

What is a good enough number?

Suppose I asked your VIPs their confidence in your skills to graduate from treatment?

Below are a few questions that can be asked to monitor progress towards the client’s graduation from treatment.

Beyebach, M., Neipp, M.-C., Solanes-Puchol, Á., & Martín-del-Río, B. (2021). Bibliometric differences between weird and non-weird countries in the outcome research on solution-focused brief therapy. Frontiers in Psychology, 12. 

Heisler, E. J., The Mental Health Workforce: A Primer https://sgp.fas.org/crs/misc/R43255.pdf. 2021.

Protecting Youth Mental Health: The U.S. Surgeon General’s Advisory

Click here for the full report: Surgeon General Youth Mental Health Advisory 2021

Solution-Focused Brief Therapy is an excellent approach to help mitigate some of the mental health systemic challenges that have only worsened since the pandemic. I have developed a Solution-Focused Safety Assessment (SFSA) tool that has helped deal with the current mental health crisis, nurturing, harnessing, and sustaining hope when experiences may, at the moment, seem insurmountable. Solution-Focused Brief Therapy (SFBT) is a short-term goal-focused evidence-based therapeutic approach that incorporates positive psychology principles and practices and helps clients change by constructing solutions rather than focusing on problems. In the most basic sense, SFBT is a hope-friendly, positive emotion eliciting, a future-oriented vehicle for formulating, motivating, achieving, and sustaining desired behavioral change. Solution-Focused Brief Therapy embraces a strength-based developmentally informed trauma perspective that acknowledges individual and family capacity in the face of adversity. This approach offers an opportunity to assess and, to some extent, address the mental health and traumatic consequences of a pandemic for youth and families.

Managing risk is the dominant paradigm in responding to suicidal thoughts and behaviors in the mental health field. Risk assessment focuses on ensuring the client’s safety and minimizing the danger of harm without treatment. By contrast, the Solution-Focused Safety Assessment (SFSA) examines the other side of the coin, confidence in the ability to keep oneself safe ( Lutz, A. B. 2014). It is a paradigm shift providing an additive dimension to conventional risk assessment. The SFSA creates a highly individualized action-oriented safety plan that incorporates individual and relationship resources (VIPs), coping strategies, reasons for living, best hopes for moving forward, and client needs based on their unique social context. The SFSA amplifies how clients have coped and managed to endure, even a little bit, the seemingly overwhelming distress that they have found unbearable at the moment.

I often am challenged with clients engaging in self-harm, suicidal thoughts, and behaviors in my practice. Incorporating a Solution-Focused Safety Assessment during times of crisis has been very helpful both for my clients, their VIPs, and managing my anxiety in these very stressful situations. Preparing clients for questions that evaluate their safety by explaining that these questions are routinely asked helps normalize their struggles, aiding them in feeling less alone. Framing questions about safety in the context of intense emotions and good reason communicate empathy. Asking clients about their good reasons for their decisions to harm themselves often reveals how clients engage in these behaviors because, in some way, the behaviors are helpful for them. The question does not condone the behavior but instead helps understand the client’s motivation and can help lead the conversation towards safer alternatives. When clients have contemplated suicide and not followed through, it is essential to ask what kept them from acting on their thoughts—asking clients their reasons for living guides the conversation towards their hopes, goals, and future dreams.

Below is a picture of the Solution-Focused Safety Assessment. To download this form as a PDF Please visit our Solution-Focused Tools.

Before the pandemic, I kept a stack of solution-focused safety cards available in my office. I would write the plan on the card with the client present and, if possible, also include their VIPs in the conversation. I have found that giving clients the safety card generated collaboratively provides a tangible reminder of the work we have accomplished together. It can cue them to their strengths, resources, and coping strategies in times of distress. I had one intellectually disabled client bring her tattered and worn down card with her to every appointment, telling me her safety number and proudly telling me what she had been doing to help her keep safe!

Since the pandemic, telepsychiatry has been a promising tool for children and adolescents in emergencies (Finlayson, B. T., Jones, E., & Pickens, J. C. 2021). Indeed, telepsychiatry has rapidly become a vital component in reducing safety risks related to coronavirus exposure. I have adapted the SFSA by completing it with clients using a shared screen. I then email or text the copy to the client, VIPS, and anyone they think would be helpful for them to have a copy of the SFSA plan. Because of the ease with coordinating teams remotely with telehealth, I have been able in many cases to include important VIPs that in the past would not have been immediately available in the development of a safety plan. I have invited parents, teachers, outside therapists, school counselors, emergency room nurses and physicians, and mobile crisis response teams, to name a few.

The Scope Of The Current Child Mental Health Crisis

Failure to address emergency mental health care impacts people of all ages resulting in increased health care costs and repercussions on local Emergency Departments (ED). Mental health workforce shortages and increased demand for services have required mental health professionals and organizations to devise innovative care delivery strategies. The pandemic has disrupted life for many months, an exceptionally long time for children and teens deprived of crucial connections to friends and school support networks. The pandemic has highlighted how we need to adapt our skills to emergency environments to creatively use available resources to meet the needs of youth and families. Solution-Focused Brief Therapy is an excellent approach to help mitigate some of these systemic challenges. With unprecedented challenges comes the requirement to adapt and utilize resources creatively to navigate horrendous situations. I have developed a Solution-Focused Safety Assessment (SFSA) tool that has helped deal with the current mental health crisis, nurturing, harnessing, and sustaining hope when experiences may, at the moment, seem insurmountable.

Many children and adolescents seeking treatment during the pandemic have a previous diagnosis of a mental health disorder, but others are in crisis for the first time (Kontoangelos, K., Economou, M., & Papageorgiou, C. 2020). For adolescents ages 13 to 18, mental health insurance claims doubled as a share of total medical claims during the height of COVID in 2020 (Ferget, Vitiello, Plener, and Clemens 2020). The shortage of psychiatric treatment beds and qualified staff existed well before COVID, but it has grown to alarming levels (Roadmap for behavioral health reform, Massachusetts). I recently witnessed a child awaiting a psychiatric bed for over 90 days! Not only is there a dire shortage of psychiatric beds for children, but there is a workforce shortage crisis. Hospitals are struggling to recruit and retain enough qualified staff, including mental health workers, social workers, nurses, psychologists, and psychiatrists (Behavioral health-related emergency department boarding in Massachusetts, 2021).

Many of the mental health failures and gaps have only worsened since the COVID-19 Pandemic. COVID-19 is as much a challenge of how we will frame it from a mental health perspective as it is a public health crisis. The fragmentation of the mental health system in the United States has contributed to poor patient outcomes, lack of access to mental health treatment, and rising medical costs for all. Mental health patients and treatment providers have endured the COVID-19 pandemic, responded to the exacerbated mental health crisis, and coped with a chronically underdeveloped mental health workforce.

Children and young people account for 42% of the world population. As a practicing child psychiatrist, I am acutely aware that the COVID-19 pandemic represents an extraordinarily stressful experience for youths and families. The mental health consequences of the COVID-19 pandemic in youth have been diverse, ranging from the onset of stress-related disorders to the exacerbation of pre-existing mental health disorders, including increases in internet and electronic addictions, sleep disorders, and depression. As the death toll rises, numerous children and families are grieving a loved one in a context that is often highly traumatic, unable to participate in rituals to help them grieve and honor the loved ones in their lives. The lock-down has also interfered with culturally accepted mourning processes, further aggravating unresolved and complicated grief.

Caring for children with special needs such as autism spectrum disorders, intellectual disabilities, developmental disabilities, chronic complex trauma, and attachment disorders has created even more of a challenge for families and caregivers to access much-needed services. The severity and outcome of mental health conditions have worsened because of delays in prompt diagnosis and treatment (Rousseau, C., & Miconi, D. 2020).

Parents and caregivers attempting to work remotely or unable to work while caring for children at home have only worsened disparities between high and low socioeconomic status families. In particular, women leaving the workforce while caring for their children has strained families even further. The economic impact of the pandemic has further added to the pressure families have endured leading to upsurges in domestic violence, substance abuse, depression, anxiety, and PTSD. Recognizing the extent to which family mental health affects youth mental health, we are compelled to appreciate the cross-generational stress caused by the pandemic (Leeb, R. T., Bitsko, R. H., Radhakrishnan, L., Martinez, P., Njai, R., & Holland, K. M. 2020).

Workforce Mental Health Shortages Impact On Children’s Mental Health

Emergency departments (EDs) are often the first point of care for children experiencing mental health emergencies, particularly when other services are inaccessible or unavailable. The pandemic has highlighted how we need to adapt our skills to emergency environments to creatively use available resources to meet the needs of youth and families. In recent years an ever greater number of patients find themselves seeking care for psychiatric illness in the Emergency Department (ED) . 6-10% of ED visits present for psychiatric illness. These visits weigh heavily on the ED system. Patients with psychiatric illness occupy 42% more time than non-psychiatric visits in the ED (McEnany, Ojugbele, Doherty, McLaren, & Leyenaar 2020). A survey of 1400 ED directors by the American College of Emergency Physicians (ACEP) found 79% having psychiatric patients boarding in their EDs, with 62% reporting that no psychiatric services occur while patients are boarding in the ED. Even when services are available, there are prolonged waiting times to see clinicians. ED boarding carries a high-cost burden. In 2017, mental and substance use disorder emergency department (ED) visits had service delivery costs of more than $5.6 Billion, representing more than 7% of the $76.3 billion total ED visit costs (Karaca and Moore, 2020).

A Case Example: How The Solution-Focused Safety Assessment Tool Can Be Helpful In Responding To The Mental Health Crises With Children and Families In The Emergency Department

The following is a fictionalized case vignette based on real clients I have treated in crises. The vignette uses a family case within the emergency room to illustrate how to incorporate a Solution-Focused Safety Assessment with children and families experiencing a mental health crisis.

Case Vignette Summary

Sara is a 17 y/o girl who I had been treating as an outpatient. She has been diagnosed with PTSD, Autism, School avoidance, and depression. Her mother called me, learning that she had taken a week’s worth of her medication and was now being evaluated in a crowded emergency department (ED) by the psychiatric mobile crisis team. Her mother was anxious about her staying in the emergency room and waiting weeks for a child psychiatric inpatient bed to become available. She was also concerned about Sara being exposed to distressing conditions within the ED, including agitated patients, medical emergencies, COVID infection, and under, inadequately trained staff regarding the mental health needs of children. Her mother, just recovering from breast cancer treatment, was understandably cautious about bringing her to the emergency room, knowing the risk of COVID and having an immunocompromised status. She knew about the long waits to obtain a psychiatric inpatient bed – often many weeks, and how this would further exacerbate her daughter’s fragile condition.
Sara lives with her mother, a single parent and her 8y/o brother. Her mother has a history of breast cancer, currently in remission. Her brother is treated for ADHD and PTSD. Her father has severe substance use issues, has been in and out of jail, and had his parental rights terminated due to the severity of abuse inflicted on the family. Sara, her brother, and her mother endured significant trauma for many years resulting in complex trauma.

Sara had challenges preceding the pandemic, including school refusal, bullying, and school failure. The situation for Sara only worsened during the pandemic as she would often spend hours in her room online, staying up at night, disrupting her sleep, increasing her anxiety, depression, and isolation even further. Sara had other episodes of depression, including thoughts of hurting herself during the pandemic.
Sara was very challenging to engage using telehealth. She would often refuse to join the sessions, and if she could tolerate them, her video was off, and the conversations would last 5 minutes. As a result, sessions often focused on supporting and increasing her mother’s confidence in helping her navigate the immense challenges of having 2 children with significant mental health needs while also managing her stress, including her medical condition and being the primary caretaker and financial provider for her children.
Sara was taking several medications and required some medication adjustments. This required necessary blood work, which she refused to do, preventing other more helpful pharmacological interventions.

While in the ED, the mobile crisis team would do a 5-minute telehealth check-in stating the bed search continues. The ED provided no other treatment or interventions due to limited resources and staffing shortages.

Solution-Focused Interventions in the Emergency Department

I began by providing her mother with many “for you” statements regarding how challenging and scary this must have been for her. I bridged this with a coping question asking her how she has been able to get through this moment to moment. I complimented her mother for taking the necessary steps to get her daughter the help she needed while managing all her other demands as a single parent. Given my relationship with Sara and her mother, I offered telehealth sessions to both her and her mother while in the ED. Sara was exhausted and asleep, unable to meet. Her mother was desperate to meet and develop a safety plan that would get Sara out of the ED as quickly as possible. I discussed with her mother her best hopes and what she knew Sara needed. I also considered what my best hopes were for her and the family so I could feel confident she was safe enough to be discharged home. Her mother’s best hopes that would tell her Sara was ready to be discharged home were for her to agree on daily safety check-ins, manage her daily expectations at home including sleep schedule, participating in telehealth appointments and tutoring for school, going on a walk daily and managing a healthy electronic diet in a good enough way. She also hoped she would stay out of her room and help with some daily family chores. My best hopes were to know the safety plan was “good enough” and that Sara could get the necessary medical tests to adjust her medications more effectively. I also wanted to provide a stress test while in the ED to ensure Sara could manage safely upon discharge to home.

I went through the Solution-Focused Safety Assessment with her mother and the ED nurse with the suggestion that this be filled out with Sara when she was awake. In addition, we discussed the need for Sara to know the expectations at home and the plan if she had challenges meeting these expectations. We agreed that she would not be discharged without the written safety plan, expectations, and necessary medical tests completed. In addition, the SFSA plan would need to be discussed with the ED team and mobile crisis team, ensuring their agreement with this plan.

I have attached the SFSA plan based on this vignette.

Sara was discharged and I had a follow-up appointment with her four days later. She was on the zoom with a video camera on and pleased to tell me she had gone on a hike with her mother and brother. She was getting some of her school work done, going to sleep, and waking up at more consistent times. We had begun a medication adjustment, and she reported tolerating the adjustments 7/10 (good enough) and was hopeful the new medication would help her anxiety and depression. I complimented both Sara and her mother on the many ways they handled this very stressful and challenging situation, including getting her blood work done, managing electronic expectations and sleep, and checking in daily with her mother regarding her confidence in her ability to keep herself safe from 1-10.

Below is the Safety and Recovery Plan co-developed with Sara and her team while in the ED that also functioned as a stress test, helping to increase the team’s confidence that she was ready to be discharged home.

Stress Test

1. Meet with your therapist and doctor, including participating in the zoom meetings, staying logged in with the video
2. Take a walk for 15 -20 minutes every day.
3. Work on getting to bed and waking up at the same time every day
4. Work on developing an electronic health diet What do you know is a healthy electronic diet?
   • What do you know is a healthy youtube diet?
   • How confident are you from 1-10 that you can maintain a healthy electronic diet?
   • What would be a good enough number?
5. Complete the Solution-Focused Safety Assessment with your mother and review it with the ED staff and your outpatient clinician/doctor before discharge
6. Complete the necessary medical tests

How confident are you that you can complete the expectations from 1-10?

How confident is your mother that you can complete these expectations from 1-10?

What would be a good enough number?

Resources

The National Suicide Prevention Lifeline number is: 1-800-273-8255

For the National Text Hotline, text the word TALK to 741741

Locally, the crisis line for Call2Talk is 508-532-2255. Or text C2T to 741741

The American Foundation for Suicide Prevention has additional resources at https://afsp.org/find-support/

References

Bartels, S. J., Baggett, T. P., Freudenreich, O., & Bird, B. L. (2020). Covid-19 emergency reforms in Massachusetts to support behavioral health care and reduce mortality of people with serious mental illness. Psychiatric Services, 71(10), 1078–1081. https://doi.org/10.1176/appi.ps.202000244 

Behavioral health-related emergency department boarding in Massachusetts. Retrieved October 7, 2021, from https://www.mass.gov/doc/behavioral-health-related-emergency-department-boarding/download. 

Chen, S. (2020). An online solution-focused brief therapy for adolescent anxiety during the novel coronavirus disease (covid-19) pandemic: A structured summary of a study protocol for a randomized controlled trial. Trials, 21(1). https://doi.org/10.1186/s13063-020-04355-6 

The cost of mental illness: Massachusetts facts and figures. (n.d.). https://healthpolicy.usc.edu/wp-content/uploads/2018/07/MA-Facts-and-Figures.pdf. 

Fegert, J. M., Vitiello, B., Plener, P. L., & Clemens, V. (2020). Challenges and burden of the coronavirus 2019 (COVID-19) pandemic for Child and adolescent mental health: A narrative review to highlight clinical and research needs in the acute phase and the long return to normality. Child and Adolescent Psychiatry and Mental Health, 14(1). https://doi.org/10.1186/s13034-020-00329-3 

Feinstein, Robert. (2021). Crisis intervention psychotherapy in the age of covid-19. Journal of Psychiatric Practice, 27(3), 152–163. https://doi.org/10.1097/pra.0000000000000542 

Finlayson, B. T., Jones, E., & Pickens, J. C. (2021). Solution-focused brief therapy telemental health suicide intervention. Contemporary Family Therapy. https://doi.org/10.1007/s10591-021-09599-1 

Karaca, Z., & Moore, B. (n.d.). Costs of emergency department visits for Mental and Substance Use Disorders in the United States, 2017: Statistical brief #257. National Center for Biotechnology Information. Retrieved October 7, 2021, from https://pubmed.ncbi.nlm.nih.gov/32550678/. 

Kontoangelos, K., Economou, M., & Papageorgiou, C. (2020). Mental health effects of covid-19 Pandemia: A review of clinical and psychological traits. Psychiatry Investigation, 17(6), 491–505. https://doi.org/10.30773/pi.2020.0161 

Leeb, R. T., Bitsko, R. H., Radhakrishnan, L., Martinez, P., Njai, R., & Holland, K. M. (2020). Mental health-related emergency department visits among children aged <18 years during the COVID-19 pandemic — United States, January 1–October 17, 2020. MMWR. Morbidity and Mortality Weekly Report, 69(45), 1675–1680. https://doi.org/10.15585/mmwr.mm6945a3 

Lutz, A. B. (2014). Learning solution-focused therapy: An illustrated guide. American Psychiatric Publishing, a division of the American Psychiatric Association. 

McCluskey, P. D. (2021, August 7). This is a crisis on top of a crisis’: Patients with mental illness are waiting for overwhelmed hospitals to treat them. Boston Globe. 

McEnany, F. B., Ojugbele, O., Doherty, J. R., McLaren, J. L., & Leyenaar, J. A. K. (2020). Pediatric mental health boarding. Pediatrics, 146(4). https://doi.org/10.1542/peds.2020-1174 

Pearlmutter, M. D., Dwyer, K. H., Burke, L. G., Rathlev, N., Maranda, L., & Volturo, G. (2017). Analysis of emergency department length of stay for mental health patients at Ten Massachusetts emergency departments. Annals of Emergency Medicine, 70(2). https://doi.org/10.1016/j.annemergmed.2016.10.005 

Pediatric and adolescent mental health emergencies in the emergency medical services system. (2011). PEDIATRICS, 127(5). https://doi.org/10.1542/peds.2011-0522 

Roadmap for behavioral health reform. Mass.gov.  https://www.mass.gov/service-details/roadmap-for-behavioral-health-reform. 

Rousseau, C., & Miconi, D. (2020). Protecting youth mental health during the COVID-19 pandemic: A challenging engagement and learning process. Journal of the American Academy of Child & Adolescent Psychiatry, 59(11), 1203–1207. https://doi.org/10.1016/j.jaac.2020.08.007

 Anne Bodmer Lutz, M.D.

Mental health workforce shortages combined with increased demand for services have required mental health professionals and organizations to devise innovative service delivery strategies. In emergencies and crises, the inability to offer multiple session treatment and follow-up for mental health often makes Single Session Therapy the only option. Solution-Focused Brief Therapy, an evidenced-based pragmatic approach, is an ideal method to use in Single Session Therapy.

Solution-Focused Single Session therapy provides an evidenced-based, trauma-informed practice that can be implemented in crisis situations. The absence of intake, triage, waiting list or assessment is key to the accessibility of single session services. Single Session Therapy has potential applications as used in emergency triage, EMS, crisis call centers, emergency settings, and where access to care can be poor (Paul & van Ommeren 2013). The World Health Organization has proposed Single Session Therapy as a potential model when responding to the Psychosocial and Mental Health needs of people who have experienced trauma. Mental health professionals have adapted the Single Session Therapy framework in emergency settings, including Hurricane Katrina, the armed conflict in Columbia, and the 2010 Haiti earthquake (WHO et al., 2012). In emergencies, Single Session Therapy can be offered as part of a specialized mental health crisis service (Miller 2010).

Single Session Therapy is not new. In 1977, a walk-in counseling center in Minneapolis, Minnesota, provided Single Session Therapy (Love, 1983). Talmon in 1990 found that at 3-12 month follow-ups, 58.6% of their sample reported that a single session had been sufficient and led to improvement in the presenting problem (Talmon and Hoyt 2014). Bernard Bloom wrote in 1981 that “Single Session Therapy would potentially be the only way for publicly funded mental health agencies to meet rising service demands and long waitlists of the future.” (Bloom, 1981).

Solution-Focused Single Session Therapy requires the clinician to view every interaction as an intervention.  Solution-Focused Single Session Therapy is intended to be pragmatic and based on the clients’ presenting concerns focusing on what the client has already done to cope and what the client wants, rather than exploring history or theories about root causes. The goal is for the client to leave with a plan and know they have the skills and resources available to move forward in a good enough way.  

Solution-Focused Single Session Therapy promises to mitigate many of the access-to-service barriers in mental health organizations and modify the relationship between therapists and their communities. Solution-Focused Single Session Therapy can also foster a relationship with the organization providing service beyond the professionals who provide that service. Broad access to this service would enhance the mental health delivery system, provide a solution to workforce mental health shortages, and improve the quality of care in any community (Slive and Bobel 2011).

Solution-Focused Brief Therapy is an approach that operationalizes common factors in a practical and evidence-based way that is consistent with Single Session Therapy. Research on common factors relates a positive therapeutic outcome to focus on client’s strengths and resources, a solid therapeutic alliance, focusing on client’s motivation, needs, what they want, and continually gathering feedback from the client while activating their resources (Lambert 1999, Lambert 2005, Lambert & Ogles 2014). Psychotherapy research findings suggest that most change occurs during the first couple of therapy sessions (Hansen & Lambert, 2002 & Seligman, 1995). The single-session model proposes that many people receive sufficient support from a single session with the offer of future single sessions if needed. A review of the clinical and research literature shows that between one-third and one-half of randomly selected clients seen in single-session psychotherapy report being sufficiently helped by the experience so that the therapeutic episode can be terminated (Bloom, 2001).

Solution-Focused Single Session requires more in-depth training and relies upon previous clinical experience and skill sets. The purpose of Psychological First Aid is to assess the immediate concerns and needs of an individual in the aftermath of a disaster and not to provide on-site therapy.

The following is a practice exercise to help guide clinicians through a solution-focused single-session interview. This exercise is a learning opportunity to practice some solution-focused techniques and questions within single-session therapy.

Setting a collaborative, positive tone at the beginning of a Solution-Focused Single Session Therapy conveys confidence in the client’s abilities.

• Thank you for reaching out.
• I hope this conversation will be helpful for you.
• I will ask you several questions and will do my best within the next hour, so this session will be worth your time.
• Would this be ok with you?

The yes-set is a solution-focused skill that involves creating a conversation in which both the clinician and client say yes and agree on as many aspects of the conversation as possible. “For you” statements enhance the “yes-set” while providing validation and acknowledgment of the client’s predicament. Clients and families coping with crises often experience a lack of control, exhaustion, fear, frustration, and anxiety, requiring a great deal of “for you” responses. “For you” statements are often combined with coping questions enabling clients to recognize how they have been managing.

• This must be so difficult for you; how have you been managing?
• This must be exhausting for you; how have you managed to get through even a part of your day?
• This must be so frustrating for you; how have you managed to make this even a little bit more bearable for you?

Activating resources at the onset of the conversation helps build client engagement. Resource activation co-discovers with clients aspects of their life that are satisfying. What has been working well?  How have they managed in a tolerable way?   Different from listing strengths, activation of resources questions in detail how clients have managed, how have they endured, where do they get their strength from, and what keeps them going? Questioning clients in-depth on their strengths co-discovers hidden resources often ignored by clients unless specifically noticed and asked.  

Client’s coping with acute crises experience many challenges affecting the quality of their daily life. Asking clients what they know and have tried regarding their situation affirms their knowledge in managing their circumstances. Compliments can impart much-needed energy and stamina to both clients and their loved ones. It is important to ask questions that detail these successes. 

• Tell me some things you enjoy and are good at?
• What else do you enjoy?
• How did you learn these skills?
• How have you been coping given the challenges you have been facing?
• Where do you get your strength from?
• What else has helped? 
• How else did you cope? 

Listening for and discovering positive differences when clients have had or are having some measure of success is crucial. Positive differences, also known as exceptions, are when the presenting problem could have occurred but did not or was less severe. These past successes may include when clients have had periods of relief from their distress- even if very brief. Perhaps they were able to manage for a moment in a tolerable way. Maybe they had the strength to work and manage their responsibilities despite their intense emotions. Perhaps they persevered in their efforts to care for their needs and those they are responsible for.

Inviting clients to identify their VIPs and what they most appreciate about them is especially critical when engaging clients who are coping with crises. Mapping out a client’s social context is essential in understanding and assisting them in building solutions from multiple perspectives expanding their relational resources.

• Who are the most important people in your life?
• What do you most appreciate about them?
• Are there people/pets you are responsible for helping care for?
• What do you most appreciate about them?
• What do you suppose they would say they most appreciate about you?
• What do you suppose they would say they know about you that you can get through this challenging time?

“What are your best hopes for this one-hour appointment so you can say it was helpful and worth your time?” This question is future-directed, assists in goal negotiation, and conveys a belief in your client that they have best hopes.  Solution-Focused Brief Therapy focuses on the client’s expertise in knowing their situation and condition best. Asking clients (and their loved ones) what they know about their condition and what they have tried helps attest to their competence. For many clients in crisis, their situation can seem out of control. Solution-focused brief therapy invites clients to focus on how they have adapted and managed to deal with their challenges in a “tolerable/bearable” way. This increases their self-efficacy in managing their situation.

Asking a client’s best hopes is only the beginning of goal negotiation. Moving from their best hopes to specific actions requires discovering with clients what they would be doing instead when they have achieved their best hopes?  

• What are your best hopes (in the client’s words) that would tell you this one-hour session will be helpful for you and worth your time?
• What do you know about your best hopes?
• What do you know has helped you manage even a little bit?
• What do you know about yourself that you can achieve your best hopes?
• What do your VIPs know about you that you can achieve your best hopes?
• When was the last time things were a little better or more bearable for you?
• What have you tried to do to help?
• Supposing you achieve your best hope, what would you be doing differently?
• What would your VIPS notice you doing differently?

Scaling questions invite clients to rate their goals on a numerical scale from 1-10. Scaling questions are used to rate solutions, different from many other scales which rate problems. They are developed from the client’s best hopes and can be amplified by asking patients to predict how their VIPs would rate them. Scaling questions convey empathy, are client-centered and can assist clients and clinicians in understanding perspectives from multiple viewpoints quickly.  They are extremely useful in even brief Single Session Therapy encounters.

It is essential to amplify scaling questions. Working the scale provides additional opportunities to activate resources. What keeps the number from being lower? What’s the highest number it has been?  What would be a good enough number? Clients often do not need the best but are very satisfied with good enough.

• Suppose 10 is you are confident in your plans to achieve your best hopes, and 1 is the opposite; where would you say you are now?
• Suppose 10  is confident you can keep yourself safe, and 1 is the opposite; where are you now?
• What would be a good enough number?
• What keeps the number from being lower?
• Suppose we asked your VIPS how confident they are in you that you can achieve your best hopes from 1-10 (10 being the best); where would they say you are?
• What do you suppose you would be doing when the number goes up by one point?
• How confident are you from 1-10 that you can take that next small step to increase your number by 1 point?
• What do you know about yourself that you can do this?

In Solution-Focused Single Session Therapy, end-of-session feedback includes compliments, positive differences, VIPs, and successes co-discovered in the conversation. Scaling questions challenge clients to consider the next small steps to take toward achieving their goals. Feedback confirms that there is no other information clients think would be helpful for the clinician to know to be most beneficial for them.

• Provide a list of compliments
• Reiterate next steps that were co-discovered
• On a scale from 1-10, how helpful was this session?
• What was most helpful for you?
• Is there anything else before we end that would be important for me to know?

Click here for more information on having your organization receive training in Solution-Focused Brief Therapy Practices.

For those wishing more training in using the Solution-Focused Brief Therapy approach, you may wish to check out the following Institute online, self-paced courses:

Solution-Focused Brief Therapy: An Introduction to the Pragmatics of Hope (3 CE Credit/Clock Hours available)

Foundations of Solution-Focused Practice Online Intensive (3 CE Credit/Clock Hours available)

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