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Solution-Focused Documentation

2022-09-19T16:45:55+00:00September 16th, 2022|

solution-focused documentation

Embedding solution-focused documentation templates within electronic health records could help build solution-focused fluency, sustain solution-focused practices within organizations, and improve care coordination, communication, and client outcomes.  Thank you for reading this article on solution-focused documentation, which I would venture to say is not the most exciting topic. How did you decide to take the time while working tirelessly on the front lines of the mental health pandemic, given how staying up to date on notes is the miserable bane of our daily grind?  As my colleagues used to say, a “note is just a note” and “a done note is a good note,” but notes (documentation) now serve so many additional purposes, including accountability to reimbursing third parties, accreditation agencies, legal records of care, informing clinical decision supports and creating a repository of information for clinical research and quality improvement initiatives. Medical and mental health professionals are required to complete all sorts of documentation such as comprehensive psychological intake assessments and ongoing documentation to determine whether a client is appropriate for counseling,  what types of treatment are indicated, formulating treatment plans, coordinating care with multiple providers, documenting when clients are ready to complete or  “graduate” from discrete treatment episodes, and whether a higher level of care is indicated, such as in emergency and crises. However, little empirical attention has been given to this intake and subsequent paperwork (Richmond et al., 2014), and there is little evidence in the literature to guide the selection of specific data entry methods according to the type of data documented (Wilbanks 2018). 

Primary care and behavioral health clinicians often differ in their reporting requirements, codes, regulations, and language. Working with clinical teams to create solution-focused customized shared templates that are unique to each practice context is essential. Providing practitioners within organizations the opportunity to review their current documentation forms, get input directly from clinicians, and test out the forms with practitioners is essential for successful implementation.  Incorporating solution-focused questions within semi-structured data entry by creating text narratives and structured data entry could harness positive aspects of electronic records (Janett & Yeracaris 2020)

At the end of this article, there are solution-focused documentation examples for an intake evaluation, a progress note with a case example, and a solution-focused safety assessment (SFSA).

How Solution-Focused Documentation Can Help Sustain This Evidenced-Based Practice (EBP)

Solution-Focused Brief Therapy entails a paradigm, order, and language shift. These components can be easily integrated into documentation templates to enhance practitioner fluency and assist in sustaining the solution-focused brief therapy approach within organizations. 

Documentation is considered static and unchanging; however, what questions are asked, how they are asked, and when they are asked all make a difference in the narrative created.  The solution-focused practitioner harnesses hope by assisting clients in developing a narrative in which they can recognize their agency and resources while developing an action plan moving forward. Solution-focused documentation can help clinicians and clients develop a hopeful report while making record keeping a little more tolerable and bearable for practitioners. 

Solution-focused brief therapy (SFBT) is fundamentally a linguistic therapeutic approach. Questions are constructed to convey confidence in the client while simultaneously recognizing their agency, strengths, and resources and creating a collaborative treatment plan with the client.  Questions are formulated to help clients articulate what has worked, what is working, and what their best hopes are so they will be confident and have the necessary “good enough” skills to graduate from defined treatment episodes.  The solution-focused practitioner attempts to highlight positive language while simultaneously conveying a belief and confidence in their client. Solution-focused documentation templates can provide friendly reminders and cues for clinicians to ask hopeful questions.  What questions we ask, what we listen to, what we ignore, how we construct questions, and what order we ask questions matter. 

Imagine if the following questions were part of an electronic record semi-structured document. 

    • “What are your best hopes?”: conveys the assumption that they do have best hopes.
    • “What has been better since we last met?: conveys something has been better and looks for positive differences/exceptions.
    • “What has been happening that you want to continue to happen?” conveys some things have been working.
    • “What do you know about your condition?”: conveys that they do have knowledge and expertise. 
    • “What do you know about your child that they will succeed in life?”:  conveys a belief that they do know their child will succeed. 
    • “Supposing ten is you are confident that your skills are good enough to graduate from this treatment episode, and 1 is the opposite; where are you now?”: conveys clients have the capabilities to develop skills and graduate from discrete treatment episodes.

How Solution-Focused Documentation Differs from Problem-Focused Documentation

Traditional intake and follow-up paperwork have relied on a medical model that requires a detailed description of the client’s problems. Problem-oriented approaches require a complete understanding of all the symptoms to make a diagnosis and then treat the client. Solution-focused brief therapy (SFBT)  stands in sharp contrast. SBFT is the only therapeutic modality not requiring a complete understanding of the problem for clients to move forward with their goals. SFBT starts by revealing a detailed understanding of the client’s best hope for their future and collaboratively looks for client-related resources, actions, and agency that build this outlook. The focus is on detailing what a client will do 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.  

Resource activation and therapeutic interventions that reinforce the client’s agency and abilities play a central role during successful treatment (Gassmann & Grawe 2006).  Therapists who create an environment where clients perceive themselves as well-functioning and activate their resources early in the session have more successful outcomes (Gassmann & Grawe 2006). Research was done to test problem-focused versus solution-focused intake questions on pre-treatment change and compared a standard written intake form with problem-focused questions to a solution-focused brief therapy intake form (Richmond 2014). Clients answering the solution-focused questions described significantly more solutions and fewer problems than the comparison group. Clients in the SFBT intake interview improved significantly on the Outcome Questionnaire before their first therapy session, whereas those in the traditional diagnostic intake did not. This study demonstrated that intake procedures are not neutral information gathering and that strength-based questions have advantages (Richmond 2014). 

Solution-Focused Documentation Clinical Case Example:

The following is a brief example of a case and one possible way to incorporate solution-focused documentation. Of course, there are many different mandates and requirements; this example only provides one. All documentation templates need input from staff and organizations to ensure they meet requirements.

Karl is an 18y/o transgender male (preferred pronoun is he) who presented to the emergency department following a motor vehicle accident. He reportedly was texting his friends about meeting to hang out with them while driving when he didn’t realize the car in front of him had stopped. The car was totaled. Karl sustained a broken leg and back injury. He was hospitalized due to the severity of his injuries and the need for surgery on his leg. While awaiting surgery, Karl was reporting suicidal thoughts and wanting to die. Karl’s father was out of town caring for his elderly parents on the car accident day and had not yet arrived back home. Karl had a difficult time when his father was away and had a prior overdose attempt six months ago while his father was caring for his elderly parents. Karl’s mother died from cancer when Karl was 12 years old, and Karl spent much of his youth witnessing her treatments, decline, and death. The following is an excerpt from Karl’s crisis evaluation while in the hospital medical unit.

Tx: Hello Karl – is that how you like to be called?
Karl: Yes
Tx: Thank you for taking the time to meet with me. My hope is that I will be helpful to you. I will do my best. Would it be ok if I asked you a few questions in hopes of being helpful for you? Some questions may be a bit challenging.
Karl: Ok
Tx: Thank you. It must be difficult for you to be here; how have you been holding up these past few days?
Karl: It’s been hard. It’s loud, and I can never get any rest. I just want to go home.
Tx: Of course. It must be so frustrating for you to be here. What do you know has helped make things even a little bit bearable while you are here?
Karl: Getting pain medication.
Tx: How has getting pain medication been helpful for you?
Karl: It was bad after the accident. I was in so much pain. All I could think of was killing myself just to relieve my agony.

Discussion: Tone Setters and Activating Resources:

The therapist sets the tone by thanking Karl and confirming how he wants to be called, as well as providing consent for the conversation to follow. The therapist also provides plenty of “for you” responses followed by coping questions that activate Karl’s individual resources early in the conversation.

Tx: I’m glad the medications are being helpful for you. How well would you say you are tolerating your pain from 1-10 (10 being the best)?
Karl: Probably a 5.
Tx: What would be a good enough number?
Karl: A 7.
Tx: What keeps the number from being lower than a 5?
Karl: I’m able to get some sleep.
Tx: What else keeps it from being lower?
Karl: It’s gone up from a one, and I’m hoping the surgery will help even more.
Tx: What have you done that has helped the medication work, even a little bit?
Karl: I just try and distract myself by playing video games. The nurses have brought me some games, and that helps a bit.

Discussion: Scaling Pain Tolerability

The therapist attends to his pain and how well he is tolerating it demonstrating concern about his wellbeing. Scaling how well Karl is tolerating the pain and how helpful the medications are from 1-10 is a more constructive way to assess pain. It promotes his agency in managing his pain.

Tx: I’m impressed with how you are handling this. I wonder if you know whose idea it was for me to come and see you today?
Karl: I think it was the nurse.
Tx: What do you know the nurse was concerned about that asking me to come to see you would be helpful for you?

Discussion: Exploring External VIPs

Asking Karl whose idea it was for the therapist to come and framing this as concern can be helpful in exploring important VIPs in Karl’s immediate social context. Notice that the therapist did not ask “why” rather instead what the nurse was concerned about guiding the narrative to one of care and compassion.

Karl: I don’t know. (Pause) Probably because I said I wanted to die and couldn’t take it anymore.
Tx: What do you mean by “take it anymore”?
Karl: My father is in Arizona, and when he comes back, he will be furious with me. I know he will take away my driving privileges, and driving to see my friends is the only thing that helps me feel any better.

Discussion: Exploring the client’s language

Karl was able to identify the reason for the consultation – that he wanted to die. Exploring the meaning of his words provided more about Karl’s concerns and his reasons for distress. Although, it may seem to slow the conversation down, exploring the clients’ meaning often paradoxically moves the conversation forward more quickly as the therapist and client negotiate a shared understanding.

Tx: That must be very difficult for you to think about while also dealing with your pain and upcoming surgery. How have you been enduring all of this?
Karl: It’s been hard. My father is still in Arizona and won’t be home until tomorrow.
Tx: Of course, this must be hard for you. Is your father an important person in your life?
Karl: Yes. I don’t know what I would do without him.
Tx: What do you most appreciate about your father?
Karl: He’s always there for me – even when I do stupid things. He doesn’t give up on me.
Tx: What has he done to always be there for you?
Karl: He and I are close. After my mother died, we went through a lot. We helped each other.
Tx: It sounds like your father loves you a lot. Suppose I were to ask him what he most appreciates about you, what would he say?
Karl: That I’m strong, and I can deal with a lot.
Tx: What do you mean by “deal with a lot”?
Karl: My mother died when I was 12 years old, and it was so hard.
Tx: That sounds incredibly challenging. What would your father say you have done to deal with this?
Karl: He’d say that I kept going to school and kept caring about people – that I am strong.
Tx: What would he say you have done that you are strong?
Karl: That I care about people.
Tx: You both sound very strong. I’m wondering, who else are the important people in your life?
Karl: My mother. Even though she died, I think of her a lot and know she is with me.
Tx: What do you suppose your mother most appreciates about you?
Karl: She knows how much my father and I care and help each other. She would be proud of that.
Tx: What else would she say she appreciates about you?
Karl: That I don’t give up.

Discussion: Exploring VIPs

Taking the time to ask who the most important people in Karl’s life and what they most appreciate about him is critical in highlighting his relationship resources. It is often these meaningful relationships that are protective and stop people from acting on thoughts of suicide.

Tx: Supposing I asked your mother and father what their best hopes would be for you so they would know you are safe to go home, what would they say?
Karl: My father would want to make sure I don’t do anything unsafe.
Tx: What would he hope you do instead?
Karl: He would want me to let him know if I was upset and reach out for support.
Tx: What else would tell him you can keep yourself safe?
Karl: That I wouldn’t be driving and getting into accidents and wanting to end my life. I don’t want to die; it’s just sometimes I get so upset that all I can think of is the relief of being together with my mother.
Tx: Of course. These are very intense emotions you are experiencing. I’m wondering, what are your reasons for living?
Karl: I want to go to college and become a nurse.
Tx: Wow. That is impressive. Have you always wanted this, or is this different?
Karl: I’ve wanted to be a nurse for a long time. Ever since seeing how they helped my mother and our family.
Tx: Wow – you are strong. Where do you get this determination from?
Karl: Probably my father. He doesn’t give up. He keeps trying to help his parents and me.

Discussion: Exploring Best Hopes

Often clients experiencing intense emotions are more able to answer what their best hopes are from the perspectives of their VIPs. This is another reason to have some knowledge of who are the most important people in your clients’s life. Karl was able to answer what his parents’ best hopes were quite easily – to stay safe. Following this, every question or response was focused on activation of his resources including exploring his reasons for living. This is in contrast to exploring why he wants to die. Exploring his reasons for living uncovered additional resources and opportunities to compliment Karl and explore positive differences with him.

Tx: Sometimes, I ask number of questions to help me help you. Would that be ok?
Karl: Ok
Tx: Suppose ten is you are confident that you can keep yourself safe and one is the opposite; where are you now?
Karl: about a 5.
Tx: And what would be a good enough number?
Karl: A 6
Tx: What keeps the number from being lower than a 5?
Karl: Knowing that my father will be here soon.
Tx: What do you know about your father being here for you soon is helpful?
Karl: I just need to have him nearby. He knows how to calm me down.
Tx: What else keeps the number from being lower?
Karl: That I wouldn’t do anything. I wouldn’t want to hurt my father. It would kill him.
Tx: Suppose I asked your father how confident he is in terms of your ability to keep yourself safe from 1-10; what would he say?
Karl: I don’t know.
Tx: You know your father best. There is no right answer. I’m just wondering what you think?
Karl: Probably a 3
Tx: What do you think is the reason your number is a 5 and not a 3?
Karl: I think he would say he’s scared that I had another accident and did the same thing a few months back. He would probably say he’s scared that I could’ve died.
Tx: of course – I’m sure that must be frightening for him to know you could have died. What do you suppose keeps his number from being lower than a 3?
Karl: That I’m here and getting help.
Tx: What else do you think keeps his number from being lower?
Karl: That he’s on his way and will be here soon.
Tx: I’m wondering, Karl, what would you be doing when your confidence is just a bit higher, at a 6?
Karl: I would have a plan for when I leave the hospital.
Tx: What do you mean by a plan?
Karl: That my father and I would talk, and I would have someone to talk to.

Discussion: Scaling Confidence in Ability to Stay Safe

Scaling confidence in Karls’ ability to stay safe and “working the scale” is an effective way to develop a collaborative safety plan. Even though his parents were not present in the session, their perspectives could easily be incorporated into the conversation. Numbers limit language confusion and allow for a clear plan moving forward in small manageable steps. Numbers often help clients manage the intensity of their experiences safely, as working the scale provides further opportunities to highlight their agency and a plan. And Hope = agency + plan!

Documentation Examples

References

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, 4926.

Gardner, C. L., & Pearce, P. F. (2013). Customization of electronic medical record templates to improve end-user satisfaction. CIN: Computers, Informatics, Nursing, 31(3), 115-121.

Gassmann, D., & Grawe, K. (2006). General change mechanisms: The relation between problem activation and resource activation in successful and unsuccessful therapeutic interactions. Clinical Psychology & Psychotherapy, 13(1), 1–11.

Janett, R. S., & Yeracaris, P. P. (2020). Electronic Medical Records in the American Health System: challenges and lessons learned. Ciencia & saude coletiva, 25, 1293-1304.

Richmond, C. J., Jordan, S. S., Bischof, G. H., & Sauer, E. M. (2014). Effects of solution-focused versus problem-focused intake questions on pre-treatment change. Journal of Systemic Therapies, 33(1), 33.

Wilbanks, B. A., & Moss, J. (2018). Evidence-based guidelines for interface design for data entry in electronic health records. CIN: Computers, Informatics, Nursing, 36(1), 35-44.

Training The Emergency Medical System And EMTs In Solution-Focused Crisis Interventions

2022-08-09T11:43:17+00:00June 28th, 2022|

A Video Conversation

Emergency Medical System, EMS professionals, handle tens of millions of calls in the United States each year and make life-altering patient decisions daily. Embedding solution-focused crisis interventions within EMS services who already work 24/7 within the medical and mental health system provides an opportunity to mitigate the mental health system crisis. Training EMS providers in Solution-Focused brief crisis interventions have the potential to deliver greater access to mental health services while conserving healthcare resources. Solution-Focused Brief Therapy has been applied successfully across a wide range of professions and fields, in a transdisciplinary manner, for a broad range of mental health conditions (Beyebech, M. et al., 2021). Specially trained paramedics have effectively employed triage algorithms to screen and select patients experiencing an acute mental health crisis for transport directly to psychiatric treatment facilities (Mackey & Qiu 2019). In this article, we are proud to share a conversation of 2 Emergency Medical Technicians, EMTs, who have successfully integrated solution-focused brief crisis interventions within their daily work. Interviewing these two dedicated and talented professionals working on the front lines of the healthcare system was a privilege and highlighted the incredible work EMTs do every day to serve communities around the nation!

The United States is in the midst of a mental health workforce pandemic. The mental health workforce is a key component of mental health care quality, access, and cost. The quality of mental health care is influenced by the skills of the people providing the care. Access to mental health care depends on appropriately skilled providers being available to render treatment. EMS professionals, with little to no training in mental health, are already providing emergency mental health triage and response. EMS practitioners provide much more than transportation while earning a median income of $17.00/hour, $35, 360 a year. They are left out of the medical system feedback loop when delivering patients to the ED, never learning the outcome of their patients, what they did successfully, or gaining learning opportunities for how to improve. EMS professionals endure a high rate of occupational violence that is about 22 times higher than the average for all other U.S. workers. As EMS professionals continue to be undervalued, their work has never been more important, especially in light of their service during the Covid-19 pandemic.

In recent years an ever greater number of patients find themselves seeking care for psychiatric illnesses 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 illnesses occupy 42% more time than non-psychiatric visits. 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, which represented more than 7% of the $76.3 billion in total ED visit costs (Karac & Moore 2020).

911 dispatchers are often the first point of contact after an individual is in an accident, needs emergency assistance, or witnesses a crime. A lack of high-quality training was identified by emergency service call-takers and dispatchers as contributing to increased stress levels. 911 Call Takers must be further trained to navigate police, fire, and medical emergencies, with an ever-increasing focus on crisis intervention and training. They must also be further trained in identifying and allocating the proper resources and services based on the call information that they receive.

Due to the complexities in managing many patients experiencing mental illness, according to a recent Atlanta Journal article, patients are often charged with crimes, typically “nuisance crimes” and include anything from disorderly conduct to trespassing. This often results in arrest and jail for their mental health condition. In most American cities, it is police officers who respond to such calls, an approach law enforcement experts say increases the risk of a violent encounter because they aren’t always adequately trained to deal with the mentally ill. In 2017, police officers spent 21% of their time responding to or transporting people with mental illness, according to preliminary data from a survey of 355 U.S. law enforcement agencies. At least one in every four people killed by police has a serious mental illness, according to the Treatment Advocacy Center, a nonprofit based in Arlington, Va. Basic training for U.S. police officers takes 21 weeks, on average, and rarely includes training on bias, de-escalation of tense situations, recognition of psychiatric symptoms, or mental health first aid techniques. Bringing a uniform and a weapon to the scene creates a power dynamic that is not in the best interest of either party. Even when officers undergo training in these areas, research demonstrates that it is not effective. In the United States, a police encounter with a civilian is 16 times as likely to result in that person’s death if they have an untreated mental illness when compared to someone who does not. (Rafla-Yuan et al., 2021)

Ultimately a cohesive transdisciplinary mental health system that embraces EMS practitioners within the existing mental health system is one intervention that would help address the catastrophic failures of the mental health system. Training EMS providers who already give 24/7 community triage and response interventions in solution-focused brief crisis interventions could help divert patients away from emergency rooms to other more effective and appropriate community provider locations. As can be seen from this interview, EMTs specially trained in mental health emergencies have the potential to strengthen workforce diversity and competency successfully making a difference for all patients, including those experiencing mental health conditions.

REFERENCES

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

Hoge, M. A., & Hirschman, R. (1984). Psychological training of emergency medical technicians: An evaluation. American journal of community psychology, 12(1), 127.

Jacobs, G. A., Gray, B. L., Erickson, S. E., Gonzalez, E. D., & Quevillon, R. P. (2016). Disaster mental health and community-based psychological first aid: Concepts and education/training. Journal of Clinical Psychology, 72(12), 1307-1317.

Karaca, Z., & Moore, B. J. (2020). Costs of emergency department visits for mental and substance use disorders in the United States, 2017: statistical brief# 257.

Mackey, K. E., & Qiu, C. (2019). Can mobile integrated health care paramedics safely conduct medical clearance of behavioral health patients in a pilot project? A report of the first 1000 consecutive encounters. Prehospital Emergency Care, 23(1), 22-31.

Rafla-Yuan, E., Chhabra, D. K., & Mensah, M. O. (2021). Decoupling Crisis Response from Policing — A Step Toward Equitable Psychiatric Emergency Services. New England Journal of Medicine, 384(18), 1769–1773. https://doi.org/10.1056/nejmms2035710 

Riaz, I., Gal Lapid, E. M. T., Mihir Kumar, E. M. T., Trivedi, R., & Sulley Park, E. M. T. (2021). Creating a Protocol for Campus EMS Response to Mental Health Complaints. JCEMS, 4.

Waters, R. (2021). Enlisting Mental Health Workers, Not Cops, In Mobile Crisis Response: The article examines local programs that send health crisis workers and emergency medical technicians, rather than police, to people experiencing serious mental health distress.

How Solution-Focused Brief Therapy Training Can Support The Mental Health Workforce

2022-07-08T19:03:32+00:00June 24th, 2022|

mental health workforce trainingHow can the mental health workforce be sustainably and successfully trained in an evidenced-based brief treatment approach all while meeting their own needs and the mental health needs of a client? How can this be accomplished? This article attempts to provide a framework for answering this very challenging question. Training clinicians within the mental health workforce is a critical component that impacts the quality, access, and cost of mental health care. 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 practice (EBP)  that can assist clinicians, and behavioral health organizations manage long waitlists and increase access to treatment for more clients.  Solution-Focused Brief Therapy has been applied successfully across a wide range of professions and fields, in a transdisciplinary manner, for a broad range of mental health conditions (Beyebech, M. et al., 2021).

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.

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 evidence-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 a client’s often unrecognized resources both individually and within their social context. SFBT empowers clinicians and clients to navigate purposeful conversations to assist clients in reaching their targeted goals.

The Need for Mental Health Workforce Development

Workforce development and training must advance as an integral centerpiece of behavioral health policy and funding priorities for all policymakers to address the critical mental health needs of our nation. The COVID-19 pandemic has only worsened what were already significant challenges facing the mental health workforce. The Centers for Disease Control and Prevention (CDC) reported that the percentage of U.S. adults with recent symptoms of anxiety or a depressive disorder increased from 36.4% to 41.5% and the percentage reporting unmet mental health needs to be increased from 9.2% to 11.7%, with the largest increase seen among young adults (18-29) during August 2020 to February 2021 (Vahratian A. et al, 2021).  In the early months of the pandemic, the nation saw an 18% increase in overdoses compared with the same months in 2019. The trend only continued throughout the rest of 2020. The American Medical Association recently reported that every state had seen increases in opioid-related mortality (Petterson, S. et al 2020). 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 reality is that individuals with mental health and substance use needs are facing challenges accessing adequate, timely, and affordable care in every state in the country. Often this leads to dire consequences such as the need for acute care services, engagement in the criminal justice system and in some cases, suicide or overdose. Furthermore, the current crisis is contributing to long documented health disparities, including significant (and avoidable) early mortality for those with behavioral health conditions (de Mooij et al, 2019). Prior to COVID -19, the addiction treatment workforce was experiencing annual turnover rates ranging from 13-52% with nearly half of all organizations operating with significant staff shortages, low recruitment, and retention success. Many workers are continuing to leave the field for higher-paying and less demanding work with young professionals often filling jobs until they are eligible for higher-paying private practice (National Council, HMA prepare recommendations for workforce crisis. Annapolis Coalition. (2022, March 30)

Access to behavioral health services is complex and impacted by systemic factors such as federal and state policy, payment, provider capacity, social determinants of health, historical disparities, and an individual’s capacity to engage in services. Limited funding streams for behavioral health contribute to non-competitive salaries for the nation’s behavioral health workforce. This forms the foundation of the workforce shortages that have developed over time and are now at a crisis point. (Behavioral Health Workforce is a National Crisis: Immediate Policy Actions for States, retrieved 2022).  In addition, the economic, political, and social context in which an organization resides as well as the structure, leadership, and culture of an organization impacts the delivery of quality healthcare. The need for evidence-based training and treatment interventions that can be implemented effectively in a sustainable way within organizations is more critical than ever.

What are the Challenges Associated with Training the Mental Health Workforce in Evidence-Based Practices?

Strategies specifically designed to facilitate the training of mental health practitioners in evidence-based practices (EBPs) have lagged behind the development of the interventions themselves. A report by the United States Surgeon General (1999) suggests that the majority of clients with mental illness do not receive EBP. There are obstacles to the dissemination and implementation of EBP being translated into clinical practice (e.g., criticism of treatment manuals, inadequate training, and unsupportive organizational climates). Understanding how to best disseminate EBP is paramount to reducing the gap between research and practice (Beidas and Kendall 2010). This gap in training mental health practitioners has resulted in a shortage of treatment providers who are adequately trained and supported to provide EBPs and is a major contributor to the “research-to-practice gap”. (Kazdin, A. E. 2008).

General themes and definitions have emerged from the theoretical and empirical literature on training. In the adult education literature, teaching and initial education have been distinguished from training or “retraining” and “mastery of action”. (Thompson 1976). Two complementary processes have been identified as essential for effective implementation of training: the methods through which professionals learn new skills and techniques and systems of ongoing feedback and support to continue to develop the newly acquired skills (Welch et al., 2006).

It has been shown consistently that a “one and done”, or single-exposure training model is limited. “One and done” trainings are inadequate in their ability to produce sustainable results. In order to provide practice related behavioral change and have it be effective, previous training on the EBP seems to be required (Fixsen et al., 2005; Beidas & Kendall 2010).

What is known regarding the implementation and sustainability of training programs?

The ability to engage and train a large, multidisciplinary workforce in the use of EBPs is a necessary but not sufficient condition to demonstrate training effectiveness. It is also necessary for the workforce, once trained, to sustain the use of the EBP (Shapiro et al., 2012). When considering the efficacy and sustainability of effective training programs, it is essential to consider the organization, system, and unique context in which training occurs. Prior research has identified a diversity of elements that affect training implementation. These include the training program, provider characteristics, and the unique social context of organizations implementing training programs (Beidas and Kendall, 2010). Program factors include the quality of an evidence-based practice, training content, and methods of training. Active learning which includes interactive processes that focus on action and reflection within a clinical context is most helpful. Active learning includes modeling, practice opportunities, building self-efficacy, interaction among learners, and role-plays. In addition, ongoing supervision and feedback that builds confidence have been shown to improve therapist adherence and competence (Henggeler et al., 2002). A practitioner’s belief that a particular treatment is useful for their client population improves successful training outcomes.  This includes having success with the treatment approach in a range of settings with “challenging cases”.

The following factors have been shown to promote sustainable transdisciplinary mental health workforce training programs (Lyon et al., 2011).

  • Provider motivation
  • Congruence with existing experience
  • Trained personnel who meet with clinicians in their work settings to discuss the use of specific practices and techniques
  • Encouraging learner participation through active, open-ended questioning
  • Delivering a small number of key empirically-derived messages
  • Distributing concise graphic reference materials
  • Repeat key messages
  • Developing specific plans for individual or group organizational behavioral change
  • Ongoing case-based consultations
  • Interprofessional learning (members of two or more professions learn together)
  • Learning by bringing together multiple disciplines for multiple contacts and exercise
  • A combination of didactics, role plays, case-based learning
  • Small group discussion
  • Web-based resources and facilitator support
  • Formation of peer-to-peer group networks
  • Coaching through direct feedback following observation
  • Reminders to engage in clinical practice behaviors such as being displayed on the screen, stickers or printouts in clinical charts, and clinical checklists
  • Self-regulated learning to help practitioners guide their own goal-setting Self-monitoring for skill acquisition

How does the Institute for Solution-Focused Therapy Develop and Provide Customized Training to Organizations and Their Staff?

The Institute for Solution-Focused Therapy provides diverse and flexible online training choices, including customized hybrid program options that combine live-interactive synchronous experiences with self-paced remote learning components maximizing training effectiveness. We offer a broad range of courses, from introductory to advanced in the practice of SFBT. We also provide ongoing enhancement programs which include solution-focused supervision.  Most of our courses are eligible for continuing education credit. Our transdisciplinary approach engages with many professional disciplines, including physicians, mental health practitioners, educators, para-professionals, nurses, child protection services, EAP organizations, military, chaplains, probation officers, crisis clinicians, and in-home therapy teams, and others.  We provide an initial one-hour free zoom consultation to learn about each unique organization and develop a customized program that meets their needs. Our customized live courses are also available as self-paced versions so staff who are new or unable to attend can be trained while also receiving continuing education credits. Our customized courses include recordings of all the training if desired, copies of slides, materials, and any customized materials that were utilized throughout the course. These customized courses can be purchased at a later date as a self-paced version for new staff or for staff who are unable to attend the entire training. The self-paced customized courses are available for continuing education and include an exam. We hope this will facilitate a sustainable training solution to workforce challenges given the high turnover of staff within many organizations.

During the past 18 months, we have had the privilege of training over 35 organizations. The following are a few training case examples to showcase how organizations have customized their training needs.

Training Case Examples

Integrative Health Care Organizations: CrescentCare

New Orleans, Louisiana

CrescentCare’s mission is to bring caregivers and the community together as partners in health and wellness for all. Their experience builds on more than 30 years of impact through their founding organization, NO/AIDS Task Force. Now, as a Federally Qualified Health Center, they are taking that expertise and expanding it! Federally Qualified Health Centers are community-based health care providers that receive funds from the HRSA Health Center Program to provide primary care services in underserved areas. They must meet stringent requirements, including providing care on a sliding fee scale based on ability to pay and operating under a governing board that includes patients. CrescentCare offers a broad range of health and wellness services for anyone and everyone who is seeking healthcare services in Greater New Orleans and Southeastern Louisiana. https://www.crescentcare.org/

Mainstreaming of mental health services has led to an increase in the presentation and care of mental health patients in generalist health settings. There is a well-documented lack of adequate mental health educational preparation within healthcare. Many groups, including primary care physicians, nurse practitioners, and specialty health practitioners, have been identified as ill-equipped to meet the mental and physical health needs of clients.

There are broadly two groups of patients who require mental health services within medical settings: (i) clients with an existing diagnosis of mental illness who have physical conditions requiring ongoing care and (ii) clients who have physical health conditions who develop mental health conditions ( Brunero et al., 2012).

General and specialty practitioners have tremendously demanding workloads, leading to a lack of time, interest, and motivation to attend training. In addition, there is often a lack of organizational support that creates a barrier to the effective implementation of evidence-based practices. Cost and time constraints are also common barriers. To address these issues, CrescentCare reached out to train their Integrative Behavioral Health Team. After an initial Zoom consultation,  the following customized training program was developed.

The entire primary care provider team: CrescentCare began by offering their entire primary care team the 2-hour live training “A Taste of Solution-Focused Skills and Practice”. All providers were invited to a 2-hour live interactive training program. The TASTE has unlimited participants, so the entire provider team could be introduced to the approach and learn how SFBT could help them in their practice across disciplines. This interactive introduction included an overview of the SFBT approach, video demonstrations, and interactive chat discussions with opportunities for questions. It can be used across an organization where executives, administrators, clinicians, case-workers, supervisors, and any staff interested can attend. This provided all staff with 2 hours of continuing education credits. This course can also be recorded as a customized version for new staff or staff unable to attend as a self-paced course that includes a short exam.

For supervisors and “champions” of this approach: A small group of 6 supervisors and integrative behavioral health clinicians choose a combination of more intense self-paced and synchronous training sessions to build their confidence and fluency in order to provide support for other clinicians in their organization. This group took the Foundations of Solution-Focused Online Intensive combined with a small-group BASIC Solution-Focused Skills and Practice interactive training. This small group received more intensive individualized training to support and sustain their staff and serve as “peer champions” of the SFBT approach within the organization. This hybrid intensive training approach provided clinicians with 19.5-course hours plus 12 hours of training for a total of 31.5 continuing education credits.

For the behavioral health clinical staff: A transdisciplinary group of behavioral health clinicians, nurse practitioners, and psychiatrists took the self-paced Solution-Focused Brief Therapy: An Introduction to Clinical Practice combined with the BASIC Solution-Focused Skills and Practice interactive training. This training helped build their confidence and skills in the SFBT approach.

The combination of the self-paced course with written and video demonstrations and the BASIC Solution-Focused Skills and Practice course provided hybrid training opportunities to solidify the foundations of the SFBT approach. The BASIC live course offers 12 hours of training divided into 2-hour sessions every other week. Offering continuing education training in group cohorts builds relationships. Further, it sustains a workforce while also providing a context for staff to continue practicing the skills they develop with each other. BASIC and ADVANCED small group sessions include some review of the material, an ongoing framework of the approach, role-plays, case discussions, interactive video demonstration discussions, breakout sessions, and recommended practice exercises discussed in the following session called “Success and Challenges” rounds. This hybrid training approach provided clinicians with 17 hours of training for a total of 17 continuing education credits.

A Current New Training cohort: Because of the success of the training, a new cohort of clinicians working with the homeless population is getting trained. This cohort includes a talented transdisciplinary staff of clinicians, case managers, and supervisors. They are also receiving a hybrid training approach, including Solution-Focused Brief Therapy: An Introduction to Clinical Practice combined with BASIC Solution-focused skills and practice for agencies.

Future Training options: In addition, there is the opportunity for further training, including ENHANCEMENT sessions to sustain the approach, ADVANCED Solution-focused skills further and practice online interactive sessions, and Solution-Focused SUPERVISION skills and practice. All of these offer further opportunities to sustain the approach within their organization.

Many organizations also pair the self-paced courses with the live cohort training of BASIC Solution-Focused Skills and Practice for agencies. Because we record these live interactive trainings, we now offer SELF-PACED CUSTOMIZED BASIC SKILLS AND PRACTICE  versions for each organization that new staff can take at a later time or for staff who are unavailable for the training, all while obtaining continuing education credits. Providing continual professional development with colleagues and education credits are common reasons for staff satisfaction and can help sustain the workforce and may decrease staff turnover. A combination of Solution-Focused Brief Therapy: An Introduction to Clinical Practice paired with the live or self-paced customized interactive BASIC Skills and skills and practice (that can be offered to staff at later times in a self-paced format) provides 17 continuing education credits!

Click here to see an interview with Lucy Cordts: https://solutionfocused.net/lucy-cordts-crescentcare-health-centers-success-solution-focused-brief-therapy/

Lenape Valley Foundation, Pennsylvania

The mission of Lenape Valley Foundation is to partner with members of their community encountering mental health, substance use, and intellectual or developmental challenges as they pursue their personal aspirations and an enhanced quality of life.  For over 60 years, Lenape Valley Foundation has served adults in the community with a variety of behavioral health needs. Their qualified staff work to provide individuals in our mental health programs, services for individuals with intellectual disabilities, and crisis services with the best possible care to meet their unique needs so that each person can work toward achieving their individual treatment goals. Lenape Valley Foundation also offers a full spectrum of services, dependent on the needs of the individual child and family assisting children and their families to reach their full potential by providing individualized, compassionate care. https://www.lenapevf.org/

Lenape Valley Foundation reached out for training during the COVID-19 pandemic hoping a brief evidence based treatment approach could help to manage the increased demand for mental health services and long waitlists. Their best hopes were to provide comprehensive training within their organization for their dedicated support staff, agency leaders, and full-time staff and clinicians serving on the front lines of the mental health pandemic. After an initial Zoom consultation, the following customized training program was developed.

All of the support staff and agency leaders took the self-paced course: Solution-Focused Brief Therapy: An Introduction to Clinical Practice. All of their full-time staff and therapists took the self-paced course: Foundations of Solution-Focused Practice Online Intensive. In addition, all of their full-time staff and therapists took the live synchronous BASIC Solution-focused skills and practice course.

In our final session on graduation day, we scaled how confident they are in their solution-focused skills as well as how confident they are that they will sustain their skills within their organization. All of the staff rated their confidence between 7-9 and all stated that this is “good enough”. I am summarizing a few of the comments from this dedicated and talented group of clinicians regarding what they have found most helpful from the training and what they know will help them sustain their skills.

  • Having written reminders of the “four-square” guide to the overall approach available to use as needed
  • Maintaining the “yes-set” and incorporating the client’s language within the formulation of questions
  • Incorporating scaling questions to develop a plan
  • Incorporating VIPs – including spiritual VIPs
  • Asking about Best Hopes
  • Asking coping questions and “what have you tried?”
  • Consciously incorporating solution-focused language and questions in conversations
  • Appreciating the solution-focused framework with their other skill sets
  • Listening differently while hearing the same things and choosing to ask different questions
  • Appreciating the client’s progress seeing more hope and actions
  • Having greater skills to manage clients who are “stuck”
  • Asking what do you know questions
  • Having more skills to help clients focus on their goals
  • Starting sessions with “What’s better” or “what’s been happening that you want to continue to happen?
  • Appreciating how useful the approach is with families and couples
  • Helpful in reducing vicarious trauma and increasing vicarious resilience
  • Using “for you” statements paired with coping questions to minimize power struggles and take the pressure off needing to find a solution for clients
  • Seeing the effectiveness of the approach inspires them to do more
  • Incorporating solution-focused approaches within supervision and monthly group meetings
  • Reviewing success and challenges rounds
  • Taking small steps to practice each of the skills
  • Learning the fundamentals and then taking a “deep dive” into more of the skills

Alzheimer’s Association

The Alzheimer’s Association leads the way to end Alzheimer’s and all other dementia — by accelerating global research, driving risk reduction and early detection, and maximizing quality care and support. The Alzheimer’s Association 24/7 Helpline (800.272.3900) is available around the clock, 365 days a year. Through this free service, specialists and master’s-level clinicians offer confidential support and information to people living with dementia, caregivers, families, and the public. https://www.alz.org/

The Institute for Solution-Focused Therapy has had the privilege to provide training for the Alzheimer’s Association’s 24/7 crisis call line. Their goal was to provide skills for their staff so that one 30-minute call would make a difference for those living with or caring for someone with Alzheimer’s or other forms of dementia. During the pandemic, they experienced the all too common challenges associated with managing an increase in  demand for their crisis call hotline services.

The organization had received prior solution-focused training through the Institute of Solution Focused Therapy and was now interested in providing enhancement training for their staff. New staff were offered the self-paced Solution-Focused Brief Therapy: An Introduction to Clinical Practice. Several different cohorts were put into courses based on their prior training experience. The trainings included a review of cases, role-plays, didactics, video demonstrations, and opportunities for practice and questions. All of the sessions were recorded so the organization could use these sessions for future staff training.

Click here to see an interview with David Parris, Clinical Director of the Alzheimer’s Association 24/7 Helpline: https://solutionfocused.net/solution-focused-brief-therapy-alzheimer/

Seacoast Mental Health Center, New Hampshire

Seacoast Mental Health Center’s mission is to provide a broad, comprehensive array of high-quality, effective and accessible mental health services to residents of the eastern half of Rockingham County in New Hampshire. They are a federally qualified health center (FQHC). Federally Qualified Health Centers are community-based health care providers that receive funds from the HRSA Health Center Program to provide primary care services in underserved areas. They must meet a stringent set of requirements, including providing care on a sliding fee scale based on ability to pay and operating under a governing board that includes patients. Services are available to all individuals in their large service region throughout every stage of life. Services can be accessed in a variety of ways: in their two offices and various community settings, including schools, primary care offices, and telehealth in your own home. https://smhc-nh.org/

Seacoast Mental Health Center reached out for training during the COVID-19 pandemic hoping a brief evidenced treatment approach could help to manage the increased demand for mental health services and long waitlists. Their best hopes were to provide comprehensive training within their organization for their dedicated support staff, agency leaders, and full-time staff and clinicians serving on the front lines of the mental health pandemic. After an initial Zoom consultation,  the following customized training program was developed.

Seacoast Mental Health Center invested in training their entire clinical staff of approximately 125  clinicians. Clinicians were provided a hybrid training approach including a combination of the self-paced course Solution-Focused Brief Therapy: An Introduction to Clinical Practice with the live interactive course BASIC Skills and Practice for Agencies. They invested in 5 separate cohorts so clinicians could experience more personalized training including role-plays, breakout sessions, case discussions, opportunities for consultation with challenging cases, video observation discussions, and between-session practice exercises. All the synchronous training sessions were recorded and available for new hires as a self-paced course with options to earn continuing education credits.

Northwest Human Services, Salem Oregon

Northwest Human Services has been providing residents of Marion and Polk counties with comprehensive medical, dental, mental health, and social services for 50 years. They are a federally qualified health center (FQHC). Federally Qualified Health Centers are community-based health care providers that receive funds from the HRSA Health Center Program to provide primary care services in underserved areas. They must meet a stringent set of requirements, including providing care on a sliding fee scale based on ability to pay and operating under a governing board that includes patients. Their programs are integrated and designed to help support those in our community who need it most. They offer medical, dental, and mental health services on a sliding fee scale based on family size and income.  No one is turned away due to their inability to pay. Homeless youth and adults at our HOST and HOAP Programs access basic needs services, case management, peer support, and health care at our Community Health Centers. Their Crisis & Information Hotline provides 24-hour crisis support and suicide intervention as well as limited emergency financial assistance for rent, utilities, and prescription medications. As long as there is a need, Northwest Human Services will continue to be a safety net providing health care and social services in our community. http://www.northwesthumanservices.org/

Northwest Human Services reached out for training during the COVID-19 pandemic hoping a brief evidenced treatment approach could help to manage the increased demand for mental health services within their integrated behavioral health organization. In particular, they were interested in learning how solution-focused brief therapy could be applied with clients who have experienced trauma.  After an initial Zoom consultation, the following customized training program was developed.

They choose to provide their 16 staff with the self-paced cours:e Solution-focused therapy for the treatment of trauma. They found this helpful and then, a few months later, provided both current and new staff with the self-paced course: Solution-Focused Brief Therapy: An Introduction to Clinical Practice. They also added our self paced introductory course as part of the onboarding process for newly hired staff. Providing faculty with consistent training that can be offered at different times can help to cement an equitable and fluent education to this specific approach of therapy within an organization.

Conclusion

Training with a one-shot method is largely ineffective. The use of traditional workshop models or any single strategy is unlikely to be successful. Instead, a combination of approaches that comprise overlapping techniques and interventions such as interactive didactics, goal identification, small group discussion, critical thinking, self-reflection, peer collaboration, independent access to information, direct feedback, and follow-up have been found to be the most effective. Successful training is complex and involves attention to clinician engagement, active methods of promoting skill acquisition and providing ongoing support to solidify skills and build confidence. Transdisciplinary training emphasizing real-world clinical examples in practice and promoting self-regulated learning is essential. Of course, there is a need for implementation training to be studied including intervention fidelity, client outcomes, provider confidence, and the mechanisms for training effectiveness. Comprehensive training programs are essential to achieve implementation. Providers will need time and resource allocation to solidify their skills and acquisition. We invite all clinicians to complete evaluations and post-training feedback surveys to continue to improve and develop engaging, evidence-based, cost- and time-effective training.

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Behavioral Health Workforce is a national crisis: Immediate policy … (n.d.). Retrieved June 20, 2022, from https://www.thenationalcouncil.org/wp-content/uploads/2022/01/Behavioral-Health-Workforce-is-a-National-Crisis

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

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

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Mental Health Disparities in the Latinx Community: A Solution-Focused Perspective

2022-10-07T17:46:48+00:00April 21st, 2022|

By Valeria Chavez, Paula Ogalde-Carmona, Sabrina Rosario Santana, and Anne Lutz

Latinx community mental healthThe Institute for Solution-Focused Therapy was born from the need to spread the solution-focused approach to as broad a public as possible. From the very beginning, our compass has been on finding new ways to enable people around the world to have access to the evidence-based tools and resources associated with the approach. The idea to translate our courses and related material to Spanish was born from a conversation in early 2020 between Dr. Lutz and Ms. Chavez. The question was how can we broaden the population that has access to the resources we offer? At the time, the COVID-19 pandemic had effectively taken over the world and exposed the structural racial and social inequities inherent to the American healthcare system (CDC 2022). As the pandemic spread, so did a much less talked about mental health crisis. As an organization dedicated to the spread of mental health resources and wellness, we felt it was our responsibility to do our part to address these inequities. After discussions with our team, we concluded that the most effective way to make an impact would be to challenge one of the main barriers preventing ethnic groups from accessing mental health resources: language.

In the latter half of 2020, the Institute of Solution-Focused Therapy set out on an ambitious project: translate all its material into Spanish. Considering the incredible diversity of the Latinx community within the United States – not to mention the world – this was no small feat. With this in mind, the Institute put together a team of diverse native Spanish speakers to begin our translation efforts. The goal for the project went beyond the textual translation of our material but rather the natural adaptation and interpretation of an approach originally designed around the English language. After several months of work, the Institute of Solution-focused Therapy is proud to announce the release of the Spanish translation of its introductory course – Terapia Breve Centrada en Soluciones: Introducción a la Práctica Clínica – is set to happen in May 2022. Below, you can learn more about the importance of increasing the accessibility of mental health resources to the Spanish-speaking community in the United States as well as our unique translation process.

In the context of the mental health crisis caused by the COVID-19 pandemic, the need for mental health resources available for ethnic and racial minorities in the United States could not be overstated. According to the National Alliance on Mental Health, “approximately 34% of Hispanic/Latinx adults with mental illness receive treatment each year compared to the U.S. average of 45%” (NAMI 2022). This is due to a number of reasons including access to healthcare, concerns related to deportation, stigma related to mental health, language barriers, reliance on traditional healing, religious and cultural beliefs, etc. Reviews of the literature and research point to the need for services that focus on the unique context of the Latinx community in the United States (Lawton and Gerdes 2014) as well as the increased availability of culturally competent mental health resources (Martinez 2020). A systemic review of solution-focused therapy with Latinos suggests SFBT is applicable among Latino populations and that there is an increasing interest in its use in Latin America (Gonzalez et at., 2016).

Why We Translated Our Solution-Focused Course into Spanish?

The solution-focused approach recognizes that successful therapeutic outcomes depend on the quality of the therapeutic alliance. One of our main goals in translating our materials to Spanish is in providing our students with tools to enhance the therapeutic alliance in a solution-focused way. Our translation efforts are focused on increasing awareness of the need for culturally-competent mental health resources in Spanish as well as on spreading the solution-focused approach across the Latinx/Hispanic community.

The Latin American region has a history of social and political instability which has forced people to migrate and flee from poverty, political violence, and social injustice. Throughout the process of relocation and migration, people face intense stressors that make them susceptible to developing psychological distress such as depression, anxiety, and PTSD (Blackwell and Ford, 2009). Stressors such as racism and other forms of discrimination, unemployment, poverty, family separation, language barriers, among others, are all risk factors associated with long-term trauma, depression, suicidal ideation, and substance abuse for Latinx immigrants and second-generation Latinx people living in the United States (Idem). The Latinx community is the fastest-growing ethnic group in the United States and is predicted to represent 28.6% of the population in the United States by 2060 (Colby and Ortman, 2015). Over 16% of Latinx/Hispanic people in the U.S. have expressed experiencing mental illness (MHA 2022) yet, only about only 34% receive treatment each year compared to the U.S. average of 45% (NAMI 2022).

The Prevalence of Mental Health Issues in the Latinx/Hispanic Community

Despite the alarming prevalence of mental health issues in the Latinx/Hispanic community, most people do not have access to mental health services or do not receive quality mental health care as a result of social and systemic inequities among people of color (Toro Garcia, 2021). Despite the decrease in poverty rates in the United States, 15.7% of the Hispanic/Latinx community live in poverty which is more than twice as much as non-Hispanic whites (7.3%) (Creamer, 2020). Prior research implies that there is a connection between poverty and mental illness, suggesting that either poverty is linked to a higher risk of mental illness or people experiencing mental illness are more vulnerable to living in poverty (NAMI, 2022). Both of these possibilities suggest there is an urgent need to increase mental health resource accessibility to the Hispanic/Latinx population in the US. In addition, approximately 19% of Hispanic/Latinx people do not have health insurance (NAMI, 2022), which further prevents people from seeking professional help. These statistics largely exclude undocumented immigrants as there is very limited information about healthcare utilization for mental health among this population (Bucai-Harari et al 2020).

Another factor is the notably strong stigma in the Latinx/Hispanic community associated with seeking support from mental health professionals (NAMI, 2022). People from Latin America highly value strong family bonds and tend to be reserved when it comes to personal and familial problems. Depending on the family context, the strong sense of family connections can be either a protective or a risk factor for Latinx youth’s mental health. Family can be a very effective support system that helps people cope with challenges, but they can also contribute to the cultural stigma surrounding mental health (Lawton & Gerdes, 2014). It is a commonly held belief that personal problems or struggles should remain inside the household and not be shared with others due to fear of bringing shame to the family (MHA 2022). Similarly, mental illnesses can be perceived by strongly devout households as a result of the lack of faith by the individual or as a punishment for sinful behavior. By working with religious or spiritual leaders in the community alongside parents and other family members, Hispanic/Latinx people can be more informed about mental health and make faster progress in their treatment. Through the use of VIPs – or the client’s important relationships -, the solution-focused approach is a great option for this population as the community and the unique context of the client are incorporated in the formulation of solutions.

The Shortage of Bilingual and Culturally Competent Mental Health Professionals

The shortage of bilingual and culturally-competent mental health professionals is also a factor contributing to the access disparities in the Latinx/Hispanic community (LULAC 2022). Hispanics are significantly more likely than non-Hispanic Whites to report poor communication with their health care provider (Alegría et al 2013; AHRQ 2010). The literature on the subject suggests that policies centered on assisting Latinx patients overcome linguistic and cultural barriers to health care directly contribute to the improvement of access to care by the Latinx population (Oh et al. 2020). In particular, programs centered around increased workforce diversity can help reduce communication barriers and improve provider-client relationships. According to the 2021 NHDR, Hispanic people represent 18% of the U.S. population but only 8% of therapists and 10% of psychologists; no data is available on the percentage of Latinx mental health professionals with solution-focused training. Many Latinx people are hesitant to seek mental health services because the field lacks culturally competent professionals who can reflect the intersecting identities of their clients (Martinez 2020). Whether it involves racial and socio-economic barriers, stigma, or cultural competency, there are many factors standing in the way of equitable access to mental health resources by the Latinx/Hispanic community.

How We Translated our Solution-Focused Course into Spanish?

According to a 2013 study by the PEW research center a record 36.7 million persons ages, 5 and older speak Spanish at home (PEW 2013). This makes Spanish the most spoken non-English language in the United States. When we realized that translating our material to Spanish would increase access to solution-focused resources to millions of people, not only in the US but around the world, our team got to work. In order to create a product that would be accessible to the incredibly diverse Hispanic/Latinx community, we had to build an equally diverse translation team. After several months of recruiting, we put together a team made up of Central and South American native speakers as well as second-generation Latinx people from Spanish-speaking households in the US. Using automated translation software in combination with our native language skills and hours of research on existing Spanish-language mental health resources, we crafted a neutral solution-focused vocabulary in Spanish that allowed us to communicate the soul of the approach across regional differences within the language.

Due to the linguistic nature of the solution-focused approach, our team spent hours debating the best ways to translate specific words and phrases. Should we use “tu” or “usted”? How do we use gender-neutral language? How do we say “hope-friendly” and “best hopes”? What about the word “manage”? Does it make sense to say “maravillarse mentalmente” for “mind-wander”? Do we keep the word “haboob”? We learned that beyond translation our job was to interpret and adapt our material to communicate the same message, even if textually our words did not reflect the original writing. We marveled at Dr. Lutz’s ability to lecture on video without laughing at the sound of her own voice and to enjoy the “bloopers” as learning opportunities. Above all, we realized how compatible the solution-focused approach is with the values of the Hispanic/Latinx community as a compassionate and collaborative approach to therapy that maximizes the potential of community, family, and faith-based resources. Our team is thrilled to be in the beta-testing stages of Terapia Breve-Centrada en Soluciones: Introducción a la Práctica Clínica and we look forward to sharing our work with the world.

What Makes This Translation of Solution-Focused Therapy Different?

A common theme in Spanish-language mental health resources out there is the blind reliance on Google Translate or similar automated translation software. While the overall message is there, due to the grammatical complexity of the Spanish language, the final products read like they had been written by cavemen. Our team carefully combined the outputs provided by automated translation software with our native language skills and hours of research on existing Spanish-language mental health resources to craft a neutral solution-focused vocabulary in Spanish that allowed us to communicate the soul of the approach across dialectic differences within the language. Our consistent use of subject pronouns and prepositions, as well as our language interpretation beyond textual translations, makes the Institute’s Spanish-language material remarkable in comparison to existing Spanish-language mental health resources.

One of the easiest ways to note if something has been carefully translated from English to Spanish or simply plugged into an automated translation software is to look at the consistency (or inconsistency) of the use of the formal and informal “you.” As any Spanish speaker will tell you, the difference between “usted” (or formal “you”) and “tu” (or informal “you”) is very important and it varies depending on who you are addressing. This detail, however, is often overlooked by automated translation software which will pivot back and forth from formal to informal “you” within a single sentence; for example: “Sí un 10 significa que usted está muy seguro de que puede llegar a su meta, ¿qué nota te pondrías a ti mismo?” Note the use of the formal “you” in the form of “usted está” (underlined) at the beginning and then the careless transition to the informal “you” in the form of “te pondrías a ti” (bold) at the end. Our translation team spent hours fixing and reformulating these discrepancies for a product that respected the correct use of subject pronouns and corresponding verb conjugations.

Another important aspect of English to Spanish translations is the interpretation of the message rather than the direct textual translation of the language used. In comparison to Spanish, English is a “reductive” language as it takes fewer words to say the same thing. This results in translations that require more words within a single sentence to communicate the same message. However, this is where interpretation becomes really important as it is rather easy to fall into the trap posed by repetitive language – something that most automated translation software are not aware of; for example: “¿Qué se necesita para que usted pueda alcanzar un puntaje que es 1 punto más alto?” This sentence directly translates to “What is needed for you to reach a score that’s one point higher?” In English, there is no issue with this sentence. However, the Spanish translation uses the words “puntaje” and “punto” which have the same etymological root and the result reads closer to “What is needed for you to reach a score that’s one score higher?” Our translation team worked really closely on these details to provide an accurate interpretation of the material in a way that could be read more naturally.

Our team’s attention to detail is evident in the quality of our final output. As a therapeutic approach that is linguistic by nature, the solution-focused language was translated and interpreted deliberately and carefully. This course is different from other solution-focused and mental health resources in Spanish out there because it was created to be more than just a translation. Terapia Breve-Centrada en Soluciones: Introducción a la Práctica Clínica goes beyond a textual translation of an approach designed for the English language; instead, it is a natural adaptation of the soul of the approach across language barriers.

REFERENCES

Recognizing The Power Of A Woman’s Voice: A Solution-Focused Approach To Domestic Violence

2022-04-23T10:19:28+00:00April 21st, 2022|

Solution-Focused Domestic Violence ApproachDomestic violence is a major public health concern and has significant impacts on the health and well-being of victims and their families. Solution-Focused Brief therapy provides a therapeutic context for people who have experienced domestic violence (intimate partner violence) to recognize their agency in these harrowing situations. The application of SFT to clients experiencing trauma stems from compelling conceptual reasoning that a solution-focused approach is an effective means of treating trauma without exposing clients to the stress of directly focusing on traumatic memories.

Health practitioners are crucial to early intervention, given their pivotal role in domestic violence identification, safety assessment, response, and referral (Garcia-Moreno et al., 2015). According to the World Health Organization (WHO) estimates, 35% of women worldwide are at risk of domestic violence, and their spouses commit as many as 38% of women’s homicides (WHO 2013). In the USA, a review estimated that partner abuse of women accounted for 50% of all acute injuries and 21% of all injuries requiring urgent surgery (Guth 2000).

Individuals exposed to violence require comprehensive, gender-sensitive healthcare services that address the physical and mental health consequences of their experience and aid their recovery from a traumatic event. Healthcare providers who come into contact with women facing violence need to be able to recognize signs of it and respond appropriately and safely. Advocacy and empowerment interventions have increased referrals to services and are the mainstay of response to DV (Rivas et al., 2015). In a previous WHO systematic review, mother-child interventions have had the most robust evidence for assisting women [World Health Organization 2013).

Solution-Focused Brief Therapy embraces a strength-based, developmentally informed trauma perspective that acknowledges the individual and family’s capacity in the face of adversity. SF interventions enhance an individual’s resilience, decrease distress and minimize the potential risk of re-traumatization. SFBT assists in counterbalancing intense emotions, collaboratively supporting people in developing meaningful coping strategies, cultivating competencies, and navigating gradual next steps for the immediate future.

In the wake of crisis and trauma, the solution-focused practitioner fundamentally listens to and recognizes clients’ agency and resourcefulness. Appreciating what clients have already done to manage incredible challenges provides privileged conversational moments that are often very different from what clients have experienced. These uniquely privileged conversational spaces show clients how they have coped and dealt with their distressing and harrowing experiences. Solution-focused practices can also simultaneously elicit positive emotion, kindle hope and evoke a feeling of empowerment. Recognizing moments when clients have harnessed their uniquely adaptive behaviors, cognitions, and social context that characterize their experience of relative well-being or “moments of tolerability” underscores and magnifies what they have already done to cope. Because these uniquely personalized behaviors are already present within clients’ existing behavioral and social repertoire, they can be more readily accessed and utilized to develop effective treatment plans and solutions that clients can readily embrace. The solution-focused practitioner invites the client to voice their agency and resourcefulness. Clients learn to realize, acknowledge, and appreciate their capacity, fostering their potential to replicate what has worked and helped them cope with adversity.

What does the Solution-Focused literature say about treating survivors of trauma?

The existing outcome literature provides initial evidence of the overall effectiveness of Solution-focused therapy for treating survivors of trauma (Eads and Lee, 2019). In particular, within-subjects treatment effects showed moderate to large effect sizes on direct trauma symptoms and recovery measures and large effect sizes for post-traumatic growth and sleep problems (Eads and Lee, 2019).

Solution-Focused therapy has also been utilized with domestic violence offenders (Lee et al., 2004). Building on a strengths perspective, a solution-focused approach holds a person accountable for solutions while not denying or minimizing aggressive behaviors. The solution-focused approach harness external VIPS such as the legal system, community support, and social service agencies to address safety concerns and negotiate goals integrating the clients’ unique social context.

The Solution-Focused approach operationalizes trauma-informed care. Questions are formulated from the clients’ language, conveying a belief in them while fostering their agency. The solution-focused practitioner assumes that clients have the necessary resources to live a more satisfying life and have the capacity to endure adversity and even move beyond their circumstances to experience post-traumatic stress growth. This belief in the client’s resilience and power is harnessed throughout the conversation and can be productively utilized to help cope with the aftermath of a crisis and build a healthy, satisfying future (Dolan, 1998; Froerer et al., 2018).

SFBT provides both clients and therapists an ability to look beyond the way things are and envision desirable options for how things can be. Solution-focused therapists use carefully constructed questions to activate the client’s resources. SF questions trigger the client to answer, remember and discover the resources within their cognitive, behavioral, and social repertoire in their real-life experiences. This therapeutic approach is compelling because clients find a compassionate, collaborative guide to help them work toward their best hopes for their preferred future.

A Video Demonstration Of A Solution-Focused Approach To Domestic Violence

REFERENCES

Dolan, Y. (1998). One small step: Moving beyond trauma and therapy to a life of joy. New York: IUniverse. 

Eads, R., & Lee, M. Y. (2019). Solution Focused Therapy for trauma survivors: A review of the outcome literature. Journal of Solution-Focused Practices, 3(1), 9.

Froerer, A., von Cziffra-Bergs, J., Kim, J., & Connie, E. (Eds.). (2018). Solution-focused brief therapy with clients managing trauma. Oxford University Press.

Garcia-Moreno C, Hegarty K, d’Oliveira A, Koziol-McLain J, Colombini M, Feder G. The health-systems response to violence against women. Lancet. 2015;385:1567–79

Guth AA, Pachter L. Domestic violence and the trauma surgeon. American Journal of Surgery 2000;179(2):134-40.

Lee, M. Y., Uken, A., & Sebold, J. (2004). Accountability for change: Solution-focused treatment with domestic violence offenders. Families in Society, 85(4), 463-476.

Lutz, A. B. (2013). Learning solution-focused therapy: An illustrated guide. American Psychiatric Pub.

Responding to Intimate Partner Violence and Sexual Violence Against Women: WHO Clinical and Policy Guidelines. Geneva: World Health Organization; 2013. Available from: https://www-ncbi-nlm-nih-gov.umassmed.idm.oclc.org/books/NBK174250/

Rivas C, Ramsay J, Sadowski L, Davidson L, Dunne D, Eldridge S, et al. Advocacy interventions to reduce or eliminate violence and promote the physical and psychosocial well-being of women who experience intimate partner abuse. Cochrane Database Syst Rev. 2015;3(12):CD005043.

World Health Organization. Global and regional estimates of violence against women: prevalence and health effects of intimate partner violence and non-partner sexual violence. Geneva: WHO; 2013.

Solution-Focused Therapy Is Trauma-Informed Care

2022-02-25T14:56:53+00:00February 25th, 2022|

trauma therapySolution-Focused Brief Therapy (SFBT) is an approach ideally suited amid adversity, trauma, and crises. Solution-focused (SF) interventions support people in the aftermath of a crisis by providing a safe and reassuring therapeutic relationship. SFBT is a respectful approach that assists in counterbalancing intense emotions, collaboratively supporting people in developing meaningful coping strategies, cultivating competencies, and navigating gradual next steps for the immediate future. Solution-focused interventions enhance an individual’s resilience, decrease distress and minimize the potential risk of re-traumatization.

The SF approach assumes that clients have the necessary resources to live a more satisfying life and have the capacity to endure adversity and experience post-traumatic growth. This belief in the client’s resilience and capacity is harnessed throughout the conversation and can be productively utilized to help cope with the aftermath of a crisis and build a healthy, satisfying future (Dolan, 1998; Dolan, 1991; Froerer et al., 2018).

What Is Trauma-Informed Care?

Trauma-Informed care stems from a values base of client safety and empowerment as well as an orientation to strong engagement between clients and their providers. Trauma-informed care is a “strengths-based framework that is grounded in an understanding of and responsiveness to the impact of trauma that emphasizes physical, psychological, and emotional safety for both providers and survivors; and creates opportunities for survivors to rebuild a sense of control and empowerment” (Hopper et al., 2010, p. 82). Trauma-informed care broadens the approach to intervention from “how can I fix you” to “what do you need to support your development and recovery?” (DeCandia 2015).

How Solution-Focused Interventions Are Congruent with Trauma-Informed Care

The SF clinician elicits, in detail, what the client and those most important to them would notice them doing when their problem is solved. If this is not possible, the clinician will assist the client in determining how they can manage in a good enough or bearable way to best handle their current crisis. The SF clinician listens intensely for prior moments of success and amplifies these moments increasing the clients’ sense of agency. Based on the client’s answer, the client and clinician together begin to develop a detailed behavioral, cognitive, and relational description of the client’s life when the problem is resolved or managed in a good enough way.

Guiding the conversation with questions that simultaneously convey competence and choice assist clients in discovering how they have already coped and endured amid the adversity they have faced. Leading the conversation with questions, incorporating the client’s language in the formulation of questions and responses, remaining attuned to the client’s need for empathy, focusing on positive differences, and persisting in activating the clients’ resources all convey a belief that clients have the necessary resources to cope. All of these solution-focused techniques are congruent with a trauma-informed approach.

A Language of Empathy: Amygdala Whispering

Clients who present in crisis often experience significant stress activating the brain’s amygdala- the fight, flight, and protect response. Anne Lutz has termed “Amygdala Whispering” as a technique to calm the “emotional fever” or “trauma fever” resulting from the client’s perceived and natural stressors. When the amygdala gets activated, it is very challenging for clients to harness the neurological tools available from their frontal lobes, including a myriad of choices beyond only the fight or flight response – such as planning, questioning, and considering realistic alternative options. In the eye of an amygdala storm, the only choices available are fight, flight, or protect. Solution-focused interventions communicate respect and safety by remaining attuned with the clients’ language and guiding the conversation with questions that foster agency and empathy. Responding in this way helps to calm the clients’ amygdala storm and engage their frontal lobes consistent with trauma-informed care.

Solution-focused interventions foster hope, self-agency, resource activation, and planning. All of these interventions are uniquely suited to calm the amygdala and assist clients in returning to the frontal lobe or to the “upstairs” of their brain, where many more choices and action plans are available. Solution-focused interventions help counterbalance the crisis response by enhancing coping skills, connections, constructive cognitions, competencies, and behaviors, so an individual has a plan, thus hope, moving forward.

A language technique that can help provide empathic responses quickly and easily to clients is integrating the words “for you” within statements and questions. “For you” statements can be used in several different ways, helping to build emotional agreement within the conversation while providing validation and acknowledgment of the clients’ situation and feelings. Clients and families coping with adversity often experience intense emotions such as fear, anger, and sorrow. Some examples of “for you” statements include how scary and frightening it must be “for you” to see your child struggling with substance use and be worried they may die from an overdose. For the adolescent, acknowledging how difficult it must be “for you” to be forced into a rehabilitation program where you don’t want or think you need to be. Incorporating the words “for you” within responses is a linguistic empathic tool that confirms the intense emotional experience clients may be enduring. Clients experiencing adversity and intense emotions often benefit from these two simple words.

The SF practitioner moves beyond just confirming the client’s emotional experience and bridges the “for-you” statement with Solution-Focused questions. The pairing offor-you” statements with SF questions, such as compliments, normalization, and coping questions, gently inspires clients to appreciate what they have already been accomplishing to move towards a solution enhancing their self-efficacy and agency. It must be so difficult “for you” to experience all this stress; how have you managed to get through day-to-day? Where do you get your strength?

How Solution-Focused Interventions Foster Vicarious Resilience Tempering Clinician Burnout

The SF clinician believes in client resilience, which has the added benefit of clinicians experiencing “vicarious resilience” instead of “vicarious trauma” from clients. Vicarious trauma (secondary trauma), experienced by clinicians, has been defined as “the transformation that occurs in the inner experience of the therapist [or worker] that comes about as a result of empathic engagement with clients’ trauma material” (Pearlman & Saakvitne, 1995, p. 31). Vicarious trauma (VT) can result in physiological symptoms resembling post-traumatic stress reactions, such as flashbacks, nightmares, obsessive thoughts, numbing, and disassociation (Beaton & Murphy 1995). It may also result in disruptions to important beliefs, called cognitive schemas, that individuals hold about themselves, other people, and the world (Pearlman & Saakvitne 1995). In contrast, vicarious resilience (VR), also experienced by clinicians, is a complex collection of elements contributing to the empowerment of therapists through interaction with the clients’ stories of resilience (Hernandez et al., 2007). These elements of witnessing and reflecting on human beings’ remarkable capacity to heal can result in the clinician reappraising the significance of their own challenges and generating new possibilities and hope on the part of the clinician.

SFBT is an approach that can foster VR. Awareness of the phenomenon of VR and introducing the concept into the professional vocabulary can guide clinicians and organizations in nourishing themselves and their practice. Co-constructing and transforming the clients’ narratives to one of courage, strength of character, resilience, and empowerment foster clients’ growth while simultaneously tending to the clinicians’ sustenance and purpose. Integrating SFBT within an organizational context such as the organizational culture, work environment, supervision, consultations, and workplace meetings can generate an increase in VR.

Solution-Focused Interventions Facilitate Post-traumatic Growth

The majority of Americans will experience a traumatic event at some point in their life with lifetime prevalence rates as high as 89.7% (Kilpatrick et al., 2013). However, the national lifetime prevalence of post-traumatic stress disorder is between 6% and 8% (Kessler, 1995; Kilpatrick et al., 2013). Most people who experience trauma and adversity respond with resilience, and a relatively small percentage go on to develop post-traumatic stress disorder. Tedeschi and Calhoun 2004 have described the response with resilience as Post-traumatic growth and have defined it as:

The experience of individuals whose development, at least in some areas, has surpassed what was present before the struggle with the crises occurred. The individual has not only survived, but has experienced changes that are viewed as important, and that goes beyond what was the previous status quo. Posttraumatic growth is not simply a return to baseline – it is an experience of improvement that for some persons is deeply profound (pg. 4).

Reports of growth experiences following traumatic experiences far outnumber reports of psychiatric disorders. Personal distress and growth often co-exist (Tedeschi & Calhoun, 2004). Research suggests that people who have experienced more severe trauma than those who have not experienced trauma report a higher level of positive personal changes (Tedeschi & Calhoun, 1996).

What Are Solution-Focused Assumptions in Crisis

Individuals and groups rely on a certain set of assumptions and beliefs in their world that guide their thinking, behaviors, and sense of meaning and purpose. Crises can present major challenges to a person’s understanding of their world and are associated with significant psychological distress. Analogous to earthquakes, crises shake, threaten and damage many of the structures that have maintained the safety, benevolence, predictability, and controllability of a person’s world (Tedeschi & Calhoun 2004). The SF approach collaboratively constructs a hopeful narrative that assists clients to “re-construct” and persevere in the face of adversity.

Key SF Assumptions Amid Crisis, Adversity And Trauma
Until Proven Otherwise Clients Amid Adversity, Crisis And Trauma Have:

  1. The necessary resources to carry on
  2. The necessary skills to cope
  3. The ability to learn skills to mobilize their strengths
  4. The capacity to harness their social resources
  5. The capacity to return to function
  6. The capacity for personal growth, including an enhanced appreciation for life and greater meaning in what is most important in their life
  7. The capacity to recognize the importance of things formerly taken for granted
  8. The capacity for more intimate and more meaningful relationships with others
  9. The capacity for greater empathy and compassion for others
  10. The capacity for increased personal strength
  11. The capacity for new possibilities for one’s life
  12. The capacity for greater spiritual and existential growth
  13. The capacity to view aspects of the crisis as a potential gift
  14. The capacity for enhanced mutual support and understanding
  15. The capacity for a revised life narrative that may be recognized as a turning point
  16. The capacity for emotional relief and cognitive clarity

How Solution-Focused Interventions Enhance Hope Amid Adversity

In the face of adversity and crisis, hope is considered an important source of strength and resilience. Hope taps into clients’ beliefs that they will resolve their problems and their futures can and will be better. (Synder & Synder 2000). Snyder and his colleagues have defined hope as cognitive pathways to generate goal attainment and a capacity for agency, the capacity to initiate and sustain moments along their chosen route (Snyder 1994; Snyder 2002). Hope links self-efficacy, experiences of positive emotion, and successful goal attainment. When people are hopeful, they are energetic about their desires and can generate diverse strategies, dedication, and hard work to achieve progress towards their goals.

Hope plays an essential role in preventing, treating, and promoting positive outcomes after traumatic experiences (Long and Gallagher, 2017). In the context of crisis and trauma, early evidence suggests hope provides a protective factor from developing post-traumatic stress disorder (PTSD). A study of people who experienced Hurricane Katrina showed people who reported higher hope experienced fewer symptoms of PTSD (Glass et al., 2009).

Solution-Focused Approach to Crisis Intervention: ↑Hope = ↑agency + ↑Plan

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. In an ideal session, the client leaves with a plan and knows they have the skills and resources available to move forward in a good enough or tolerable way.

SF interventions comprise skills that help clients develop goals and agency thinking. SF interventions focus on concrete behavioral endpoints through the use of scaling questions. Goals are intrinsically reinforced, acknowledged, celebrated, and noticed with others, strengthening a positive feedback loop.

Case Example: Solution-Focused Interventions Amid A Traumatic Event

Karl is an 18-year-old transgender male (preferred pronoun is he) who presented to the emergency department following a motor vehicle accident. He reportedly was texting his friends to hang out with them while he was driving when he didn’t realize the car in front of him had stopped. The car was totaled. Karl sustained a broken leg and back injury. He was hospitalized due to the severity of his injuries and the need for surgery on his leg. While awaiting surgery, Karl was reporting suicidal thoughts and a desire to follow through with them. Karl’s father was out of town caring for his elderly parents on the day 0f the accident and had not yet arrived back home. Karl had a difficult time when his father was away and had a prior overdose attempt six months ago while his father was caring for his elderly parents. Karl’s mother died from cancer when Karl was 12 years old, and Karl spent his youth witnessing her treatments, decline, and death. The following is an excerpt from Karl’s crisis evaluation while he was in the hospital.

Tx: Hello Karl – is that your preferred name?
Karl: Yes
Tx: Great! Thank you for taking the time to meet with me. My hope for this session is that I will be helpful to you. I will do my best. Would it be ok if I asked you a few questions in hopes of being helpful for you? Some questions may be a bit challenging.
Karl: Ok
Tx: Thank you. It must be difficult for you to be here; how have you been holding up these past few days?
Karl: It’s been hard. It’s loud, and I can never get any rest. I just want to go home.
Tx: Of course. It must be really frustrating for you to be here. What do you know has helped make things even a little bit more bearable while you are here?
Karl: Getting pain medication.
Tx: How has getting pain medication been helpful for you?
Karl: It was bad after the accident. I was in so much pain. All I could think of was killing myself just to relieve my agony.

Discussion: Tone Setters and Activating Resources:

The therapist sets the tone by thanking Karl and confirming how he wants to be called, as well as providing consent for the conversation to follow. The therapist also provides plenty of “for you” responses followed by coping questions that activate Karl’s individual resources early in the conversation.

Tx: I’m glad the medication is helpful for you. How well would you say you are tolerating your pain from 1-10 (10 being the best)?
Karl: Probably a 5.
Tx: What would be a good enough number?
Karl: A 7.
Tx: What keeps the number from being lower than a 5?
Karl: I’m able to get some sleep.
Tx: What else keeps it from being lower?
Karl: It’s gone up from one, and I’m hoping the surgery will help even more.
Tx: What have you done that has helped the medication work, even a little bit?
Karl: I just try to distract myself by playing video games. The nurses have brought me some games, and that helps a bit.

Discussion: Scaling Pain Tolerability

The therapist attends to his pain and how well he is tolerating it demonstrating concern about his well-being. Scaling how well Karl is tolerating the pain and how helpful the medications are from 1-10 is a more constructive way to assess pain. It promotes his agency in managing his pain.

Tx: I’m impressed with how you are handling this. I wonder if you know whose idea it was for me to come and see you today?
Karl: I think it was the nurse.
Tx: What do you know the nurse was concerned about that asking me to come to see you would be helpful for you?

Discussion: Exploring External VIPs

Asking Karl whose idea it was for the therapist to come and framing this as a concern can be helpful in exploring important VIPs in Karl’s immediate context. Notice that the therapist did not ask “why” rather instead what the nurse was concerned about guiding the narrative to one of care and compassion.

Karl: I don’t know. Probably because I said I wanted to die and couldn’t take it anymore.
Tx: What do you mean by “take it anymore”?
Karl: My father is in Arizona, and when he comes back, he will be furious with me. I know he will take away my driving privileges, and driving to see my friends is the only thing that helps me feel better.

Discussion: Exploring the client’s language

Karl was able to identify the reason for the consultation – that he wanted to die. Exploring the meaning of his words provided more about Karl’s concerns and his reasons for distress. Although it may seem to slow the conversation down, exploring the clients’ meaning often paradoxically moves the conversation forward more quickly as the therapist and client negotiate a shared understanding.

Tx: That must be very difficult for you to think about while also dealing with your pain and upcoming surgery. How have you been enduring all of this?
Karl: It’s been hard. My father is still in Arizona and won’t be home until tomorrow.
Tx: Of course, this must be hard for you. Is your father an important person in your life?
Karl: Yes. I don’t know what I would do without him.
Tx: What do you most appreciate about your father?
Karl: He’s always there for me – even when I do stupid things. He doesn’t give up on me.
Tx: What has he done to always be there for you?
Karl: He and I are close. After my mother died, we went through a lot. We helped each other.
Tx: It sounds like your father loves you a lot. Suppose I were to ask him what he most appreciates about you, what would he say?
Karl: That I’m strong, and I can deal with a lot.
Tx: What do you mean by “deal with a lot”?
Karl: My mother died when I was 12 years old, it was the hardest thing that I’ve ever had to deal with.
Tx: That sounds incredibly challenging. What would your father say you have done to deal with this?
Karl: He’d say that I kept going to school and kept caring about people – that I am strong.
Tx: What would he say you have done that you are strong?
Karl: That I care about people.
Tx: You both sound very strong. I’m wondering, who else are the important people in your life?
Karl: My mother. Even though she died, I think of her a lot and know that she is with me.
Tx: What do you suppose your mother most appreciates about you?
Karl: She knows how much my father and I care and help each other. She would be proud of that.
Tx: What else would she say she appreciates about you?
Karl: That I don’t give up.

Discussion: Exploring VIPs

Taking the time to ask who the most important people in Karl’s life are and what they most appreciate about him is critical in highlighting his relationship resources. It is often these meaningful relationships that are protective and stop people from acting on thoughts of suicide.

Tx: Supposing I asked your mother and father what their best hopes would be for you so they would know you are safe to go home, what would they say?
Karl: My father would want to make sure I don’t do anything unsafe.
Tx: What would he hope you do instead?
Karl: He would want me to let him know if I was upset and reach out for support.
Tx: What else would tell him you can keep yourself safe?
Karl: That I wouldn’t be driving and getting into accidents and wanting to end my life. I don’t want to die; it’s just sometimes I get so upset that all I can think of is the relief of being together with my mother.
Tx: Of course. These are very intense emotions you are experiencing. I’m wondering, what are your reasons for living?
Karl: I want to go to college and become a nurse.
Tx: Wow. That is impressive. Have you always wanted this?
Karl: I’ve wanted to be a nurse for a long time. Ever since seeing how they helped my mother and our family.
Tx: Wow – you are strong. Where do you get your determination from?
Karl: Probably my father. He doesn’t give up. He keeps trying to help his parents and me.

Discussion: Exploring Best Hopes

Often clients experiencing intense emotions are more able to answer what their best hopes are from the perspectives of their VIPs. This is another reason to have some knowledge of who are the most important people in your clients’ life. Karl was able to answer what his parents’ best hopes were quite easily – to stay safe. Following this, every question or response was focused on activation of his resources including exploring his reasons for living. This is in contrast to exploring why he wants to die. Exploring his reasons for living uncovered additional resources and opportunities to compliment Karl and explore positive differences with him.

Tx: Sometimes, I ask “number questions” to help me help you. Would that be ok?
Karl: Ok
Tx: Suppose 10 means that you are confident that you can keep yourself safe and one is the opposite; where are you now?
Karl: about a 5.
Tx: And what would be a good enough number?
Karl: A 6
Tx: What keeps the number from being lower than a 5?
Karl: Knowing that my father will be here soon.
Tx: What do you know about your father being here for you soon is helpful?
Karl: I just need to have him nearby. He knows how to calm me down.
Tx: What else keeps the number from being lower?
Karl: That I wouldn’t do anything. I wouldn’t want to hurt my father. It would kill him.
Tx: Suppose I asked your father how confident he is in terms of your ability to keep yourself safe from 1-10; what would he say?
Karl: I don’t know.
Tx: You know your father best. There is no right answer. I’m just wondering what you think?
Karl: Probably a 3
Tx: What do you think is the reason your number is a 5 and not a 3?
Karl: I think he would say he’s scared that I had another accident and did the same thing a few months back. He would probably say he’s scared that I could’ve died.
Tx: of course – I’m sure that must be frightening for him to know you could have died. What do you suppose keeps his number from being lower than a 3?
Karl: That I’m here and getting help.
Tx: What else do you think keeps his number from being lower?
Karl: That he’s on his way and will be here soon.
Tx: I’m wondering, Karl, what would you be doing when your confidence is just a bit higher, at a 6?
Karl: I would have a plan for when I leave the hospital.
Tx: What do you mean by a plan?
Karl: That my father and I would talk, and I would have someone to talk to.

Discussion: Scaling Confidence in Ability to Stay Safe

Scaling confidence in Karls’ ability to stay safe and “working the scale” is an effective way to develop a collaborative safety plan. Even though his parents were not present in the session, their perspectives could easily be incorporated into the conversation. Numbers limit language confusion and allow for a clear plan moving forward in small manageable steps. Numbers often help clients manage the intensity of their experiences safely. By scaling their experience, the client is more easily able to identify their agency within the problems in their life, thus giving them a plan and subsequential hope.

REFERENCES

Beaton, R. D., & Murphy, S. A. (1995). Working with people in crisis: Research implications. In C. Figley (Ed.), Compassion fatigue: Coping with secondary traumatic stress disorder in those who treat the traumatized (pp. 51–81). New York: Brunner/Mazel

DeCandia, C., & Guarino, K. (2015). Trauma-informed care: An ecological response. Journal of Child and Youth Care Work, 25, 7-32.

Dolan, Y. (1991). Resolving sexual abuse: Solution-focused therapy and Ericksonian hypnosis for adult survivors. New York: Norton.

Dolan, Y. (1998). One small step: Moving beyond trauma and therapy to a life of joy. New York: IUniverse.

Froerer, A.S., Von Cziffra-Bergs, J., Kim, J & Connie, E. (Eds.) (2018). Solution-focused Brief Therapy With Clients Managing Trauma. New York: Oxford Press.

Glass, K., Flory, K., Hankin, B. L., Kloos, B., & Turecki, G. (2009). Are coping strategies, social support, and hope associated with psychological distress among Hurricane Katrina survivors?. Journal of Social and Clinical Psychology, 28(6), 779-795.

Hernández, P., Gangsei, D., & Engstrom, D. (2007). Vicarious resilience: A new concept in work with those who survive trauma. Family process, 46(2), 229-241.

Hopper, E. K., Bassuk, E. L., & Olivet, J. (2010). Shelter from the storm: Trauma-informed care in homeless service settings. The Open Health Services and Policy Journal, 3, 80–100.

Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & Nelson, C. B. (1995). Posttraumatic stress disorder in the National Comorbidity Survey. Archives of general psychiatry, 52(12), 1048-1060.

Kilpatrick, D. G., Resnick, H. S., Milanak, M. E., Miller, M. W., Keyes, K. M., & Friedman, M. J. (2013). National estimates of exposure to traumatic events and PTSD prevalence using DSM‐IV and DSM‐5 criteria. Journal of traumatic stress, 26(5), 537-547.

Long, L. J., & Gallagher, M. W. (2017). Hope and Post-Traumatic Stress Disorder. The Oxford Handbook of Hope.

Lutz, A. B. (2014). Learning Solution-Focused Therapy: An Illustrated Guide. Arlington, VA: American Psychiatric Press.

Pearlman, L. A., & Saakvitne, K. W. (1995). Trauma and the therapist: Countertransference and vicarious traumatization in psychotherapy with incest survivors. WW Norton & Co.

Snyder, C. R. (1994). The psychology of hope: You can get there from here. Simon and Schuster.
Snyder, C. R., & Snyder, C. R. (2000). Handbook of hope: Theory, measures & applications. Academic Press.

Snyder, C. R. (2002). Hope theory: Rainbows in the mind. Psychological Inquiry, 13(4), 249-275.

Tedeschi, R. G., & Calhoun, L. G. (2004). ” Posttraumatic growth: conceptual foundations and empirical evidence”. Psychological inquiry, 15(1), 1-18.

Tedeschi, R. G., & Calhoun, L. G. (1996). The Posttraumatic Growth Inventory: Measuring the positive legacy of trauma. Journal of traumatic stress, 9(3), 455-471.

Celebrating With Lucy Cordts: Crescentcare Health Center’s Success with Solution-Focused Brief Therapy

2022-04-21T18:49:51+00:00December 13th, 2021|

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!

Solution-Focused Brief Therapy Addresses Mental Health Workforce Shortages

2021-12-15T20:16:30+00:00December 13th, 2021|

Pink Mountain Laurel Flowers

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.”

How Solution-Focused Brief Therapy Can Address Some Of The Recommendations Made In the Surgeon General’s Health Advisory on Youth’s Mental Health

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.

Solution-Focused Brief Therapy is Trauma-Informed Care

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

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.

How Solution-Focused Brief Therapy Can Mitigate Clinician Burnout

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.

How Solution-Focused Brief Therapy Training Cares for the Mental Health Workforce

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. 

How Solution-Focused Brief Therapy Differs From More Traditional Longer-Term  Approaches?

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. 

How Solution-Focused Brief Therapy Harnesses Every Interactional Moment

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.

How The Solution-Focused Approach to Graduation Sets The Stage for Brief Treatment Episodes

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.

How Solution-Focused Graduation Scales Enhance Treatment Completion

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.

Questions to Assess Readiness for Treatment Graduation

  • Suppose ten is you are confident in your skills to graduate from this treatment episode, and one is the opposite; where are you now? What would be a good enough number?
  • What keeps it from being lower? What else?
  • What do you know has been most helpful in moving you toward your goal?
  • What would you be doing, supposing the number increased by 1 point?
  • Suppose we asked your VIPs how ready they think you are for treatment graduation and completion; where would they rate you from 1-10?
  • Suppose ten is you are confident in your skills to continue what has been working for you, and one is the opposite; how confident are you that you can maintain your skills?
  • What is a good enough number?

References

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

A Solution-Focused Safety Assessment Tool (SFSA)

2022-01-17T16:37:31+00:00October 11th, 2021|

mental health crisis managementSolution-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.

solution-focused safety assessment page 1
Solution-focused safety assessment page 2

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.

Solution-focused safety assessment completed example 1
Solution-focused safety assessment completed example 2

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

Can One Call Make A Difference? Training Mental health professionals within the Alzheimer’s Association

2021-08-01T12:15:22+00:00July 30th, 2021|

solution focused Therapy Alzheimer

Institute Director Emeritus Yvonne Dolan interviews David Parris, Alzheimer’s Association Care Consultants Director, about their clinician’s experience using Solution-Focused Brief Therapy to help caregivers and patients deal with the crises associated with Alzheimer’s.

One of the most rewarding aspects of being a Solution-Focused Brief Therapy trainer is the opportunity to interact with inspiring colleagues and organizations. Getting to know the Alzheimer’s Care Consultants who staff the Alzheimer Association’s 24/7 Helpline: 800-272-3900 provided a unique opportunity for our Institute staff to learn about the invaluable services provided by the organization. Working with the Alzheimer’s Association Care Consultant Clinicians who staff the Contact Center was a singularly uplifting experience.

A few months ago, the Contact Center’s wonderful Clinical Director, David Parris LCSW, graciously allowed me to record an interview with him. David and his colleagues exemplify what I consider to be the best combination of counseling skills: expertise and compassion. As you will see in the following interview, the Alzheimer’s Association is truly an organization with heart.

In the conversation that preceded our interview, David made such poignant observations that I decided ( with his permission) to start with this.  You can watch my interview with David here:

For the latest updates on Alzheimer’s disease research, support, resources, and information on how to get a proper diagnosis and the warning signs for Alzheimer’s and other related dementias, go to alz.org.

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

For those wishing more training in using the Solution-Focused Brief Therapy approach with clients experiencing trauma and grief, You may wish to check out the following Institute online, self-paced courses:

Solution-Focused Brief Therapy for the Treatment of Trauma (4 CE Credit/Clock Hours available)

Clients Experiencing Grief: A Solution-Focused Approach (5 CE Credit/Clock Hours available)

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