An Inspiring Conversation with Dr. Margret Cheng

I have had the immense pleasure of meeting Dr. Cheng, who has combined training in both Pediatrics and Internal Medicine. She dedicates her work to the care of medically and socially complex patients in underserved areas. She recently has been trying Solution Focused Skills in the care of her patients and has found it both inspiring for herself and beneficial for her patients. We recently spent a few hours sipping tea and conversing about the ways in which she has found Solution-Focused tools helpful in her practice. Below are a few of the pearls she has noticed in her work.

We began our conversation about a very complex patient she has been particularly inspired by. Briefly this patient is a 15y/o girl who is being treated for Diabetes and has coped with trauma and homelessness, Child protection involvement and family addiction. We will call her Sue.

Sue initially presented to the emergency room for chest pain and came to Dr. Cheng for a “sick visit” as an urgent appointment. She was not a patient she was regularly following. During this visit, Dr. Cheng discovered that she had poorly controlled diabetes (Her blood glucose in the upper 300s), and also found out she had visited the emergency room 6 times in the past 4 months and during all those ER notes, there was no mention that she had Diabetes Mellitus. During her ER visit, the focus was on her complaint of chest pain. She was given an EKG, told that her chest pain was due to anxiety and referred back to her Primary care provider.

Dr. Cheng met with both Sue and her mother for what was her initial visit with her and asked her gently how she could be helpful for them and whether it would be ok to talk with her about her Diabetes. Sue looked toward her mother for a response, and her mother said she wanted to keep her daughter out of the emergency room. Dr. Cheng had only 15 minutes during this visit, but by simply asking what they wanted help with and took time to validate and acknowledge the challenges of caring for her daughter’s complex needs, they both agreed to come back the following week.

They did return for the next appointment and also followed up with the request to get labs. During this visit, Dr. Cheng discovered Sue’s Hemoglobin A1C (A marker of how well Diabetes is managed) was the highest she had ever seen – almost 16. Dr. Cheng began the appointment by thanking them for coming to the appointment and inquiring how they were able to make it there and follow-up with the labs. She again asked their “best hopes” for this appointment so it would be helpful for them, and her mother said that she was now homeless. Dr. Cheng responded with a “for you” statement about how difficult this must be for them, followed by this question “Where do you get your strength from to continue?” This question invited Sue’s mother to open up about how she was one of 13 children and was “given nothing”. She was raised to just “carry one and not trust anyone, but to do what you needed to survive”. When asked how she had been coping, her mother said they have a place to stay with their family for now, and Dr. Cheng provided her with resources to help with housing. Sue and her mother were now making all follow-up appointments and during the next appointment when asked how she could be helpful for Sue, both her mother and Sue stated to “get her blood sugars under better control”. She asked her how she has tried to manage her sugars, and Sue and her mother said they were told by her brother’s endocrinologist to “do what he does”. Dr. Cheng asked what Sue and her mother know about how to manage blood sugars, and it became apparent they needed education on how often to monitor blood sugars. The next appointment Sue stated she was self-initiating checking her blood sugars once per day. She noticed it was high. Dr. Cheng explored this positive difference. Was it different for her to monitor her own sugars? Sue said yes. When asked how it was different, she stated she would often not check her sugars for days at a time. When asked if it was helpful for her, she stated that she is beginning to notice that when her sugars are high, she observes she is also more tired. When asked her how she managed to remember to check it, she stated she was getting a reminder from her mother and wanted to get better and get her driver’s license. Her mother was complimented on her support and asked how she managed to remember to remind her daughter.

This vignette brought up a several pearls for Dr. Cheng. The first being “You can do medicine best only after you have engaged positively with your client and their VIPs.” Dr. Cheng also noticed the paradox of starting “slowly” and how this paradoxically speeds things up. Dr. Cheng was inspired with the movement and progress of her patient. The nurses also were excited and pleased. Practicing the Solution-Focused Approach can be used to satisfy both patients and clinicians. Dr. Cheng began conversations by activating resources, identifying both Sue and her mother’s strengths toward achieving their best hopes for their future, and aiming to do more of what is already working. Dr. Cheng was inspired by the difference it made to focus on what is currently working, how clients are coping with extremely challenging life situations and redirecting the conversation towards positive elements of their situation. She was reminded that a patient’s “best hopes” may or may not align with those of the physician, but this is the place to start. At the end of the conversation, Dr. Cheng began reflecting on her excitement to try some additional questions we talked about when she returned to work: “ What’s happening that you want to continue to happen?” and “On a scale from 1-10, where 10 is you are satisfied with how you are coping with your challenges and 1 is the opposite, where are you now?” “ What keeps the number from being lower” What else? What would be a good enough number?” “How satisfied are you with how you are managing the diabetes from 1-10, where 10 is you are satisfied” “What number would your mother give you?”

We agreed to meet next month for tea and continue the inspiring conversation about how solution-focused skills are very effective tools when working with medically complex patients. Stay tuned!

By Anne Bodmer Lutz, M.D.

In my over 20 years as a practicing child and family psychiatrist, I have come to realize that in addition to a very different paradigm than problem-focused therapies, solution-focused therapy pays meticulous attention to language and words that instill hope and respect. I invite you to consider a few examples of how the choice of words used can make a difference in navigating a solution-focused conversation.

I have asked many people who have fluency in multiple languages what they have found most helpful in learning a new language, and four consistent answers have emerged. One, there is a need and motivation to want to learn the new language. Two, there is a need to have knowledge and fluency of basic verbs as well as some general vocabulary. Three, there is a need to understand fundamental grammar. And four, it is essential to practice and speak with other people who are fluent in the language you are trying to learn, and to speak with others at a level commensurate with your skill level in order to build confidence. With these concepts in mind, I invite you to consider my first translation, the word “problem.”

A problem can be defined as a matter or situation regarded as unwelcome or harmful and needing to be dealt with. Problems generally cause difficulties, complications, obstacles, and trouble for people. I realize how often and continually I, and those around me use this word. Contrast the problem-focused word “problem” to the solution-focused translation “challenge.” The word challenge summons one to a contest of skill and strength. It is a task that tests someone’s abilities assuming it will be met with success. Requesting clients to accept and confront their problem is very different than asking them whether they are up for the challenge of learning new skills. Asking children to do homework to address their problem of anxiety is much less palatable than posing to them whether they are up for the challenge of learning new skills. Challenges invite and dare people to succeed. Problems need to be faced and fixed and convey something burdensome and onerous. Personally, I have taken on the challenge to rid myself of the word problem from my lexicon, and hope you may take this challenge on as well and see what difference it makes for you.

I’m looking forward to sharing a few more of the following translations in our upcoming newsletters.

By Anne Bodmer Lutz, M.D.

“And for all those tea drinkers out there: Let’s learn a lesson from tea. It shows it’s real worth when it gets into hot water” ~ Annonymous

“There are questions which illuminate, and there are those that destroy. We should ask the first kind” ~ Quote from Nobel physicist Isaac Isador Rabi.

Suicide presents a major challenge to public health in the United States and worldwide. Current global estimates indicate that approximately one million people die by Suicide each year, accounting for more than half of all violent deaths in the world. (Ting, Sarah, A., et al.). In the mental health field, managing “risk” is the dominant paradigm in responding to suicidal thoughts and behaviors. Risk assessment focuses on ensuring the client’s safety and minimizing the danger of harm without treatment. A solution-focused safety assessment (SFSA) is a paradigm shift providing an additive dimension to conventional risk assessment and cultivates hope. It highlights individual, and relationship resources (VIPs), coping strategies, reasons for living, and client needs. An SFSA emphasizes how clients have coped and managed to endure, even a little bit, the seemingly overwhelming distress that they have found unbearable at the moment.

INTRODUCTION TO SFSA

In my practice, I often am challenged with clients coping with suicidal thoughts and behaviors. Incorporating an SFSA has been very helpful both for my clients, their VIPs, and managing my own anxiety in these very stressful situations. Preparing clients for questions that evaluate their safety, by explaining that these questions are routinely asked, helps to normalize their struggles, aiding them in feeling less alone. Framing questions about safety in the context of “pain” and “good reason” imparts empathy. Asking clients their “good reasons” for behaviors that appear harmful (i.e.) self-harm, drug use, staying in a domestically violent relationship, to name a few, reveals how clients engage in these behaviors because in some way they are useful and beneficial for them. The question does not condone the behavior but instead helps to understand the client’s motivation and can help lead the conversation towards 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 my Solution-Focused Safety Scale (SFSS)

I keep a stack of solution-focused safety cards available in my office. I write the plan on the card with the client present and, if possible, also include their VIPs in the conversation. I have found the act of giving them the safety card which we have worked on together and which can be kept with them at all times, provides a tangible reminder of the work with have accomplished as a team. It can cue them to their strengths, resources, and coping strategies in times of distress.

SFSA and creating a “VIP Map.”

Inquiring about a client’s VIPs early on and throughout the conversation broadens “who” the client is and assists in integrating their unique social context within the dialog. VIPs highlight relationship resources, enhancing possibilities for solutions. Assessing who is a client’s VIPs is critical in understanding and assisting them in building solutions from the multiple perspectives of those most important in their life. VIPs are often the primary reason people stop themselves from acting on destructive thoughts. VIPs may include spouses, friends, children, teachers, coaches, grandchildren, pets, people whom they feel responsible for, and even people who may have died but whom they keep in their heart. Below are questions I ask to create a client’s “VIP map.”

• Who are the most important people in your life?
• Who else? Who else?
• What do you most appreciate about them?
• What else? What else?
• Who was “worried” or “concerned” about you that they thought coming here would be helpful for you?
• Do you have pets? How are they helpful for you? What do you most appreciate about them?
• Whose wellbeing do you feel responsible for?
• Who relies on you for help and support?

SFSA SCALING

On the front of the card is a picture of a scale from 1-10 (10 being the best). Solution-focused scaling questions are constructed in such a way that the 10 highlights a positive direction of where the clients want to go. When performing an SFSA, scaling questions measure how confident the client is that they can keep themselves safe. It is important to “work the scale.” Asking a variety of questions that amplify the scale often uncovers more opportunities to compliment clients and cultivate hope. Below is a list of questions that can “work the scale”.

What do you “KNOW” questions

• What do you know you need to do to keep yourself safe?
  • This is asked to both clients and their VIPs
• What else do you know you need to keep yourself safe?

What have you “TRIED” questions

• What have you tried that has helped you endure these very painful moments and make them “even a little bit tolerable?”
• What else have you found has helped you cope to make it even a little bit bearable for you?
• What would your VIPs say has helped you manage these moments in a bearable way? What else would they say?

Scaling CONFIDENCE in safety: “On a scale from 1-10, where ten is the best:”

• How confident are you that you can keep yourself safe?
• What keeps the number from being lower?
• What else keeps it from being lower?
• What would be a “good enough” number?
• What would you be doing at this “good enough” number?
• What else would you be doing?
• What would your VIPs notice you are doing at this “good enough number?
• What else would your VIPs notice you doing?
• How would you discover when it goes up by one point?
• What would you be doing? What else would you be doing?
• How confident would you predict your VIPs would say you can keep yourself safe?
• What was the highest number it has been?
• When was this?
• What were you doing at that number? What else were you doing?
• What do you think helped the number be higher at those times? What else helped?
• At what number would you require a higher level of care, such as going to the emergency room, calling 911, or calling a crisis team?
• At what number would your VIPS say you require a higher level of care?
• How confident are you from 1-10 that you can do the necessary things you need to keep yourself safe?

Scaling a “Good enough” number to keep safe
Scaling can also help clients and their VIPs confirm what they need at particular numbers. Of particular importance is to confirm a “good enough number” in which they know they can keep themselves safe. This is important to ask both to clients and confirm with their VIPs. If clients think they can keep themselves safe and their VIPs do not agree, it is critical to detail the reasons for the discrepancy. What is the reason the client is confident 10/10 they will keep themselves safe, but their VIP thinks it is only a 2? Ensuring a client can maintain their safety requires confirmation that their VIPs are in agreement.

Asking clients what number they would be at if things are “not good enough” and they do not feel confident in their ability to keep themselves safe affords an opportunity to detail what they would be doing at that number and connecting that number to what they need. When things are “not good enough”, they may report behaviors such as contemplating Suicide, staying in their room for much of the day, not talking, sleeping all day or not have the energy to do what is required of them. Detailing the actions of clients at each of the numbers and correlating these actions to what they need acknowledges their pain while elucidating to both clients and their VIPs a concrete plan of action that corresponds to their needs. They may need to call someone, have someone stay with them, go for a walk, pet their dog, call a crisis hotline, or go to the emergency room. What is critical is to refrain from assuming what you think they need, and instead ask both clients and their VIPS what they know is required at each particular number. I have found this level of detail reassuring to clients and their VIPs, as well as equipping them with a highly individualized plan that can be mutually confirmed.

Safety Number Check-Ins with VIPs
Scaling questions also limit language confusion and assist in creating a safety plan that both the client and their VIPs can agree on. Asking clients if they think it would be helpful to have someone do a “safety number check- in” provides a way for clients and their VIPs to assess confidence in their safety quickly and easily. Inquiring with clients who they think would be most helpful to check in with, how often, and by what method (i.e.) text, phone, email, can incorporate their VIPs within a safety plan in tangible ways.

Indirect Compliments and Positive Differences
Clients and their loved ones are understandably very distressed when suicide is disclosed. Providing indirect compliments to clients in the form of a question (How did you do it?) invites clients to appreciate what they have already done and are doing to cope with their painful situation. The meticulous use of past tense verbs highlights that clients have already done something to cope with their painful situation and thus can do it again. How did they decide to have the courage to ask for help? How have they endured their pain, even if only a little bit? How have they managed even if for brief times to keep from acting on the suicidal thoughts? These moments may seem negligible and can be easily passed over in a clinical encounter, yet it is these seemingly “micro-positive” differences that are critical to amplify in times of despair. What clients are doing to cope in seemingly small ways are the very things they need to do more of to endure their situation. These positive differences may include when clients were able to get through part of a day, got dressed, talked or texted a friend, cared for their pet, ate some food, drank a cup of tea, helped a friend, accomplished even a small part of a goal, and stopped themselves from acting on their suicidal thoughts. Amplifying these differences by exploring whether these differences were helpful, how they are helpful and how they accomplished these differences uncovers additional resources.

Highlighting situations as temporary instead of permanent
“Rewording,” a client’s “permanent language” to “temporary” can help clients endure their situation even “a little bit.” Emphasizing the temporary nature of their situation can subtly impart hope. For example, when a client says “I don’t see any way out,” rephrasing it to “right now,” it doesn’t feel like there is a way out. Or when clients say nothing seems to matter, rewording their statement to “It seems right now” nothing seems to matter.

A Language of Empathy: “For You” Statements
Clients and families who are struggling with suicide often experience hopelessness, fear, anger, and anxiety, requiring a great deal of “for you” responses. Examples of “For You” statements with clients might be acknowledging how exhausting it must be “for you” to endure the suffering and painful situation you have been dealing with. For parents and loved ones, it might be validating how scary and frightening it must be “for you” to see your child struggling with suicide. Acknowledging how difficult it must be “for them” confirms their emotional perspective and can help them tolerate their situation even a little bit.

SFSA Risk Assessment
An SFSA integrates solution-focused language in a “traditional” risk assessment. The following are SFSA risk assessment questions.

• How well from 1-10 (10 being the best) are you managing your mood, anxiety, cravings, substance use, and other health conditions? What are good enough numbers for these domains? What do they need to help them manage these areas?
• Have you ever had to cope with domestic violence, abuse, natural disasters, war, homelessness, substance use, loss, divorce?
• How have you coped? How else?
• Have you ever had to cope with prior suicidal ideation or behaviors?
• How did you cope?
• What kept you from acting on those thoughts? What else?
• What treatments/providers/medications have been most helpful for you?
• What do know has been most helpful about your prior treatments/ providers and medications?
• How satisfied are you from 1-10 with your most important relationships?
• Has anyone in their family had to cope with depression, substance use, suicide, or other mental health conditions?
• What do you know has been helpful for them?
• Who in your family is doing well?
• What do you know about what has helped your family members who are doing well?
• How well from 1-10 are you managing your work and financial stress?
• What is a good enough number? What keeps the number from being lower?
• How satisfied are you from 1-10 with the treatment and resources available to you in your community?
• Do you have guns/ unlocked medications in your home?
• What do you know is needed to manage these means of harm?
How confident from 1-10 are you that you can do what is needed to minimize these lethal means?
• What is a good enough number?How confident from 1-10 are your VIPs that the lethal means can be minimized in the home can be minimized?
• How confident are you that you can call and ask for help if you are not feeling confident in your safety?
• Whose phone numbers are most important for you to have? Who else?

Remaining solution-focused when a higher level of care is needed
When a client requires a higher level of care, it is still possible to stay solution-focused. The following questions can help to sustain a solution-focused conversation encouraging both patients and their VIPs to be involved in this difficult decision while conferring a sense of control and responsibility.

• What are the patient’s best hopes for hospitalization?
• What are their VIP’s best hopes for their hospitalization?
• How are they hoping the hospitalization will be helpful?
• What will tell them they are ready to leave the hospital and have learned the necessary skills to keep safe?
• What will tell the client’s VIPs that they have learned the necessary skills to help their loved one stay safe?

Resources if you are need of help now
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
Castro, Sahily De, and Jeffrey T. Guterman. “Solution-Focused Therapy for Families Coping with Suicide.” Journal of Marital and Family Therapy, vol. 34, no. 1, 2008, pp. 93–106., doi:10.1111/j.1752-0606.2008.00055.x.

Fiske, Heather. Hope in Action: Solution-Focused Conversations about Suicide. Routledge, 2008.

Henden, John. Preventing Suicide: the Solution Focused Approach. Wiley, 2017.

Kondrat, David C, and Barbra Teater. “Solution-Focused Therapy in an Emergency Room Setting: Increasing Hope in Persons Presenting with Suicidal Ideation.” Journal of Social Work, vol. 12, no. 1, 2010, pp. 3–15., doi:10.1177/1468017310379756.

Lutz, Anne Bodmer. Learning Solution-Focused Therapy: an Illustrated Guide. American Psychiatric Publ., 2014.

Ronquillo, Linda, et al. “Literature-Based Recommendations for Suicide Assessment in the Emergency Department: A Review.” The Journal of Emergency Medicine, vol. 43, no. 5, 2012, pp. 836–842., doi:10.1016/j.jemermed.2012.08.015.

“The Solution Focused Approach in Working with the Suicidal.” Preventing Suicide, 2017, pp. 123–151., doi:10.1002/9781119162926.ch8.

Ting, Sarah A., et al. “Trends in US Emergency Department Visits for Attempted Suicide and Self-Inflicted Injury, 1993–2008.” General Hospital Psychiatry, vol. 34, no. 5, 2012, pp. 557–565., doi:10.1016/j.genhosppsych.2012.03.020.

Anne Bodmer Lutz, B.S.N. M.D.

What does “person-centered care” mean? The use of this terminology is frequent, but the concept is vague. “Person-centered care” (PCC) has been recognized as one of the critical elements needed for the redesign of our nation’s health care system (IOM, 2001). The Institute of Medicine (2001) defined PCC as “care that is respectful and responsive to individual patient preferences, needs, values, and ensuring the patient values guide all clinical decisions”. Stephanie Morgan, and Linda Yoder have defined PCC “as a holistic (bio-psychosocial-spiritual) approach to delivering care that is respectful and individualized, allowing negotiation of care, and offering choice through a therapeutic relationship where persons are empowered to be involved in health decision at whatever level is desired by that individual who is receiving the care.” (Morgan and Yoder, 2011).

The Solution-Focused approach is one of the most pragmatic ways to implement PCC when having conversations with clients. How does the solution-focused approach fit into PCC? How do you know when you are utilizing a “Solution-Focused PCC” approach? Who is the person in PCC? How might clinicians implement “Solution-Focused PCC”? Here are a few examples illustratng how assessing important relationships in a client’s life broadens “who” the person is and fosters additional possibilities to develop solutions based on each client’s unique social context.
All people live in relationships. Relationships are not only crucial for survival but essential resources that help people solve their problems. Problems are solved in one of two ways, either the problem is solved, or the individual and those most important to them no longer view the behaviors or difficulties as problematic. I think about the many youths who I don’t see who may be considered as having a substance use disorder. What is the reason I don’t see them? Certainly, access is one challenge, but also whether or not this youth and the social context they live in view this as a problem. Perhaps the youth is using substances with their parents, and it is viewed as normal. Perhaps, the parents do not view it as a problem unless their grades have declined. The context may change when the youth is discovered to be selling drugs at school; thus now the school views it as problematic. Or they are caught drinking while driving and legal entities “mandate” them to treatment.

Mapping out a client’s context is critical in understanding and assisting them in building solutions from the multiple perspectives of those most important in their life. I propose the idea of developing a “VIP map,” much like you weave a beautiful quilt that has differing colors, textures, fabrics, and designs. I define VIPs as the relationships that are most important in a client’s life. VIPS are used when negotiating goals as well as when evaluating treatment progress. For example, asking what are would your client say are their VIP’s “best hopes” for them, and incorporating VIPs when asking scaling questions such as: How confident they are that you will remain sober from 1-10? How satisfied from 1-10 would they say things are between you? How confident are they from 1-10 that you can remain safe?

Inquiring about a client’s VIPs early on and throughout the conversation broadens “who” the client is and integrates the social context within the dialog, fostering additional possibilities and hope for solutions. I invite you to consider six categories of VIPs: Classic, Vulnerable, Hidden, Spirit, Pets, and Future VIPs. Categorizing VIPs in this way has been a helpful way for me to organize and map a client’s social context.

“Classic VIPs” are those relationships that we typically think of when considering important people in our life. They may be spouses, children, friends, co-workers, grandparents, aunts, uncles, teachers, community supports, clergy, people who have died – whoever the client identifies. It is important not to assume who these relationships are, but instead, ask clients.

“Classic VIP Questions”
1. Who are the most important people in your life?
2. Who else? Who else?
3. What do you most appreciate about them?
4. What else? What else?

When practicing these questions with trainees, they are often surprised by the intimacy and vulnerability that may arise. Frequently, they feel a heightened sense of gratitude and appreciation for those important in their life. These questions can help activate relational resources when clients are experiencing thoughts of suicide. It is often important people and relationships in an individual’s life that stop them from acting on these thoughts contributing to a “resilience assessment” when evaluating safety concerns.

“Hidden VIPs” are those relationships that clients may want out of their life, yet are still important for them in that they may be critical in determining decisions in a client’s life. They may be DCF workers, Probation officers, therapists, psychiatrists, judges, or family members. Hidden VIPs are important to consider for “mandated” or “externally motivated” clients. As a child psychiatrist, there are very few youths who want to come and see me. Most of my clients are “externally motivated” with the goal of not having to see me again. Asking them who would decide when they no longer need to see me often uncovers important relationships in their life. I remember an adolescent girl who I was treating in a residential facility for substance use. When I asked her about her “Classic VIPs,” she could not identify anyone. She had been living on the streets selling and using drugs to survive as both her parents had died. This VIP map was very challenging to develop. When thinking more about her situation, I reflected that someone cared enough about her to get her into treatment, even if she did not think of this as “caring.” It was a teacher at her school. This discovery led to more questions about what she thought the teacher appreciated about her and what her teacher knew about her that she would be successful in her life.

“Hidden VIPs” Questions
1. Who was “worried” or “concerned” about you that they thought coming here would be helpful for you?
2. Whose idea was it for you to come here?
3. What are they saying you need to do so you don’t need to come here anymore or can go back to home, to the school they want, etc.?

Pet VIPs (Very important pets). In my work with children and families, I have increasingly been inspired by how important pets are in people’s lives. They are often a source of comfort, companionship, and reason for living. I discovered this by accident. In my private office, I would sometimes bring my dogs to work when I needed to get paper-work done. Because of this, I had a dog bed hidden in the corner with a small dog toy. I was amazed to discover how often both youth and parents asked whether I would bring a dog to the session. I acknowledged that my dogs are not therapy dogs, but I do enjoy bringing them when not seeing clients. This began a conversation about animals in their life. Do they have pets? Are they important in their life? What do they most appreciate about them? What difference have they made in their life? These relationships are often very beneficial. They may also be painful such as when clients divulge a beloved animal they lost.

It also led me to consider asking them if it would be helpful for them to bring their animal to the session, much like I would invite them to bring other important human family members. I have found clients very honest about whether it would be helpful. Some have said, no – it would just cause them worry about their animal destroying my office or distracting them from what they needed. Others have said it would be very helpful. This has led to the delightful discovery of including some of my client’s pets in sessions. I have met multiple dogs, cats, birds, and even a hedgehog. One particular client brings his dog to every visit. He acknowledges that it is his loving dog that is his reason for living and gives him the motivation to come to his appointments. His dog even knows when the 50 minutes are ending and will jump off the couch and politely wait for his weekly treat!

“Pet VIP Questions”
1. Do you have pets?
2. Are they helpful for you?
3. How are they helpful for you? How else?
4. What do you most appreciate about them?
5. What else? What else?
6. What do your pets most appreciate about you? What else?

“Vulnerable VIPS” are those relationships in a person’s life who are in need of support, special care, protection, and help. One of my prior workshop participants, Erin Sepe, came up with this name and I give her all the credit! Often these people are reasons and motivation for clients to move forward in their life. Another workshop participant who works with boys in detention created a group in which she had the boys identify vulnerable VIPs in their life. She then had them write a letter to them expressing their best hopes for them and what they most appreciate about them. This also helped them develop empathy and normalized their experiences with the others.

“Vulnerable VIP Questions”
1. Whose wellbeing do you feel responsible for?
2. Who relies on you for help and support?
3. Who depends on you?
4. What would they say you have done to help and support them?
5. What would they say they appreciate about you? What else?

“Spiritual VIPs” can be considered a client’s spiritual beliefs and may also include relationships people have lost. Loss is a natural part of life, and I have found this concept a helpful way to strengthen and expand resources when mapping a client’s VIPs. Spiritual VIPs are unique for every client, and can assist them in talking about beliefs around the meaning of their life, connection with others, and provide them with a sense of peace and purpose. Spiritual VIPs often help clients cope in very challenging circumstances. When I ask clients how they have coped and endured incredible loss, they often talk about their faith in God and how this has provided them the strength and endurance to carry on. This can foster hope by exploring in more detail how God has been helpful for them, how else, what they appreciate about God and what God appreciates about them. It can also provide opportunities to compliment them on their faith and how they have nurtured and developed this strength in their own life.

Spiritual VIPs may also include relationships clients have lost. Exploring losses through Spiritual VIPs can further deepen how their loved ones remain in their heart. I had a client who lost her mother, father, and her primary guardian was unable to care for her because of active substance abuse. When I asked her whether there had been important people in her life who she lost, she spoke about her grandmother. I began asking her what she appreciated about her grandmother and what her grandmother would appreciate about her. I asked her what her grandmother would say she is most proud of about her. This opened up a conversation about this loss in a tolerable way and helped her talk about all the ways her grandmother remains in her heart. Rather than feel only the loss and separation, it helped her realize how her grandmother carries on within her heart. I think of the quote by William Shakespeare: “Give sorrow words; the grief that does not speak knits up the o-er wrought heart and bids it break.”

“Spiritual VIP” Questions
1. Many people have lost important relationships in their life. Is this something you have coped with?
2. What did you most appreciate about them? What else?
3. Are there small ways in which you have kept them in your heart?
4. How have you kept them in your heart? How else?
5. Has it been helpful for you?
6. How has it been helpful for you?
7. What would they say they most appreciate about you? What else?
8. What would they say they are most proud of supposing they were with us in the room as we are talking? What else?
9. What would their best hopes be for you? What else?

“Future VIPs” are relationships clients hope to develop in the future. This again came from a prior workshop participant! It can be helpful to explore best hopes for relationships in the future and what clients would be “doing” when they are in satisfying relationships. How would they know these relationships were satisfying for them? Has there ever been even a little bit of these future VIP qualities in their current relationships? On a scale from 1-10, how confident are they that will be able to find their future VIP? How satisfied are they from 1-10 with their current VIPS? What is a good enough number? What keeps the number from being lower? How would they discover when it goes up by one point?

“Future VIP” Questions
1. What are your best hopes for a satisfying relationship?
2. What do you know that you need/want in a relationship?
3. What else?
4. What are “green flags” that would tell you this relationship is what you hope for? What else?
5. Are there aspects of your “future VIP” happening even a little bit now in your relationships?
I hope this article helps you to see the beauty, complexity, and challenge of broadening “who” the client is in PCC. I invite you to try some of these questions and co-create a beautiful tapestry that is helpful for your clients and enriching for the privileged work we all do.

References:
Crossing the Quality Chasm. (2001). doi:10.17226/10027
Morgan, S., & Yoder, L. H. (2011). A Concept Analysis of Person-Centered Care. Journal of Holistic Nursing, 30(1), 6-15. doi:10.1177/0898010111412189

Anne Bodmer Lutz, B.S.N., M.D.

Human beings are unique in two ways – we are tool-bearing and talkative. This ability to talk provides us with opportunities to communicate with others. Some conversations enhance possibility, while others diminish it. When possibility is enhanced, we have self-agency – a sense that we can take the necessary actions to address what concerns or troubles us – to accomplish our hopes, ambitions, and dreams. How can we help people transform their stories and create a conversational space that enhances hope and possibilities? Solution-Focused brief therapy (SFBT) can be thought of like a new language requiring fluency and skills different from the native problem-solving language we are all fluent in.

SFBT is a future-focused, goal-directed approach to brief therapy. The developers meticulously observed hundreds of therapy sessions, carefully noting which questions proved to be most consistently linked to clients’ subsequent reports of progress. These questions were then incorporated into the solution-focused approach. (More Than Miracles, de Shazer et al.).

Let’s get started on the Top Ten Solution-Focused Translations!

#10: The Indirect Compliment: How did you do it?

Let’s look at this lovely question. How conveys “in what manner? By what means?” Notice the question is not “Did you do it?” but instead “HOW” did you do it. Did (observe it is past tense), conveys they have done it already. Noticing with clients what they have already done enhances a sense of self-efficacy because they have already accomplished it. The second verb “to do” (to accomplish, perform and execute) conveys past success. How are problems (or as I like to translate “challenges”) solved? It requires action or the verb “to do.” Most of us are less fluent in the use of the indirect compliment, which is in the form of a question, and have greater ease when providing “direct compliments” such as “Wow” or “Congratulations.” Listening for opportunities to compliment clients based on their complaints (and who doesn’t love to complain) with indirect compliments is a powerful question to enhance self-efficacy and hope. What the heck – try asking the indirect compliment with your patients, colleagues, children, loved ones. I assure you no harm will be done!

#9: What are your best hopes?

This is the solution-focused translation of the chief complaint (What brought you here). The question is not “do you have hopes?, But rather “What” are your best hopes. It is hopeful, future-directed and creates a narrative which communicates to clients their competence and hopes to live a more satisfying life on their behalf.

#8: What else? How else? Who else?(Three for the price of one)

Effective solution-building requires getting as many details as possible about prior successes. These questions leave no potential strength uncovered and are the metaphorical “language shovels” that dig for the details of success. What else are you good at? How else did you do it? How else was it helpful? Who else is most important to you?

#7: Who are the most important people in your life and what do you most appreciate about them?

All people live in relationships. Relationships are not only crucial for survival but also essential resources that help people solve their problems. Problems are solved in one of two ways. Either the problem is solved, or the client and those most important to them no longer view the behaviors as problematic. For “challenges” to be considered solved, the client’s system must be in agreement that there are no significant problems. What better way to learn who is important to your client than to ask.

#6: What do you know?

What do you know conveys that clients have knowledge, understanding and a recognition of what is important in their life. Asking clients what they know about marijuana, medications, their diagnosis attests to their competence. One of my favorites is to ask parents “What do you know about your child that tells you they will succeed in life?” It has continually amazed me that parents are always able to answer this question no matter how dire the situation appears.

#5: Have you ever had to cope with trauma, domestic violence, hurricanes, homelessness, mudslides, poverty, loss, death, etc. ?

Incorporating the one-word “cope” within the question demonstrates that your client has coped. If they say yes, my next question is “How have you coped?” When clients are sitting in front of you talking, they have indeed coped. Remember that cope is one letter away from hope.

#4: You must have a good reason?

Asking clients their good reasons for behaviors that appear harmful (i.e.) self-harm, drug use, staying in a domestically violent relationship, to name a few, reveals how clients engage in these behaviors because in some ways they are useful and beneficial for them. The question does not condone the behavior but instead helps to understand the client’s motivation to do what they are doing. This can help lead the conversation towards alternatives.

#3: Was it different for you?

Noticing positive differences, also known as exceptions, are times when an expected problem could have occurred but didn’t. Positive differences often go unnoticed by clients. Meticulously paying attention to these differences often discovers past successes.

#2: On a scale from 1-10, where ten is you are satisfied, and things are good enough, and one is the opposite, where would you say you are?

Scaling questions can minimize language confusion that often occurs within conversations. They are quick, easily adaptable and client-centered. Solution-Focused scaling questions are constructed in such a way that the 10 highlights a positive direction of where the clients want to move forward (i.e.) confidence in ability, satisfaction with relationships, ability to keep safe, or helpfulness of medications. Asking what keeps the number from being lower (and what else) often uncovers further undiscovered strengths and past successes. It is one of many potential amplifying questions used to “work the scale” and often leads to more possibilities to compliment and bring to light more past successes.

#1: What are you good at and enjoy?

This question affords your client an opportunity to talk about parts of their life going well and communicates they are more than their presenting problem. These strengths are essential resources that would otherwise often be undiscovered within the conversation and are critical resources that can often assist them in solving their problem. Investigating details by asking how they learned the skills; what else they are good at and how else they learned these skills recognizes a client’s expertise and mastery expanding the narrative of their accomplishments and abilities.

De Shazer, Steve, et al. More than Miracles: the State of the Art of Solution-Focused Brief Therapy. London, Routledge, 2012.

Franklin, Cynthia, et al. Solution-Focused Brief Therapy: a Handbook of Evidence-Based Practice. New York, Oxford University Press, 2012.

Lutz, Anne Bodmer. Learning Solution-Focused Therapy: an Illustrated Guide. Arlington, VA, American Psychiatric Publishing, a Division of American Psychiatric Association, 2014.