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Single Session Solution-Focused Therapy: Harnessing the Moment in Crisis Mental Health

2021-12-20T19:24:58+00:00July 30th, 2021|

 Anne Bodmer Lutz, M.D.

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

About Single Session Therapy

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

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

About Solution-Focused Single Session Therapy

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

Can Solution-Focused Single Session Therapy reduce barriers to mental health access?

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

How does Solution-Focused Therapy Address the Therapeutic Common Factors?

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

How does Solution-Focused Single Session Therapy Differ from Psychological First Aid?

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

How can Solution-Focused Brief Therapy be applied to Single Session Therapy?

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

Introductions:

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

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

Building a Yes-Set:

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

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

#1: RESOURCE ACTIVATION (INDIVIDUAL):

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

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

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

Punctuating positive differences (Past successes)

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

#2: RELATIONSHIP RESOURCE ACTIVATION (VIPS – MAPPING THE SOCIAL CONTEXT)

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

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

#3: BEST HOPES (GOAL NEGOTIATION)

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

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

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

#4: SCALING QUESTIONS

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

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

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

 

#5: END OF THERAPY SESSION FEEDBACK

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

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

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

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

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

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

References

Asay, T. P., & Lambert, M. J. (1999). The empirical case for the common factors in therapy: Quantitative findings. The Heart and Soul of Change: What Works in Therapy., 23–55. https://doi.org/10.1037/11132-001 

Bloom, B. L. (2001). Focused Single‐Session Psychotherapy: A Review of the Clinical and Research Literature. Brief Treatment and Crisis Intervention, 1(1), 75–86. https://doi.org/10.1093/brief-treatment/1.1.75 

Budman, S. H. (1981). Forms of brief therapy. Guilford Press. 

Campbell, A. (2012). Single-Session Approaches to Therapy: Time to Review. Australian and New Zealand Journal of Family Therapy, 33(01), 15–26. https://doi.org/10.1017/aft.2012.3 

Courtnage, A. (2020). Hoping for Change: The Role of Hope in Single-Session Therapy. Journal of Systemic Therapies, 39(1), 49–63. https://doi.org/10.1521/jsyt.2020.39.1.49 

Gullickson, T. (1992). Review of Single-Session Therapy: Maximizing the                                                Effect of the First (and Often Only) Therapeutic Encounter. Contemporary Psychology: A Journal of Reviews, 37(5), 501–501. https://doi.org/10.1037/032170 

Guthrie, B. (2016). Single Session Therapy as a framework for post disaster practice in low and middle income countries. Intervention, 14(1), 18–32. https://doi.org/10.1097/wtf.0000000000000107 

Hansen, N. B., Lambert, M. J., & Forman, E. M. (2002). The psychotherapy dose-response effect and its implications for treatment delivery services. Clinical Psychology: Science and Practice, 9(3), 329–343. https://doi.org/10.1093/clipsy.9.3.329 

Hoyt, M. F. (2021). The Hope and Joy of Single Session Thinking and Practice. Single Session Thinking and Practice in Global, Cultural, and Familial Contexts, 29–41. https://doi.org/10.4324/9781003053958-2-4 

Hymmen, P., Stalker, C. A., & Cait, C.-A. (2013). The case for single-session therapy: Does the empirical evidence support the increased prevalence of this service delivery model? Journal of Mental Health, 22(1), 60–71. https://doi.org/10.3109/09638237.2012.670880 

Lambert, M. J. (2005). Early response in psychotherapy: Further evidence for the importance of common factors rather than “placebo effects.” Journal of Clinical Psychology, 61(7), 855–869. https://doi.org/10.1002/jclp.20130 

Lambert, M. J., & Ogles, B. M. (2014). Common factors: Post hoc explanation or empirically based therapy approach? Psychotherapy, 51(4), 500–504. https://doi.org/10.1037/a0036580 

Lambert, M. J., & Ogles, B. M. (2014). Using clinical significance in psychotherapy outcome research. Quantitative and Qualitative Methods in Psychotherapy Research, 189–203. https://doi.org/10.4324/9780203386071-12 

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Lutz, A. B. (2014). Learning solution-focused therapy: an illustrated guide. American Psychiatric Publ. 

Paul, K. E., & van Ommeren, M. (2013). A primer on single session therapy and its potential application in humanitarian situations. Intervention, 11, 8–23. https://doi.org/10.1097/wtf.0b013e32835f7d1a 

Perkins, R. (2006). The effectiveness of one session of therapy using a single-session therapy approach for children and adolescents with mental health problems. Psychology and Psychotherapy: Theory, Research and Practice, 79(2), 215–227. https://doi.org/10.1348/147608305×60523 

Responding to the Psychosocial and Mental Health Needs of Sexual Violence Survivors in Conflict-Affected Settings. Resource Centre. (2019, April 23). https://resourcecentre.savethechildren.net/library/responding-psychosocial-and-mental-health-needs-sexual-violence-survivors-conflict-affected. 

Seligman, M. E. (1995). The effectiveness of psychotherapy: The Consumer Reports study. American Psychologist, 50(12), 965–974. https://doi.org/10.1037/0003-066x.50.12.965 

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Slive, A., & Bobele, M. (2011). When one hour is all you have: effective therapy for walk-in clients. Zeig, Tucker and Theisen. 

Slive, A., & Bobele, M. (2012). Walk-In Counselling Services: Making the Most of One Hour. Australian and New Zealand Journal of Family Therapy, 33(01), 27–38. https://doi.org/10.1017/aft.2012.4 

Talmon, M. (1990). Single-session therapy: maximizing the effect of the first (and often only) therapeutic encounter. Jossey-Bass. 

Talmon, M., & Hoyt, M. F. (2014). Capturing the moment: single-session therapy and walk-in services. Crown House Publishing Limited. 

Todahl, J. (2012). When one hour is all you have: effective therapy for walk-in clients. Journal of Marital and Family Therapy, 38(3), 569–569. https://doi.org/10.1111/j.1752-0606.2012.00313.x 

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Health Needs of SexualViolence Survivors in Conflict-Affected Settings, Final Report. Technical meeting on Responding to the Psychosocial and Mental Health Needs of Sexual Violence Survivors in Conflict-Affected Settings, Ferney-Voltaire, November  28-30, 2011.

Young, J. (2013). Implementing Single-Session Therapy. PsycEXTRA Dataset. https://doi.org/10.1037/e605172013-001 

Solution-Focused Article List Evidence 2019 updated

2020-07-21T19:36:08+00:00February 5th, 2020|

Brockman, Mariah, et al. “Managing Child Behavior Problems in Children With Autism Spectrum Disorders: Utilizing Structural and Solution Focused Therapy With Primary Caregivers.” The American Journal of Family Therapy, vol. 44, no. 1, 2015, pp. 1–10., doi:10.1080/01926187.2015.1099414.

Carr, Alan, et al. “Parents Plus Systemic, Solution-Focused Parent Training Programs: Description, Review of the Evidence Base, and Meta-Analysis.Family Process, vol. 56, no. 3, 2016, pp. 652–668., doi:10.1111/famp.12225.

Corcoran, Jacqueline. “A Comparison Group Study of Solution-Focused Therapy versus ‘Treatment-as-Usual’ for Behavior Problems in Children.Journal of Social Service Research, vol. 33, no. 1, 2006, pp. 69–81., doi:10.1300/j079v33n01_07.

Creswell, Cathy, et al. “Clinical Outcomes and Cost-Effectiveness of Brief Guided Parent-Delivered Cognitive Behavioural Therapy and Solution-Focused Brief Therapy for Treatment of Childhood Anxiety Disorders: a Randomised Controlled Trial.The Lancet Psychiatry, vol. 4, no. 7, 2017, pp. 529–539., doi:10.1016/s2215-0366(17)30149-9.

Franklin, Cynthia, et al. “Solution Focused Brief Therapy: A Systematic Review and Meta-Summary of Process Research.Journal of Marital and Family Therapy, vol. 43, no. 1, 2016, pp. 16–30., doi:10.1111/jmft.12193.

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

Froeschle, Janet, et al. “The Efficacy of a Systematic Substance Abuse Program for Adolescent Females.Professional School Counseling, vol. 10, no. 5, 2007, pp. 498–505., doi:10.5330/prsc.10.5.a458605px1u57217.

Gassmann, Daniel, and Klaus Grawe. “General Change Mechanisms: the Relation between Problem Activation and Resource Activation in Successful and Unsuccessful Therapeutic Interactions.Clinical Psychology & Psychotherapy, vol. 13, no. 1, 2006, pp. 1–11., doi:10.1002/cpp.442.

Gingerich, W. J., and L. T. Peterson. “Effectiveness of Solution-Focused Brief Therapy: A Systematic Qualitative Review of Controlled Outcome Studies.Research on Social Work Practice, 2013, doi:10.1177/1049731512470859.

Gong, Huoliang, and Weisu Hsu. “The Effectiveness of Solution-Focused Group Therapy in Ethnic Chinese School Settings: A Meta-Analysis.International Journal of Group Psychotherapy, vol. 67, no. 3, 2016, pp. 383–409., doi:10.1080/00207284.2016.1240588.

Hosany, Z., et al. “Fostering a Culture of Engagement: a Pilot Study of the Outcomes of Training Mental Health Nurses Working in Two UK Acute Admission Units in Brief Solution-Focused Therapy Techniques.Journal of Psychiatric and Mental Health Nursing, vol. 14, no. 7, 2007, pp. 688–695., doi:10.1111/j.1365-2850.2007.01161.x.

Kim, Johnny S. “Examining the Effectiveness of Solution-Focused Brief Therapy: A Meta-Analysis.Research on Social Work Practice, vol. 18, no. 2, 2007, pp. 107–116., doi:10.1177/1049731507307807.

Kim, Johnny S., et al. “Solution-Focused Brief Therapy in China: A Meta-Analysis.Journal of Ethnic & Cultural Diversity in Social Work, vol. 24, no. 3, 2015, pp. 187–201., doi:10.1080/15313204.2014.991983.

Kim, Johnny S., et al. “Solution-Focused Brief Therapy to Improve Child Well-Being and Family Functioning Outcomes with Substance Using Parents in the Child Welfare System.Developmental Child Welfare, vol. 1, no. 2, 2019, pp. 124–142., doi:10.1177/2516103219829479.

Kim, Johnny S., et al. “Solution-Focused Brief Therapy With Substance-Using Individuals.Research on Social Work Practice, 2016, p. 104973151665051., doi:10.1177/1049731516650517.

Kim, Johnny, et al. “Is Solution-Focused Brief Therapy Evidence-Based? An Update 10 Years Later.Families in Society: The Journal of Contemporary Social Services, vol. 100, no. 2, 2019, pp. 127–138., doi:10.1177/1044389419841688.

Kramer, Jeannet, et al. “Effectiveness of a Web-Based Solution-Focused Brief Chat Treatment for Depressed Adolescents and Young Adults: Randomized Controlled Trial.Journal of Medical Internet Research, vol. 16, no. 5, 2014, doi:10.2196/jmir.3261.

Mache, Stefanie, et al. “Evaluation of Self-Care Skills Training and Solution-Focused Counselling for Health Professionals in Psychiatric Medicine: a Pilot Study.International Journal of Psychiatry in Clinical Practice, vol. 20, no. 4, 2016, pp. 239–244., doi:10.1080/13651501.2016.1207085.

Panayotov, Plamen A., et al. “Solution-Focused Brief Therapy and Medication Adherence with Schizophrenic Patients.Solution-Focused Brief Therapy, 2011, pp. 196–202., doi:10.1093/acprof:oso/9780195385724.003.0078.

Roeden, J. M., et al. “Processes and Effects of Solution-Focused Brief Therapy in People with Intellectual Disabilities: a Controlled Study.Journal of Intellectual Disability Research, vol. 58, no. 4, 2013, pp. 307–320., doi:10.1111/jir.12038.

Schmit, Erika L., et al. “Meta-Analysis of Solution-Focused Brief Therapy for Treating Symptoms of Internalizing Disorders.Counseling Outcome Research and Evaluation, vol. 7, no. 1, 2016, pp. 21–39., doi:10.1177/2150137815623836.

Smock, Sara A. “A Review of Solution-Focused, Standardized Outcome Measures and Other Strengths-Oriented Outcome Measures.Solution-Focused Brief Therapy, 2011, pp. 55–72., doi:10.1093/acprof:oso/9780195385724.003.0026.

Smock, Sara A., et al. “Solution-Focused Group Therapy for Level 1 Substance Abusers.Journal of Marital and Family Therapy, vol. 34, no. 1, 2008, pp. 107–120., doi:10.1111/j.1752-0606.2008.00056.x.

Stermensky, Gage, and Kristinas Brown. “The Perfect Marriage: Solution-Focused Therapy and Motivational Interviewing in Medical Family Therapy.” Journal of Family Medicine and Primary Care, vol. 3, no. 4, 2014, p. 384., doi:10.4103/2249-4863.148117.

Trepper, Terry S., et al. “Solution-Focused Brief Therapy Treatment Manual.Solution-Focused Brief Therapy, 2011, pp. 20–36., doi:10.1093/acprof:oso/9780195385724.003.0015.

Zhang, Anao, et al. “The Effectiveness of Strength-Based, Solution-Focused Brief Therapy in Medical Settings: a Systematic Review and Meta-Analysis of Randomized Controlled Trials.Journal of Behavioral Medicine, vol. 41, no. 2, 2017, pp. 139–151., doi:10.1007/s10865-017-9888-1.

Solution-Based Therapy Finding More Prominent Role

2020-01-31T19:42:04+00:00January 31st, 2020|

As physicians shift care from a disease-centered to a patient-centered clinical method, there is a need for a compatible counseling paradigm. Solution-focused therapy is a competency-based model that minimizes emphasis on past problems and failings and instead focuses on patient strengths and resources (Trepper et al., 2006).

Read the full article on Psychiatric New Update

How Solution-Focused-Therapy can enhance care of the medically complex patient

2021-05-11T20:54:45+00:00June 4th, 2019|

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!

A Language of Hope: Solution-Focused Translations

2021-05-11T20:55:29+00:00May 16th, 2019|

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.

Cope is one letter away from Hope: Solution-Focused Safety Assessment (SFSA)

2021-05-11T20:56:12+00:00May 3rd, 2019|

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)

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.

“Who” is the person in person-centered care? A Solution-Focused perspective.

2021-05-11T21:02:23+00:00March 25th, 2018|

 

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

A Language of Hope: The Top Ten Solution-Focused Translations

2021-05-11T21:04:44+00:00February 10th, 2018|

 

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.

Anxiety in Youth: Solution-Focused Brief Therapy Approaches that Produce Results

2022-10-07T00:21:53+00:00October 4th, 2017|

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

Anxiety is common for children and adolescents, with lifetime prevalence rates ranging from 2.6% to 20%. Children and adolescents coping with anxiety may experience lower achievement, difficulties with social and emotional functioning, depression, and substance use disorders. There are many examples of how anxiety presents with youth: school refusal, anxiety when transitioning from middle school to HS, from HS to college, and from college to becoming a working adult, fears of separation and illness of loved ones, somatic symptoms such as headaches, stomachaches, discomfort in social situations, intense fear that occurs unexpectedly panic attacks, obsessions, and compulsions.

Solution-Focused Brief Therapy is an effective treatment approach for youth managing anxiety. This article aims to demonstrate how to apply solution-focused techniques with youth coping with anxiety and how these strategies can provide an additive dimension to the problem-focused treatments typically utilized.

Traditional problem-focused Cognitive Behavioral Treatment (CBT) of anxiety addresses deficits in coping with children and parents, such as avoidance, distraction, rumination, self-blame, and catastrophizing. There is a focus on education about anxiety, threat overestimation and the use of fear hierarchies, cognitive restructuring, problem-solving, and contingency management. Parental anxiety, “over-controlling” parenting behaviors, and parental accommodation are additional focus areas. The classic CBT triangle focuses on the interaction of thoughts, feelings, and behaviors.

Some Specific Solution-Focused Approaches in the treatment of Anxious Youth

Commencing with Competencies: Commencing with strengths is especially important for youth coping with anxiety. Activating resources from the onset of the conversation by exploring what they enjoy and are good at creates a narrative in which the client views themselves as more than their presenting problem. For example, one client who presented with severe anxiety and refused to go to school talked about her love for animals and biking. She was unique in her ability to bond with her snake and in her skill of riding dirt bikes with her older brother. Taking time to explore these “problem-free” areas was essential and not a waste of time, exemplifying positive behaviors (actions) in which she was able to courageously approach situations that are typically challenging for many others.

Complimenting: Children and adolescents experiencing anxiety frequently present with significant distress. Children in distress often generate fear and concern on the part of their parents. Parents try their best to support their child, but this often presents as reassurance, accommodations, and frequent texting and phone calls. It is important to compliment parents on their efforts to remain calm, demonstrate empathy, maintain consistent limits and get their child to school despite the child’s level of discomfort. Asking about the specific details of how they managed to get their child on the bus to school and refrain from texting them while at the same time successfully managing their anxiety helps strengthen parental confidence and competence in supporting their child. These compliments can impart much-needed energy and stamina to youth and families, enabling them to persevere when they are feeling exhausted and overwhelmed.

For You Statements: Integrating the words “for you” into responses to clients is a language technique that serves to quickly and easily communicate empathy. “For you” statements can be used in several ways, helping build emotional agreement within the conversation while validating and acknowledging the client’s situation and feelings. Clients and families coping with anxiety and panic are experiencing significant distress, which is critical to acknowledge. Some examples of “For You” statements include how scary and frightening it must be “for you” to see your child struggling with anxiety. For the adolescent, this may take the form of acknowledging how difficult it must be “for you” to have these experiences, how frustrating it must be “for you” to be forced to go to school, and how uncomfortable it is to be experiencing such distress. “For you” statements can also be used to acknowledge positive client experiences, such as how exciting it must be “for them” to progress towards their goals, make it to school, and experience academic and social successes. Positive “for you” statements reinforce with clients that what they are doing is working for them.

Positive Differences/Exceptions: Listening for and discovering positive differences when youth have some measure of success is crucial. These may include times when they can approach and “do” things that are challenging. Acknowledging and appreciating how children managed to get to school even 1 out of 5 days, or even part of a day, made a decision even if seemingly small, slept in their own bed for part of the night, talked to people even if for only brief moments, tried something new, no matter how small, tolerated uncomfortable feelings even if for a short-lived amount of time. While these moments could easily go unnoticed, they are the very times that are crucial to amplify. It is important to explore whether these actions constitute differences for the parents and children. If so, how were they different? Were they helpful for them? How were they helpful? How did they do it? How else? (Notice how the use of the past tense (how “did” they do it) highlights accomplishments clients have already had success with and further builds their sense of self-efficacy.)

Best Hopes: Inviting clients to talk about their “best hopes” for treatment and asking how you can be most helpful for them so that meeting with them is worthwhile maintains the focus on the client’s wants and desired outcome. For example, “to not feel so stressed,” ” feel comfortable going to school,” ” be able to sleep in their own bed,” ” be better able to make decisions,” ” not have panic attacks,” and ” make more friends,” ” not pull at their hair.” The list is endless and unique, just as clients are each unique.

After eliciting a client’s best hopes, the question becomes how to help clients achieve their goals. What do they need to make their best hopes come to fruition? Moving from best hopes to solutions takes actions (doing). “Doing” means explicitly helping clients discover outward actions such as speaking up a few more times in class, attempting to talk to someone new, or staying in their own bed a little longer. These “outwardly doing” actions are best discovered by the client and what they have already tried and know about themselves. The word “do” can also include what clients think, what they are saying inwardly to themselves, and how they manage uncomfortable feelings. It can also include a conversation about what their VIPs have noticed they have done and what they know about them that has already helped them achieve their goal.

In solution-focused therapy, most of the “actions” come from the client and their social context, which are most important in their lives. Discovering client-based “actions” and solutions does not mean a clinician refrains from offering possible action steps that they think may be helpful for the client. Instead, these suggestions come much later in the conversation and only after detailed questions about what the client has already done and knows they need to do to meet their goals.

Ericksonian idea is epitomized by his adage, “The patient knows the solution to his problem; he only does not know that he knows.”

Solution-Focused Triangle Approach to the Treatment of Anxiety

The following explains how I have adapted a Solution-Focused Triangle approach to treat anxiety. I begin by exploring the client’s best hopes for today’s session. If clients use the word “anxious,” I make sure to explore what they mean by this word. It can mean many different things to people, and taking the time to understand what it means for them is important when building a shared dialect. Exploring what they have tried to manage their anxiety suggests they have been trying their best to deal with their difficulties.

Providing education about how anxiety is a common occurrence for all humans (and mammals) and normalizing the fight or flight response helps youth feel they are “not alone” in their distress and how anxiety “and worry” can be a protective mechanism.

Use of Small Index Cards:
I begin by drawing a triangle on one side of a small index card and a scale from 1-10 on the opposite side, where ten is they are managing their anxiety in a satisfactory “good enough” way, and 1 is the opposite. The front side of the index card addresses the three core focal points when successfully managing anxiety:

1: What they are “doing” to approach challenging situations
2. What are they doing to manage and tolerate uncomfortable feelings while still approaching challenging situations
3. What helpful self-talk and questions do they ask themselves to assist in approaching their unique, challenging situations?

The back of the card has a scale from 1-10. I also use scaling to create courage hierarchies (instead of fear hierarchies). I find that children are more inclined to be able to answer, “Are you up for the challenge of making a courage hierarchy? We then list from 1-10 courage challenges, with one being the easiest and ten the most challenging. I ask them where they are at now. If it is higher than a 1, we explore how they managed to overcome the challenge, how ready they are to try the next challenge (from 1-10) and how confident they are that they can try their best to overcome this challenge.

Following our discussion of discovered hopes and skills, I give the card to the client and make a copy for my chart. Often clients will put the card in a special place and bring it back to the next session on their initiative.

I provide clients the analogy of how airline pilots face an emergency. Pilots don’t “wing it” but instead refer to their emergency checklists. When people feel they are in danger, their amygdala gets shaken up. And when your amygdala is shaken up, it is challenging to think clearly. Having this index card available assists clients in remembering what to do and checking on when they are having “psychic emergencies.”

The importance of sleep: I also make sure to ask about sleep.

  • How satisfied are you with your sleep from 1-10, where ten is the best?
  • What is good enough?
  • When was it last good enough?
  • What have they tried to do to help them sleep?

Sometimes simple things can be very effective in helping improve sleep, such as getting on a regular sleep schedule, turning off electronics an hour before bedtime, and limiting caffeine, to name a few. The important point is to assess sleep satisfaction. It is difficult to calm the amygdala and manage anxiety without good sleep.

The Solution-Focused Triangle Approach for Treatment of Anxiety

The Solution-Focused Triangle Approach for Treatment of Anxiety

OVERALL GOAL NEGOTIATION (BEST HOPES)

  • What are your best hopes for today?
  • What are your best hopes that would tell you that you are managing your anxiety in a way that is “good enough” and “satisfactory” for you?
  • What will you be doing when you are managing “good enough”?
  • What else will you be doing?
  • What will your VIPS notice you are doing? What else will they notice you are doing?
  • What have you tried to do to manage your anxiety?
  • What has been most helpful?

DOING (APPROACHING)
Supposing we made a list of challenges to approach that would tell you that you are managing your anxiety, what would you be doing?

What else would you be doing? What else?

(i.e.) Going to school, getting my homework done, talking to teachers, staying in class, calling people on the phone, trying a new activity, studying for tests, starting on homework sooner, writing in my agenda, talking to one friend at school, managing unexpected situations.

What would others notice you are doing that tells them you are managing your anxiety?

What else? What else?

Scaling Approaching Challenging Situations:

  • Supposing ten is you are satisfied with how well you have approached situations that are challenging for you, and one is the opposite, where would you say you are now?
  • What is a good enough number?
  • What is the highest number it has been?
  • What keeps it from being lower?
  • What else?
  • What number would your VIPS give you regarding your ability to approach situations that are challenging for you?
  • What would be the next step that would tell you that number went up by one point?

HELPFUL SELF-TALK AND HELPFUL QUESTIONS THAT ASSIST IN YOU APPROACHING/”DOING” CHALLENGES

What are your best hopes that would tell you that you are managing your anxiety? What do you want?
What else?

  • (i.e.) I want to be able to graduate to the next grade
  • I want to spend time with friends
  • I want to be successful
  • I want to go to school and enjoy it
  • What questions could you ask yourself that you think would be helpful for you in approaching your challenges?
  • Is it going to help me to stay at home?
  • What have I done when I’ve made it to school before?
  • In what ways have I successfully managed my OCD symptoms?
  • What has helped me calm down?
  • What would I say to my friends in this situation?

MANAGING/TOLERATING UNCOMFORTABLE FEELINGS

What have I done to manage uncomfortable feelings?
What else? What else?

(i.e.) Take a walk, acknowledge feelings are uncomfortable but not dangerous, practice deep breathing and smiling, practice breathing and counting, remind myself that uncomfortable feelings usually last 10 minutes and then pass and what have I done to tolerate them before?

SCALING THE TRIANGLE

For each of the points on the triangle I scale where they are:

DOING/APPROACHING:

  • How satisfied are you with your ability to approach challenging situations where ten is the best, and one is the opposite?
  • What is a good enough number?
  • What keeps it from being lower? What else?
  • What number would your VIPS say you are at? What number would they say would be “good enough”?
  • What would you be doing when it goes up by one point? What else?
  • How confident are you that you can try your best to raise it by one point?

HELPFUL SELF-TALK AND QUESTION:

  • How satisfied are you with your ability to ask yourself helpful questions and tell yourself helpful statements that will encourage you to approach the challenging situations we discussed?
  • What is a good enough number?
  • What’s the highest it has been?
  • What number would your VIPS give you?
  • What would you be doing when that number goes up by one point?
  • How confident are you that you can try to raise that number by one point from 1-10?

MANAGING UNCOMFORTABLE FEELINGS:

  • How satisfied are you with your ability to manage your uncomfortable feelings so that you can approach the challenges you hope to achieve?
  • What is a good enough number?
  • What is the highest it has been?
  • What keeps it from being lower? What else?
  • How well would your VIPS say you are managing your uncomfortable feelings so that you can approach the challenges you hope to achieve from 1-10?
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