Solution-Focused Brief Therapy Addresses Mental Health Workforce Shortages

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

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

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

Doctor Vivek Murphy further writes:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

What is a good enough number?

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

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

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

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

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

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