Solution-Focused Therapy Is Trauma-Informed Care

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Solution-Focused Brief Therapy is intended to be pragmatic and based on the clients’ presenting concerns focusing on what the client has already done to cope and what the client wants, rather than exploring history or theories about root causes. In an ideal session, the client leaves with a plan and knows they have the skills and resources available to move forward in a good enough or tolerable way.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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