Historical perspective of solution focused brief therapy

This essay will critically review the evolution of Brief Therapy paying particular attention to the influences that brought about the formation of Solution Focused Brief Therapy (SFBT) Therefore attention will be given to the practice of Milton Erickson and the work of the Mental Research Institute. Extensive reading indicates that attention needs to be given to defining the concept of brief therapy as a common understanding of the term remains elusive. A historical overview of developments will be provided but it must be noted that SFBT evolved in America and therefore political and economic influences need to be considered within a geographical framework. The essay will also consider the role of SFBT within the context of the move towards postmodernism and social constructionist theory as opposed to the structural stance of scientific truth. Finally thought will be given to current developments within brief therapy and its relevance to the British climate.

The growing acceptance of the importance of therapeutic interventions for mainstream society brings with it a common but vague understanding of the terms psychotherapy and counselling, closer evaluation, however, showing a clear and explicit definition remains elusive. While some practitioners claim differences between the forms of practice, others see common links between the two. Furthermore, when exploring the concept of brief therapy it is clear that this can incorporate ideas of time, Feltham 1997, and complexity of intervention, Cade/O’Hanlon 1993 and Kreider in Hoyt 1998. Palmer 2004 notes that the term brief therapy can also refer explicitly to SFBT rather than a broader model of therapy. The concept of psychological support is not newly being associated with religious and educational mentoring throughout history but modern psychotherapy is often seen as emerging from the work of Sigmund Freud. In the early days of the psychoanalytic movement the psychotherapeutic process was often brief, many of Freud’s treatments being completed in weeks or months as opposed to years, Budman/Gurman 1988. The move towards long term analysis can be seen as a combination of the growing complexity of analytic practice and theory and more ambitious goals of therapy. Linked to this are the pragmatic influences on Freud in later life, of ill health, disappointment in the outcome of earlier cases and a wish to participate in the advancement of science. The concept of brief therapy is neither new nor limited to specific models of practice. This essay, however, will focus on the development of strategic brief therapy and the emergence of social constructionism in the field of therapeutic intervention and their relationship to SFBT.

The first references to strategic therapy were made by Jay Haley in 1973 when writing of the influence of Milton Erickson on the development of his work Cade/O’Hanlon 1993. Although originally part of the Mental Research Institute (MRI) team Haley became increasingly concerned with structure and hierarchy in the process of therapy when working with Salvador Minuchin during the late 60’s / early 70’s. This led him away from the work of the MRI with its emphasis on process rather than form in therapy and two distinct models of strategic brief therapy emerged. As SFBT evolved from the work of the MRI it is this model that this essay will focus upon.

Founder members of the MRI, a multidisciplinary organisation based in Pala Alto California as well as having a background in psychoanalytic theory, family therapy and systems theory also had connections with Erickson, a psychiatrist and hypnotist, very influential in the development of strategic therapy. Milton was interested in the “utilization” of problem behaviours, thoughts and feelings as part of the solution to problems, Quick 1996. Before the formation of the MRI, founder members under the direction Bateson and then Jackson had been involved in research on human communication and its effects within the family. This linked well with Erickson’s interests and he was consulted regularly by the team. The values and beliefs of Erickson can be seen as the foundations on which later MRI work evolved. Erickson approached each case from the stance that individuals were unique requiring an individual response as opposed to “fitting” into existing theory. Erickson avoided the use of diagnosis, aiming to communicate a sense that change would occur as part of the development process. Furthermore, clients already had the resources for change; the role of the therapist being to help with the identification and utilization of these resources. Central to Erickson’s approach was the use of language familiar to, and produced by the client along with close observation before making personal judgements on what to believe and do. This often led to a rejection of both commonsense and theoretical assumptions on solutions and the use of innovative intervention Hoyt 2001

In 1965 a group of MRI therapists started the Brief Therapy Project (BTP) the emphasis here is to offer intervention limited to 10 sessions. Central to the approach was the belief that individuals create understanding from social interaction and that multiple views of reality co-exist rather than a definitive truth being out there to be found. The approach focused upon the main complaint, using a variety of techniques to work on the surface problem as opposed to exploring underlying pathology. In adopting such an approach, the problem focus was shifted from individual psychology to a social interaction model. Watzlavick in Hoyt 2001 clearly shows the limitations of adopting a specific theoretical stance. In drawing attention to the often contradictory explanations offered by psychological theoretical models he questions the value of the assumption of needing to uncover the cause of a problem to develop an effective solution. Watzlavick argues social interaction presents individuals with situations that can come to be defined as problematic. In attempting to find solutions to these difficulties individuals do whatever makes sense to them. This can lead to a positive feedback loop, Weakland 1974, as more of the same solution strategy leads to more of the same problem. The term strategic therapy was adopted as the Brief Therapy Centre (BTC) therapists worked to interrupt the problem maintaining behaviour by developing a form of therapy that looked explicitly at the process, the aim being to utilise strategies that would interrupt the problem maintaining cycle. As well as building on the existing work of the MRI, its interest in family therapy and Ericksonian principles, the influence of systemic theory is also evident in the BTC approach. This form of therapy acknowledges that change adopted by one individual can lead to change within their extended network. Identifying the individual most ready to change or with most influence makes this an important approach for family and couples therapy. It is from the strategic therapy of the BTC that SFBT can be seen to emerge.

SFBT was developed as a variant of the BTC approach by de Shazer and his colleagues at the Brief Family Therapy Centre in Milwaukee in 1978. Initially, the approach mirrored that of the original centre but gradually the problem exploration stage became briefer, the emphasis shifting to a discussion of the times when the problem did not occur. Rather than a change in philosophy or theoretical shift SFBT placed the emphasis on developing discussion on hopes for the future as opposed to evaluation of problem behaviour. In doing this it became clear that difficulties were not consistent. Even entrenched and chronic problems had times when they were less pronounced. de Shazer 1988 provides a graphic description of the early evolution of SFBT using the concept of “skeleton keys” to describe the development of techniques that could be used across problem behaviours and with different clients. Consideration was first given to shifting the emphasis of homework tasks towards solutions as opposed to problem interventions, “do something different / notice what works”, followed by the exploration of exceptions. A further skeleton key was the development of the miracle question, originally used in nearly every first session to help client and therapist develop a vision of the future based upon concrete and specific goals.
“Suppose that one night while you were asleep there was a miracle and this problem was solved. How would you know? What would be different? How would your husband know without you saying a word to him about it?” De shazer 1988 p5

Further techniques of solution-focused therapy involve identifying pre-session change, scaling and positive feedback. Fundamental to the approach is the concept of the consultation break when the therapist consults with the team behind the mirror or if working alone reflects on the process before giving feedback. The influence of Erickson is visible in this process, offering compliments, derived from his concept of a “yes set” whereby the therapist shows an agreement with and understanding of the client’s perspective to facilitate change. The essence of SFBT is to work with the person rather than the problem, looking for resources rather than deficits. In exploring preferred futures it is possible to identify what is already contributing towards making this a reality and in so doing treat clients as “the experts in all aspects of their lives.” George et al 2003. SFBT is a pragmatic approach that has evolved from reflection on technique and evaluation of what works. ”Noticing the difference that makes a difference”, de Shazer 1988.
While the influence of individuals such as Erickson and the therapists of the MRI and the BFTC in Milwaukee have been central to the development of SFBT these practitioners did not work in a vacuum. A broad range of experience has already been noted, as has a commitment to research. The breadth of this experience would have ensured an understanding of both previous and current thinking in the social sciences. The development of strategic brief therapy and SFBT can be seen as evolving within a wider context of psychological investigation than the work of these North American practitioners. O’Connell/Palmer 2003 note the difficulty and undesirability of looking to discover the origins of SFBT while drawing attention to the influence of the psychoanalyst Alfred Adler. Adler took an optimistic view of individuals in that people have created their personalities and therefore can choose to change, Emphasis on valuing clients strengths, equity and an understanding of the importance of social interaction are concepts that predate the work of Erickson, the MRI and the BFTC. In line with this view Watzlawick in Hoyt 2001 sites Dr Thomas Szasz and his views on the myth of mental illness as the most influential individual in his career development in brief therapy. Szasz (1974) condemned the use of public mental hospitals as unauthorized prisons, while a group of like-minded psychiatrists inspired by R D Laing questioned the validity of biological based theories and diagnosis of mental illnesses and insisted on a broader ecological analysis of how these problems might arise", Dallos & McLauglin 1997. In challenging the status quo these individuals encouraged a climate where the ideals of SFBT could flourish.
Since the period of Enlightenment, the solving of problems has been understood to require an understanding of underlying causes before strategies can be developed to solve and control them. The medical model stemming from this modernist approach, therefore, gives legitimate power to the professional to dictate appropriate problem-solving interventions. SFBT when promoting the client as the expert on their own lives counteracts the medical model/discourse and its emphasis on diagnosis and treatment, introducing a collaborative and equitable approach to therapy. In looking to remove the role of an expert practitioner seeking to utilise their knowledge of scientific theory to solve clients’ difficulties, the role of theory and models in SFBT has however been downplayed While a rejection of the paradigm of the helping professions (De Jong/Berg 2001) is appropriate and necessary to SFBT, minimising the role of theory risks undermining the complexity of the philosophy behind the development of SFBT and its links to the broader context of postmodernism and social constructionist theory. It has been noted that critics are sceptical and argue the techniques of SFBT are simplistic and easy to learn, Sharry et al 2001. Cade/O’Hanlon 1993. Lipchik 2002 argues for leaving out the term brief from solution-focused therapy claiming that it is much more than the “trademark techniques” it is known for. Promotion as a pragmatic and minimalist approach has led to misunderstanding. SFBT is a sophisticated model that can be applied across a diversity of situations. The influence of postmodernism has led to the rejection of a theory base reducing SFBT to “nothing but language” The concept of language in postmodernist terms, however, is not restricted to the words people speak. But in a broader sense;
“as located in the consensual behavioural interactions between persons not inside “the mind” of either. Rather than a vehicle that carries abstract communications back and forth between individual minds, it is a coordination of bodily states within members of a social group that preserves the structural integrity of both the social group and that of each group member. Griffith/Griffith in Lipchik 1994 p7

As. Pugh 1996 argues language is rarely neutral; it conveys particular ideas about the world. Its expression reveals power and potentially creates and sustains it. Again we can see that referring to SFBT as simplistic undervalues its contribution in the development of collaborative therapy. Attention is explicitly given to the role of language within the therapeutic relationship the therapist aiming to empower the individual by valuing and acknowledging their perspective and joining with them in familiar dialogue.

Fundamental to any exploration of the role of postmodernism and social constructionist influences on the development of brief therapy is the work of French philosopher Michel Foucault and his ideas on discourse.
“Foucault uses the term discourse to refer to the way to which language and other forms of communication act as the vehicle of social processes …. For example, medical discourse not only reflects the power of the medical profession but actively contributes to constructing, re-enacting and thus perpetuating such power Thompson 2001 p 32

Rather than power lying with the individual power relations are embedded within social interaction, Foucault in challenging scientific truth and the notion that the professional knows best gives an authority and underpinning philosophy to the values and process of SFBT.
Postmodernism and social constructionism challenge the traditional approach to psychotherapy and McNamee/Gergen 1994 to indicate the geographical breadth of contributors to social constructionist therapy of which SFBT is one model. Social constructionism provides the opportunity for reflection that opens up an understanding of multiple realities. Significant to the development of constructionist therapy is the fact that many postmodernist thinkers have been influential in the development of communication and language and its relationship to identity.
“In the postmodernist conception identity is largely shaped by the social context in which we operate. However this is not a narrowly defined or fixed social context, but rather a fluid and developing social context------For postmodernists there is no core self, no essential “I” at the centre of our being. Instead what we have is a flow of activity interactions and communications.” Thompson 2003p27

SFBT with its emphasis on solutions as opposed to problems and seeing “the problem as the problem and the individual as the individual” is instrumental in developing a positive framework within which the identity can form.

In looking to the development of brief therapy it must be noted that along with the influence of social constructionism and key individuals, other powerful structures within society have influenced the development of brief (in the context of time-limited) therapy. Lipchik 2002 notes the influence of managed care companies on briefer therapy in America. Insurance companies reacting to research evidence also drove the brief therapy movement forward. Milner/Palmer 2001 comment on the move towards brief therapy in the UK and the influence of financial restraints on the National Health Service (NHS). This is a theme explored by Thorne 1999. When describing the move towards briefer therapy he acknowledges the role of NHS waiting lists and an expanding clientele. Reviewing the appropriateness of brief therapy for all individuals and all problems Thorne challenges the advocates of brief therapy to consider its limitations along with its strengths. Supporters may look to the evidence base, and pragmatic influences on practice that opens therapy up to a diverse population but Thorne argues that brief therapy may also be “the inevitable dysfunctional response to a sick society”, a society that ever increasingly looks for a quick fix to problems rather than exploring the essence of being. Feltham 1997 also explores the appropriateness of brief therapy, distinguishing between problem symptoms and personality characteristics of the individual. Individuals who are severely damaged or unsupported, along with those with an extensive personal growth agenda are among the people considered inappropriate for brief therapy. However, should such individuals be deprived the collaborative approach of SFBT? SFT opens intervention up to multicultural understandings of mental well being while at the same time avoiding restricting intervention to the constraints of either the medical model or western ideas of psychology. Pathologosing individuals and/or their behaviour is avoided. Adopting a constructivist approach ensures that reality is not defined within one set of cultural assumptions and stereotypes.

While research indicates SFBT is as effective as other brief therapies, de Shazer et al 1986 De Jong/Hopwood 1996 in Barker 1999, Lethem 2002, Darmody/Adams 2003, its roots in social constructionism ensures it is not limited by a specific paradigm and is, therefore, open to adaptation. The danger lies in a brief therapy approach being adopted primarily for economic and efficiency reasons. The collaborative approach of SFBT emphasising the client as an expert opens up the opportunity for therapy to be tailored to individual need across a diversity of settings. Feltham 1997 notes that therapy is often brief by default, individuals attending only a percentage of available sessions. By following Lipchik 2002 example and leaving the word brief out of SFT its potential to meet the requirements of all individuals is expanded. I would argue if therapy is to be truly collaborative it is for the individual to decide the length and depth of the intervention they are seeking and SFBT offers the scope for this. While Iveson 2004 adheres to the minimalist roots of SFBT following de Shazer’s lead in looking for little evidence of the therapist’s presence within the interaction, Lipchik highlights the importance of the therapeutic relationship. As constructionist therapies and more specifically SFBT evolve, the scope for modification and growth increases. O’Hanlon/Beadle 2000 describing Possibility Therapy as Carl Rogers with a twist move away from the techniques of de Shazer while Milner/O’Byrne utilise SFBT and narrative therapy in their Solution Talk therapy. Such deviation can only enhance the potential for SFT to meet the needs of a diverse clientele. In agreement with O’Conner/Palmer 2003, I would argue that the future for SFBT is optimistic. Its strength lying not only in its anti-oppressive stance in helping individuals find solutions and optimism for the future but also in its ability to continually evaluate its development and technique. In moving beyond the constraints of therapeutic intervention into other fields such as education SFBT is showing itself to be flexible and responsive to the demands of a modern stakeholder society.

In this essay, I have considered the development of brief therapy and more specifically the strategic brief therapy of the MRI and its influence on the development of SFBT. It has been argued that brief therapy did not evolve in isolation but can be traced back to Freud and Adler. More recently the influences of Erickson and Foucault are evident as is the influence of postmodernism and social constructionism. The importance of language in the development of the approach has been emphasised and the collaborative nature of the therapeutic relationship. The essay has shown that SFBT offers an optimistic and flexible approach for exploring solutions in multiple settings and with a diversity of individuals.

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