A Clinical Case Study of Solution-Focused Brief Therapy for Young Adult Cancer Patients’ Psychological Distress: Focusing on Positive Emotions

Abstract

Psychological distress is highly prevalent among adolescent and young adult (AYA) cancer patients, an age-defined population (15–39) disproportionately impacted by their cancer diagnosis. Solution-focused brief therapy (SFBT) is a strength-based and evidence-supported approach for youth with medical conditions. The use of SFBT in young cancer patients, however, has been rarely described. Building on the broaden-and-build theory of positive emotions, this study describes how SFBT clinicians intentionally foster positive emotions, especially hope, in an AYA cancer patient to foster therapeutic change. We found improvements in the patient’s psychological distress as well as growth in levels of hope both in the immediate post-intervention assessment and in the 2-week follow-up. The findings of the study suggested that SFBT is a promising approach to the unique challenges confronting AYAs with cancer. It was not feasible for this case study to match the sex and racial identities for a therapist with the client’s preference, which is considered a main limitation of this study.

Keywords

solution-focused brief therapy adolescent and young adult cancer positive emotion psychotherapy

1. Theoretical and Research Basics for Treatment

Adolescent and young adult (AYA) cancer patients, an age-defined population (15–39 years old), are disproportionately impacted by their cancer diagnoses (Zebrack et al., 2014). Studies report a two times greater prevalence rate of psychological distress, that is, depression and anxiety, among AYAs in comparison to their pediatric or adult counterparts (Zebrack et al., 2014). Psychological distress among AYA cancer patients is associated with treatment disengagement, poor quality of life, and suicidality (Kaul et al., 2017; Zhang et al., 2020), which highlights the significance of addressing such challenges among AYAs with cancer. While evidence-supported treatments for psychological distress are available for young adults without cancer (Weersing et al., 2017), these interventions become less or minimally effective when delivered to AYA cancer patients (Zhang, Wang, et al., 2021). Scholars have argued that the diminished treatment effects were due to the unique etiology and clinical manifestation of psychological distress among cancer patients (Greer et al., 2010).

First, distress among AYA cancer patients is caused by a complex interaction between medical and psychosocial risk factors that may develop before a cancer diagnosis and often persist during and after AYAs’ cancer treatment (Pulewka et al., 2017). Problem-focused psychotherapies that target these risk factors may not work effectively because many AYAs have to live with these distressful, often unexpected, triggers for the rest of their lives. Additional challenges may develop throughout the course of their medical treatment, compounding the medical and psychological impacts for AYAs. Therefore, postmodernist approaches focusing on accepting the “new” reality may be more effective than those diagnostic/deficit-based approaches, that is, identifying the cause(s) of the issue and addressing the causes accordingly. Second, many cognitive patterns considered irrational or problematic (i.e., “People around me don’t understand what life is like for me,” or “What if I don’t make it out of this alive?”) among individuals without cancer become normal and rational among cancer patients (Greer et al., 2010). Consequently, some validated psychotherapeutic techniques to modify or change these thinking patterns may work less effectively than those focusing on meaning-making and reality construction (Neilson-Clayton & Brownlee, 2002). Finally, many existing therapies do not effectively incorporate the idiosyncratic role of positive emotions, such as hope and resilience, among cancer patients (Martins et al., 2018). While therapists do not want AYA cancer patients to be unrealistically too hopeful about their cancer trajectory, it is important that cancer patients remain hopeful and use their positive emotions to counteract psychological distress (Larsen et al., 2007). Taken together, many existing evidence-supported treatments that are diagnostically /deficit-oriented have certain limits when delivered to AYA cancer patients, and a postmodernist approach focusing on meaning-making and positive emotions is likely to improve psychological distress among AYA cancer patients. One promising approach is solution-focused brief therapy.

Solution-focused brief therapy (SFBT) is a strength-based, postmodernist approach with a substantial body of literature supporting its effectiveness for psychological distress (Franklin, 2015; Kim et al., 2018; Schmit et al., 2016). Notably, a published meta-analysis supported SFBT’s effectiveness for medically ill patients (Zhang, Franklin, et al., 2018), endorsing its potential effectiveness for AYA cancer patients’ psychological distress. Grounded in social constructivism, SFBT uses specific language techniques (e.g., miracle question, exception question) to co-construct conversations between the therapist and patient to achieve therapeutic growth (Franklin et al., 2017). Solution-focused brief therapy therapists intentionally use the co-construction of meaning and closely follow the patient’s frame of reference (i.e., the client’s own (exact) words) throughout the intervention—a principle ensures an individualized treatment formulation so that treatment goals and change strategies come directly from the patients (Korman et al., 2013).

Notably, rather than focusing on patients’ problems in the past (a diagnostic/deficit-based model), SFBT explicitly focuses on patients’ inner strengths and resilience in forming solutions to achieve their goals and their preferred future. Instead of asking what may have caused psychological distress (e.g., what makes you feel down all the time?), SFBT therapists would ask if there was an exception when the patient was supposed to encounter a problem but did not (e.g., was there a time when the incident happened, but you did not feel extremely sad). The therapist then focuses on that exception to guide the patient to identify successful behavioral or cognitive strategies (clients’ inner strengths), and ways to replicate what the client has already successfully achieved (i.e., solutions) for future success.

Solution-focused brief therapy can also help clients to articulate what hopes they have, despite the current challenges and difficulties (i.e., cancer). It is important, from an SFBT perspective, to not believe that clients have no hope simply because of a cancer diagnosis. Therapists might spend time asking the client to describe the details that would let them know they were coping with the illness and the compounding challenges in just the right way. Therapists would also access resources, like family members and support systems, within the descriptions of strength. AYA’s could be asked to articulate how doctors, nurses, or family members might notice that would let them know that the AYA was doing their very best in the midst of the challenges associated with cancer.

Most importantly, SFBT is among the selective therapies that explicitly use positive emotions (e.g., hope and resilience) as core ingredients in its change theory/mechanism (Kim & Franklin, 2015). Consistent with the broaden-and-build theory (Fredrickson, 2004), SFBT therapists guide the patient to envision a preferred future and how they are already successful in achieving it. In doing so, SFBT techniques generate positive emotions and further elicit thought-action repertoires that are broad, flexible, and receptive to new thoughts and actions (Fredrickson, 2004; Kim & Franklin, 2015). Simultaneously, the generated positive emotions help clients build durable and sustainable resources for future use. These generated resources further enhance clients’ positive emotions and cognitive capacity in creating behavioral change, resulting in an upward spiral process that sets in motion a series of positive therapeutic changes (Fredrickson, 2004). This emotion-focused change mechanism (illustrated in Figure 1) distinguishes SFBT from many other cognitive- or behavioral-based approaches that center the psychotherapeutic treatment based on cancer patients’ thinking and behaviors. A language-based psychotherapy approach that also uses positive emotion, like SFBT, therefore is more fitting for cancer populations, especially among adolescents and young adults, due to their future-oriented developmental trajectory and the significance of “feelings” to this population (Zhang et al., 2020).

Figure 1.

Emotion change theory/mechanism of SFBT*.

Modifying SFBT for AYA Cancer Patients

While SFBT has significant potential to effectively address AYA cancer patients’ psychological distress, traditional SFBT and its techniques should be tailored for AYAs diagnosed with cancer. Traditional SFBT invites the client to envision a preferred future and then guides the client to identify possible solutions to achieve that future. Generally, a client’s vision of the future needs to be realistic and achievable. When a client’s vision starts with something that is not realistic, a therapist can use other techniques to guide clients to think more realistically but, in the meantime, allow them to keep hopeful about their long-term goals that may not be realistic at the moment. However, when working with AYA cancer patients, the SFBT therapist needs to be especially careful in setting these goals because many clients, when given a chance, will hope their cancer is cured or they are cancer-free for the rest of their lives, both of which cannot be guaranteed. In doing so, the therapists expose their clients to false hope and further exacerbate the negative psychological consequences when a condition relapses or becomes no longer curable.

In addition, SFBT therapists need to be cognizant that many AYAs do not have previous experience living with a cancer diagnosis. Traditional SFBT often solicits clients’ previous success or exceptions in similar situations so that a client can incorporate them into solution building. For an AYA who undergoes treatment for the first time, SFBT therapists need to be careful when using various techniques to identify clients’ strengths and/or previous successes like the coping questions (“Was there a time this incident happened but you were able to manage it?”) and the exception question (“Was there ever an exception when this stressor was present but you did not respond to it, what happened that was helpful?”). While these techniques still have significant therapeutic value, a therapist needs to be mindful that these questions need to be relevant to AYA cancer patients.

For example, “What is the hardest thing you have ever had to do, that you were successful at?” If the client responds that they had to move from one state to a different state within the United States. We could ask follow-up questions like, “What trait do you have that you had to draw on during the move that helped you?” If the client responds with, “I guess, I had to be courageous,” we can use the language of courage to ask further resource questions that could be used to manage during the battle with cancer. We might ask something like, “And if you saw that same kind of courage coming back during your battle with cancer, even if it was really scary or tough, what would be some of the signs that would let you know this courage was back?” The adaption, therefore, isn’t to change the SFBT approach but rather to change the language we use to help the client co-construct a reality in which they are capable of coping, even though it might be difficult. It is imperative that we acknowledge the hardships AYA’s will face, but at the same time, we help them build a reality, through language, that helps them manage the difficulty.

Finally, there exists a strong relationship between psychological distress and cancer-related symptoms. Escalation of psychological distress is often associated with somatic symptoms like nausea, vomiting, chronic pain, and deterioration in functional ability (Greer et al., 2010). Through a neuroendocrine pathway, worsened psychological distress, in turn, exacerbates clients’ cancer-related symptoms, which creates a vicious circle (Yan, 2016). Therefore, SFBT therapists should address salient medical-related concerns while alleviating AYA cancer patients’ psychological distress. To bridge this gap in the treatment literature, previous studies (Kok & Leskela, 1996; Zhang, Ji, et al., 2018) have tested modified manuals of SFBT in hospitals, including in oncology settings. However, a detailed description of modifications and specific case presentations were lacking to guide clinical psychotherapists who are interested in delivering SFBT to cancer patients.

2. Case Introduction

Bonnie (name changed to protect anonymity) is a 19-year-old African American female who was recently (6 months ago) diagnosed with Stage II localized Ewing sarcoma close to her chest area—an early stage of sarcoma with an overall promising prognosis but often requires surgery to remove cancer cells. This can sometimes result in removing a small portion of the bone or the breast. After completing multiple rounds of chemotherapy and just finishing surgery 6 weeks ago, Bonnie was referred to the clinician (first author) as a study participant for her depression by her treating oncologist. The study was part of a larger study evaluating the effectiveness of a sarcoma clinic. The specific purpose of the study component I oversaw was to evaluate the use of SFBT for psychological distress among AYA cancer patients. Bonnie uses she/her pronouns.

3. Presenting Problem

The stated reason for her referral was due to “concerning psychological distress caused by chemotherapy side effects as well as visible changes in her chest area due to salvage surgery.” During a brief phone conversation with her parents, they expressed concerns about Bonnie “shutting down” and not sharing a lot of what she is thinking with her family. Both Bonnie’s oncologist and parents reported Bonnie feeling sad “all the time” and that she often seemed worried or nervous. During the initial referral process, Bonnie was unwilling to see me as she preferred working with a black female therapist with experience with young adult cancer patients. With her parents’ insistence, Bonnie agreed to “give it a try” and made it clear that she would “end it” at any time when the therapy made her uncomfortable.

4. History

Bonnie grew up happily in a middle-upper class family and had a close extended family system. Both of her parents are college-educated and shared no concerning history with Bonnie growing up. Bonnie is in a stable relationship with Matt (again, the name changed), her high school sweetheart since she was 16-years old. However, things have been “really tough” since Bonnie was diagnosed with cancer over 6 months ago. According to Bonnie’s mother, Jennifer, “Bonnie has changed so much emotionally, and I just want to know how she is doing and how we can be there and support her. It felt helpless to us to watch her going through everything and just take things on her own.” Both Bonnie’s oncologist and her parents reported her psychological health has been “in a really bad place” throughout her cancer journey. Bonnie shut herself down when she first learned about her cancer diagnosis and was at the time reluctant to talk about her feelings to date. Since her cancer diagnosis, Jennifer (her mother) has found Bonnie weeping in her room from time to time, and had occasional nervous breakdowns (“cannot catch her breath or had a really fast heartbeat for no reason”). Bonnie is currently on medical leave from college and discloses that she misses her friends.

5. Assessment

Brief assessment measures using the Patient Health Questionnaire, 9-item (PHQ-9) and the Generalized Anxiety Disorder, 7-item (GAD-7) revealed high levels of depression and anxiety at baseline, that is, 21 out of 27 for PHQ-9 and 14 out of 21 for GAD-7. The Structured Clinical Interview for DSM-5, The Clinician Version (SCID-5-CV) (First et al., 2014) confirmed that Bonnie meets the DSM-5 diagnostic criteria for major depressive disorder, moderate (core symptoms of depressed mood; anhedonia; insomnia; feelings of worthlessness; fatigue; and poor concentration), and generalized anxiety disorder (core symptoms of feeling keyed up or on edge; easily fatigued; irritability; and sleep disturbance). The SCID interview also ruled out Bonnie having active psychosis, active suicidal ideation, or bipolar disorder.

Bonnie’s Brief Symptom Inventory, 18-item score (BSI-18, based on oncology norm) also indicated a marked elevation in psychological distress, with a total t-score of 69 (≥63 considered high). Notably, Bonnie reported high levels of distress on all BSI-18 subscales, that is, depression, anxiety, and somatic symptoms. Bonnie also reported low levels of hope at baseline with a 19 out of 48 Herth Hope Index (HHI) score.

6. Case Conceptualization

The Primary Contributor(s) to Bonnie’s Manifesting Psychological Distress

As one of the leading causes of death and a potentially terminal condition, a cancer diagnosis can trigger a complex set of psychosocial disruptions to a patient’s life, which would set in motion various psychological and behavioral challenges, including elevated psychological distress. Even among patients without cancer, causes/contributors to their manifesting symptoms are often not singular, but it is especially the case for those living with a cancer diagnosis. The co/multimorbidity of cancer and psychological disorders is multi-faceted, and there can be many life stressors and risk factors that trigger/contribute to Bonnie’s psychological distress simultaneously. It is also important to be mindful of salient psychosocial stressors impacted by cancer that are common among the AYA population, for example, disruptions in peer or intimate relationships, or issues related to self-image and identity forming. These stressors, regardless of their direct impact to Bonnie’s distress, should be integrated into the case conceptualization, that is, recognizing and evaluating the impact of disruptions in typical developmental milestones.

I was cognizant of the fact that Bonnie had not shared a lot of what was going on with her oncologist or her family, so the “true cause(s)” of her distress, that is, high levels of depression and anxiety, were most likely to be something beyond what has been indicated by her referring oncologist (i.e., chemotherapy side effects and change in appearance). Therefore, when conceptualizing Bonnie’s case, it is important to move away from a diagnostic approach, that is, identifying the primary cause(s) of Bonnie’s distress, and be flexible and collaborative in understanding Bonnie’s manifesting distress. SFBT’s treatment philosophy fits well for this requirement. Given that SFBT intentionally moves away from the diagnostic model, I was careful so that I did not “cancer-victimize” Bonnie, meaning attributing her psychological distress to her cancer diagnosis, treatment, and side or late effects presumptively. I did thoroughly study Bonnie’s medical chart focusing on those major physical and functional side effects of her cancer treatment because they often play an important role in the manifestation of cancer patients’ psychological distress.

Key Benchmarks to Facilitate Therapeutic Change in Bonnie

First, we worked to identify one or two goals that Bonnie wanted to work on the most by the end of session one. This may seem straightforward but is often difficult to achieve when supporting individuals with comorbid cancer and mental health conditions. Patients are often overwhelmed with a myriad of biopsychosocial, emotional, and spiritual challenges related to cancer. As a result, many find it difficult to identify just one or two things to work on that will be most helpful to them. SFBT has several unique questioning techniques, such as the pre-session change question, the “best-hopes” or desired outcome question, the miracle question, and the solution-talk technique, to effectively achieve this without rushing them to come up with treatment goals that are of lower priority.

Second, fostering Bonnie’s positive emotions to promote change. A key change mechanism underlying SFBT is the explicit fostering of the patient’s positive emotions, and this is especially important for those diagnosed with cancer. The pain brought by cancer manifests physically (e.g., nausea, vomiting, fatigue), psychologically (e.g., distress, fear, depression), and spiritually (e.g., confronting death, cancer recurrence, meaning/purpose of life). Many cancer patients’ life view is full of negativities, and they are often too stressed out to pay attention to their inner strengths, the positive aspects of their lives, and being hopeful. Consistent with the core principles of SFBT, clinicians intentionally engage in therapeutic conversations with the client to invoke their positive emotions. Specific SFBT techniques, such as the exception question (e.g., “Was there a time the problem was no longer a problem or less severe?”) or the coping question (e.g., “Was there a time that you were able to somehow cope with or overcome the issue successfully?”), have been found effective in achieving this benchmark. These exceptions or times of coping could be directly related to Bonnie’s battle with cancer, or they could be related to other times in her life when she was coping with something else that was challenging. It might be difficult for individuals dealing with cancer to think about exceptions because since finding out about cancer, there has never been a time that they did not have it. Therefore, it is important for the therapist to be flexible in their phrasing of these questions to expand possible responses. With this in mind, during my session with Bonnie, I used extensive validation and praise on her strengths and resilience throughout her cancer journey to promote positive emotions.

Third, facilitating cognitive and behavioral progress via strength-based solution talk. Based on the broaden-and-build theory, enhanced positive emotions will broaden a client’s thought-action repertoire, meaning that the clients are cognitively more receptive to new suggestions and more likely to try out new behaviors. SFBT clinicians intentionally use a set of techniques to co-construct (different/new) behaviors and (alternative) ways of thinking proposed by the client to form solutions that address issues confronting them. With extensive validation and praise on the client’s resilience and strengths, I carefully listened to Bonnie’s narrative and strategically selected language components from her that could be used for solution building (i.e., solution-talk). For example, when Bonnie said, “well, most of the time, it is very difficult for me to cope,” and I followed up with, “OK, you said most of the time, and were there a couple of times that you were able to deal with it?” to explore components of solutions. Techniques like this have resulted in Bonnie sharing her coping behaviors, such as thinking positively and seeking help from her support systems, among others.

7. Course of Treatment and Assessment of Progress

Treatment Overview and Individual Session Outline

The treatment started with a 4-session SFBT intervention protocol that has been evaluated and validated in previously published clinical trials (Zhang, Ji, et al., 2021; Zhang, 2022). SFBT is one of the briefest psychotherapies, with studies showing an average of 3–4 sessions to create positive change (Franklin et al., 2012). It was essential to adopt a brief protocol when working with AYAs diagnosed with cancer because many of them have hectic schedules to receive cancer care and are more likely to refuse or drop out of psychotherapies if the sessions are too long (Gardner et al., 2014; Zhang et al., 2022). The overall structure of the four sessions included Session 1: Building rapport and establishing client-preferred goals through clinician-client co-construction; Sessions 2 and 3: Co-constructing solutions using the client’s inner strengths and resources; and Session 4: consolidating solutions build (progress) and working on potential setbacks. See the session structure outlined in Table 1.

Table 1.

SFBT with AYA Cancer Survivor Session by Session Outline.

Session One: establishing a relationship, setting goals, and exploring solutions
Goals and aims	The overarching goal of session one is to establish an effective and collegial therapeutic relationship between the SFBT therapist and the client. Simultaneously, having a mutually agreed upon goal by both the clinician and the patient is another important objective of this session
Session structure	‐ [Check In] A therapist may begin with a brief check-in with the client and start the session with the pre-session change question. Tell the client that it is typically 4 sessions/times of meeting. By the end of the 4^th meeting, if the client feels strongly about continuing services, the therapist will have a conversation with the client about other available resources
	‐ [Solution Building] Based on the client’s response to the pre-session change question, the therapist then establishes solution- focused goals, using the future-oriented question, scaling question, or miracle question
	‐ [Solution Building] In developing goals with the client, the therapist needs to assure the goals are solution-oriented, feasible, and come directly from the client
	‐ [Discussion] Towards the end of the session, the therapist may use exception questions, scaling questions, coping questions, and other techniques to explore components to develop a solution
	‐ [Summary] The clinician ends the session by complimenting strengths and resources, and past success or exception if any, from the client during the session
	‐ [Assignment] if appropriate, while complimenting the client for his/her past exceptions or successes, feasible assignments related to behavioral changes or creating solutions may be suggested to the client based on the client’s past successes or future behaviors they desire
Session two: Reaffirming goals and co-constructing solutions
Goals & aims	The overarching goal of session two is to build on goals from session one and to co-construct solutions with the client. A key focus is given to identifying and solidifying components of the solution(s)
Session structure	‐ [Check in] a therapist may begin with a brief check-in with the client and start the session with the pre-session change question
	‐ [Solution Building] based on the client’s response to the pre-session change question, the therapist then focuses on identifying components of a solution using scaling question, exception question, coping question, and with client’s own frame of reference
	‐ [Solution Building] The therapist pays close attention to details and components that can help the client in further developing solutions to his/her challenges and to achieve a preferred future
	‐ [Discussion] Under the client’s own frame of reference and using the details regarding past exceptions, solutions, and successes, the therapist then guides the client (lead from one step behind) to develop specific behavior and/or lifestyle change plans to engage positive changes
	‐ [Summary] Therapists conclude the session by complimenting the client on progress made during the session as well as on specific details in building solutions identified by the client him/herself
	‐ [Assignment] if appropriate, while complimenting the client for his/her past exceptions or successes, feasible assignments related to behavioral changes or creating solutions may be suggested to the client based on the client’s past successes or future behaviors they desire
Session three: Further building and establishing effective solutions
Goals and Aims		The overarching goal of session three is continuing solution building with more details to further solidify positive changes
Session structure		‐ [Check In] The therapist begins the session with a brief check-in and starts the session with the pre-session change question
		‐ [Solution Building] Building on the client’s response to the pre-session change question, the therapist then explores details, using the coping question, scaling question among other techniques, to further co-construct and establish solution(s) to the client’s situation
		‐ [Solution Building] In further co-constructing the solution(s), the therapist complements the client to guide the client to use his/her own frame of reference to engage behavior and/or lifestyle changes
		‐ [Discussion] If some of the client’s efforts have been working, reinforcing these efforts using SFBT techniques and responses are strongly recommended
		‐ [Summary] In ending the third session, the therapist will notify the client that session four will be the final session and briefly share with the client what’s going to happen in session four
		‐ [Assignment] if appropriate, while complimenting the client for his/her past exceptions or successes, feasible assignments related to behavioral changes or creating solutions may be suggested to the client based on the client’s past successes or future behaviors they desire
Session four: Reinforcing effective solutions and wrapping up
Goals and aims	The overarching goal of session four is to summarize signs of progress made so far and offer necessary resources for the client after the intervention ends
Session structure	‐ [Check In] The therapist starts the session by complimenting the progress he/she made so far. The complements need to be specific
	‐ [Solution Building] The therapist then invites the client to share his/her experiences focusing on the positive changes he/she has noticed throughout the intervention period
	‐ [Solution Building] Using the scaling question, the therapist evaluates the client’s current status and, ideally, invites the client to identify specific reasons he/she gives a higher score now than before
	‐ [Termination] Using the future-oriented question, the therapist invites the client to think about needed resources and methods he/she need to keep building or maintaining solutions. “What do you think we can talk about for the rest of the session so that you walk out of the room and feel more confident that you can now manage the situations on your own?”
	‐ [Termination] The therapist may provide psychoeducation to the client on resources available if the client needs further support
	‐ [Termination] The therapist uses the relational question to further motivate the client to think about strategies in managing his/her own situations, maybe with support from his/her social relationships
	‐ [Termination] The therapist concludes the sessions

Session by Session Outline/Description

I started session 1 with SFBT’s pre-session change question and asked Bonnie, “What’s better since the last time I met with her (initial study enrollment)”? Then, I used a set of SFBT techniques, especially the future-oriented question, the miracle question, and the coping question, to facilitate my conversation with Bonnie to co-construct goals she wanted to work on. I focused on listening to Bonnie’s narrative and carefully followed/selected Bonnie’s frame of reference (i.e., her own exact words) to work with her on goal setting. By the end of session 1, I learned that even though Bonnie found her cancer diagnosis and treatment-related side effects highly distressing, she had accepted her cancer diagnosis and was “managing her symptoms with good and bad days.” Bonnie shared that, at the moment, she was most worried about her relationship with her boyfriend, Matt. Cancer-related changes in fertility and her physical appearance made her “constantly doubt her future with Matt.” Bonnie shared her feelings of guilt (“I don’t deserve Matt”), worry (“I keep worrying about Matt breaking up with me, and it’s getting worse”), and sad (“It’s just depressing to think about it (i.e., relationship with Matt)”). Throughout session 1, I avoided digging deeper into Bonnie’s negative feelings and her thinking behind these feelings (which would have been consistent with a diagnostic model) but focused instead on co-constructing a positive and strength-based narrative with Bonnie to highlight the strengths of her relationship with Matt both before and after her cancer diagnosis.

In sessions 2 and 3, I primarily focused on solution building with Bonnie to “improve” her relationship with Matt and reduce her anxiety about the relationship. I engaged in extensive solution talk with Bonnie and encouraged her to elaborate on the positive aspects of her life and relationship with Matt. SFBT techniques, for example, the exception question, coping question, and relational question, were used to guide Bonnie’s sharing of previous successes (so that they can be replicated), positive interaction patterns (so that these can be reinforced), and the various ways she remembered overcoming perceived relationship challenges with Matt (to highlight previous successes and increase the possibility of repeating these behaviors). We had a breakthrough moment during the early part of session 3 in which Bonnie shared, “… If you look at it that way, I can see myself making things up about how bad it is between Matt and I. I know it is not true, he has been nothing but more caring to me after my diagnosis, and I need to be better so that it does not get into my head.” Following that, I explored what Bonnie meant by “getting into her head” and her previous exceptions or successes in coping with “it getting into her head.”

A key challenge I worked on supporting Bonnie during sessions 2 and 3 is her thinking pattern of “I understand it is not that bad, but …” a mentality that Bonnie often catastrophizes an experience or jumps to an (irrational) conclusion. Although this is typical among many clients with psychological distress, it was especially evident in Bonnie’s case. There were numerous significant cancer-related stressors confronting Bonnie, for example, oncofertility, sexuality, functional impairment (e.g., nausea, fatigue, insomnia), and, understandably, she often felt bad or thought negatively about her experiences, including her relationship with Matt. Given the philosophy and change theory of SFBT, I refrained from further exploring (and correcting) these negative feelings or negative thoughts (again, a diagnostic model) but used various strategies to redirect our clinical conversations to focus on her strengths, hope, and resilience to co-construct solutions to the concerns she had.

In session 4, I focused on reinforcing the progress made so far in the intervention and worked with Bonnie on relapse prevention, including a discussion on how Bonnie can use her inner strengths and resilience for solution building when her cancer experience brings additional challenges, for example, reactions to a new treatment regimen, potential additional surgeries in her chest area, and other potential setbacks. Bonnie shared that she understood there could be many challenges ahead, especially considering the uncertainty of her cancer trajectory, but reported that she felt better because “I have a new set of tools to work on my relationship with Matt, and they have worked well.” Bonnie also used some behavioral experiments discussed during the session with her parents, which resulted in improved communication patterns. I ended the session by providing additional resources available locally and in the healthcare system to Bonnie in case she needed further support in the future.

Assessment and progress evaluation

Progress evaluation occurred quantitatively using clinical measures and qualitatively using SFBT and other interview questions. Key clinical measures evaluating Bonnie’s progress included: PHQ-9 for depressive symptoms, GAD-7 for anxiety symptoms, BSI-18 for psychological distress, and HHI for Hope. In addition to baseline assessment, PHQ-9, GAD-7, BSI-18, and HHI were administered weekly at the beginning of each session and 2 weeks post-intervention. Figure 2 provides a visual illustration of Bonnie’s clinical progress over time.

Figure 2.

Clinical progress over.

Quantitatively speaking, in addition to evaluating Bonnie’s clinical progress descriptively, I also calculated the reliable change index (RCI), a psychometric criterion used to evaluate the statistical significance of an individual score change over time (Guhn et al., 2014). RCI can be calculated by dividing the score difference (between two times) by a standard error of measurement of the difference (SEM), and an RCI ≥1.96 is considered statistically significant, that is, significant improvement. Specifically, Bonnie’s depression (PHQ-9 score) reduced from 21 (severe depression) at baseline to 12 (moderate depression) 2 weeks post-intervention. This baseline to 2-week post-intervention change reflected a reliable change index (RCI) of 4.5, suggesting significant improvement.

Similarly, Bonnie’s anxiety (GAD-7 score) reduced from 14 (moderate anxiety) at baseline to 9 (mild anxiety) 2 weeks post-intervention, and her psychological distress (BSI-18) reduced from 68 at baseline (severe distress) to 52 2 weeks post-intervention (moderate distress). Changes in Bonnie’s GAD-7 and BSI-18 represented significant improvements evidenced by RCIs of 2.64 and 3.2, respectively. Finally, Bonnie’s level of hope increased from 18 (low) at baseline to 32 (moderately high) 2 weeks post-intervention, reflecting an RCI of 3.5. Detailed descriptive statistics and RCIs are presented in Table 2.

Table 2.

Descriptive Statistics and Reliable Change Indices across Outcomes^a.

Measure	Baseline	Session 4	2-Week Post	SEM	RCI 1	RCI 2
PHQ-9	21	15	12	2.00 (Lowe et al., 2004)	3.0	4.5
GAD-7	14	12	9	1.89 (Bischoff et al., 2020)	1.06	2.64
BSI-18	68	55	52	5.0 (Calderon et al., 2020)	2.6	3.2
HHI	18	25	32	4.0 (Rustøen et al., 2018)	1.75	3.5

Note: An RCI value of 1.96 or greater is considered significant improvement.

^aPHQ-9 = Patient Health Questionnaire—9 items; GAD-7 = Generalized Anxiety Disorder—7 items; BSI-18 = Brief Symptom Inventory—18 items; HHI = Herth Hope Index; Baseline = Bonnie’s Baseline Score; Session 4 = Bonnie’s Session 4 Score; 2-Week Post = Bonnie’s score 2 weeks post-intervention; SEM = standard error of measurement, which is used to calculate the reliability change index; RCI 1 = Reliable Change Index 1, which reflects the change between baseline and session 4 scores; RCI 2 = Reliable Change Index 2, which reflects the change between baseline and 2-week post.

Qualitative evaluation occurred primarily via the SFBT pre-session change question, that is, “Is there anything different in a good way since the last time we talked?” At the beginning of session 2, Bonnie shared, “Nothing too much, but I told Matt that I am seeing you, and he was very supportive.” At the beginning of session 4, Bonnie shared that some of the behavioral experiments discussed during the session were helpful for positive interactions between her and Matt. Significant progress was observed, evidenced by both quantitative and qualitative measures. Additional qualitative feedback from Bonnie’s parents and oncologist also suggested that Bonnie made meaningful progress.

8. Complicating Factors

Bonnie’s cancer diagnosis and its related biopsychosocial challenges are salient complicating factors in this case. As Bonnie shared during the session, “It (cancer) changed everything, I don’t know if I can be who I was again. And just thinking about living with cancer probably for the rest of my life, you know, it’s depressing and that can’t be good for Matt either.” Her recent experience with cancer and many ongoing treatment-related side effects (e.g., vomiting, nausea, fatigue, and appearance change) significantly impacted Bonnie’s feelings and ways of thinking throughout the sessions. Understandably, in a forward-looking phase of Bonnie’s life (late adolescence and emerging adulthood), it can be stressful to think about her future, including a romantic relationship (the primary goal of the intervention).

In addition to Bonnie’s underlying worry associated with cancer-related uncertainties, she was constantly confronted with the stresses of managing her physical symptoms caused by her cancer treatment. Throughout the sessions, Bonnie often disclosed that she had setbacks during the behavioral experiments (i.e., homework) because she was too tired to do them, had a terrible day (in terms of reacting to cancer treatment), or had things come up for her cancer care. These challenges have created additional difficulties for the clinician to maintain a strength-based conversation with Bonnie because the symptoms and her busy cancer care schedule are a part of Bonnie’s daily life, and many can lead to physical and psychological distress.

Closely adhering to SFBT’s core treatment principle, the clinician viewed Bonnie as a survivor of cancer with 6 months of experience. The clinician firmly believed that Bonnie had the necessary experiences and skills to manage her cancer. Even when facing new challenges, Bonnie would have the inner resources and resilience to cope with these challenges. For example, Bonnie shared during session 3 that she was upset when she planned to make a snack for Matt but failed to do so because she was feeling sick and nauseous. The clinician strategically “ignored Bonnie’s failure” and focused on how well Bonnie managed her physical symptoms, which, upon further disclosure by Bonnie, allowed her to have a great movie night out with Matt the next day.

Notably, it is essential to contextualize the psychotherapeutic conversations with Bonnie in her cancer diagnosis, that is, to provide necessary qualifiers when delivering certain SFBT techniques. For example, when using the miracle question with Bonnie, I made sure that I qualified this question with the statement “… if your cancer trajectory remains the same …’. This was important because I did not want to infuse “false hope” to Bonnie so that she would envision a preferred future of being cancer-free. Although most SFBT techniques transfer well to individuals diagnosed with cancer, it is important to adopt this type of changes for cancer patients and survivors.

Finally, it was salient for me to remain mindful of Bonnie’s initial preference to speak to a Black female therapist and, due to study feasibility, ended up with a male therapist of Asian descent. Understandably, the therapist’s gender identity and cultural upbringing can make critical differences, and this is especially true in Bonnie’s case, given her primary goal was to focus on her intimate/romantic relationship. I was very upfront about the “mismatch” in the therapeutic relationship with Bonnie, and highlighted what I could bring to the therapeutic conversation, for example, a male perspective and my experience working with many Black female AYAs who have relationship concerns. I was also realistic about potentially important conversations that Bonnie may not feel comfortable disclosing, and I understand that this may impact the efficacy of treatment. To gently raise some of these topics, I used examples from other clients, for example, sexual drive, to normalize sensitive topics while not forcing Bonnie to discuss these topics. As expected, Bonnie did not spend too much time on these topics within the therapy setting.

9. Access and Barriers to Care

No salient barriers to care were identified during the course of assessment or treatment, but several important factors should be noted. First, Bonnie comes from a middle-upper class family, which enables her to reside in close proximity to the cancer center and contributes to an easy commute. Second, a brief (4-session) treatment regimen made it easier for Bonnie to complete the entire course of treatment without committing too much on top of her already busy cancer care. This is considered a strength of delivering SFBT to cancer patients to reduce health disparity. Finally, when appropriate, the clinician scheduled the sessions with Bonnie on the same day of her clinic visit so that she could complete multiple appointments in 1 day. This arrangement may not have been possible for other individuals who did not have the flexibility that Bonnie had.

10. Follow-Up

As indicated earlier, standard study assessment time points included baseline, at the beginning of each session, and 2 weeks post-intervention. Upon study completion, Bonnie’s psychologist conducted two more assessments, that is, 4-week and 8-week post-intervention, and, with Bonnie’s permission, shared results/feedback with this clinician. Findings indicated that Bonnie’s distress remained stable (low) when compared to her baseline scores but did not further decline over time. Given the nature of the clinical contact, which is primarily within a research study, the clinician was unable to engage in additional follow-up assessments.

11. Treatment Implications of the Case

This case study intends to demonstrate the potential of SFBT, as a brief and strength-based approach, for patient outcomes among young adults living with a cancer diagnosis. In this case study, SFBT is conceptualized as an alternative to many validated psychological interventions that are based on a diagnostic/deficit model, that is, identifying cognitive and/or behavioral errors of the client and changing these errors (Friedberg & McClure, 2015). This is an important adjustment to consider when working with AYAs diagnosed with cancer, especially considering that many of their cognitive patterns and coping behaviors considered “irrational” or “maladaptive” are often realistic yet still distressing (Zhang, Ji, et al., 2021). SFBT’s explicit focus on the solution (versus the problem) likely motivated Bonnie to disclose her relationship concerns with Matt as the primary concern over commonly identified ones, for example, depression or anxiety, or other directly cancer-related concerns. As indicated throughout the study, challenges confronting AYA cancer patients are dynamic and complex, and the unique co-constructive language styles of SFBT (and future-oriented questions or miracle questions) enable the SFBT clinician to effectively identify client’s top goals to work on within a limited time frame.

Another important treatment implication of this case is the brevity of the SFBT. Delivered in a 4-session format, this study suggested promising, though preliminary, results of SFBT in improving Bonnie’s clinical distress. As one of the briefest psychotherapeutic approaches, SFBT fits well with cancer patients’ hectic care schedules and enables them to receive needed psychotherapy without an excessive time commitment. In addition, this brief treatment, with constructive results, may also positively influence ongoing medical care and compliance post-therapeutically. This is also an important factor, especially for AYA cancer patients, as they consider the possibility of receiving psychotherapy. For example, Selekman (2015) revealed that adolescent clients are more open and receptive to counseling approaches when they are brief. One of the reasons that Bonnie’s oncologist referred her to this study was because she expressed unwillingness to receive long-term counseling during her cancer treatment.

Finally, the findings of this study suggested the important therapeutic value of positive emotions, for example, hope and resilience, among AYAs diagnosed with cancer. Although SFBT was originally developed as an atheoretical approach (Franklin et al., 2012), theoretical and conceptual studies have consistently underlined the important role of positive emotions in facilitating clinical progress in SFBT (Franklin et al., 2017; Kim & Franklin, 2015). For individuals diagnosed with cancer, they often are overwhelmed with negative emotions and experiences related to cancer; and many individuals rarely have the time or energy to reflect on feeling of hope, strengths, and inner resilience. Therefore, it is essential for psychosocial clinicians supporting AYAs with cancer to maximize the therapeutic value of positive emotions, and SFBT offers an effective structure to do so. Findings revealed that Bonnie’s increased levels of hope paralleled the improvement in her clinical distress and provide empirical support for the role of positive emotions in overcoming her psychological distress.

12. Recommendations to Clinicians and Students

This case study highlights several points of guidance for the implementation of SFBT for AYAs diagnosed with cancer. First, SFBT, as a psychotherapeutic approach focusing on positive emotions, is promising in alleviating psychological distress among AYA cancer patients. When utilizing this approach, it is essential for clinicians to co-construct solutions to what brings the patients to the session by highlighting and soliciting their positive emotions, inner resources, and strengths. Second, a brief delivery format is critical. Given many psychosocial challenges confronting AYA cancer patients are complicated, many providers find it difficult to address all their client’s issues in a brief format. However, researchers (Zhang, Wang, et al., 2021) have found that brief psychosocial treatments are associated with greater treatment effects, especially for AYAs diagnosed with cancer, which underscores the importance of keeping therapies brief for the AYA cancer population. It is important to note that SFBT may also be employed in long-term treatment if desired. This flexibility makes SFBT an ideal treatment option for AYA cancer patients. Finally, this case demonstrates the significance of tailoring SFBT and its techniques for individuals with cancer. As highlighted throughout the study, specific techniques of SFBT, such as the miracle question or the exception question, need to be intentionally tailored to the unique context of cancer. While the change theory associated with most, if not all, SFBT techniques remains the same when being delivered to individuals with cancer, specific changes to some techniques are necessary for effective delivery. This change is predominantly done by altering the language of the technique rather than changing the delivery format.

In conclusion, our results suggest that a 4-session SFBT treatment regimen may be feasible and efficacious for improving psychological distress among AYAs diagnosed with cancer. SFBT could be a strong alternative to many diagnostic/deficit-based psychotherapeutic approach when supporting individuals with cancer.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Anao Zhang

Author Biographies

Anao Zhang, PhD, LCSW, ACSW, ACBT, is an assistant professor at the University of Michigan School of Social Work and the clinical research director at the University of Michigan Health Adolescent and Young Adult Oncology Program. A clinical social worker by training, Dr. Zhang's research focuses on innovative assessment and intervention methods to support the psychosocial wellness of adolescents and young adults living with a cancer diagnosis. Dr. Zhang has clinical expertise in solution-focused brief therapy and cognitive behavioral therapy, and is a diplomate and certified therapist by the Academy of Cognitive and Behavioral Therapies.

Adam S. Froerer, PhD., LMFT is the Director of Research and Training for the The Solution Focused Universe and one of the leading SFBT researchers and trainers. He worked as a university professor for 11 years, training marriage and family therapists and clinical psychologists. Adam has had the privilege of working with amazing clinicians, trainers, and researchers from around the globe.

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