Solution-Focused Brief Therapy (SFBT) with individuals with brain injury and their families

Abstract

BACKGROUND:

Brain injury is considered a chronic condition and the medical model has long been the traditional paradigm underlying rehabilitation programs for people after acquired brain injury (ABI). In recent years, strengths-based approaches have been increasingly proposed, but little has been written about specific psychotherapeutic application in ABI rehabilitation.

OBJECTIVE:

To describe a strengths-based model, Solution-Focused Brief Therapy (SFBT) and its clinical application to individuals with ABI and their families.

METHODS:

The author describes the assumptions, tenets, and principles of SFBT, a competency-based and resource-based model that orients to the future and focuses on strengths and successes. A direct comparison is made between the traditional medical paradigm and the solution-focused paradigm.

RESULTS:

Key ingredients of SFBT are described, including specific strategies, techniques, and its clinical application with individuals with ABI and their families. Limitations around using SFBT and the need for further research with ABI populations are reported.

CONCLUSIONS:

SFBT is a welcome shift away from the problem-saturated stories that underlie traditional rehabilitation approaches. The strengths-based underpinning of SFBT is a promising psychotherapeutic intervention that merits further investigation with ABI populations.

Keywords

Solution-Focused Therapy brain injury psychotherapy

1 Introduction

Brain injury is a significant public health problem and is the leading cause of disability and death worldwide 1 The consequences of brain injury are wide-ranging and can include physical, cognitive, and behavioral/emotional changes that may be temporary or permanent. Brain injury is considered a chronic condition and the medical model has long been the traditional paradigm underlying rehabilitation programs for people after acquired brain injury (ABI). In this model, disability is seen as a medical problem that resides within the individual. In order to manage the disability, an in-depth clinical assessment is undertaken by a trained healthcare provider, who then develops a treatment plan. The goals of intervention are cure, amelioration of the condition to the greatest extent possible, education around managing the condition, and rehabilitation (i.e. the adjustment of the person with the disability to the condition and to the environment). Persons with disabilities assume the role of patient or learner being helped by trained professionals (Olkin 1999).

In keeping with the medical model, the ABI literature is replete with papers focusing on neurocognitive deficits, emotional and behavioral dysregulation, mood and anxiety disorders, sleep disturbance, family dysfunction, etc. This author considers these the ‘D’ words that underlie traditional rehabilitation paradigms –dysfunction, disorder, deficit, disability, and disturbance. Although this literature has made a significant contribution to our understanding of the challenges after ABI and possible ways of intervening, there is increased interest in focusing on strengths and resources of clients and ways of enhancing resilience.

In recent years, there has been a shift towards fostering resilience and adopting more strengths-based approaches in ABI rehabilitation with adults (Andrewes, Walker & Oneill, 2014; Kreutzer et al., 2018; Simpson & Jones, 2012; Stesjkal 2012) as well as children and families (Gan & Ballantyne, 2016; Gan, De Pompei, & Lash, 2013; Gauvin-LePage, Lefebvre, & Malo, 2015). As highlighted in an earlier paper by this writer (Gan & Ballantyne, 2016), research has found that strengths-based approaches contribute to a sense of personal empowerment and greater life satisfaction (Hanks, Rapport, Waldron-Perrine, & Millis, 2014), are protective of physical and mental health (Taylor, Kemeny, Reed, Bower, & Gruenewald, 2000), and create a climate of optimism, hope, and possibility (Hopps, Pinderhughes & Shankar, 1995). Strength-based approaches can also contribute to satisfying relationships with family members and peers (Gingerich, Kim, & MacDonald 2012), and enhance one’s ability to deal with adversity and stress (Gingerich et al., 2012; Taylor et al., 2000).

The strengths-based orientation fundamentally alters the traditional medical model of viewing people as damaged and in need of fixing, to seeing them as challenged with potential for healing and growth. Those who embrace a strengths-based perspective hold the belief that individuals have strengths, resources and the ability to move forward from adversity. A strengths-based paradigm allows one to move away from trying to reclaim one’s former life, and instead to see opportunities, possibilities, and hope for building a new future worth living.

This paper adds to the emerging body of literature on strengths-based approaches in brain injury populations by describing the strengths-based model, Solution-Focused Brief Therapy (SFBT), and its psychotherapeutic application to individuals with ABI. Apart from a few papers that support the use of a SFBT framework in ABI (Gan et al., 2010; Gan, Gargaro, Kreutzer, Boschen & Wright, 2012; Stesjkal, 2012) including stroke (Wichowicz, Puchalska, Rybak-Komeluk, Gasecki, & Wisniewska, 2017), practical guidelines around its use in ABI have only been reported by Gan and Ballantyne (2016). That paper describes the key elements of SFBT and its application to an empirically-based protocol - Brain Injury Family Intervention with adolescents (BIFI-A). This writer builds on that work by describing the use of SFBT in psychotherapeutic intervention with children and adults with ABI and their families. Expanded examples of interventive questions and scripts are provided including the use of the miracle question. The purpose of this paper is to: (1) introduce the model of SFBT and related outcomes research, (2) outline the assumptions and tenets of SFBT, and (3) illustrate how key ingredients of SFBT can be applied in psychotherapeutic intervention with adults, children, and families. Limitations of using SFBT in ABI rehabilitation and implications for practice and future research will conclude the paper.

2 What is Solution-Focused Brief Therapy?

Solution-Focused Brief Therapy (SFBT) is an evidence-based psychotherapeutic and family therapy approach (de Shazer et al., 1986). It is a competency-based and resource-based model, which de-emphasizes past failings and problems. Instead SFBT is future oriented and focuses on clients’ strengths, and previous and future successes. Differing from skill building and behavior therapy interventions, the model assumes that solution behaviors already exist for clients (Bavelas et al., 2013). SFBT also applies the purposeful use of the client’s language to co-construct meaning in a way that is different from some other therapies (e.g. Cognitive Behavioral Therapy).

SFBT has been applied in many different clinical settings including mental health (Macdonald, 2007; Pichot, 2007), domestic violence (Lee, Sebold, & Uken, 2007), addictions (Berg & Miller, 1992), and the field of sexual abuse (Dolan, 1991). Some reported outcomes include cost efficiency in mental health settings (MacDonald, 2007) and lower recidivism and better program completion rate with domestic violence offenders (Lee et al, 2007). Dolan (1991) described the use of SFBT assessments that are oriented towards solutions (versus problems), using language of the client. SFBT has been used extensively with children and adolescents (Franklin & Gerlach, 2007; Hackett & Shennan, 2007; Selekman, 1997) with applications in child protection services (Berg & Kelly, 2000; Turnell, 2007), adolescent chronic illness (Viner, Christie, Taylor, & Hey, 2003), and in pediatric rehabilitation coaching (Baldwin, et al., 2013). The value of SFBT has been described in these settings, including its future focus, the collaborative stance, and focus on strengths. Selekman (1997) offers creative ways in which SFBT can be expanded to make it more flexible with different therapeutic options (i.e. family and play art therapy, narrative therapy). In families of children with chronic physical disorders (Pless et al., 1994) and intellectual disabilities (Dallos, 2006), SFBT was used to promote parent-professional partnerships. SFBT has also been used in group treatment with mothers of children with autism (Zhang, Yan & Liu, 2014). Those who attended the SFBT group reported higher post-traumatic growth scores at post-treatment and 6- month follow-up compared to those in the no treatment control group. Its use in assessing persons who present to an ER with suicidal ideation has also been described, but not yet subject to empirical research (Kondrat & Teater, 2010).

3 SFBT outcomes

The results of two meta-analyses (Kim, 2008; Stams, Dekovic, Buist, & de Vries, 2006) and systematic reviews (Gingerich, Kim, & MacDonald, 2012) indicated that SFBT is an effective approach with children, adolescents and adults, with effect sizes similar to other evidence-based approaches, such as cognitive behavioral therapy. In a qualitative review of 43 controlled outcome studies, SFBT was found to be an effective approach with many psychosocial conditions with children, adolescents, and adults (e.g. adult mental health, child academic and behavior problems, marriage and family). Thirty-two (74%) of the studies reported significant positive benefit from SFBT; 10 (23%) reported positive trends (Gingerich & Peterson, 2013). Evidence further indicated that SFBT is especially efficacious for adults with depression (Gingerich & Peterson, 2013).

One study also found that SFBT required fewer sessions (average of 10) than alternative therapies, lending support to the assertion that SFBT is briefer and less costly (Knekt et al., 2008). Other studies found that positive change occurs sooner and that treatment is also more likely to be continued and completed when solution talk is employed as early as possible (Gingerich, deShazer, & Weiner-Davis, 1988; Shields, Sprenkle & Constantine 1991). Solution-focused questions have been found to produce a significantly greater increase in self-efficacy, goal approach, and action steps than problem-focused questions, and a significantly greater decrease in negative affect (Franklin, Zhang, Froerer, & Johnson, 2017; Neipp, Beyebach, Nuriez, & Martinez-Gonzalez, 2016).

The evidence for strengths-based SFBT is growing and some tentative themes are emerging in SFBT research. Studies have shown that SFBT performs as well as other psychotherapies (i.e. cognitive behavioral therapy) in research studies for adult depression (Franklin, 2015). Research from various countries suggests that internalizing disorders (e.g. depression, anxiety, and stress) are areas in which SFBT may work well with youths and adults (Franklin, 2015). In addition, SFBT has been successfully used in training interprofessional teams to be more effective in interviewing and communicating with clients in health care and school settings (Franklin, 2015).

Although SFBT has been applied with pediatric ABI (Gan & Ballantyne, 2016) and in group interventions with caregivers of stroke survivors (Plosker & Chang, 2014), its outcomes have only been studied with an adult stroke population (Wichowicz, Puchalska, Rybak-Komeluk, Gasecki, & Wisniewska, 2017). Stroke patients were randomly assigned to one of two groups: 10 sessions of SFBT versus control (not participating in any psychotherapy). Although the intensity of depression and anxiety decreased in the SFBT intervention group compared to the control group, it is not clear if the change was attributable specifically to SFBT, especially as psychotherapies in general have positive effects when compared to no treatment. Moreover, it was not clear around the ingredients used in the 10 session SFBT intervention as there are typically no expectations around the number of sessions needed in SFBT.

4 Assumptions of Solution-Focused Brief Therapy

The following assumptions guide the solution-focused approach (Thomas & Nelson, 2007).

Focusing on resources, competence, and strengths is more helpful than focusing on impairment, disability, and what is wrong or not changeable.

The client’s experience is privileged above that of the therapist –the client is the expert on his or her experience and the changes that are desired in their lives. This is contrary to the traditional medical model where it is the expert-healthcare provider’s job to tell clients not only what is wrong, but also what they need to do to correct the problem.

Finding the cause of the problem is not necessary to construct solutions. The therapist’s role is not to take a medical history, diagnose and repair, but to identify and amplify potential solutions. Instead of orienting to the past and the cause of the problem, SFBT orients towards exceptions to the problem, resources for resolving the difficulties, and the strengths that clients bring to solve their situations.

Focusing on possibilities and what is changeable is more helpful than focusing on what is permanent and cannot be changed. Conversations that orient towards an individual’s ABI and all their deficits can be demoralizing, not just for the individual, but also the family. Strengths-based discussions are oriented towards helping clients understand that while the ABI may not be cured, they can discover different ways to cope and to live a meaningful life in spite of the ABI.

No problem happens all the time. There are exceptions, times when the problem could have happened but did not. These exceptions can be used by the client, family and clinician to co-construct new solutions and to find very creative ways to accommodate the changes arising from their ABI. Focusing on exceptions to the problem can help the client and therapist co-construct solutions that may not have been considered.

A small change can lead to bigger change. In addition to the ‘ripple effect’ of beginning change, one assumes that people can create additional changes once the initial change occurs. For example, when the mother makes a small change in how she interacts with her son, the assumption is that the son will also change, prompting others in the family system to change.

A favorite syllogism of SFBT – ‘If it ain’t broke, don’t fix it! Once you know what works, do more of it! If it doesn’t work, then don’t do it again – do something different!’ – (Berg & Miller 1992). Focus on what is working. If it does not work, do something different. People tend to apply old ways of interacting and problem-solving based on their pre-injury experiences. After an ABI, people necessarily have to do something different to accommodate for the challenges resulting from the ABI.

5 Tenets of Solution-Focused Therapy

The tenets of the solution-focused paradigm compared to the traditional medical paradigm are compared in Table 1. As illustrated, the solution-focused paradigm orients towards what the client wants to happen in the future versus fixing or getting rid of their ABI.

Table 1
Comparison of traditional medical paradigm with solution-focused paradigm

Traditional medical paradigm Solution-focused paradigm

Expert approach – professional defines goals Client driven – client/family defines goals

Hierarchical approach Partnership and collaborative approach

Focuses on ‘doing for’ the client Focuses on ‘doing with’ the client

Focuses on deficits and what is wrong Focuses on strengths and resources

Pathology orientation Non-pathologizing stance

Problem dominated and complaint focused Solution oriented and resource focused

Orients to the past and details of the problem Orients to the future and client goals

Focuses on failures and what doesn’t work Focuses on successes and what works

Focuses on fixing the problem Focuses on possibilities for the future

Fosters dependence, helplessness, and despair Promotes competence, optimism and hope

Traditional medical paradigm	Solution-focused paradigm
Expert approach – professional defines goals	Client driven – client/family defines goals
Hierarchical approach	Partnership and collaborative approach
Focuses on ‘doing for’ the client	Focuses on ‘doing with’ the client
Focuses on deficits and what is wrong	Focuses on strengths and resources
Pathology orientation	Non-pathologizing stance
Problem dominated and complaint focused	Solution oriented and resource focused
Orients to the past and details of the problem	Orients to the future and client goals
Focuses on failures and what doesn’t work	Focuses on successes and what works
Focuses on fixing the problem	Focuses on possibilities for the future
Fosters dependence, helplessness, and despair	Promotes competence, optimism and hope

Adapted from Gan, C., Ballantyne, M.: Brain injury family intervention for adolescents: a solution-focused approach. NeuroRehabilitation 38(3):p. 234, 2016, with permission from IOS Press. The publication is available at IOS Press through https://dx-doi-org-s.web.bisu.edu.cn/10.3233/NRE-1601315.

6 Key ingredients in SFBT

In SFBT, the client is the expert, and the clinician assumes a stance of ‘not knowing’ and of ‘leading from one step behind’ through solution-focused questioning and responding by using the client’s language as much as possible. SFBT conversations focus on client concerns and what they want to be different in their lives. Instead of making interpretations, offering advice, or giving directives, SFBT therapists use “questions” as their primary intervention tool. Through these interventive questions, clients are invited to co-construct a vision of a preferred future, ways of drawing upon past successes, strengths, and resources to make that vision a reality (Bavelas et al., 2013).

6.1 Therapeutic alliance and relationships in SFBT

The therapeutic alliance is essential for effective therapy and the most robust predictor of positive outcomes in the psychotherapy, family therapy, and brain injury psychotherapy literature (Block & West, 2013; Judd & Wilson, 2005, Klonoff, 2010; Klonoff, Lamb, & Henderson, 2001; Sprenkle, Davis, & Lebow, 2009). Research indicates that stronger provider-client alliances are associated with better client outcomes and higher client satisfaction (Baldwin, Wampold & Imel, 2006; Horvath & Symonds, 1991). Failure to develop an alliance is often attributed to an incorrect approach when engaging clients. Berg and Miller (1992) suggest there are three types of client-therapist relationships to consider in SFBT: visitor, complainant, and customer. The type of relationship will influence the engagement strategy.

The visitor often comes to therapy at another’s request. Some examples of a visitor include an individual who is referred by a rehabilitation provider, an adolescent who is brought to therapy by parents, or a spouse who attends therapy at the partner’s insistence. In each of these situations, the individual is not invested in the therapy. He/she is willing to attend, but often it is to appease another. These scenarios are common after ABI as there may be issues involving organically-based insight where clients may not fully appreciate the challenges related to the ABI. Individuals with ABI may also present with denial or defensiveness that contribute to hesitancy to engage. As an example, coming to therapy may not be viewed as “cool” by adolescents with ABI.

People who are visiting often are checking us out. Can we be trusted? Is it worth their time to come and meet with us? Visiting relationships call for warm and caring hosting rather than a sales pitch around the benefits of intervention. The therapist can start off from a position of curiosity and not knowing. “Whose idea was it that you come here today? What’s your understanding of why you’re here?” If the individual is reticent and prefers not to talk, allow the individual to sit back and listen. Empathize with them about having to attend the session against their wishes. Acknowledge their ambivalence about therapy and reframe their response. Thank them for coming and staying in the session, in spite of their reservations. If the therapist can find out what would make it worthwhile for them to return, the individual can be engaged around possible meaningful goals.

“I know you were not really keen on coming in today. I really appreciated that you stayed and let us talk ... I don’t know where you learned to be so patient and such a good listener ... Suppose we meet again, what would make it worth your time?”

People in a complainant position are very aware of the problem and its effects, but don’t see themselves as contributing to the problem or its solution (Selekman, 1997; Thomas & Nelson). They can be parents, spouses, family members or others in the support network. The complainant is burdened by the problem, but may see the solution as residing with the therapist or within the person who is brought to therapy (most often the person with the ABI). They often are very good at describing the problem, their frustrations with the problem, and unsuccessful attempts to solve the problem. At this stage, they want help from the “expert” to “fix” the problem. They often are not yet able to see how examining their involvement or behavior could alleviate the problem.

The best thing to do when a person is complaining is to listen and sympathize. This is not the time to do solution-building until the person is ready to engage in change behavior. Offer empathic responses such as “A lot of family members would have given up by now, but here you are, still looking for answers. What has helped you cope so far?” The family member (i.e. parent) can also be asked to act as a ‘supersleuth’, to observe and notice when the person with the problem is behaving better. The parent can then be encouraged to think about what he/she is doing differently that may be helping with the positive change.

The customer is the person who is most concerned about the changes in the family and is interested in working closely with the therapist to find a solution. The therapist in the customer-type relationship has been ‘hired’ and the task of solution building can begin. The client is open to new ideas, suggestions, reframes, and encouragement. During the engagement phase, it is important to identify who in the family may be a customer so this person can be recruited to help find solutions. The following questions can be used to determine the customer(s) in the family system: “Who in the family is most concerned about finding a solution to this problem? Who next, then who? What difference will it make to each person in the family when the problem is solved?” (Selekman, 1997, page 56).

6.2 Normalizing

Clients can become distressed and consumed by their own thoughts, feelings and behaviors and often lose perspective when they are distressed (De Jong and Berg, 2008). Individuals might think of their problems as unique and beyond the bounds of normality. This is often the case with individuals with ABI and their family members, who report feelings of isolation and aloneness around the changes in their lives post-ABI. Reframing their problems as common and normal experiences after ABI can help them to view themselves in a less pathologizing and more hopeful way. Statements such as “most people with brain injuries describe the same frustrations as you” can be reassuring and can assist the individual to feel a connection with others who have experienced similar difficulties.

Family members’ emotions and experiences can also be normalized in the context of caregiver coping and adjustment. Family members need permission to grieve the loss of their injured loved one, especially as this loss often goes unrecognized by friends and family, who focus instead on how “great” the injured relative looks, or how they’re “walking and talking again”. Unlike a death, there is no funeral or ritual to acknowledge these feelings of loss. There is also no closure to this loss as the grief can be re-activated during different developmental stages or life events (Gan et al., 2013). Educating families about the grieving process after ABI and normalizing these losses can prepare families for these experiences so they can learn ways to mourn resiliently.

6.3 Goal setting

A major active ingredient in SFBT is setting measurable and changeable goals (Trepper, McCollum et al., 2012). Well-formed SFBT goals show the following characteristics: (1) are important to the client and perceived by the client as involving their hard work, (2) identify the presence of something desirable rather than the absence of something undesirable, (3) emphasize first steps rather than end points, (4) are small rather than large, (5) are concrete, achievable and measureable, (6) involve use of the client’s language, and (7) are realistic and within the client’s control (Bavelas et al., 2013; De Jong & Berg 2002). As an example, instead of I don’t want to be depressed anymore, the goal is stated in the positive I want to wake up and begin to feel good again. When prompted to think about what that might look like, examples might be: doing things with my family again, having coffee with a friend, going to a movie.

If the client has difficulty coming up with goals in the session, the therapist can ask any of the following:

“What would need to happen today to make this a really useful session?”

“What needs to be different in your life for you to be able to say that it was a good idea you came in and talked with me?”

An alternative in-between session task could be:

“Between now and the next time, think of something that you want to continue happening, or see more of.”

6.4 Miracle question

The miracle question is a foundational SFBT intervention that was created to help the client envision a preferred future. In addition to lifting clients out of the problem-saturated view that nothing can change, the miracle question helps them develop a vision of what their lives could be like in the absence of the problem (Stith et al., 2012). The client is asked to imagine the specific details that would let them know that change has occurred. The precise language of the intervention may vary, but the basic wording is,

“Let me ask you a strange question. Suppose that while you are sleeping tonight, a miracle happens. The miracle is that the problem which brought you to therapy is solved. You are asleep so you don’t know that the miracle has happened. When you wake up tomorrow morning, what will be different that will tell you that a miracle has happened and the problem which brought you here is solved?” (Bavelas et al., 2013, p. 13; De Jong & Berg, 2002, p. 85)

Clients with ABI have a number of reactions to the question. They may say they “don’t know” or they may have difficulty formulating an answer. A common answer is “my brain injury would be gone.” To continue orienting towards a preferred future, the therapist can respond with the following questions:

“Suppose the brain injury wasn’t holding you back the way it is now, what would be different in your life? What would you be doing? Who else would be involved? What difference would it make in your life? Who else would notice that part of this miracle is beginning to happen? What would they see?”

It is important to allow sufficient pause to allow the client to reflect on each question as the client’s response will guide the therapist around the next question to ask. Through a step by step detailed description of how they would like their lives to be, clients can co-construct with the therapist their goals of therapy and ways of moving towards their preferred futures. The therapist can also introduce times when the miracle picture might be happening.

“Can you think of times, even briefly, when the miracle picture is happening? – tell me more, what was happening? How did you do it? What do you have to do to make it happen even more?”

In therapy with couples, families, or groups, the miracle question can be asked of individuals or the group as a whole. If asked of individual members, each one would give his or her response to the miracle question, and others might react to it. If the question is posed to the family, group, or couple as a whole, members may “work on” their miracle together. The SFBT therapist, in trying to maintain a collaborative stance with family members, punctuates similar goals and supportive statements among family members (Bavelas, et al., 2013).

6.5 Scaling questions

Scaling questions are used to secure a quantitative measurement of the presenting problem and where individuals would like to be on a scale of 1 to 10. Scaling helps to generate hope by rating the range of problem experiences in comparison to dichotomous all or none thinking (Trepper et al., 2012). Scaling is particularly suited for people with ABI because of its concrete nature. It is also suited for individuals who may experience word finding difficulties when talking about their feelings. For example, if a goal is ‘to feel good again’, the individual can be asked to rate on a scale of 1–10, where he thinks he is, with 10 being ‘pretty good’ and 1 being ‘pretty bad’. If he identifies a rating of ‘3’, the therapist can ask what a ‘4’ might look like –

“Suppose you moved to a ‘4’ over the next week, what would be different? What would you be doing that you’re not doing now? What are some steps you can take to move to a 4? How confident are you that you could raise the number to a 4?”

This helps to break goals into smaller more achievable goals and helps to instill hope for positive change. If a client is feeling particularly discouraged about possibilities for change, the therapist can scale back the question by asking “What would it take to get to a ‘3½’?”

Scaling questions can also highlight progress already made. For example, if the client gave a rating of ‘2’ at the start of therapy, the therapist can ask “what did you do to advance yourself from a ‘2’ to ‘3’?” It is important to attribute any positive change to the client’s efforts, not the therapist. Therapists can also use scaling questions to scale confidence or hopefulness that change will occur, or motivation to work towards change.

Scaling questions can be particularly useful in family system intervention (Gan & Ballantyne, 2016). For example, each member of a family can rate their confidence in solving their problems. A comparison of each member’s ratings can offer an opportunity to explore what makes some member’s ratings higher, which could provide a basis for discussion around potential new solutions or creative brainstorming. Ratings around motivation to work on the problem can also offer clues around who in the family may be in a customer, complainant, or visitor relationship.

6.6 Exception questions

In the traditional medical model, the focus is on gathering as much information as possible about the problem, assessing when it occurs, and the factors that contribute to its recurrence. In SFBT, understanding the details regarding the problem is de-emphasized. Instead, a major active ingredient in SFBT is focusing the conversation on exceptions to the problem, especially those exceptions related to what the client wants to be different and encouraging the client to do more of what he/she did to make the exceptions happen (Trepper et al., 2012). There are also times when the problem recurs with less intensity, frequency, or regularity. By asking questions to elicit responses to when the problem is not happening or when it is less intense, the client uncovers the strengths they bring with them from current or past experiences. These conversations orient towards their already proven ability to master challenges which may then be applied to help solve the client’s current situation rather than teaching the client new skills.

“Tell me about the times when anger could have taken over, but you kept your cool? How did you do it? What did you do to win over anger? How does it make your day go differently when you keep your cool?”

A key element of using exception questions is assuming that the client has some element of control over the change. Amplifying their role in the exceptions helps to underscore their power and control in solving their problem. Adding a relationship dimension to the exception questions can also highlight the impact of these exceptions on key support systems in the individual’s life.

“Who else noticed you keeping your cool? What difference did/will that make in your life?”

6.7 If it works, do more of it

Once SFBT therapists have identified previous solutions and/or exceptions to the problem, they gently nudge the client to do more of what has previously worked. It is rare for a SFBT therapist to make a suggestion or assignment that is not based on the client’s previous solutions or exceptions. It is always best if change ideas emanate from the client rather than from the therapist.

6.8 Coping questions

The following questions help to highlight the coping resources in a family system:

“What are the signs of progress you have noticed in (client’s name)? Name three things that you respect or appreciate about (client’s name). Name three things that you respect or appreciate about each member of the family.”

By actively listening for descriptions of everyone’s strengths, the clinician can underscore how the family is already practising a positive coping strategy to deal with their problem situation.

Jumping too quickly to miracle questions can inadvertently invalidate a client who might be in deep pain or feeling bleak and hopeless. These are the times to acknowledge the client’s experience and to employ coping questions:

“This sounds so hard for you. How have you coped so far? What are you doing to help you get through each day?”

“Sounds like you had a rough week. How did you manage to get through that week?”

Only after a client has been validated and the client’s pain has been acknowledged that the therapist can move on to explore what the client is doing to mobilize his or her strengths in order to get through this difficult time. (De Jong & Berg, 2002).

6.9 Compliments and focusing on successes

Compliments are an essential part of SFBT. Clinicians are encouraged to highlight client strengths and what the client is already doing that is working. Any positive change is attributed to the client or family, not the therapist, as compliments encourage greater cooperation and increase the likelihood of returning to therapy (Lipchik, Derks, Lacourt et al, 2012). The result of giving compliments and observing how clients respond to them is a direct step toward asking questions about the positives in their lives, as well as their strengths and resources.

Compliments can be direct (e.g. “That was impressive how you handled that situation.”) or indirect (e.g. “How did you figure out how to solve that problem?”). Listening for opportunities to offer indirect compliments is a powerful question to enhance self-efficacy and hope.

7 Limitations

Therapists who are new to SFBT often focus their efforts on learning the techniques and scripts of SFBT. However, these scripts are bound to fail if the therapist does not engage in self-reflection around their own philosophical stance and beliefs about clients and the ingredients that are necessary for change. As there can be incongruence between what a therapist says in front of the client and what the therapist believes, training and live supervision are essential to facilitate learning around ‘being’ a solution-focused therapist, versus ‘doing’ solution-focused therapy.

SFBT has often been criticized for being ‘problem-phobic’. This can be a pitfall when there is failure of emotional attunement to the client and the therapist moves too quickly into successes, goals, and solutions. Similarly, it is important to avoid falling into the trap of becoming ‘Pollyanna” (being optimistic, positive, and strong), when the situation does not warrant such an attitude. In these situations, focusing on coping questions may be more suited. Setting goals that are realistic (e.g. learning to live a comfortable life in spite of the ABI) can also help to avoid being caught in an overly-optimistic stance. Novel SFBT therapists are encouraged to routinely evaluate how they are using SFBT language to co-construct meaningful conversations with clients that orient towards achievable and realistic goals.

SFBT is an effective treatment modality, but it is not a panacea – one should not assume it works for everyone and for every situation (Thomas, 2007). There may be situations where a different therapeutic modality is preferred. If it isn’t working, do something different. There are also circumstances that may warrant use of the medical model, such as when pharmacological or neuropsychiatric intervention is indicated to address organically-based neurobehavioral changes. After an ABI, there may also be changes around self-awareness and insight that may limit the accuracy of a client’s self-reflection or judgment. Issues around impulse control and associated safety concerns are other ABI related challenges that may benefit from an integrated approach (i.e. SFBT, behavioral, and psychoeducational).

As entering the world of ABI rehabilitation is foreign to clients, moving prematurely into SFBT without providing proper psychoeducation about ABI can put people at a disadvantage. Adopting an educational expert stance may be an important starting point when people are faced with confusion around their suddenly altered states, an unknown future, and unexpected incursion of rehabilitation professionals into their lives. Using principles of ‘normalizing’, information about ABI can be woven into the therapy process to help clients better understand what is common or normal after ABI and what might be expected throughout their rehabilitation journey. This would allow the therapist to co-construct solutions to mitigate the effects of the ABI and to co-create the best version of the new self.

The idea that one does not need to know a lot about the problem in SFBT can inadvertently lead clinicians down a path that ignores the wider context. This can create ‘situational blindness’ to larger and more encompassing problems that require different paths to change (Thomas 2007).

Rehabilitation professionals, especially legal representatives often express skepticism around strengths-based approaches and the ‘de-emphasis’ on problems. They often rely on expert assessments and emphasis on the ‘D’ words (e.g. disability, deficits, dysfunction) to underscore the numerous problems brought about by the brain injury and its negative and permanent impact on a person’s life. A report, focused on strengths, successes, and hopes for the future, could potentially undermine a medico-legal case or access to insurance funding for rehabilitation or school supports. In these situations, it is important to distinguish between the need for a report for medico-legal purposes or one that is used to advocate for rehabilitation/school supports versus the rationale for adopting a SFBT psychotherapeutic approach.

8 Implications for practice

Adopting a solution-focused approach within a problem oriented culture can be frustrating for the SFBT therapist (De Jong & Berg, 2008). Introducing SFBT into a traditional rehabilitation team can be a challenge as it requires a paradigm shift from the medical model to a solution-focused paradigm. This can be especially challenging for experienced professionals who have been trained in the traditional medical model and are accustomed to focusing on problems. Even with training in SFBT, clinicians can easily slip back into ‘problem talk’ when the dominant discourse within a team or organization is the medical model. To mitigate this, a solution-focused coaching approach can be applied with an interdisciplinary group of clinicians (Baldwin et al., 2013). Introduction of a solution-focused model across disciplines can help to facilitate a cultural shift towards a solution-focused model of care in rehabilitation.

Therapists who seem to embrace and excel as solution-focused therapists have these characteristics: (a) are warm and friendly, (b) are naturally positive and supportive (often are told they “see the good in people”), (c) are open minded and flexible to new ideas, (d) are excellent listeners, especially the ability to listen for clients’ previous solutions embedded in “problem-talk”, and (e) are tenacious and patient (Bavelas et al., 2013). There is a common misperception that SFBT is easy to learn and that the time involved in therapist training is much less compared to other psychotherapeutic approaches such as Cognitive Behavioral Therapy. To avoid the pitfalls and limitations that can come with learning a new psychotherapeutic approach, therapist training should incorporate video examples of the different ingredients of SFBT, role playing, live supervision, and practice with video-taped feedback. Feedback and supervision will facilitate self-monitoring of therapist’s beliefs, reactions, biases, and non-verbal communication tendencies. Watching examples of the self or therapists asking questions successfully and unsuccessfully will enable novice SFBT therapists to learn about the appropriate timing, phrasing, pacing, and follow-up of questions. For example, in SFBT training, specific guidelines are provided around the delivery of the miracle question, including the introduction and timing of the miracle question, pacing of the question, appropriate use of pausing, and transition in and out of scaling questions (Stith et al., 2012). As with learning any new therapy language, supervision and training are necessary components to becoming fluent with SFBT.

It is important to realize that there is no ‘one size fits all’ and that not all approaches work all the time. Therapists need to be flexible and open to matching the therapeutic approach with the needs of the client, the presenting situation, the stage of rehabilitation, and client readiness for change. There may be times when it is helpful to look at the past and to explore the history of the problem, but to incorporate a view of listening for competencies and potential resources. The use of SFBT with culturally diverse clients also requires additional consideration and research, as people’s preferred ways of working with rehabilitation professionals might differ depending on their preference for a hierarchical versus collaborative approach to care.

9 Implications for research

There is a paucity of research on psychotherapy outcomes in the ABI field. Hart and colleagues (Hart, Rabinowitz, & Fann, 2019) suggest that the lack of evidence to support psychotherapeutic intervention guidelines in ABI may be due in part to uncertainty as to how best to modify these “talking therapies” to accommodate cognitive and communication deficits. Inconsistent reporting of adaptations for people with ABI has been identified as an additional barrier to developing replicable psychotherapies for research (Gallagher, McLeod, & McMillan, 2019). Developing more systematic ways of reporting modifications in psychotherapy could enhance future ABI psychotherapeutic intervention studies.

Ethical considerations also make it difficult to have RCT designs with control groups. One potential solution is to compare outcomes of SFBT with different psychotherapeutic models that have been described in the ABI literature (e.g. cognitive behavioral therapy, mindfulness-based cognitive therapy, motivational interviewing). However, in contrast to manualized psychotherapies that focus on outcome variables (i.e. depression, anxiety), SFBT also emphasizes the importance of process variables (i.e. therapeutic alliance, collaborative stance, using client language) as moderators of therapeutic effectiveness (Franklin et al., 2017). The use of therapeutic strategies is also tailored to the unique strengths and characteristics of each client which make it difficult to manualize and replicate across clients.

Although SFBT has been studied widely with a range of clinical populations, its use with ABI populations has only been recently studied with an adult stroke population (Wichowicz, et al., 2017). Further empirical research around its use and effectiveness with adults and children with ABI and their families is clearly needed. Given the challenges of psychotherapy outcome research with ABI populations, it may be helpful to consider other ways of building an evidence base for SFBT. As therapeutic alliance is the most robust predictor of therapy outcomes across all models (Klonoff et al., 2001; Sprenkle et al., 2009), the role of SFBT in enhancing therapeutic alliance appears to be an area that is worthy of study. Consideration can also be given to future research around the specific ingredients of SFBT and how they contribute to psychosocial outcomes after ABI.

Building on the process research findings in SFBT may also be helpful for future research with ABI populations. A systematic review of SFBT process research shows that therapeutic strategies directed toward the strengths and resources of the clients show the most positive results (Franklin et al., 2017). The linguistic and collaborative language approaches also have relatively strong support in SFBT and this finding adds to the empirical support for the co-construction of meaning (Franklin et al., 2017). The use of mixed methods designs incorporating both process and outcomes variables, and combining self-report measures and qualitative interviews could be considerations for building an evidence base for SFBT with ABI populations.

10 Conclusion

This paper contributes to the growing body of literature on strengths-based psychotherapeutic approaches to rehabilitation through its description of Solution-Focused Brief Therapy (SFBT). The tenets, potential benefits, and application of SFBT with individuals with ABI and their families have been described, including limitations around its use with this client population. Nonetheless, with its strengths-based underpinning and client-centred orientation, SFBT is a promising psychotherapeutic intervention that merits further consideration in psychotherapy and family training with rehabilitation professionals.

At a time when many clients with ABI and their families are feeling overwhelmed and devastated by the sudden trauma of the unexpected ABI event in their lives, SFBT can instill hope by focusing on possibilities for the future and what remains strong, versus what is wrong and cannot be fixed. An orientation to the future supports individuals and families to plan their lives post-ABI, with an emphasis on optimizing existing strengths and resources. Strengths-based discussions can help clients realize that while the ABI may be life long, they can discover different ways to cope with it and live a good life in spite of the ABI. We cannot change the reality of the ABI, but we can help change how people view it, the way they manage their lives, and the resources they discover within to help them move forward and become stronger.

Conflict of interest

The author has no conflict of interest to declare.

Footnotes

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