Transcript Dialogue and Collaboration
Theories and Methods of Family Therapy: Post-Modern Models
University of Guelph Centre for Open Learning and Educational Support William Corrigan, BA, MTS and Carlton Brown, MSc, MDiv AAMFT Approved Supervisors and Itinerant Therapists (519) 265-3599 (905) 388-8728 [email protected]
Day Two
• • Check-in Solution-focused Therapy – Principles and assumptions – Types of relationships – Setting goals – Use of questions • • Work on debate for Day 5 Evaluation 2
Checking In
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One thing I ’ve been thinking or feeling since we last met is…
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Case Study: The African Violet Lady
http://youtu.be/5t5EN6FPByY 4
Important Contributors
• • • • • Milton Erickson Gregory Bateson – “ the difference that makes the difference ” MRI group: Jackson, Haley, Watzlawick, Weakland, Fisch – Problem-focused approach Steve de Shazer & Insoo Kim Berg; Scott Miller – BFTC, Milwaukee Bill O ’ Hanlon; Michelle Weiner-Davis
Paradigm Shift
• • De Shazer – Causes of problems may be complex – Solutions need not be – Insight does not always lead to change Related ideas – Problems are clients ’ attempts at solutions – Start with a new solution and go from there
Strengths Perspective
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Despite life ’s struggles, all persons possess strengths that can be marshalled to improve the quality of their lives. Practitioners should respect these strengths and the directions in which clients wish to apply them.
Client motivation is increased by a consistent emphasis on strengths as the client defines them.
Saleebey in de Jong & Berg (2002), p. 10 7
Strengths Perspective
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Discovering strengths requires a process of cooperative exploration between clients and helpers; expert practitioners do not have the last word on what clients need to improve their lives.
Focusing on strengths turns practitioners away from the temptation to judge or blame clients for their difficulties and toward discovering how clients have managed to survive, even in the most difficult of circumstances.
All environments – even the most bleak – contain resources.
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Problem-focused approach (7+1)
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Focus on disease/illness/dysfunction Give the client what she needs to get well Learn as much theory as possible and use the latest, best, evidence-based approach Don ’ t be too simple or clients won ’ t trust you
Problem-focused approach (7+1)
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Clients don ’ t change on their own – that ’ s why you have a job Need to understand the root cause of the problem or it won ’ t change The client must cooperate, and some clients just don ’ t want to be better
Problem-focused approach (7+1)
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Keep to the code: No pain, no gain If it works too fast, the client isn ’ t really better yet – you ’ re missing something If it doesn ’ t work, either you or the client are doing it wrong – try again
Solution-Focused Approach (7+1)
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Focus on health/function/competence Use what the client has (stone soup) Not bound by theory Keep it simple Trust in change Stay in the now (and tomorrow) Cooperation makes it happen
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8. Keep to the Code (core philosophy)
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If it ain ’ t broke, don ’ t fix it!
If it works, do more of it If it doesn ’ t work, do something different! (de Shazer & Berg, 1989)
Insanity
(def ’ n): doing the same thing over and over again expecting different results (A.A.)
1. Focus on Health
• • • • Explore client strengths What ’ s going right and how to use it?
Despite the problem, healthy patterns exist in the client ’ s life. Can you find them?
Example
• • • •
2. Use what the client has
Stone soup – You provide the pot, the stones and the water – Your client brings everything else What is the client particularly good at?
How can I use this to help find solutions?
Example (Erickson) – Problem: alcohol, tobacco and food – Strength: likes walking – Intervention?
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3. Not bound by one theory (including this one)
Do learn different theories of self and problem formation Do not take any one theory too seriously Tailor what you know to the client ’ s needs Do what works!!!
3. Not bound by one theory
• Example – Problem: drinking – Theories • AA: alcoholism is a disease, abstinence is the cure • CAMH: people are in control of their own drinking and can “ Say When ” (harm reduction) – Which stand would you use with client?
4. Keep it Simple (Parsimony)
• • • • • Take the presenting problem at face value, not as the “ tip of the iceberg ” Don ’ t look for additional problems Find the simplest solution What is the minimal intervention necessary to get the client unstuck?
Then get out of the way
5. Trust in Change
• • • • Change is inevitable; you cannot not change Believe in people ’ s ability and desire to change Avoid the fallacy that people can ’ t change or that some problems are intractable Ask them at the first appointment, “ How have things improved since you first called?
”
5. Trust in Change
• • If they did this much before their first appointment, imagine how much more they will change with you!
Problem-based approach assumes falsely and reinforces that problems take forever to change – but they don ’ t!
5. Trust in Change
• • Instead of asking, “ How long has this been a problem?
a problem?
” ” ask, “ When is this not Examples – To a problem drinker: “ When don ’ t you drink?
” – re. defiant child: “ When does he listen to you?
” (very important to reinforce: Barkley)
6. Present and Future Orientation
• • Most people assume that they have to understand their past in order to move forward, e.g. “ Those who do not understand history are doomed to repeat it.
” Is it true?
6. Present and Future Orientation
• Response to low mood 1. Think, “ Why am I feeling this way?
” , start to ruminate, low mood is prolonged 2. Distract by doing something you enjoy or trying to think about something positive, mood is elevated – Zindel V. Segal et al. (2002), Mindfulness-Based Cognitive Therapy for Depression (Guilford), pp. 33-34
6. Present and Future Orientation
• • • “ Why am I this way?
” is a question about the present leading one into the past “ Try to find something positive ” something that you enjoy ” or “ Do is about the present present orientation leads to better outcomes for depression
6. Present and Future Orientation
• • • It might not be necessary to understand the past in order to move forward Excessive time spent understanding the past may make things worse for the client Envisioning a change in the present or near future engenders hope, one of the four main factors in client change
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7. Cooperation
There are no resistant clients, only resistant therapists Cooperating with the client is a central organizing principle of SFT Help the client with the client ’ s goals, even if and when you see things that you think the client should work on instead Example – Elmer the glue head
BREAK 10:30 – 10:45
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Solution-Focused Therapy
Types of Relationships 28
Types of Relationships
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Customer Relationship Complainant Relationship (Observer Relationship) Visitor Relationship • Note that customer, complainant and visitor describe the relationship, not the client
Customer Relationship
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A complaint or goal has been identified jointly by client and therapist The client sees himself as part of the solution and is willing to do something The therapist cooperates with what the client wants to do
Complainant (Observer) Relationship
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A complaint or goal has been identified jointly by client and therapist The client does not see himself as part of the solution and often believes that
someone else has to change
The therapist cooperates with the client
Complainant Relationship
• • • • Client is a victim of somebody else ’ s behaviour (e.g. drinking) The problem is the kids my kid hangs out with Disempowering: problem in one place, solution lies somewhere else Challenge: how to turn complainant rel ’ n into customer rel ’ n?
Visitor Relationship
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The client and the therapist have not yet jointly agreed upon a goal or complaint The client says either that there is no problem, or that somebody else has a problem Challenge: to change visitor rel ’ n into customer rel ’ n
Visitor Relationship
• • • Why do visitors come to therapy?
Usually because someone (who would be in a complainant relationship with you if they were in your office) told them to come Parole officer, lawyer, court, spouse, parent
Cooperating = recognizing type
• • • Customer relationship – Client and therapist work together on the goal Complainant relationship – Therapist agrees to explore the complaint further with the client to change perspective Visitor relationship – Goal may be to get complainant off their back – “ What would we have to do so that X wouldn ’ t complain anymore?
”
Customer Relationship
• • Straightforward You both agree on a problem and a goal and the person willing to work on the goal is in the room
Complainant relationship
• • • • • A little more difficult The person in the room agrees with you on the goal The solution is outside of the room Your client feels disempowered Empower the client
Complainant Relationship
• • • • Bypass the problem as much as possible Don ’ t force ownership (= resistance) Compliment and build alliances Reframe the client ’ s behaviours as “ sacrifice ” and positively motivated
Complainant Relationship
• Example – “ My son is controlling our house. We ’ re scared of him – he ’ s really angry ” – “ He won ’ t go for help. He says we make him mad, that we ’ re bugging him all the time ” – “ I just want him to stop getting angry all the time. It stresses everyone in the house ”
Visitor Relationship
• • • • • Bracket the reason for the referral What does the client want?
Agree with the goal and sympathize with the client ’ s plight of having to see you Compliment the client Ask about the client ’ s view of the referring person ’ s demands
Visitor Relationship
• Example – “ I don’t know why I’m here. My probation officer said I have to come or I’d be breached. I’m not angry and I don’t have a problem. My ex wanted me out of the house so she called the police and told them some bullshit story about me threatening her. So here I am. I need you to write a letter for me for court saying I came here. Can I go now?
”
Solution-Focused Therapy
Setting Goals 42
Setting Goals
• • • • • • • Salient Small Specific Something Start Sensible Serious
Salient
• • • Treatment goal must be important to the client Client sees goal as personally beneficial Example – Husband wants wife to stop drinking – Wife wants husband to stop nagging – Both want to get along better…have more of a social life…have friends (benefits)
Small
• • Something the client can achieve in a reasonable time (like before the next session) Example – “ Get my life together ” – Therapist: what would be the first small step?
– “ Get up at 11am ”
Specific
• • • Best goals are concrete, specific and behavioural “ Communication ” is too broad “ Call my husband on his cell phone when I am going to be late for dinner ” is more specific
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Something
The presence rather than the absence of something Most clients want to stop doing something: smoking, drinking, affairs, fighting, etc.
What will they do instead?
Positive, proactive language Easier to determine when goal is met Reverse psychology: when you try to tell yourself not to do something, you want it even more
Start
• • • • Many clients want to be all done, e.g. “ Have my life together ” or “ Have the perfect marriage ” Negotiate a “ first small step ” , a start When the client starts, he will feel better Example: “ What will be the first small sign that will show you that he is beginning to live up to his potential?
”
Sensible
• • • The goal makes sense in the context of the client ’ s life What is realistic and achievable for this client?
Example: “ becoming a doctor ” vs. taking a course in biology
Serious
• • • • The goal should be perceived as involving “ hard work ” “ This will be difficult to do, but… ” Compliment them on small steps accomplished Allows face-saving in case of failure
LUNCH 12:30-1:00
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Solution-Focused Therapy
Five Useful Questions 52
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Questioning
The questions we ask shape the answers we get If you don ’t like the answers, change the questions You don ’t need to know what the problem is in order to ask good questions Exercise – “Mother May I?” (adapted) 1. Divide into groups 2. One person has a problem that they ’re ashamed of and don ’t want to talk about 3. Other people ask questions to find out what it is 53
1. Pre-session change
• • • Changes occur constantly “It is my experience that many people notice that things are better between the time they set up an appointment and the time they come in for the first session. Have you noticed any such changes in your situation?
” Starts on a positive note, can build from there 54
2. Exception-finding questions
• • • • Core element of SFT approach Search for exceptions to the problem Capitalizes on client ’s resources “Are there any times when X hasn’t been a problem for you?
” • Follow up with curiosity & compliments: – “That’s awesome! How were you able to do that?
” 55
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2. Exception-finding questions
“Catch your partner doing something that you appreciate once each day for the next week. Let him or her know about it as specifically and as quickly as possible.
” (p. 48) “Search in your history for times when you felt closer. What was going on then? What were you or your partner doing that you have stopped doing or are doing less these days? Look back at the very beginning of your relationship to remind you of what worked better.
” (p. 78) Stop Blaming, Start Loving! (1995) O ’Hanlon & Hudson 56
3. The miracle question
• Suppose that tonight, after the session, you go home and fall asleep and while you are sleeping a miracle happens. The miracle is that the issues that brought you here today are resolved … When you get up the next morning, what ’ s the smallest thing that would tell you that this miracle has happened?
Susan Lee Tohn and Jordan A. Oshlag (1996), Solution-focused therapy with mandated clients. In: Miller et al (eds) Handbook of Solution-Focused Brief Therapy (San Francisco: Jossey-Bass), 152-153 57
3. The miracle question
• • • • • Orients client to the future, when the problem is no longer a problem Go from solution and work backwards Small behavioural steps: “What would you notice is different? What else?
” Engenders hope, empowering Usually realistic, achievable answers 58
3. The miracle question
• Follow miracle question up with: – “What will be the first sign that things are getting better, that this problem is having less of an impact on your current life?
” – “When was the most recent time that you had a morning like that?
” – “What would others notice about you that would be different?
” – “What might be the first small step in moving toward where you want to be?
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4. Scaling Questions
Worst No Longer Ever A Problem ├──┼──┼──┼──┼──┼──┼──┼──┼──┼──┤ • • • 0 1 2 3 4 5 6 7 8 9 10 “On a scale from 0 to 10 where 0 is the worst it’s ever been and 10 is that it is no longer a problem, where would you put yourself right now?
” “I am interested that you’ve given yourself that score. What makes you score that rather than a 0 or 10?
” “What would have to happen for you to give yourself a score+1?
”
4. Scaling Questions
• • • • • • Playful way to keep track of change More collaborative than clinical scales Helps client take ownership of treatment Client as the expert, uses their words Very adaptable Very helpful with children – Use faces or pictures 61
5. Coping questions
• • • • Gently challenge client ’s belief system Look for small successes “How do you keep going everyday?” “What do you do so that you get through each day?
” • • Answers provide clues to what they need to continue to do or do more of “How come your life is not worse?” 62
5. Coping questions
• • • • • • What client is doing to survive A special case of exception finding q ’ns “What have you found helpful so far?” Respect value of client-generated coping Improves confidence Client becomes more aware that she/he is coping, despite problem 63
Formula first-session task
• • • “Between now and next time we meet, I would like you to observe what happens in your family that you want to continue to have happen ” re. “If it works, do more” Pay attention to what is going right vs. what is going wrong Keys to Solution in Brief Therapy (1985) Steve de Shazer 64
The Surprise Task
• • for couples and families “Do at least one or two things that will surprise your parents (or partner). Don ’t tell them what it is. Parents (or partner), your job is to see if you can tell what it is that he/she is doing. Don ’t compare notes: we will do that next session.
” In Search of Solutions (1989) Hudson O ’Hanlon & Weiner-Davis, p. 137 65
Amplifying exceptions
• Use your “E.A.R.S.”: – E – Elicit the exception – A – Amplify the exception • What ’s different between exception times and problem times • Explore how it happened in detail, highlight personal agency – R – Reinforce success and strength exception represents – S – Start again – “What else is better?” 66
Complimenting
• • • • • Genuine, sincere; not an act or a role Comes from curiosity and wonder, belief in clients strengths and abilities Reality-based, from things you saw or heard in interview Draws attention to strengths and past successes Helps client become more hopeful and confident 67
• • • • •
Complimenting
“ How did you do that?
” “ Wow! That ’ s awesome!
” “ Most men wouldn ’ t be caught dead in my office. You must really love her.
” “ Wow, you came to see a therapist! You must really want to change.
” May be direct or indirect (e.g. implying something positive)
Mandated Clients
• • • Need to know: – what is important to the client – who is important to the client – what are they willing to do – what are they able to do encourage them to do more of what they are able to do link what is important to them with what is important to you in order to get them what they want 69
Outcome Studies
• • First study at BFTC (Kiser, 1988) 80.3% success rate (65.6% of clients met their goal while 14.7% made significant improvements) within an average of 4.6 sessions • After 18 months, rate increased to 86% 70
Outcome Studies
• • • • 1992-93, 275 clients included, 8 practitioners 26% came for 1 session; >80% came for 4 or less; avg. # sessions = 2.9
26% described no progress; 49% described moderate progress; 25% described significant progress on goal At 7-9 month follow-up, 45% said their goal was met; 32% said some progress was made; 23% said no progress was made 71
Recommended Reading
• • Insoo Kim Berg and Scott Miller (1992), Working with the Problem Drinker. New York: W. W. Norton Peter de Jong & Insoo Kim Berg (2002). Interviewing for Solutions (2 nd ed.) Pacific Grove, CA: Brooks/Cole.
Recommended Reading
• • Scott D. Miller, Mark A. Hubble, Barry L. Duncan, eds (1996). Handbook of Solution-Focused Brief Therapy. San Francisco: Jossey-Bass.
Matthew D. Selekman (2002), Living on the Razor ’ s Edge: Solution-Oriented Brief Family Therapy with Self-Harming Adolescents. New York: W.W. Norton
BREAK 2:30-2:45
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Work on debate for Day 5
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Wrap Up
• • • • Questions Readings Evaluations Day 3 and 4 agenda 76