Department of the Navy2015 CAP Training

Solution-Based Therapy:Time Sensitive Strategies to Foster Change

Bob Bertolino, Ph.D.Associate Professor, Maryville University-St. Louis

Senior Clinical Advisor, Youth In Need, Inc.Senior Associate, International Center for Clinical Excellence

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• Contact: bertolinob@cs.com; +01.314.852.7274

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Overview

1. Philosophy and Worldview as a Foundation for Change

2. Evidence-Based Practice (EBP)3. Solution-Based Therapy (SBT)

The Strength WithinPersonal Philosophy and the

Road to Change

PRACTICES“What we do”

↑THEORY/MODELS

“How we think”↑

PERSONAL PHILOSOPHIES“Who we are”

What is My Philosophy?1. What are my core beliefs, ideas, or assumptions about the

clients with whom I work?2. How did I arrive at those beliefs?3. What has most significantly influenced my beliefs, ideas,

and assumptions as they relate to my clients?4. How have my beliefs, ideas, and assumptions affected my

work with clients? With colleagues/peers? With larger communities?

What is My Philosophy (cont.)?4. How do I believe that change occurs?5. Do I believe that some degree of change is possible with

every client? (If you answered “yes” then end here.)(If you answered “no,” proceed to the next question.)

6. How do I work with clients whom I believe cannot (or do not want to or are resistant to) change? What do I do?

7. If I do not believe that every client (and/or family) can experience some degree of change, what keeps me in doing this kind of work?

Evidence-Based Practice (EBP)

Evidence-Based Practice (EBP)

“The integration of the best available research with clinical expertise in the context of patient

characteristics, culture, and preferences.” (p. 273)

APA Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61(4), 271–285.

Clinical ExpertiseThe APA Task Force on EBP

“Clinical expertise… entails the monitoring of patient progress (and of changes in the patient’s circumstances—e.g., job loss, major illness) that may suggest the need to adjust treatment… If progress is not proceeding adequately, the psychologist alters or addresses problematic aspects of the treatment (e.g., problems in the therapeutic relationship or in the implementation of the goals of the treatment) as appropriate” (2006, pp. 280, 276-277).

APA Presidential Task Force on Evidence-Based Practice. (2006). Evidence-based practice in psychology. American Psychologist, 61(4), 271–285.Lambert, M. J., Bergin, A. E., & Garfield, S. L. (2004). Introduction and overview. In M. J. Lambert (Ed.), Bergin & Garfield’s handbook of psychotherapy & behavior change (5th ed.)(pp. 3-15). New York: Wiley.Warren, J. S., Nelson, P. L., Mondragon, S. A., Baldwin, S. A., & Burlingame, G. A. (2010). Youth psychotherapy change trajectories and outcomes in usual care: Community mental health versus managed care settings. Journal of Consulting and Clinical Psychology, 78(2), 144-155.

Patient (Client) Characteristics,Culture, and Preferences

• Client characteristics (i.e., age, gender, gender identity, ethnicity, race, social class, disability status, sexual orientation, developmental status, life stage, etc.).

• Strengths, resources, beliefs, and factors that can influence change.

• Understanding of the local knowledge and culture.• Personal preferences, values, and preferences related to

treatment (e.g., goals, beliefs, worldviews, treatment expectations).

Solution-Based Therapy (SBT)

1988

1997

2003 2012

2007

Best Available ResearchA Focus on Strengths & Solutions

Isolation, fear, anxiety, depression, PTSD

The Pathology Bias• Freud thought the best we could hope for in life was

“ordinary misery.”• Behavioral health has historically focused on pathology.• Until recently, psychological publications and studies

dealing with negative states outnumber those examining positive states by a ratio of 15 to 1.

• A bias in behavioral health has been to get people back to zero; a result of which is the “empty person.”

• We can help individuals, families, couples, groups, and systems to better leverage strengths and resources…

• A result of which is a reduction in negative symptoms and an increase in well-being.

• Higher well-being has been shown to lengthen lifespan, boost the immune system, strengthen relationships, increase productivity, and so on.

From Pathology to Strengths“What we have learned over 50 years is that the disease model does not move us closer to the prevention of these serious problems. Indeed the major strides in prevention have largely come from a perspective focused on systematically building competency, not correcting weakness. Prevention researchers have discovered that there are human strengths that act as buffers against mental illness: courage, future-mindedness, optimism, interpersonal skill, faith, work ethic, hope, honesty, perseverance, the capacity for flow and insight, to name several… We need now to call for massive research on human strength and virtue. We need to ask practitioners to recognize that much of the best work they already do in the consulting room is to amplify strengths rather than repair the weaknesses of their clients.” (p. 6-7)

Seligman, M. E. P., & Csikszentmihalyi, M. (2000). Positive psychology: An introduction. American Psychologist, 55(1), 5–14.

High well-being, thriving, Posttraumatic Growth

A Strengths-Based FoundationA strengths-based perspective emphasizes the abilities and resources people have within themselves and their support systems to more effectively cope with life challenges. When combined with new experiences, understandings and skills, those abilities and resources contribute to improved well-being, which is comprised of three areas of functioning: individual, interpersonal relationships, and social role. Strengths-based practitioners value relationships convey this through respectful, culturally-sensitive, collaborative, practices that support, encourage and empower. Routine and ongoing real-time feedback is used to maintain aresponsive, consumer-driven climate to ensure the greatestbenefit of services.

Bertolino, B. (2014). Thriving on the front lines: Strengths-based youth care work. New York: Routledge.

Pathology vs. Solution-Based

Traditional View• Identify, uncover, discover—deficits,

impairments, pathology• Belief is people are bad, have

hidden agendas, and as resistant• Practitioner finds and administers

cures• The practitioner is the “expert”• Focus is on the past/past events• Expression of emotion considered

necessary for change• Practitioners diagnose stuckness• Emphasis is on finding identity and

personality problems

Solution-Based• Identify competencies/abilities• Focus is on promoting well-being• Belief is people have good intentions, are

cooperative• Focus is on identifying small changes

that lead to bigger ones• Services are collaborative with shared

expertise• Focus is on the present and future• Practitioners validate experience• Practitioners are change-oriented• Emphasis is on action and process

descriptions

Solution-Based Assumptions 1. If it isn't broken, don't fix it.2. If it works, do more of it. 3. If it's not working, do something different.4. Small steps can lead to big changes.5. The solution is not necessarily directly related to the problem. 6. The language for solution-development is different from that needed to

describe a problem. 7. No problem happens all the time; there are always exceptions that can

be utilized. 8. The future is both created and negotiable.

de Shazer, S., & Dolan, Y. (Eds.) (2007). More than miracles: The state of the art of solution-focused brief therapy. New York: Haworth.

Conceptualization of Problems

1.SBT is focused on finding solutions not problems and therefore does not look at a person in the sense of being maladjusted.

2.It is behavior that causes maladjustment and not the innate qualities of the person.

3.The client’s narrative determines much about the repeated patterns of dysfunctional behavior.

From Assumptions to PrinciplesResearch-Based Principles of a

Solution-Based Perspective

Principles of Change

• Castonguay and Beutler (2006), “We think that psychotherapy research has produced enough knowledge to begin to define the basic principles that govern therapeutic change in a way that is not tied to any specific theory, treatment model, or narrowly defined set of concepts” (p. 5).

Castonguay, L. G., & Beutler, L. E. (2006). Common and unique principles of therapeutic change: What do we know and what do we need to know? In L. G. Castonguay & L. E. Beutler (Eds.), Principles of therapeutic change that work (pp. 353–369). New York: Oxford University Press.

Clients are the Most Significant Contributors to Service Success

Key CompetencyMaximize client contributions to change

• The client and factors in the client’s life account for more variance (80-87%) in the outcome than any other factor.

• Focus on client ratings of distress and change.• Recognize clients as competent and capable of change.• Identify and utilize client contributions including internal strengths (i.e.,

abilities, coping skills, resiliencies) and external resources (i.e., relationships, social support systems).

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The Variance in Treatment Outcome

• Client/Extratherapeutic Factors = 80-87%• Treatment Effects = 13-20%

• Therapist Effects = 4-9%• The Alliance = 5-8%• Expectancy, Placebo, and Allegiance = 4%• Model/Technique = 1%

Bertolino, B., Bargmann, S., & Miller, S. D. (2013). Manual 1: What works in therapy: A primer. The ICCE manuals of feedback informed treatment. Chicago, IL: International Center for .Clinical Excellence. Wampold, B. E., & Brown, G. S. (2005). Estimating variability in outcomes attributable to therapists: A naturalistic study of outcomes in managed care. Journal of Consulting and Clinical Psychology, 73(5), 914-923.

Client Contributions

• Use assessments as opportunities to explore both risks and strengths.

• Identify and assist with developing supportive social systems, resources, and networks.

• Explore client stories by using questions that elicit past solutions and successes:

• Utilization• Exceptions• Difference• Influence (Problem or Person over)• Coping• Splitting• Linking

1Clien

t

2Family

3Friends/Social

Relation-ships

4Community

5Outside Helpers

6School/

Education

7Work/

Employment

8Other

The Therapeutic Relationship Makes Substantial and Consistent Contributions to Outcome

Key CompetencyEngage clients through the working alliance

• The quality of the client’s participation (engagement) in services the most important process determinant in outcome.

• Clients who are more engaged and involved in services are likely to receive greater benefit.

• The client’s rating of the alliance is more highly correlated with outcome than provider ratings.

• Work with clients to establish goals and methods to achieve those goals.

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Positive Relationships

Countless studies document the link between society and psyche: people who have close friends and confidants, friendly neighbors, and supportive co-workers are less likely to experience sadness, loneliness, low self-esteem, and problems with eating and sleeping. The single most common finding from a half century's research on the correlates of life satisfaction, not only in the United States but around the world, is that happiness is best predicted by the breadth and depth of one's social connections.

Putnam, R. D. (2000). Bowling alone: The collapse and revival of American community. New York: Simon & Schuster.

What is the Therapeutic Alliance?

The therapeutic alliance refers to the quality and strength of the collaborative relationship between the client and therapist and is comprised of four empirically established components: 1) agreement on the goals, meaning or purpose

of the treatment;

2) agreement on the means and methods used;

3) the client’s view of the relationship (including the therapist being perceived as warm, empathic, and genuine); and,

4) accommodating the client’s preferences.

Means or Methods

Goals, Meaning or

Purpose

Client’s View of the Therapeutic Relationship

Consumer Preferences

Realms of Change

Possibility LanguageDissolving Impossibility Talk

1. Reflect client statements in the past tense.

From: “It’s always that way.”

To: “It’s been that way.”

2. Move from global (“everybody,” nobody,” “always,” “never”) to partial (“recently,” “somewhat more,” “a lot”).

From: “I’m always in trouble.”

To: “You’ve been in trouble a lot.”

3. Move from truth/reality to perception (“It seems to you,” “You’ve gotten the idea”).

From: “Things will never get better.”

To: “It really seems to you that it will never get better.”

Possibility LanguageFuture Talk: Acknowledgment and a Vision for the Future

1. Assume the possibility of future change and/or solutions by using words such as “yet” and “so far.”

From: “It’s always going to be this way.”To: “So far you haven’t found any evidence that things will be different than the way they are now.”

2. Recast the problem statement into a statement about a preferred future or goal.From: “I’ll never be able to have the life I really want.”

To: “So you’d like to be able to move toward the life you really want.”

3. Presuppose that changes and progress toward goals will occur by using words such as “when” and “will.”

From: “No one wants to be around me.”To: “So when you begin to notice that there are people who enjoy your company and want

to be around you what will be different for you?”

Possibility LanguageGiving Permission

• Give permission “to,” “not to have to,” and both

• From: “I shouldn’t be angry.”

• To: “It’s okay to be angry.”

• From: “People keep saying that it really should make me angry.”

• To: “It’s okay to not be angry about it.”

• From: “Sometimes I’m angry and sometimes I’m not. I must be crazy!”

• To: “It’s okay to be angry and you don’t have to be angry and you’re not crazy.”

Using Action-Talk• Non-Action Talk• Cab driver talk

• Opinions, evaluations, assessments, judgments• Politician talk

• Vague, general, not specific as to person, place, time, thing, or action

• “Someday” talk• Vague as to time or frequency

Using Action-Talk (cont.)

• Action-Talk/Videotalk• Move from vague, non-sensory-based descriptions to clear,

observable, behaviors• Using Action-Talk to Clarify Meanings

• Action complaints – specifics about what one doesn’t like or one wants to have change

• Action requests – specifics about what one would like to have happen

• Action appreciation – specifics about what has liked about something and would like more of

• Specific to person, place, time, thing, action, or result• Who is to do what by when?• Who did what, when?

3-Point Strategy

1. Problem Description: What needs to change?• Scaling questions

2. Vision of the Future: How will we know that change has been achieved?

• Miracle question, crystal ball, time machine, etc.• General future-oriented questions• Scaling questions (revisited)

3. Movement: How will we know that progress is being made?

• Scaling questions (revisited)

A Solution & Outcome-Focus

• Franklin, Trepper, Gingerich, & McCollum (2011)

• Gillaspy & Murphy – Chapter 5: “Incorporating Outcome and Session Rating Scales in Solution-Focused Brief Therapy”

• Bertolino• Chapter 4: Directions: Information-

Gathering and Planning• Chapter 7: Exchanges: Progress and

Transitions

• ICCE• Manual 2: Feedback-Informed Clinical Work

Culture Influences and Shapes All Aspects of Clients’ Lives

Key CompetencyConvey respect for clients and their cultures

• Provide services with respect to client culture and preferences.• Maintain self-awareness of one’s heritage, background, and experiences

and their influence on attitude, values, and biases.• Emphasize a multi-level understanding, encompassing the client, family,

community, helping systems, etc.• Recognize limits of multicultural competency and expertise; consult others

who share cultural similarities and expertise with clients being served.• Acknowledge clients as teachers and experts on their own lives.

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Culture Influences and Shapes All Aspects of Clients’ Lives (cont.)

• Create culturally meaningful experiences and activities.• Use person-first language.• Individualize services (avoid “one-size-fits-all” approaches).• Create plans of action that are culturally sensitive.• Exercise care in matching methods (i.e., techniques, interventions)

with clients.• Use culturally sensitive methods of research and evaluation.• Conduct ongoing cultural self-assessments.

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Effective Services Promote Growth,Development, and Well-Being

Key CompetencyUtilize strategies that empower clients and improve their lives

• Early response to services is strong indicator of eventual outcome.• The longer clients go without experiencing positive change the greater the

likelihood they will have a negative or null outcome and/or drop out.• View problems as challenges instead of fixed pathology.• Maintain a future focus.• Use language as a vehicle for change.• Explore exceptions—how change is already happening.• Focus on small changes.• Focus on maximizing the impact of each interaction.• Monitor change from the outset through feedback.

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Realms of Change

Changing Views and Actions

• Learn from clients the problematic patterns that repeat

• Identify specific incidents to find descriptions and patterns

• Relationship to problems: Learn how clients situate themselves in relation to concerns and problems. Listen for “I,” “Me,” “Myself,” or “We” statements as opposed “You,” “He,” “She,” “Him,” “Her,” “They,” “Them” statements (Note: Be aware of cultural differences in language)

• Explore coping style

• Explore preparation for change

Views

• Points of view• Attentional patterns• Interpretations/Explanations• Evaluations• Assumptions• Beliefs• Identity Stories

Pathway 1:Identify and Build on Exceptions

• Search for exceptions

• Building Accountability through Exceptions

• Suggest Alternative Viewpoints that Fit the Same Evidence

• Search for Hidden Strengths

• Externalize the Problem

• Foster Resilience

• Life Witnesses as Supports

Pathway 2:See Things Anew Through Attention

• Change language• Broaden Perspectives (consider different points of view)• Find a Vision for the Future• Encourage Clients to Cast Doubt on Their Thoughts• Change Some Quality of Remembered Experience• Shift between the Past, Present, and Future• Shift Focus from Internal Experience to the External

Environment or Other People or Vice Versa• Shift sensory attention

The Costs of Negativity• A recent study shows that extensive discussions of problems and

encouragement of ‘‘problem talk,’’ rehashing the details of problems, speculating about problems, and dwelling on negative affect in particular, leads to a significant increase in the stress hormone cortisol, which predicts increased depression and anxiety over time.

• People who are in a more positive mood are better liked by others and more open to new ideas and experiences.

Byrd-Craven, J., Geary, D. C., Rose, A. J., & Ponzi, D. (2008). Co-ruminating increase stress hormone levels in women. Hormones and Behavior, 53, 489–492.Fredrickson, B. (1998). What good are positive emotions? Review of General Psychology, 2, 300-319.

Bertolino, B. (2015). The residential youth care worker in action: A collaborative, strengths-based approach. New York: Routledge.

Say it in Another Way

• “He doesn’t want to change.”• “She is manipulative.”• “He’s got an antisocial personality”• “She’s overly reactive.”• “He’s got an anger management issues.”• “She’s too dependent.”• “He has poor judgment.”• “She’s resistant.”

Actions and Interactions

• Action patterns• Interactional patterns

Pathway 4:Depatterning

• Find and alter repetitive patterns of action and interaction that are involved with the problem (Aspects of Context)

• Change the frequency• Change the timing• Change the duration• Change the location

Pathway 5Repatterning

• Find and use solution patterns of action and interaction• Search for exception patterns• Find out about any helpful changes that have happened before

services began (preservice change)• Find out what happens when the problem ends or starts to end• Search for contexts in which the client, family member, or other feels

competent and has good problem-solving or creative skills• Find out why the problem isn’t worse• Rituals of continuity and connection

Expectancy and Hope areCatalysts of Change

Key CompetencyDemonstrate faith in the restorative effects of services

• Evidence shows that client pretreatment expectations affect engagement, retention, and outcome.

• Have faith in clients and the restorative effects of services.• Believe and demonstrate faith in the procedures/practices.• Show interest in the results of the procedure or orientation.• Ensure that the procedure or orientation is credible from the client’s

frame of reference and is connected with or elicits previous successes.

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