In the last few months after doing some training with BRIEF I have been integrating Solution Focused practice into GP consultations. Of course it is inevitably not ‘pure’ Solution Focused practice, as my priority has be doing a good job as a GP, but I have long felt that the medical model is too narrow an approach to deal with the whole range of human difficulties which GPs often find themselves asked to help with and I have found solution focus to be a very good way to expand my skills. This piece is an overview of what I am discovering as I find my own way of allowing its stance and language skills to infiltrate my consultations.
The first significant learning point has been the effect taking a Solution Focused stance can have. Leaving some space for deliberately setting aside diagnoses and labels and looking at the person as a human being who is motivated for something to be different, is doing the best they can, and has successes and resources to draw on can create openings and possibilities. I think that we have to be careful that labels don’t obscure people’s individual stories and narrow our thinking and I have always felt uncomfortable with inappropriate pathologising. In some ways rather than being an objective assessment the act of asking questions determines to an extent the picture that emerges. It can be a difficult balancing act, and I have to ensure I’m getting all the information I need to do my job safely - but keeping this stance in mind can make a difference.
Consider ‘a twelve year old boy with behavioural difficulties who is verbally aggressive, impulsive and hyperactive affecting school and home’ and the addition of ‘his best hopes are to be calm and get on well with people, he excels at playing football and despite frequently feeling angry, more often than not chooses to take himself off to his room and manages to calm down by himself as he doesn’t want to upset his family’. Same person, depends what questions are asked and where attention is focused. Relevant information is still gathered and acted on appropriately but he may see himself a little differently if these other aspects are explored a bit than if the focus of the conversation is purely on finding information to make a diagnosis. Another example from this week is to contrast: ‘a 46 year old man whose notes list diagnoses of PTSD, cyclothymia and antisocial personality disorder’ with ‘a man who served with the tank regiment for three tours and commanded a unit, who had been drinking alcohol to cope with memories of being seriously injured in a roadside bomb and stopped last year without any professional support, and who hopes that the capacities for determination and focus he previously drew on can begin to show in his life again’. I find that when I hear these kind of answers I feel a genuine sense of admiration and warmth towards the person which is likely to be picked up by them, and also that I more often have a positive sense of anticipation when seeing them on the list, resulting in a virtuous cycle.
The second way in which training in Solution Focus has helped is being more precise with use of language. I will elicit a patients best hopes early on in the consultation to give direction to the consultation and also to provide a reference point to come back to if the conversation is unhelpfully getting stuck in too much detail about the problem - ‘and if your boss started talking to you like that again tomorrow, but somehow that energy and calm you hope for was present in your life in a way that was just right for you what might you notice about the way you respond that perhaps was a little bit different?”. In the midst of describing the problem people very often say things like ‘Tuesday wasn’t so bad but every day since then has been absolutely awful....’. This jumps out at me now and I find myself asking a few details about what they did differently on Tuesday, how they did it and the difference it made. This can sometimes allow subtle shifts to be made, and can also reveal reference points to come back to later on (‘suppose that slightly lighter feeling you had last Tuesday began to show up a little bit more, how could you know’). Scaling questions - where 10 is their best hopes happening (using the language they have previously given) and 0 the opposite - provide a very useful concise framework when time is short, they enable the focus to shift to what they have done to be at that number and not lower and often have the effect of increasing hope and sense of competency as well as being an opportunity for them to hear themselves say what is working already.
So often, especially in consultations about mental health difficulties, the focus is on the absence of a symptom rather than the presence of what they would hope to see instead. With the pressures of general practice it is a huge challenge to consult and write up notes in ten minute appointments at the best of times - but I often now feel compelled to find opportunities in the patients language to ask a few questions about details of the presence of their best hopes in their day to day lives. This is often only a minute or two and I am careful that such questioning is appropriate to the consultation but people tend to receive the questions gladly and engage with them and informally the outcomes seem to be better than before I started this practice. It is particularly useful in situations where people want to feel better in mood, calmer, more able to engage in social situations - times where the medical model often has less of use to offer. I will often as an opening use whatever we have agreed as a plan, and come back to the language given to me by the patient from the best hopes question and throughout the consultation. For example ‘if two weeks off from work turned out to be just the respite you needed, and the following week you had all the fighting spirit you could hope for and life was freshened up in just the right way what might be different about the way you woke up on the Sunday before your return to work, what might be the very first thing you notice’. There is not typically time to go through a day of course and in this example a few weeks ago I asked one or two questions about what her husband and children might notice and how her colleagues at work could know that this fighting spirit was present and ‘freshening up’ had occurred, and she came back having gone back to work early, had a conversation with her boss about things she wasn’t happy with and been moved to a new shop which she was pleased with. If I remember correctly her words were ‘I think I realised nobody’s going to be able to sort things out for me, I have to be proactive, and I’ve realised I can do it’. Who knows whether she would have had the same outcome anyway but it seems there’s a good chance our conversation helped, and this shift to increase sense of personal agency and autonomy seems to be a common one which is beneficial primarily to the patient but also to the GP and health service as well.
I remember reading a quote in a newspaper once which stuck in my mind: ‘Move the authority to where the information is’ – having since looked it up it was a quote from a man called David Marquet, a US Navy Captain whose work I am not familiar with but the idea seems relevant to the integration of a Solution Focused approach into medical practice. The doctor is the authority on medical knowledge and skills which is of course why people make appointments, and the patient is the authority in the intricate details of their own lives and the ways in which their short visit to see the doctor might alter those details for the better. The authority moves in a fluid way depending on the clinical situation and the point in the consultation - clearly in emergency situations medical intervention is the clear priority, and other times the authority would best be placed with the patient. As an example, when discussing lifestyle I will share relevant information and explain what lifestyle changes are associated with improvement. Then, rather than advising (as how could we know what changes would fit for them), I will often ask whether they’d be pleased if they moved towards that sort of change then follow up with some Solution Focused questions about what they or significant others would notice. This often results in a whole range of responses - things like walking for a paper instead of driving (person with osteoarthritis who wanted to lose weight), a son being pleased his dad might live to see his future grandchildren (man who smokes forty cigarettes a day with chronic obstructive pulmonary disease), specific things like choosing to not put chocolate biscuits in the shopping (woman with poorly controlled diabetes), being able to have breakfast with the children (somebody feeling low who wanted to cut down alcohol). This may increase motivation and likelihood of change but above all feels a way of talking with people which respects their expertise and therefore authority in their own life.
You may have heard the old joke about the man ordering six pints of beer, four glasses of wine, a coke and four bags of crisps and when asked would he like a tray, replying ‘no thanks I’ve got enough to carry’. In some ways this is how I see the addition of Solution Focused practice to GP work. And yet being realistic there is no getting around the fact that it can add pressure to a busy day if not carefully integrated - something which is an ongoing challenge for me, but one that significantly increases job satisfaction. I think there are other benefits to us as clinicians as well, not least the appropriate sharing of responsibility with the patient, especially where the outcome they hope for involves changes beyond the realistic reach of medical practice. For me the most important thing is that I want to work with people in a way that fully respects them as human beings with their individual stories, hopes and resources and integrating a Solution Focused stance and language skills significantly enhance my ability to do so.
Adam Lake GP
December 2019
