On Monday I read an article that reminded me of a session with a client back in May 1990. I had met with Harriet 8 times and, if we are being honest, there had not been a great deal of improvement, a little perhaps, but not much. I was finding it hard to work with Harriet’s lengthy accounts of just how tough life was for her, and as it happened, in May 1990, Steve de Shazer and Insoo Kim Berg were due to visit us and spend an afternoon consulting to our work. Since I was due to meet with Harriet that day I asked whether Insoo might like to meet with Harriet and I would sit in the session. Everyone agreed. The session included, as I recall, one of the most minimal signs of ‘coping better’ that I have ever heard ‘I might sit in my chair and think of making a cup of tea’, not making one, just thinking of making one, however what came back to mind for me was the way that Insoo ended the session. Having connected very strongly with Harriet, having acknowledged the enormously tough time that Harriet was living through, having praised Harriet for the strength that she had shown in just keeping going, Insoo suggested that Harriet contact the therapist, me, ‘when you are ready to take the next step’. Insoo’s intervention turned the modus operandi ante on its head, it completely reversed the logic of our work up to that point. I had been continuing to offer Harriet appointments because she was not changing but now I would only see Harriet again when she knew that she was ready to change.

I was reminded of this intervention, about which I do remember feeling somewhat queasy, when reading John Harris on Monday in the Guardian writing about the work of an Eating Disorder Service which, he reports, is discharging people, often people who had lived long-term with eating disorders, if they fail to change. The first clinical example in his piece was based on a conversation with ‘Jane’
“ “They told me that they couldn’t keep seeing me because I was losing weight,” (Jane) told me. “So they discharged me back to my GP.” At that point, her BMI was a very dangerous 15. “But they told me things weren’t working: I wasn’t motivated.” . . . . Jane felt she was up against truly impossible logic: the more ill she became, it seemed, the less likely she was to get treatment. Now, in fact, her worsening condition had resulted in her simply being cut loose.”

The second scenario concerned Charley
“who began her second spell of 24/7 treatment for so-called binge-purge anorexia in October 2019. After only six weeks, she was discharged as an inpatient with a BMI of 15 (“which is a really poor BMI, on the boundary of severe anorexia”), and offered the same kind of outpatient care as Jane, before she too was discharged to the care of her GP. Subsequent . . . . . paperwork said she “did not want to engage . . . . .  on any level”. She insists she desperately wanted treatment, but that it had to be different from the kind of care that had only resulted in failure.”

John Harris, in the final paragraph of the piece offers an implied hypothesis for what he thinks is going on here, referring us to the writing of ‘One of the most senior professionals in the . . .  service’ whom he quotes as writing in a newsletter “countless attempts to treat people who do not want to change take away resources from the people who have recently developed an eating disorder and could be helped”. In other words he implies that these patients who are not changing may be being viewed by the service as the equivalent of ‘bed-blockers’, people who are using up resources that could be better used elsewhere.

What thoughts might this lead us to from a Solution Focused perspective?

1.   First of all this reminds us of Steve de Shazer’s 3 rules of SFBT, derived of course, albeit with a subtle but important difference, from the work of the MRI. The third of Steve’s rules, although the second of the MRI rules, was ‘if it doesn’t work do something different?’. This fits with the research emanating from the Beyebach team which indicated that if after three sessions nothing useful is happening that we should either change therapist or the same therapist should ‘do something different’.  Insoo’s intervention shifted the entire framing of my work with Harriet; continued therapy was now predicated on the basis that the client is ‘ready to take another step’. And of course even halting therapy might, in extremis, be regarded as doing something different if what we are doing is not working. After all if what we are doing is not working then anything different, anything else might work. All that we know for sure in such circumstances is that what we have done so far has not worked.
2. However there was more to the closure than a mere ‘do something different’. The service seems to have developed a particular view, and indeed a rather negative view of these patients. They are regarded as people who ‘do not want to change’, people who ‘did not want to engage’, people who aren’t ‘motivated’. Indeed the discharged patients appear to have been told this, they have been blamed for the lack of change that has led to the withdrawal of their service. And this is a position that the Solution Focused practitioner can never take. We choose to assume that every client is motivated, every client genuinely wants to change and that every client is doing the best that they can do at all times. We choose to work with what people can do rather than becoming critical in relation to what they are not doing.
3. On this basis if people are not changing we would choose to think ‘I have not found a way of working effectively with this person’, or perhaps ‘the service has not found a useful way to deliver an effective service with this person’. We would choose to think ‘I (or we) have not found a way to elicit and/or to connect with the client’s motivation’ or ‘we have not found a way to engage with this client’. When framed this way, rather than in the client-blaming way, we are challenged to do better, to think harder, to be more imaginative, to be more creative . . . and then sometimes, of course, we fail. ‘We have not found a way of making a difference, yet – sorry – do you have any ideas of how we could do better?’ In Solution Focus we choose to take responsibility rather than dumping the blame on the client – it is a tough and demanding approach but thinking this way is more likely to lead to a critical evaluation of our service and to new thinking about what we might do that could work.
4. There is just one more thought about what might be going on here. When the service communicates to the client ‘it is your fault that no change is happening and therefore it is your fault that your vital, perhaps life-saving service, is being withdrawn’, perhaps the service does not truly believe that. Maybe it is an intensification in order to ‘get’ the client to take action; after all many of us will remember Steve de Shazer frequently saying to the client ‘so what are you going to DO?’, indicating to the client that the onus lay with the client to do something; in the end the client has to do something. So perhaps the workers do truly own the responsibility for the failure, they perhaps do know that they have failed (which all of us are bound to do at times even when we have done everything possible), and that this withdrawal framed as blame is merely an intervention. Were that to be the case it does seem to be a particularly risky, and maybe even a somewhat cruel intervention, but an intervention nonetheless rather than a mere disowning.
5. And the last thought that I have is something that everyone working in NHS Mental Health Services will struggle with every day. Underfunded services leave professional people making desperate decisions regarding who should get a service and who should not, whose life might be saved and whose might be ‘sacrificed’. Those decisions are dreadful and those of us who are not faced with making such decisions should tread lightly when talking about the practice of those people who have to do so and who are making those decisions on our behalf, working with the inadequate resources that we as a society decide to allocate to their work. We must own our responsibility too. However at the end of the day is it ever OK for clients to feel blamed for the failure of a service to help them to change? I doubt it.

By the way my client Harriet never returned for another session. I feel bad about it to this day.

With thanks to ‘Harriet’ and Jane and Charley as well as to John Harris for his interesting and provoking piece.

John Harris Your illness worsens – so care is cut off. This is the scandal playing out in eating disorder treatment. Guardian 25^th February 2024 https://www.theguardian.com/commentisfree/2024/feb/25/illness-worsens-scandal-eating-disorder-treatment-england

Evan George
London
03^rd March 2024.