The hospital was a crack in the beauty of its surrounding, wild, moorland landscape. Victorian red brick with vestiges of factory gothic, two layers of tall windows stretching across its north facing façade, and a chimney which both dwarfed and echoed the last of its sisters from the woolen mills. In a larger city it would already have been demolished for its land or turned into luxury apartments for young people oblivious of its tortured ghosts. But here, watching the perimeter of a declining northern town, the hospital continued to offer a bleak refuge for lost souls, many of whom, despite the odds, were being helped to find the first footholds back towards a better life.
I was there for a week, not as a patient; I was running a Solution-Focused Brief Therapy training for the mental-health staff. The transfer in the 1980s of all but the most intensive psychiatric treatments to community-based home-care services had, thankfully, seen the end of most 19th century prison-like hospitals, many of which had been sold for their land. But this hospital, out in the wilds, was of little monetary value and was falling into disrepair The training department for psychiatric services was located in an abandoned ward that had remained undecorated since it had been emptied more than two decades previously. Within this architecture of depression, it was not surprising to find the thirty-six course members in a somewhat low mood. Luckily, for teachers and learners, the business of learning how to be solution-focused is an enjoyable and energizing experience, so I was not unduly fazed by their initial lifelessness. By lunchtime, I was most definitely fazed; if anything, the group had become even more down-hearted, and I was beginning to doubt my own ability to last five days in such an atmosphere. As I was eating a dubious soup served with yesterday’s bread, Miriam, the lead psychiatrist, who had arranged the training, sat down and explained the gloom.
They were expecting a death. Rosa, a suicidal young woman had been admitted over the weekend and was being detained against her will so she could be force-fed. Though only nineteen she was well known to the hospital. From the age of twelve, she had been struggling against a compulsion to starve herself to death and was now close to losing the struggle. Being familiar with the system, she had come prepared, this time, with a lethal overdose sewn into her clothing. Only the vigilance of a nursing assistant had saved her, but pumping out her stomach had left her very weak. The staff’s choice was to risk killing her by force feeding or let her die from starvation. This was not the first time that I had encountered desperate patients being protected from self-harm on locked wards nor was it the first time I had offered to meet with the client. Putting the evidence, limited as it was, that there was an 80% chance of Solution Focused Brief Therapy leading to some lasting improvements in the client’s life (Shennan & Iveson, 2011) I asked Miriam if she would like me to see Rosa that evening after the course. Already on the horns of a dilemma and thinking that it couldn’t make things any worse Miriam put the offer to Rosa and Rosa accepted.
At five o’clock, when the course finished for the day, Miriam and I crossed the hillside to the hospital’s part-functioning west wing and began the long walk through a corridor flanked by abandoned rooms and almost palpably abandoned hope. The final door, opened by a key that might have come from a medieval dungeon, led us into the secure ward.
It was all but empty though, unlike the rest of the hospital, it had received a recent coat of white paint that served to highlight even more the wire caging that guarded the windows, television, and security cameras. A scattering of beanbags provided the only furnishing for Rosa, who stood, so thin, almost transparent, beside one of the tall Gothic windows that had at one time given this building a coating of elegance.
As the three of us, an Asian Muslim psychiatrist, a (non-believing) Christian English-Irish-Scottish brief therapist and a Jewish client, settled ourselves on our beanbags, I drove away my vanity-fueled fear of looking foolish when the time came to stand up and my arthritic limbs failed to straighten. Rosa, pale-skinned, large-eyed and impassive sat upright on her cushion. She knew she was close to death.
Whatever had brought Rosa to this so-sad state would have been explored, documented, hypothesized about, diagnosed and treated, all to no effect, so far. She had slipped through the various theories and treatment modalities and, despite the vast reaches of the medical model, she was doomed. So, why had she agreed to see me, a therapist? There must have been a good reason. There always is.
In the early days of Solution-Focused Brief Therapy there had been a three-part classification of motivation – “customer, complainant, and visitor” (de Shazer, 1988). BRIEF’s first outcome study (Iveson, 1991) showed these classifications to have no predictive value, at least as far as our assessment skills went. The supposedly unmotivated clients did as well as those deemed to be highly motivated. From our point of view, we had to act on this finding and so chose to experiment by treating all clients as if they were motivated. Almost thirty years later we have discovered no evidence from our own practice to abandon this position. When we ask our opening question, “What are your best hopes from our talking together,” we expect to arrive at an answer that we and the client can work towards. The answer may not always come easily but it does not occur to us it won’t come – it is part of our job. What is impossible to know is whether the client arrives with “motivation” or that “motivation” is constructed through the conversation – but in order to make such a construction, the therapist must act as if it is true, so the distinction is clinically irrelevant. Therefore we work on the assumption that all clients have a “good reason” for being and remaining in a conversation with a therapist. This “good reason” could be that they want to keep their freedom or their children, it could be because they want to achieve something that is proving hard to reach, it could be because they still have, somewhere, the last glimmer of hope that a better life is possible. Our job is to discover that “good reason” and make it the starting point for a useful collaboration.
Once we realized that “motivation” was a constructive process and part of the therapeutic task, we have always worked with “motivated” clients, and in 25 years of running a free clinic for people in extreme difficulty, we have never turned a client away. If they come through the door, even when they are mandated, we see them as motivated and see our job as discovering what they are motivated for. Once we know that we can ask our “miracle questions” to open up descriptions of preferred futures, and we can use scales to chart the histories of those futures. That is all that is necessary for an effective therapy averaging three sessions (Shennan & Iveson, 2011).
All this was forgotten in the intensity of the first seconds of our meeting; Miriam had all but disappeared, it was just me and Rosa who returned my interest with a stare empty of life. To my opening question, “What are your best hopes from our talking together?” she answered with such flatness and despair it could have extinguished the sun,: “I don’t do hope.”
Remembering it now, I can still feel a shiver at the back of my neck as, for a moment, a pit began to open before me. What hubris had brought me here? What had led me to imagine that I had anything to offer this young woman so close to her death, so determined to die? As these thoughts threatened to drag me down into Rosa’s pit of hopelessness, they were suddenly replaced by something close to joy. What an extraordinary privilege it was to be allowed to sit on the very cliff edge of another person’s death and invite her back to life. That was all I had to do. I didn’t have to understand her or understand what was driving her to this dreadful place. I didn’t have to “cure” her or fix her or make her life somehow right. All I had to do was ask another question, a question that contained an invitation to life.
Chris: If you did? If you did do hope?
Rosa: (With the same flat tone) I…don’t…do…hope.
I will always owe to Rosa the confidence these two answers gave to my future work. Confidence in the realization that all I ever have to do is ask the next question, and as each question is answered, there is a chance that the next answer will include an acceptance of my invitation to take a small step towards life, towards a more livable future. As Rosa reiterated her refusal to hope, I saw, with the clarity of a vision, the task before me. In my mind we had entered a ‘white cube’, a room devoid of all features and not only had the door closed behind us, it had been erased forever. The only way out of this cube-like room was through a second door known only to Rosa. My job was to ask the questions that would bring Rosa to a discovery of this knowledge only she possessed: the whereabouts of the second door – the door to life. When she found it, we could both leave and go our separate ways. Since my meeting with the extraordinary Rosa, this “vision” has supported my journeys with many people close to preferring death instead of their almost unlivable lives and given me the hopefulness that awakens the next question, and the next.
Still in search of Rosa’s “good reason,” for seeing me the conversation progressed to the third question.
Chris: How come you agreed to see me?
Rosa: It’s something to do.
Chris: Is it? Seeing a counselor? Most people in here would run a mile before seeing someone like me!
Rosa: That’s true!
Chris: So how come you agreed?
Rosa: You don’t know how bad it is in here!
Chris: Don’t you like it?
Rosa: What do you think?
Chris: I don’t know, but I bet there are people here that like it so much they can’t be persuaded to leave.
Rosa: (With the first sign of animation) Well, I’m not one of them!
Chris: So, you want to leave?
Rosa: (Forcefully) Yes, I do!
Then I felt the Miriam (the psychiatrist) shift her position, and a new tension entered the room. She and Rosa knew where this was going, to leave in a coffin, and both assumed that I didn’t.
Chris: So, if our meeting, in some way helps you leave here, that means it will have been useful?
Rosa: Maybe
Chris: I mean leave here in a way that is right for you?
Rosa: (with renewed animation) Yes!
Miriam was now becoming quite agitated and was likely at any moment to call a halt, to stop me, apparently, working with Rosa towards her death since Rosa had told the hospital staff earlier that she intended to leave the hospital in a coffin.
I have never wanted to kill myself, but I could imagine that if I did, I would not regard seeing a counselor as the right route for such a venture, and neither can I imagine amusing myself with idle conversation. Consequently, I assumed that Rosa, at some level, possibly not even obvious to herself, had not entirely given up. It was this Rosa I was looking for, the Rosa with a “good reason,” but with very little time before the psychiatrist called a halt to what she was beginning to believe was a misguided and possibly dangerous conversation.
Chris: So, let’s imagine that tonight, while you are asleep, a miracle happens; it doesn’t get you out of here, but what it does do is set off the process which will enable you to leave this hospital . . .” (Miriam was now like a kettle about to blow its lid and I hoped that what I said next, though vital to the invitation, would shock her into a silence just long enough for me to finish my question) “. . . leave this hospital in a way that is absolutely right for you . . . (Now Rosa was almost aglow with anticipation of the death she has been working towards for so many years) . . . absolutely right for you – and right for the hospital. What will be the first thing that you notice that tells you that a miracle has happened?
As “right for the hospital” was spoken, Miriam slumped with relief and the light went out of Rosa’s eyes. There is a pause as we made room for her answer, and then she let out a long sigh. It was a sigh that I have heard many times since, and though it carries with it a sadness, it seemed to mark the start of a decision to give life another chance, hard work that this will be. Following the sigh,
Rosa said:
Rosa: I suppose I wouldn’t feel so bad when I woke up.
Chris: How would you feel instead?
Rosa: I wouldn’t be happy.
Chris: So how do you think you would feel after this miracle even though you weren’t actually feeling happy.
Rosa: I don’t know, maybe a sense of just getting on with it.
Chris: What time would that be?
Rosa: Too early! When they start clanking around and changing shifts.
Chris: Who might be the first to notice at that early time that you had woken up ready to “get on with it”?
Rosa: Probably, Angela, she’s one of the ward sisters and she’s on this week.
Chris: What do you think Angela might notice that gives her the first hint that this miracle has happened and you have decided to “get on with it”?
Rosa: (laughing) I’ll say “Good morning” to her.
Chris: Will she be surprised or does that happen anyway?
Rosa: She’ll definitely be surprised – I don’t talk to anyone at that time!
Chris: How do you think she’ll respond?
Rosa: She’ll probably want to hug me!
Chris: Would you like that?
Rosa: (looking at her body) as long as she didn’t snap me in half!
Chris: What would Angela notice about your response to her hug that fitted with you deciding to “get on with it”?
Rosa: I’d probably tell her she didn’t have to worry, not this time anyway.
Chris How might she respond to that?
Rosa: Knowing Angela, she’d probably cry – we’d both probably cry!
Chris: What might be the next small sign that this miracle had happened?
The chain of questions had begun. Rosa described what she, other patients and staff members would notice the following morning as she began her long and difficult journey back to a life worth living. Later in the session when describing what was keeping her just above zero on a 10-point scale where ten represented the life after the miracle that she had been describing for most of the session, Rosa reluctantly admitted that to have lived through what she had lived through, had required many great strengths and these strengths just might serve her well in the challenges ahead.
In cases such as Rosa’s my first task is to establish a legitimate outcome. Rosa’s ostensible “hope” was for death, but she would be perfectly cognizant of the restrictions on my endeavors. For most of us, helping a client commit suicide would be unethical, and Rosa would not have expected me to go down this path. Instead, I offered her a path which fitted her spoken wish to leave hospital “in a way that was right” for her, and added the legitimate safeguarding limitation on the available routes. It would be the same with other mandated clients: caring for your children in a way that is absolutely right for you and also right for the authorities; staying out of jail in a way that is absolutely right for you and right for the court.
Structurally, the session was a “textbook case”: about five minutes to establish a desired outcome, thirty or so minutes describing the fine detail of a realistic tomorrow, and around fifteen minutes using a scale to uncover the history of the client’s preferred future. In place of finishing by giving Rosa compliments, or commendations, I asked Miriam to tell me what she knew about Rosa that gave Miriam hope that Rosa would somehow win through to a better life. Miriam had plenty to say, much of it a pleasant surprise to Rosa.
The following morning Miriam arrived late for the course. She had been to see Rosa who she found, for the first time, in the dining room. She had declined breakfast (“I never eat breakfast!”) but was drinking a cup of tea. To Miriam and the entire group this was, indeed, a miracle. For several years, while Miriam was in charge, I returned every year to train the new staff in Solution-Focused Brief Therapy, all enthusiastic mental-health professionals eager to learn.
Eight years later Rosa was still “on the books” but just for six-monthly reviews. She was also married with two children.
Shennan, G., Iveson, C. (2011) From solution to description: practice and research in tandem. In Franklin, C., Trepper T., et al (Eds.) Solution-focused Brief Therapy: A Handbook of Evidence-based Practice. New York: Oxford University Press
Chris Iveson
London
17th September 2023
