One thing after another?

Steve de Shazer would often say that one way of thinking about good outcomes in therapy is to think of shifting with the client from ‘the same damn thing over and over’ to ‘one damn thing after another’. ‘One damn thing after another’ is, Steve de Shazer suggested, the way that life is for most of us. It’s the quality of stuckness in ‘the same damn thing over and over’ that distresses and bothers both us and our clients. But sometimes the new and different difficulties come thick and fast. In these circumstances families can be labelled by professionals as ‘multi-problem’ families. In turn, paying attention to the power of language and the way that description shapes expectation, Insoo Kim Berg responded to this and suggested that it might be useful to think about such families not as multi-problem but as multi-goal.

Both these suggestions are potentially useful and yet there is more I think that can be added. So how does solution focused brief therapy deal with families who present many problems at a time or one problem after another, after another after another?

From multiple problems to single solutions.

Clients can present many difficulties. For example the client may complain of an enuretic child, an out of control adolescent, an unappreciative spouse, of feeling depressed and unconfident. Traditionally in a problem-solving approach the therapist considers each problem in turn and devises with the client an individual strategy that is intended to address the problem. Thus for five apparently discrete problems the worker will consider five specific responses.

What is interesting within solution focused brief therapy is that if the worker offers the client a miracle question in relation to the enuresis, the picture of life instead typically pretty much resembles the picture of life instead when the adolescent is no longer out of control. And further this picture of life is normally pretty much the same as the client’s picture of life with an appreciative spouse. It by and large also coincides with the client’s idea of how s/he will know that the depression and the lack of confidence are resolved. So within solution focused brief therapy the worker moves from multi-problem to a unified picture of the miracle.

This of course makes absolute sense when we remember that in solution focused brief therapy the worker and client will not be attempting to move away from the problem but will be aiming to move towards the client’s picture of the preferred future. The client’s picture of life going well for him will normally be inclusive, implying the resolution of allthe problems facing her. Therapy can thus be enormously simplified.

Becoming a problem-solver (or miracle maker).

There are times when the client is not complaining of many concurrent difficulties but instead sequentially appears to raise one difficulty after another with the worker. For the client the one after another quality of her experience does not speak to her of her normality but may appear to suggest instead a hopeless and unequal struggle in the face of relentless adversity. After a while this can shift to the client appearing to begin to take on the blame and to describe herself as a hopeless and worthless person.

A particular sort of miracle question can be useful in these circumstances

‘Suppose a miracle were to happen and you were to discover that you were indeed able to face up to all the problems that life is throwing your way. How would you know? What would you see yourself doing differently? How would others know that this change had occurred? And how would you respond differently to them and how would they respond differently to you responding differently to them?’

Clearly in talking this way with the client the conversation shifts away from each individual issue and focuses instead on the client as problem-solver (or miracle-maker). Worker and client have jumped up a level of genericism and found, again, a more inclusive preferred future with which to work.

Ending with confidence

There are times when it can appear to the worker that the client raises a new issue each time that the client and worker get near to finishing their work together. One respectful way for the worker to proceed is to ask herself, or indeed to ask the client, what good reason the client may have for doing this. (Lipchik). For the client, finding herself in a situation where she has little power (particularly if she is not paying for the therapy), noticing new issues that require discussion with the therapist may be the only way that the client has to prolong the therapeutic process. If the client is not yet feeling confident enough of maintaining the changes she has made this may very well be a good reason for continuing to raise new difficulties until the new direction in her life is stabilised. The cost of this strategy to the client is often substantial, risking her being labeled as manipulative. The application of this tag can of course significantly affect the client’s future access to service.

In such circumstances the issue can then be addressed directly and straightforwardly by the worker who can ask:

‘How will you know that the time has come to end? What will you be doing differently that will tell you that your life is confidently on track? How will others notice the change?’

Alternatively of course the worker can invite the client to scale her confidence of maintaining the changes that she has made and of getting to the confident enough point on her scale:

‘What point represents on your scale you being confident enough of maintaining all the changes that you have made and of facing all the future challenges that life will throw up?’

‘How will you know that you are there?’

‘What will tell you?’

‘What will all the others in your life (family, friends, professionals) be noticing different at this point?’

The key shift that both these frames imply is that it will be the client who will determine the ending point of the therapy rather than the worker, unless, naturally, statutory concerns remain. Indeed it is suggested by both approaches that the ending will take place when the client’s concerns have been addressed and not at a point determined unilaterally by the worker, although naturally the worker may be obliged to prolong the work for monitoring or safety reasons. The move towards collaboration removes the pressure, even necessity in the client’s experience, of behaving covertly.

Evan George
September 2010