j.1447-0349.2009.00659.x

Feature Article_659 210..219 Mental health nursing from a solution focused perspective Timothy Wand Emergency Department, Royal Prince Alfred Hospital, and Faculty of Nursing and Midwifery, University of Sydney, Sydney, New South Wales, Australia ABSTRACT: Solution focused therapy (SFT) is a relatively new and increasingly popular model of brief intervention in mental health care. The central assertion of SFT is that the individual’s problem or difficulty (and its cause) need not determine the direction in which the discussion proceeds. Instead the role of the SFT practitioner is to identify what the individual wants to be different and then to explore and elaborate on that difference. This paper outlines the principles of SFT and highlights the compatibility of this approach with the core values of nursing practice. Specific strategies and techniques used in SFT are detailed with clinical examples to illustrate the application of SFT to mental health nursing practice. A summary of current research outcomes and future prospects for SFT in clinical practice and education is also presented. KEY WORDS: mental health nursing, nurse-patient relationship, solution focused brief therapy, solution focused nursing, solution focused therapy. INTRODUCTION Solution focused therapy (SFT) also referred to as Solu- tion Focused Brief Therapy developed predominantly from the work of Steve de Shazer, Insoo Kim Berg and their colleagues at the Brief Family Therapy Centre in Milwaukee, USA (de Shazer 1985; 1988; de Shazer et al. 1986). de Shazer and Berg were from a social work background and were also husband and wife. They are both now deceased. Steve de Shazer died in 2005 while on a teaching tour in Europe and Insoo Kim Berg died suddenly in Milwaukee in 2007. However, SFT con- tinues to thrive in both practice and training around the world as evidenced by two professional associations and a myriad of professional training centres. In Europe SFT has been enthusiastically embraced following the establishment of The European Brief Therapy Associa- tion in 1994, and in the USA with the formation of the Solution Focused Brief Therapy Association in 2002 (Trepper et al. 2006). Since its inception SFT has been applied to an array of age groups and problems including child protection and family therapy, domestic violence, school bullying and school refusal, the prison and juvenile justice system, sex therapy, business and management, alcohol and drug use and relationship issues. Mental health problems such as eating disorders, anxiety, depression, suicidal thinking, deliberate self harm and psychosis are all considered receptive to SFT across community, outpatient and acute inpatient settings (Blymer & Sheer 1994; Blymer & Smith 1991; De Jong & Berg 2008; Iveson 2002; Macdonald 2007; Trepper et al. 2006; Vaughn et al. 1995). This paper highlights the principles of SFT and the compatibility of this approach with nursing practice. Clinical examples of SFT strategies and techniques are used to illustrate the application of SFT to mental health nursing (MHN). The utility SFT has for nursing research, education and train- ing is also briefly identified. Correspondence: Timothy Wand, Missenden Rd, Camperdown, NSW 2050, Australia. Email: timothy.wand@sswahs.nsw.gov.au Timothy Wand, RN NP MHN DAS (Nurs) Grad. Dip (MH Nurs) MN (Hons). Accepted October 2009. International Journal of Mental Health Nursing (2010) 19, 210–219 doi: 10.1111/j.1447-0349.2009.00659.x © 2010 The Author Journal compilation © 2010 Australian College of Mental Health Nurses Inc. PRINCIPLES OF SFT de Shazer et al. developed SFT from the observation that shifting from a problem-based approach to one that con- centrated on solutions often yielded better therapeutic results in a shorter period of time for their clients (Trepper et al. 2006). The SFT approach is therefore based on solution building rather than problem solving. This is conducted by exploring the client’s current strengths and future hopes rather than discussion of present problems and their past causes (Iveson 2002). The fundamental premise underlying SFT is that the problem or difficulty that brings the individual to therapy need not determine the direction in which the discussion proceeds (Miller & de Shazer 1998). This is based on the understanding that the cause of the problem is not nec- essarily associated with resolving it and that clients them- selves have resources which they will use to make changes. Solution focused therapy also recognizes that a rapid or complete resolution of problems is unrealistic and that small obtainable goals are preferred (Blymer & Sheer 1994; Macdonald 2007; Webster et al. 1994). In a typical SFT session, little time is spent discussing the problem or the past, except to identify resources and successes that may have been forgotten or devalued (Webster 1990). Solely talking about problems and defi- ciencies is not considered sufficient to mobilize change in clients. The shift in SFT is to what is going well rather than what has gone wrong (Hosany et al. 2007). Solution focused therapy also contends that what clients say works for them matters, not what clinicians think should work. The individual is discounted if the practitioner presumes to know what the client thinks is important or what is needed in their life (Webster et al. 1994). Contemporary assessment formats are not aimed at identifying exceptions to the client’s problems or past successes, but rather designed to seek information that confirms the client’s pathology (Blymer & Smith 1991). While risk factors are considered, SFT eschews the present fixation on risk, illness and diagnosis. The SFT practitioner adopts a respectful, interested, non-blaming, non-judgemental and cooperative stance. The assumption in SFT is that the client is competent to figure out what they want and need, and is willing to do something about it. The practitioner’s responsibility is to assist the client to discover these competencies. Any notions of client ‘resis- tance’ are dismissed by SFT as professionally self serving (Macdonald 2007). Instead anger, resistance and a lack of motivation or ‘insight’ are viewed simply as indications that the practitioner has yet to find a way of working with the client (De Jong & Berg 2008). Problem oriented interventions tend to be based on behaviour modification and psychodynamic principles. In SFT the client’s goals become the focus as well as the clients own observations of what facilitates movement toward their goals (Vaughn et al. 1995). Solution focused therapy maintains that talking about problems only serves to highlight the person’s deficits while talking about the person’s goals provides an opportunity to highlight com- petency and skill. Solution focused therapy employs ques- tions aimed at surfacing the client’s strengths, resources, and vision for the future, thereby helping the client for- mulate solutions to problems rather than dwell on the problems themselves. This is not simply a psychothera- peutic approach but an alternative way of thinking and working with people (Ferraz & Wellman 2008). De Jong and Berg (2008) argue that practitioners do not directly change clients. Rather, clients change them- selves usually by deciding to do something different. Prac- titioners work more effectively when they do not think of themselves as all knowing experts but instead put clients in the position of informing practitioners what they might want, what could happen in their lives, and how to go about making those changes (De Jong & Berg 2008). This is achieved by exploring what works for the client and getting them to do more of it, emphasizing to clients that doing one thing differently may be all it takes to solve a problem and that a small change can create a ripple effect that in turn can affect other parts of the client’s life (Webster et al. 1995). Solution focused therapy also high- lights the significance of assisting the client to reframe their situation or experience. Clients become trapped by a particular view of themselves as incompetent and power- less. Change occurs not from understanding why a problem or situation has occurred but from seeing oneself (or situation) differently (Miller & de Shazer 1998). Reframing also has an effect on how clinicians view the client and the problem (Webster et al. 1994). SOLUTION FOCUSED APPROACHES AND NURSING PRACTICE Solution focused approaches have been described in MHN clinical practice and research (Stevenson et al. 2003; Vaughn et al. 1995; Webster 1990; Webster et al. 1994; 1995; Hosany et al. 2007; Ferraz & Wellman 2008; Lamprecht et al. 2007;Walsh&Moss 2007). In other areas of nursing SFT principles have been applied to a variety of practice domains such as early parenting and working with children and families (Carter 2007; Rowe & Barnes 2007), learning disabilities (Musker 2007), youth work (McAllister 2007a), acute medical care (Henderson 2007), SOLUTION FOCUSED MENTAL HEALTH NURSING 211 © 2010 The Author Journal compilation © 2010 Australian College of Mental Health Nurses Inc. long term illness (Gardner & Gardner 2007), dementia care (Adams & Moyle 2007), as well as nurse education, training and practice development (Vaughn et al. 1995; Webster et al. 1994; McAllister et al. 2006; McAllister et al. 2008; Walsh et al. 2008; McAllister et al. 2009). Webster et al. (1995) correlate the shared philosophi- cal foundations of SFT with the aims of nursing. These aims include building trust, promoting clients’ positive orientation, promoting clients’ control, affirming and pro- moting strengths, emphasizing the pragmatics (‘what works’), and setting client goals that are health directed. Webster et al. (1995) propose that older psychotherapeu- tic models concentrate on the significance of transfer- ence, resistance, confrontation, insight, personality change, and interpretations from the therapist’s theoreti- cal perspective. Newer psychotherapeutic models, however, that are based on accepting and working within the client’s view of reality and an orientation to health, are more consistent with nursing’s core values. The therapeu- tic relationship has always been central to nursing and remains the main ‘intervention’ in nursing practice. This reflects the belief that this relationship itself constitutes a major therapeutic contribution. It is therefore important to form a cooperative learning relationship which acknowledges that clients are the experts of their own lives and have invaluable contributions to decisions regarding the need for structure and participation in treatment options (Webster et al. 1995). Demonstrating an ability to listen attentively, provide reassurance and offer support is also vital in promoting therapeutic opti- mism and facilitating change (McAllister et al. 2009). McAllister (2003) argues that a problem focus may be useful for disciplines such as medicine, but not so useful for nursing with its strong focus on human relationships and identifying abilities in individuals. Intervening and taking control prematurely, acting as the expert, offering only a passive role to patients, ignoring personal strengths and abilities, and fostering an illness mentality are all aspects of health care that need to be challenged. Con- stantly searching for problems may prevent appreciating the things that are going right for a person. It may also be that some problems may never be resolved completely, and a focus on the negative is inherently pessimistic. One of the main effects of problems, and people’s experiences of them, is to blind people from noticing their strengths and capabilities, or the solution oriented behaviour that may already exist. People tend to focus on times when they have not coped rather than when they have and the medically dominated approach to health care only reinforces this through a problem based orientation (McAllister 2003). McAllister (2007b) promotes a philosophy of solution focused nursing which offers nurses a way of working with clients that is more respectful, more optimistic and more enabling. This involves skills of critical thinking, con- sciousness raising and being with clients in positive and solution oriented ways. Nurses typically work with clients around ‘life transitions’ which are the points in a life where choices are made about which direction to take. Solution focused nursing is a facilitative, participatory, respectful process that acknowledges and accepts that people will ultimately make their own decisions. Clients rely on nurses to interpret complex health information into sizes that are manageable and into practices that can be used by the person in everyday life. Nurses therefore assist clients by explaining choices and promote the build- ing of skills to facilitate informed decision making and actions. Solution focused nursing is not about taking away control or doing things to people regardless of their coop- eration (McAllister 2007b). In health care the dominant approach is to view the patient in terms of their diagnosis. McAllister et al. (2009) claim that problem identification and diagnoses have become the preoccupation of clinicians. The result is that the individual tends to be seen through a narrow bio- medical lens, rather than the wider context of the person’s life. Walsh and Moss (2007) argue that classification systems may offer some benefits, however their focus on a list of symptoms can obscure the humanity of the other. Working in solution focused ways involves conveying the message to clients that they are unique individuals with the capability of improving their situation (Walsh & Moss 2007). SOLUTION FOCUSSED STRATEGIES AND TECHNIQUES Turnell and Hopwood (1994a) recommend against fol- lowing a particular SFT recipe where ingredients are added in a certain order. Rather, they suggest modifying questions and strategies according to a sense of what best suits the client and where they want to lead the dialogue. This is emphasized by Macdonald (2007) who warns prac- titioners against being ‘solution-forced’ in their approach. Not all the techniques in SFT are applicable to every situation, while some techniques work better with some people than they do with others (Walsh & Moss 2007). Typically SFT is conducted over three to five sessions, though many clients only require one session (Iveson 2002; Macdonald 2007). Blymer and Sheer (1994) observe that studies of single session SFT reveal that the main reason clients do not return is because they 212 T. WAND © 2010 The Author Journal compilation © 2010 Australian College of Mental Health Nurses Inc. have accomplished what they intended from one session. Macdonald (2007) recommends that a fixed session limit is not helpful and simply advocates ‘no more sessions than is necessary’. Starting the session The first interview in SFT is the most important and it is when the majority of work is done. Unlike other psycho- therapeutic approaches, the treatment process begins immediately. No detailed history is taken but if an indi- vidual has clearly not had an opportunity to tell their story then this may need to be listened to before continuing. Usually, however, clients are relieved to not have to repeat their story or be asked to divulge painful details about past unhappy experiences (Macdonald 2007). Importantly, the client is first thanked for coming and the name they prefer to be called elicited. The initial task is to delineate what the goals of the client are within their frame of reference (de Shazer 1985). This is usually achieved by asking an open question such as ‘what do you hope to get out of coming here today?’ In SFT using the name or terms used by the person to describe the problem (language matching) is considered far more pow- erful than applying professional terminology or jargon to the problem. It also represents a way of staying connected to the client’s experience and demonstrates the practitio- ner is attending to the client (Macdonald 2007). It is vital to acknowledge the pain or the difficulty of the circumstances which the individual is confronting (Blymer & Sheer 1994) and to listen for clues to any pre-session changes that indicate the clientmay be less distressed since initially coming for help and explore these changes (Turnell &Hopwood 1994a;Webster et al. 1994). It is also common practice in SFT to ask the client what they have tried so far to resolve their problems – ‘What’s beenhelpful in the past in getting you through (this same problem) and/or other difficulties in your life?’ – with the aim of identifying symptom free periods and successful coping strategies. Identifying what works puts problems into per- spective andhighlights potential solutions from those areas of successful functioning (Vaughn et al. 1995). The SFT practitioner then listens to and asks for details about what the client might want to be different. Information is obtained by asking questions about who, when, where and how. Questions of ‘why?’ are not part of the SFT dialogue as they tend to elicit speculative analysis of possible underlying causes of problems and behaviours, and are a diversion from clarification of goals and what the client wants to be different (De Jong & Berg 2008; Mac- donald 2007). A list of routine SFT questions is provided in Table 1. The miracle question The miracle question is used to help clients project them- selves into the future (Webster et al. 1995) and to visual- ize and describe in detail how the individual wants things to be different (de Shazer 1988). It provides the client with permission to consider an unlimited range of possi- bilities and helps to think about moving beyond current problems to achieve a more satisfying life (Ferraz & Wellman 2008). The miracle question consists of a set format and is usually prefaced by saying ‘Can I ask you a strange question?’ Let’s imagine that tonight you go to bed and while you’re asleep a miracle happens. The result of this miracle is that you wake up tomorrow morning and all the problems you’ve come here to talk about are solved. How would you know, or what would be the first (small) things you notice that tell you this miracle has happened?’ The miracle question encourages the client to think about things differently, which can be challenging if the client is consumed by their problems. The practitioner should ask the miracle question slowly and allow for silence while the client considers this prospect. The aim is to open up a ‘miracle dialogue’ that explores in detail the changes that would be noticed, not just by the client but by family, friends or work colleagues and what each person might do or say differently when the miracle happens (Turnell & Hopwood 1994a). The following brief dialogue is a condensed example of what might follow the miracle question, though in reality it would be TABLE 1: Routine solution focused therapy questions What is it that brings you here to see me today? What do you hope to get out of coming here today? What are your best hopes for this session? How will you know that coming here was helpful? What will be different when this problem is solved? How do you keep going? What will be the first small thing that tells you things are headed in a positive direction? How did you do that? How did you decide to do that? How did that make a difference? When is it working? How do you want things to be? When are the times you feel like you handle it even a bit better? How does that make a difference? What will people see you doing that will tell them that you are happier? What will be happening when this is all over? How will other people know that things are better? SOLUTION FOCUSED MENTAL HEALTH NURSING 213 © 2010 The Author Journal compilation © 2010 Australian College of Mental Health Nurses Inc. more exhaustive. It is anticipated that the miracle dia- logue pr