Solution-Focused Brief Therapy (SFBT)

Solution-Focused Brief Therapy (SFBT) is a variant of Cognitive Behavioral Therapy (CBT) that incorporates insights from Positive Psychology.

OVERVIEW

Solution-Focused Brief Therapy, also called Solution-Focused Therapy (SFT) was developed in the mid-1980s by husband-and-wife team, Steve de Shazer (1940-2005) and Insoo Kim Berg (1934-2007).[1-3] Developed in clinical work collaboration with their colleagues at the Milwaukee Brief Family Therapy Center, their research on SFBT first began in the late 1970s.[4] The team used insights gleaned from disciplined observation of therapy sessions along with descriptive and follow-up studies of cases to develop and shape the approach into what it is today.[5,6]

Since its development, (SFBT) has become a widely-utilized therapeutic approach, practiced in a range of settings across North America, Europe, and Asia. This modality has become widely accepted among social workers and other human service professionals due to its focus on strengths and solutions, rather than deficits and problems. Further, this method is favorable as it provides a rational framework for doing therapy briefly (often less than six sessions) in a managed care environment. Comparatively, SBFT has often been recommended due to its efficacy and ability of achieve results in less time, thusly at lower cost, than other approaches.[7,8]

Solution-Focused Brief Therapy (SFBT) is a short-term, goal-focused, evidence-based therapeutic approach, incorporating positive psychology principles and practices. This method helps a person change by helping them construct solutions rather than focus on problems. At its core, SFBT has been dubbed a hope friendly, positive-emotion eliciting, future-oriented vehicle for formulating, motivating, achieving, and sustaining desired behavioral change. SFBT has continued to grow in popularity, both for its usefulness and its brevity.[9]

SFBT acknowledges present problems and past causes but predominantly explores an individual's current resources and future hopes. By focusing on solution-building rather than problem-solving, clients can look forward, utilizing their own strengths to achieve their goals. While SFBT is considered a time-limited approach, the technique is often incorporated into other long-term therapy modalities, and its effects can be long-lasting.[10]

Theoretical Model

SFBT was founded on seven basic philosophies and assumptions. These concepts are the key building blocks in the formation of the solution-focused approach:[11]

Change is both constant and certain.
Clients must want to change.
Clients are the experts and outline their own goals.
Clients have resources and their own strengths to solve and overcome their problems.
Therapy is short-term.
Emphasis is on what is changeable and possible.
Focus on the future; history is not essential.

The solution-focused approach is a humanistic therapy, focusing on one’s self-development, growth and responsibility. Goal-directed, SFBT focuses on building solutions rather than on solving a client’s problems.

Rather than dwelling on an individual's weaknesses and limitations, this Solution-Focused Therapy does the opposite: concentrating solely on an individual's strengths and possibilities helps a client move forward. SFBT’s efficacy stems by helping a person overcome problems without tackling them directly; the solution-building concept is utilized to foster change and help individuals develop a set of clear, concise and realistic goals. The therapist’s role in this regard is to help elicit and implement these solutions via a series of discussions.

Within session discussions, the therapist helps individuals envision a clear and detailed picture of how they see their future - and how things will be better once changes are carried out. Therapists also encourage clients to explore past experiences and times when they were as happy as they can envision themselves in their future. The aim of these processes is to evoke a sense of hope and expectation, making a future solution seem possible.

It is this positive vision of a client’s future that drives the therapeutic process forward. By ensuring that the aim of SFBT is focused and directional, resulting in a more timely/brief resolution of therapy. Therapists utilize their client’s future solution to shape the techniques and questions comprising discussions. By doing so, they aid the individual to realize their potential and find the courage to move forward.[12]

The practicality of the SFBT approach may stem, in part, from its development within an inner-city outpatient mental health service setting, in which clients were accepted without previous screening. De Shazer, Berg, et al. spent innumerable hours observing therapy sessions over the course several years. Within their work, the team carefully noted any questions, statements or behaviors on the part of the therapist that led to a positive therapeutic outcome. The questions, statements, and activities correlated with clients who reported progress were incorporated into the SFBT approach.

SCIENCE BEHIND IT / EFFICACY

SFBT is a well-researched, evidenced-based psychotherapy approach. With nearly 150 randomized clinical control studies, comprised of different control populations in varied clinical settings across multiple countries, nearly all reported positive benefits of SFBT.[13] Further, there have been eight meta-analyses indicating the positive effects of SFBT across a range of outcome studies, with an overall effect size ranging from small to large, for child, adolescent, and adult populations, for presenting problems such as depression, stress, anxiety, behavioral problems, parenting, and psychosocial and interpersonal problems.[14,15]

In 2013, Gingerich and Peterson published their findings on the effectiveness of SFBT utilizing a systematic qualitative review of controlled outcome studies. Conducting a meta-analysis of forty-three studies, they abstracted data regarding: problem, setting, SFBT intervention, design characteristics, and outcomes. They found that thirty-two (74%) of the studies reported significant positive benefit from SFBT, with a further 10 (23%) reporting positive trends. Gingerich and Peterson noted the strongest evidence of effectiveness came in the treatment of depression in adults, where four separate studies found SFBT to be comparable to well-established alternative treatments. Three studies they reviewed had examined length of treatment - all of which found SFBT utilized fewer sessions than alternative therapies. Gingerich and Peterson concluded the studies they reviewed provided strong evidence that SFBT is an effective treatment for a wide variety of behavioral and psychological outcomes.[16] Further, SFBT may be briefer, thus less costly than alternative approaches.

Within Gingerich and Peterson’s work, they found only one study which showed an alternative treatment to have a significantly better outcome than SFBT. A Canadian study of youth with emotional and behavioral disorders, compared a 5-day per week residential program using SFBT against an intensive in-home family preservation program. While the SFBT group improved significantly on externalizing behaviors similar to the alternate treatment group, it did not change on internalizing behaviors. The alternate group, however, showed significant improvement in this regard. Both groups showed significant and comparable improvement on two other measures of social competence and behavior problems.[17,18]

One particular study providing the most rigorous test of SFBT’s effectiveness is the Helsinki Psychotherapy Study. This study used a large sample, a randomized design, well-established alternative treatments, highly experienced therapists who had allegiance to their respective approaches, an array of objective and well-established outcome measures with an extensive follow-up period. This study compared four modalities of therapy: SFBT (using an average of 10 sessions); short-term psychodynamic psychotherapy (with an average of 18.5 sessions); long-term psychodynamic psychotherapy (with an average of 232 sessions); and psychoanalysis (with an average of 896 sessions). The Helsinki Study found the two short-term therapies achieved comparable outcomes within 6 months, which was the approximate end of treatment. Improvements in the long-term group did not begin to materialize until the second year, and by the end of the third year (end of treatment) improvements were significantly better on several of the outcome measures. The psychoanalysis group was found to perform significantly better on several outcome measures at the end of 5 years (end of treatment). Knekt et al. noted that the fact that this study found statistically significant benefits from SFBT, comparable to the alternative short-term treatment, further strengthens the reliability of SFBT outcomes.[19-22] Gingerich and Peterson add that while the Helsinki study provides clear evidence that SFBT requires many fewer sessions (and usually over a shorter period of time than alternative therapies), the longer-term therapies showed some incremental benefits later on. However, there were no data backing whether these differences were clinically significant. They also note the issue of comparing outcomes of the different treatments at widely different follow-up periods.[23]

Overall, the empirical evidence for SFBT is strong, particularly in the fields of mental health and occupational rehabilitation, thus practitioners can feel confident using SFBT in the context of evidence-based practice. This evidence appears strongest in the more traditional psychotherapy fields, where the office setting allows for interventions to be implemented consistently. There is further growing evidence of SFBT’s effectiveness in nontraditional settings; in 2013, Gingerich and Peterson noted that they expected this evidence will increase as SFBT becomes better-adapted to these settings, with outcomes more reliably and validly measured.[24]

PROCEDURE

SFBT practitioners help client develop solutions by first generating a detailed description of how their life will be different when the problem is gone or their situation satisfactorily improved in the client’s opinion. The therapist and client carefully examine the client’s life experience and behavioral repertoire to discover the necessary resources needed to co-construct a practical and sustainable solution that the client can readily implement. Typically, this process involves identifying and exploring previous “exceptions,” such as when the client had successfully coped with or addressed previous difficulties and challenges. Throughout an interview process, SFBT therapists and their clients consistently collaborate to identify goals which are reflective of the clients’ best hopes and work to develop satisfying solutions.[25]

During SFBT sessions, conversation is directed toward both developing and achieving the client’s envisioned solutions.[26] The following techniques and questions help clarify those solutions as well as the means of achieving them.

Goal Development Questions

SFBT therapists begin the first session with one or more goal development questions. These might include asking clients to describe their best hope for what will be different as a result of coming to therapy, what needs to happen as a result of therapy so that afterwards the client (and/or a person who cares about them) will be able to look back and think that it had been beneficial.

Once a goal has been identified, therapists ask their clients questions designed to generate a detailed description of what the client’s life will be like when the goal has been achieved. In some cases, this may include the “Miracle Question” (see below). Once a detailed description has been developed of how the client’s life will differ after the goal has been achieved, the therapist and client discuss times when some aspects of the goal have already happened.[27]

Pre-Session Change Question

Once a client has identified a goal, the therapist usually asks some version of the following question: “We have learned over the years that sometimes in-between making an appointment and coming in, something happens to make things better. Did anything think like that happen in your case?”

If the client answers no, the therapist simply moves on, however in the event that the client answers in the affirmative, it may likely be that the solution-development process has already begun; if so, the therapist follows with questions with the details of how, when and where things have begun to get better and how this might possibly continue.[28]

Looking for Previous Solutions

Since most people have previously solved a multitude of problems, clients may likely have some ideas of how to solve their current problem. To help clients discover these potential solutions therapists may ask, “Are there times when this has been less of a problem?” or “What did you (or others) do that was helpful?” A similar question would be, “When was the last time when something like this (client’s goal description) happened, even slightly?”[29]

Looking for Exceptions

Exception questions allow people to identify with times when things may have been different for them, such as periods in their lives that are counter to the problem they are currently facing. By exploring how these exceptions happened, while highlighting the strengths and resources used by the individual to achieve them, a therapist can empower clients to find a solution. Examples of exception questions a therapist may ask include: “Tell me about times when you felt happiest,” “What was it about the day that made it a better day?” and “Can you think of times when the problem was not present in your life?”[30]

During this process, the therapist will tend to offer plenty of praise, encouraging clients to project their exceptions into the future, feeling more confident about using their strengths and resources to achieve their new vision.[31] Even when a client does not have a fully developed previous solution that can be readily repeated, most have some type of recent example of a partial exception to their problem, as no problem continually occurs to the same. There are for example, times when a problem could occur, but does not.[32]

The difference between a previous solution and an exception is small, but potentially significant. A previous solution is something that clients previously utilized that worked, but was subsequently discontinued. An exception, however, is something that happens instead of the problem, sometimes spontaneously and without conscious intention.[33] Therapists may help clients identify exceptions by asking, “What is different about the times when this was less of a problem?”

Present and Future-Focused Questions Vs. Past-Oriented Focus

The questions asked by SFBT therapists are usually focused on the present or future. In this regard, problems are best-solved by focusing on what is already working, and how a client would like their life to be, rather than focusing on the past and the origin of problems. For example, they may ask, “What will you be doing in the next week that would be indicative that you are continuing to make progress?”[34]

Compliments

Direct and indirect compliments based on careful observation of positive things the client has done or said are an essential part of SFBT and are used throughout the therapeutic process. Validating what clients are already doing well, as well as acknowledging how difficult their problems are, encourages the client to continue to make progress while giving the sense that the therapist has been listening, understands and cares.[35]

Inviting the Clients to do More of What is Working

Once therapists and their clients have identified previous solutions and exceptions to the current problem, the therapists invite the clients to do more of what has previously worked, or to try changes they have brought up which they would like to try. These are usually referred to as experiments or homework experiments.[36]

Miracle Question (MQ)

The miracle question is one that encourages people to stop thinking about why they cannot achieve something, but instead picture how their lives could be if a “miracle” occurred. This helps one to view life from a different perspective, taking the focus off the cause of their problems. In doing so, the emphasis is placed on times when their problems are non-existent.[37]

Ultimately, the miracle question enables an individual to picture a solution. Their responses are expected to describe this solution in detailed behavioral terms - this can have powerful implications about their need to do something different.[38] Most clients visibly change in their demeanor, with many smiling as they describe their solutions in the context of the miracle question.[39] These discussions pave the way for small, realistic steps to help clients form an entirely different way of living.[40] The next step would be for clients to identify the most recent times when the have experienced some aspect of their miracle description (exceptions) and invite them to experiment with replicating these in the context of their everyday life.[41] In doing so, clients often begin to implement the behavioral changes they have pictured.[42]

Scaling Questions

Following miracle and exception questions, scaling questions will typically be asked to enable clients to perceive their problem in terms of difficulty. A scale from one to 10 is typically utilized, in which each number represents a rating of the problem, with one equating with the worst a situation could be, with 10 indicative of the best.

By identifying the degree of the problem in their client’s mindset, a therapist can explore the level with which things need to improve for the client to feel the aims of therapy have been met. From this point, they can establish specific goals and identify preferred outcomes. Such scaling questions can also prove useful for tracking ones progress.[43]

Coping Questions

Coping questions are used as a powerful reminder to clients that that have previously engaged in useful practices, despite overwhelming difficulties. Even in the midst of extreme hardship, many clients often manage to complete tasks that require major effort. Coping questions such as, “How have you managed to carry on?” or “How have you managed to prevent things from becoming worse?” help promote a client’s resiliency and determination.[44]

Consultation Break and Invitation to Add Further Information

SFBT therapists traditionally take a brief consultation break during the 2nd half of each therapy session during which the therapist reflects carefully on what has occurred in the session. Prior to the break, the client is typically asked, “Is there anything that I did not ask that you think it would be important for me to know?” During the break, the therapist reflects on what has occurred within the session.

After the break, the therapist provides the client with a compliment based on the work so far and invites their client to observe and experiment with behaviors that help maintain or result in the promotion towards achieving their identified goal.[45]

BENEFITS and LIMITATIONS

SFBT has been found successful in helping a vast array of people, including couples, families and children. It is particularly effective for persons keen to embrace change and have a goal-orientated mindset, as these individuals tend to be more responsive to therapy techniques.

Due to the brief nature of the approach, solution-focused therapy can be especially beneficial to those who lead fast-paced, modern lifestyles. On average, about five sessions of solution-focused therapy are needed, with sessions lasting for 45 minutes each. SFBT rarely extends beyond eight sessions, however further sessions and other integrated techniques can be introduced if necessary - in some cases, only one session may be required.

The versatility of this approach extends to the variety of issues it can help with. Such issues include, but are not limited to: communication difficulties; stress and anxiety; drug and alcohol abuse; behavioral problems; eating disorders and relationship difficulties. As with all forms of therapy, solution-focused therapy may result in major life changes - for example, the beginning of a new relationship or endeavor (personal, work, educational, etc.), or the ending of an old one.[46]

There are some perceived limitations to SFBT, however. According to BRIEF, Europe's largest provider of solution-focused training of over 4000 professionals annually, note that SFBT’s disadvantages tend to be the converse of, and closely related to, its advantages. Some of these disadvantages include:[47]

The therapist has to take the client at their word and cannot take the position that the client really means something else. Further, the therapist has to accept the client’s goals for the therapy to succeed, even if the therapist feels that the goals are not the right goals based on their discussions. For therapists who have developed professionally in a culture dominated by the idea of underlying causation, this change might be difficult to undertake and there is the likelihood that they will be constantly assailed with a worry that their work is superficial and failing to get to the root of the problem.
As the client dictates when the work is done in SFBT, that is the clear line of when therapy sessions must end. The disadvantages of this lies with the therapist, particularly to those with a natural desire to lead their client make the most of their undoubted skills, strengths, resources and abilities. Accepting that the client could do more and yet is deciding they are happy to accept life the way it is, can be stressful to a therapist.
Therapists utilizing SFBT can never take credit for success. If the work goes well, it is always the client who has made the changes and who will be credited. At the heart of SFBT is the image of the heroic client, with the disappearance of the therapist. At the end of the therapeutic process, clients may remain puzzled about the part that the therapy has actually played the resolution of their problems. The skill of SFBT is to work close to the client’s position, close to the client’s reality and yet sufficiently distant to make a difference. Such skill tends to be invisible.
SFBT therapists cannot be clever in their approach. In Solution-Focused Brief Therapy, the best suggestions are born logically out of the session discussions and will have been co-created by the therapist and the client. In this regard, the client will receive much of the credit, with the therapist’s contribution appearing mundane to the outsider.
SFBT tends to prevent a therapist from being helpful in some regards. Therapists must develop the discipline of leaving their “good ideas’” out of the discussion as clients need to be the ones to lead the discovery of their solutions.
SFBT therapists must be able to deal with several new clients and frequent turnover. With such few sessions needed, therapists do not have time to develop a routine as they are able to do with long-established clients.

These disadvantages, according to BRIEF, focus on potential negative experiences as deemed only from a therapist’s viewpoint. Therefore, from the client’s perspective, SFBT would seem to offer only positive outcomes. This, coupled with the therapy’s high efficacy rate makes SFBT a highly popular and well-sought modality world-wide.

If you think you may benefit from Solution-Focused Brief Therapy, please reach out to a therapist to discuss possible options and set up an appointment.

Contributed by: Jennifer (Ghahari) Smith, Ph.D.

References

1 “What is Solution-Focused Therapy,” Institute for Solution-Focused Therapy. (accessed 2-23-21) solutionfocused.net/what-is-solution-focused-therapy/

2 “Solution-Focused Therapy,” Counselling Directory. (accessed 2-25-21) www.counselling-directory.org.uk/solution-focused-brief-therapy.html#whocanbenefit

3 de Shazer, S., Berg, I. K., Lipchik, E., Nunnally, E., Molnar, A., Gingerich, W., Weiner-Davis, M. (1986). Brief therapy: Focused solution development. Family Process, 25, 207–221.

4 “What is Solution-Focused Therapy,” Institute for Solution-Focused Therapy.

5 de Shazer, S., Dolan, Y., Korman, H., Trepper, T. S., McCollum, E. E., Berg, I. K. (2007). More than miracles: The state of the art of solution-focused brief therapy. New York, NY: Haworth Press.

6 Lipchik, E., Derks, J., LaCourt, M., Nunnally, E. (2012). The evolution of solution-focused brief therapy. In Franklin, C., Trepper, T. S., Gingerich, W. J., McCollum, E. E. (Eds.), Solution-focused brief therapy: A handbook of evidence-based practice (pp. 3–19). New York, NY: Oxford University Press.

7 de Shazer et al. (1986)

8 De Jong, P., Berg, I. K. (2008). Interviewing for solutions (3rd ed.). Belmont, CA: Brooks/Cole.

9 “What is Solution-Focused Therapy,” Institute for Solution-Focused Therapy.

10 “Solution-Focused Therapy,” Counselling Directory.

11 Ibid.

12 Ibid.

13 “What is Solution-Focused Therapy,” Institute for Solution-Focused Therapy.

14 Kim, J., Jordan, S. S., Franklin, C., & Froerer, A. (2019). Is solution-focused brief therapy evidence-based? An update 10 years later. Families in Society, 100(2), 127-138.

15 Kim, J. S., Smock, S., Trepper, T. S., McCollum, E. E., & Franklin, C. (2010). Is solution-focused brief therapy evidence-based?. Families in society, 91(3), 300-306.

16 Gingerich, W., & Peterson, L. (2013). Effectiveness of Solution-Focused Brief Therapy: A Systematic Qualitative Review of Controlled Outcome Studies. Research on Social Work Practice, 23(3), 266–283.

17 Ibid.

18 Wilmshurst, L. A. (2002). Treatment programs for youth with emotional and behavioral disorders: An outcome study of two alternate approaches. Mental Health Services Research, 4, 85–96.

19 Knekt, P., Lindfors, O. (Eds.). (2004). A randomized trial of the effect of four forms of psychotherapy on depressive and anxiety disorders (Vol. 77). Helsinki, Finland: The Social Insurance Institution.

20 Knekt, P., Lindfors, O., Harkanen, T., Valikoski, M., Virtala, E., Laaksonen, M. A. (2008a). Randomized trial on the effectiveness of long-term and short-term psychodynamic psychotherapy and solution-focused therapy on psychiatric symptoms during a 3-year follow-up. Psychological Medicine, 38, 689–703.

21 Knekt, P., Lindfors, O., Laaksonen, M. A., Raitasalo, R., Haaramo, P., Jarvikoski, A. (2008b). Effectiveness of short-term and long-term psychotherapy on work ability and functional capacity—A randomized clinical trial on depressive and anxiety disorders. Journal of Affective Disorders, 107, 95–106.

22 Knekt, P., Lindfors, O., Laaksonen, M. A., Renlund, C., Haaramo, P., Harkanen, T., Virtala, E. (2011). Quasi-experimental study on the effectiveness of psychoanalysis, long-term and short-term psychotherapy on psychiatric symptoms, work ability and functional capacity during a 5-year follow-up. Journal of Affective Disorders, 132, 37–47.

23 Gingerich, W., & Peterson, L. (2013).

24 Ibid.

25 “What is Solution-Focused Therapy,” Institute for Solution-Focused Therapy.

26 Ibid.

27 Ibid.

28 Ibid

29 Ibid.

30 “Solution-Focused Therapy,” Counselling Directory.

31 Ibid.

32 “What is Solution-Focused Therapy,” Institute for Solution-Focused Therapy.

33 Ibid.

34 Ibid.

35 Ibid.

36 Ibid.

37 “Solution-Focused Therapy,” Counselling Directory.

38 Ibid.

39 “What is Solution-Focused Therapy,” Institute for Solution-Focused Therapy.

40 “Solution-Focused Therapy,” Counselling Directory.

41 “What is Solution-Focused Therapy,” Institute for Solution-Focused Therapy.

42 “Solution-Focused Therapy,” Counselling Directory.

43 Ibid.

44 “What is Solution-Focused Therapy,” Institute for Solution-Focused Therapy.

45 Ibid.

46 “Solution-Focused Therapy,” Counselling Directory.

47 “Disadvantages of Solution Focused,” BRIEF: The Centre for Solution Focused Practice. (accessed 3-2-21) www.brief.org.uk/resources/faq/disadvantages-of-solution-focus