This review and analysis of a therapy session between Insoo Kim Berg and a female client diagnosed with Acquired Immune Deficiency Syndrome (AIDS) makes use of psychologically validated knowledge of the client’s emotional well-being as well as a realized vision of a preferred future. The client is a self-described ‘working girl’ with a “terrible history”. She reports being sexually abused by her brothers and stepfather. She also reports not having any contact with her family for a number of years and being badly abused by her ‘pimp’. Berg’s provision of solution-focused brief therapy aids in helping the client describe her wish to “die well” with dignity. The primary premise for the client is that her mother know she was a “good person”.
In establishing a therapeutic relationship, the therapist asked the client to describe her unique experiences and understanding. For example, the therapist asked the client to express:
• What difference will it make (if she is able to say goodbye to her mother, tell her brothers how she feels and if she is able to go home)
• How will specific tasks be helpful in (facing her family, talking about how she feels about the way she perceives her family feels about her and talking about why her family didn’t feel the need to protect her)
• How is she able to manage (what kept her from giving up, how she managed not to listen to all the chatter from others saying that she was not a good person and how she was able to keep going despite her illness knowing death is inevitable)
The therapist used the client’s own word choice and echoes them repeatedly.
• Client described herself as a working girl/prostitute – the therapist used this same terminology throughout questioning during the interview.
• Client expressed she has been able to give up cocaine – which the therapist used in context on several occasions in a positive manner.
• Client expressed that people keep telling her that she is a terrible person – the therapist used the client words to highlight her strength and resilience.
Berg (2012) asks the client what type of work she does. The client responds that she is a working girl. Moving forward from this question, Berg uses the terminology that the client adopted by echoing these key words (Gehart, 2014). The therapist doesn’t attempt to adjust or use professional jargon which allowed Berg to build a better rapport with the client. When asked about her living situation, the client says she moved on her own. Berg highlighted and complimented the strength and courage of the client by moving away from her situation, stopping her drug use and acknowledging other accomplishments she made throughout the session. Berg asks further questions to help identify other strengths possessed by the client. Berg identified the client’s solution to her situation by asking questions based on the client’s responses (Berg, 2012). Berg used the Miracle Question to help the client identify what would be different once she got rid of the baggage she has been carrying. This question developed throughout the session as indicated in (Gehart, 2014) text. The questions asked typically started with the words ‘suppose’ or ‘… what if’? This brought about a considerable amount of thought and reflection from the client. It also seemed to spark more hope in the client.
Berg skillfully used repetition to gain further clarification of the presenting problems and proposed solutions. Repetition allowed Berg to identify hope and optimism that her client had (Gehart, 2014). After asking pressing questions about seeing her mother, the client expressed that she hoped that her mother would be pleased that she was in a better situation than when they last saw each other. The client went as far as to hope that her mother would allow her to stay with her during the visit. The client appears to be missing the connection with her mother, though reportedly her mother allowed the abuse to keep going after knowing about it (Berg, 2012). Throughout the session, Berg used repetition to come back and identify wants, needs, and to allow the client to probe deeper into her ‘whys’.
The therapist used the client language to make the problem solvable thus engendering hope as demonstrated by the client’s assertion that she is able to make better decisions during the beginning of the week when she is stronger and the client’s validation that dying in peace would mean that she is able to say goodbye to important people in her life, make sure that friends don’t worry about her and that she feels hope and worthwhile in knowing that there are people who will miss her.
Assessing Client Strengths:
Solution-based therapy is a strength-based process whereby the therapist assesses strengths by outright asking about strengths or just pointing out strength the client may not know they have (Gehart, 2014). Through questioning during therapy, the therapist was able to be success in gaining the client’s trust as well as helping the client realize that she is capable of more than she might have realized. Berg empowers the client to realize her own strengths and what she already does well, in this case, provides a needed tool/resource toward hope. Berg assumed the client had the strengths and resources to solve her own problems (Rabkin, 1983; O’Hanlon & Wilk, 1987; O’Hanlon ; Weiner-Davis, 1989).
Strength Question: How have you managed to stay strong and say “No” in the face of all your difficulties? Strengths Identified:
• Ability to say “No” to people who want to harm her.
• Ability to say “No” to cocaine.
• Ability to say “No” to people attempting to tell her how to die.
• Trust in own intuition, verbalization of wanting to find her own way and clear sense about self (integrity).
• Thoughtfulness given toward life along with the understanding of how wants to end life, what feel comfortable and what’s right for her.
• Care for self, survival instincts, need to prove others wrong about her (not allowing them to win).
SFBT therapists employ interventions to include specific questioning techniques, scales, empathy and compliments engineered to aid the client in recognizing their own virtues, such as courage and strength, that have recently gotten the client through hard times and are likely to work in the future. Clients learn to focus on what they can do, not what they can’t do. This allows the client to find solutions and make positive change more readily.
SFBT is reportedly an intervention itself. The “miracle question” is probably the most significant intervention in solution-focused therapy. This intervention is not comprised of a single question but a conversational sequence in which the client explores the outcome of a miracle. Use of this intervention assist the client in thinking of an exception to the presenting issue (de Shazer, 1988). The miracle question opens the mind to creative thinking and to setting goals and developing a clear plan that will lead to life-changing solutions.
GOAL: Client will increase sense of control and safety when remembering abuse to reduce dissociation and hypervigilance.
This goal is solution-focused as it prompts the client to delve into issues surrounding control, safety and abuse to explore ways which the past influences the present while working toward the future (Gehart, 2014). The approach is to seek motivation and find solutions to problems while not solely focusing on the actual problems or symptoms but rather what can be done to achieve a meaningful lifestyle.
1. How do you manage, in the face of difficulties, to fulfill your daily obligations? (Antin, 2016)
2. What does your life look like without your problems? (Antin, 2016)
These questions are asked to provoke thinking and discussion about goal setting and problem solving. The aim is for the client to recognize and tap into their own resiliency and look within for skills already achieved to effectively cope with their problems. Recognizing that change is certain and continual. This type of question can result in the client reflecting on behaviors currently engages in that are helpful and effective while searching for other ways to facilitate problem solving.
Integration of the Recovery Model
Recovery is the developing of expectations and dreams. The recovery process involves attaining the knowledge to determine one’s desires by learning to create choices that bring strength rather than harm. Recovery entails living a meaningful life strengthened by a capacity for loving oneself and others. Recovery is a way of life, an attitude or a way of approaching challenges. Integrating the Recovery Model with Solution Focused Therapy incorporates the determination of the necessary tools for the management of symptoms while coping with difficulties. Three concepts that demonstrate how the recovery model can be supplemented along with solution-focused therapy to facilitate change entails (Gehart, 2014): 1) viewing change as constant; 2) looking at exceptions to problems; and 3) recognizing that language has meaning.
Initial Tasks (Gehart, 2014)
1. Evaluation of interrelated problems domains established by discussing with client the various different attitudes and suggestions that can affect relationships with others to work on primary reason for referral.
a. Assist client in developing a collaborative relationship that inspires hope, optimum utilizing “beginner’s mind” and “listening for hope”.
2. Assess individual, systemic and broader cultural dynamics by ruling out substance abuse.
a. Use of miracle question of concretely and behaviorally define solutions…
3. Define and obtain agreement relative to treatment goals.
a. Ask questions to identify reasonable goals.
Working Tasks (Gehart, 2014)
1. Determine the need for stabilization to establish safety
a. Assess risk of harm, ability to provide basic self-care and ability to function or communicate effectively.
2. Determine problems to be solved specifically and opportunities for contingencies to promote treatment participation.
a. Identify impairment, need and strengths relative to financial, legal, employment, housing, social/family and medical.
Closing Phase Tasks (Gehart, 2014)
1. Develop aftercare plan and maintain gains by determining areas of prior success around which to organize future treatment interventions.
a. Coping questions relative to the presence or absence of existing and ongoing supportive family, peer support or therapeutic community; quality and safety of recovery environment.