The power of the few
Healthcare Counselling and Psychotherapy Journal, April 2021

Solution-focused practice was devised by a group of American therapists, who set up the Brief Family Therapy Centre (BFTC) in Milwaukee in 1978. The approach was developed inductively, through watching each other’s practice and studying videos of conversations. The group was surprised to find that, for most clients, it was possible to achieve the changes they wanted in fewer sessions than was usually expected. A series of follow-up studies¹ confirmed that, for many clients, the changes were long lasting.

I first came across the approach in 1991. I was working in a child and adolescent mental health service (CAMHS) in Gateshead, and attended a workshop by Chris Iveson, one of the founders of BRIEF, a centre for solution-focused practice in the UK. I was also surprised to see how quickly people could achieve change, when I used the approach in my conversations with children, young people, adults and families.

The model fitted well with my aspiration to match the therapy to the clients, not the other way round. As Milton Erickson, the psychiatrist, wrote: ‘Each person is an individual. Hence, psychotherapy should be formulated to meet the uniqueness of the individual’s needs, rather than tailoring the person to fit the Procrustean bed of a hypothetical theory of human behaviour.’²

When I carried out my own research in 1995,³ I found that my engagement with clients had increased from 75% to 80% since using solution-focused practice. Successful outcomes, as confirmed by clients, had also increased from 44% to 68%.

I have since met some of the therapists who originally developed the approach, in particular Insoo Kim Berg, Steve de Shazer and Eve Lipchick. In 1999, Insoo Kim Berg presented a workshop in my area. Insoo recalled that advertising the BFTC in the local telephone directory had not attracted enough clients. So, the practice invited local services,  including mental health, probation and safeguarding, to refer any clients they had been unable to help.

I was not particularly surprised to hear that the new approach had brought about lasting improvements for most of the clients who had chosen to contact the BFTC. I was more surprised that equally successful outcomes had been achieved with most of the clients who had been mandated to attend, who also typically presented with complex and long- standing difficulties.

The experience of the American therapists gave me greater confidence to use the approach with clients who had been mandated to attend my service, particularly parents referred by safeguarding services. I, too, found that significant improvements were possible with more clients than I would have previously expected.

When I train therapists, counsellors and other practitioners, I am always keen to stress that effective solution-focused practice requires a particular mindset, especially when clients come with long-standing and/or complex difficulties we might otherwise assume could not be resolved in relatively few meetings. 

Key features of this mindset can be found in the assumptions that inform solution-focused practice. They can be organised into assumptions about clients, problems, change and practice.⁴ Some of the assumptions are common to many approaches to therapeutic practice; others are specific to solution-focused therapy.

Assumptions about clients

Every client is unique. I might, for example, meet three clients who are struggling with depression. When I ask about their best hopes for our work together, one might want to sleep better, one might want more energy and one might want to spend more time with friends.

Clients come to us with resources and strengths, both internal and external. All clients have the ability to find their own solutions to their difficulties. At the very least, this assumption encourages us to check with the client. A health visitor attending a follow-up training session reported that every time parents told her about their problems, she would now ask if they had any possible solutions. Most, it turned out, already had ideas. 

You cannot change clients; they can only change themselves.

The client, not the therapist, is the expert on the client and their social network.

A client’s solution is more likely to fit their particular situation and more likely to be implemented and maintained. 

Assumptions about problems

No problem is constant. There are always times when the problem is not there – and those times can be identified and built on. It was this observation that eventually resulted in the development of the solution-focused approach.⁵

A focus on the possible and changeable is more helpful than a focus on the overwhelming and intractable.

The client is not the problem. The problem is the problem. The problem and solution occur in the interaction between people, rather than residing within people.

Problems that appear complex do not necessarily require a complex solution.

Assumptions about change

Change is happening all the time. 

Small changes can make a big difference.

Rapid change or resolution can happen when people hit on ideas that work.

There may well have been some pre-session change. In a research study by Michele Weiner-Davis and colleagues,⁶ two-thirds of families who were asked about changes they had noticed before their first appointment reported signs of progress, compared with only 5% of a control group.

Assumptions about practice

Lasting change is more likely to happen when you find out what’s working and help people figure out how to do more of it.

Given that change is happening all the time, our role is to identify and amplify changes that fit with how the client wants life to be.

People are more likely to behave and/or think differently when you work with their goals for change.

Conversation openers

In my current practice and training, I tend to draw on four, principal conversation openers:

• questions about the client’s preferred future
• questions about times when the client has already
• experienced some of what they want
• scaling questions
• the miracle question.

I continue to value, in particular, the pragmatism of solution-focused practice, which allows me to use these conversation openers according to how the client responds. It therefore speaks to my aspiration to fit the therapy to the client.

Questions about the client’s preferred future

As practitioners have continued to develop and refine solution-focused practice, many questions have been found to be helpful in ensuring the conversation is attuned to the changes the client wants to see. BRIEF typically starts a conversation by asking the client to identify their best hopes for the sessions. The use of the term ‘best hopes’ has proved particularly beneficial.⁷ In my own practice, I might also ask the following questions, according to how the client presents:

• by the end of our meeting today, how would you know our conversation had been useful?
• what do you hope could be better, even by the time we finish talking today?
• after we’ve met for as many times as you want, what in particular do you hope will have changed for the better?

Preferred future questions invite clients to describe the improvements they want to see in their lives. They also trust the client to make those judgments and recognise that the client is best placed to do so. Such questions can also provide clients with a different way to think about the challenges they are facing. In my experience, many clients have become stuck with unproductive thinking about the past or the present. Using the future as a reference point can make a difference. Also, for some clients, their ambition is defined by the absence of problems. I have seen clients’ faces light up when I ask: ‘So, what do you want instead of that?’.

Questions about variations

The possibility of a different approach to therapy in BFTC started with the observation that clients’ problems are not constant.⁵ A person who usually struggles to get out of bed in time to have breakfast might refer to a day when they were successful. A person who is usually too scared to leave the house might mention an occasion when they had to overcome their fear. Insoo recalled, in my interview in 2006,⁵ thinking that it would be worth exploring these interesting variations.

More recent texts have brought the word ‘instances’ into the vocabulary of solution-focused practice. The word comes from a realisation that ‘…as our work is organised from the outset around what the person wants from it, and not around the problems they bring, it makes sense to think about times when what is wanted is happening, rather than times when the problem is not happening’.⁸

A conversation about such exceptions or instances typically comes about either through noticing if a client mentions an interesting variation, or through direct questions. It can also develop from follow-up questions to scaling questions or the miracle question.

Scaling questions

Scaling questions are by no means unique to solution-focused practice. Indeed, Steve de Shazer often attributed the first employment of a scaling question at BFTC to a client who used one to describe how much better she was feeling.⁸ What might be special about scaling questions in solution-focused practice is the way they are used to open up conversations about what is already working for the client, and signs of progress.

Given that preferred outcomes are defined in terms of what is wanted, it follows that scaling questions in solution-focused practice are usually positively defined. For example, a 12 year old who was scared to go out on her own told me she wanted to ‘…get rid of the stupid thinking’. I asked: ‘What if you could? What would you then have more of that you don’t have much of at the moment?’ She replied: ‘Freedom.’ We then explored her hopes for more freedom, prior experiences of freedom and how she could tell she had a little more.

I have often found that when a client reports they are at, say, three on a scale, where 10 represents where they want to be, many practitioners will go straight to a conversation about four, through an understandable intention to help the client improve. Another discovery at BFTC was that, in such situations, unpacking the three can often lead to informative realisations for the client. A client might, for example, describe the difference between three and two, reflect on how they can tell they are at three and not zero, or recall what helped them move to three. Scaling questions can then lead into conversations about times when what is wanted has already happened, by asking about the last time the number had been higher and signs of progress.

The miracle question

The miracle question is another conversation opener that emerged from practice at BFTC. Insoo recalls⁸ that a client had commented that it would take a miracle to change what was happening in her life. Insoo had replied: ‘OK, well suppose a miracle did happen…’ Earlier texts, for example by Steve de Shazer, present the miracle question in a generic form, designed to invite descriptions of preferred changes with regards to many different challenges. ‘Suppose that one night, while you were asleep, there was a miracle and this problem was solved. How would you know? What would be different?’⁹

Over time, the miracle question has been adapted in many ways by practitioners to suit their clients – waking up to a perfect day, opening the door to the therapist’s room and seeing the life they want to have, and so on. An eight-year-old girl was asked by a school-based support worker, who had attended further training with me, to imagine she was visited in the night by a fairy who sprinkled her with magic dust.

As with the other conversation openers, the miracle question is most likely to generate useful information for the client when they are encouraged to reflect in detail. Often, in my experience, within the detailed descriptions of what’s wanted lie important clues that can help clients to identify what really matters, as well as the changes that are small enough to make.

For example, a client who struggles with anxiety and depression might say their best hope from therapy is more confidence. The miracle question might invite the client to imagine that they have all the confidence they need. The client is then encouraged to speculate on the various differences that would become apparent, if the miracle happened. The client might describe how they would get out of bed when the alarm went off, have a shower, make fresh coffee, listen to their favourite music and enjoy seeing their reflection in the mirror. The therapist could then ask: ‘And when was the last time some of this happened?’ Alternatively, it could be framed as a scaling question, with zero as no instances of the ‘miracle’. 

Solution-focused practice can now be found in many settings around the world. Further research, including randomised controlled studies and meta studies, has strengthened the evidence base for this approach.¹² Over time, an implicit theory underpinning solution-focused practice has become more explicit, as presented by Peter Sundman and colleagues.¹³

A growing number of practitioners have described how solution-focused practice can be adapted to the challenges that clients bring to health and allied services in the UK, for example Kidge Burns,¹⁴ Alasdair MacDonald¹⁵ and Paul Hanton.¹⁶

I have now moved from CAMHS to private practice, where I continue to see clients making great improvements in their lives, often over remarkably short periods of time.