solution focused therapy case study examples

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Solution-focused approaches in adult mental health research: A conceptual literature review and narrative synthesis

Lauren jerome.

1 Unit for Social and Community Psychiatry, Wolfson Institute of Population Health, Queen Mary University of London, London, United Kingdom

Philip McNamee

2 Unit for Social and Community Psychiatry, Newham Centre for Mental Health, East London NHS Foundation Trust, London, United Kingdom

Nadia Abdel-Halim

Kathryn elliot, jonathan woods.

3 Department of Clinical Psychology and Psychological Therapies, The University of East Anglia (UEA), Norwich, United Kingdom

Associated Data

Solution-focused approaches are one approach to treatment used in a wide variety of settings in modern mental healthcare services. As yet, there has been no overall synthesis of how this approach is understood in the adult mental health literature. This conceptual review aimed to synthesize the ways that solution-focused approaches have been conceptualized and understood, within the adult mental health literature, in the five decades since their conception. A systematic search followed by multiple techniques from the narrative synthesis approach were used to develop a conceptual framework of the extracted data. Fifty-six papers published between 1993 and 2019 were included in the review. These papers spanned a variety of clinical contexts and countries, but despite this the underlying key principles and concepts of solution-focused approaches were remarkably similar over time and setting. Thematic analysis of extracted data outlined five key themes relevant to the conceptualization of this approach. This conceptual framework will help support clinicians using solution-focused techniques or therapies by giving them a coherent understanding of such approaches, by what mechanisms they work, and how key principles of this approach can be utilized in adult mental health settings.

1. Introduction

One in six adults in England were found to have a common mental health disorder in a 2014 National Statistics report, and one third of them reported current use of a mental health treatment, with medication being the most common form of treatment reported ( 1 ). However, health care services including GPs, inpatient, outpatient, and community services were all utilized for mental health treatment where a range of psychotherapeutic approaches were also being delivered ( 1 ). Solution-focused therapy is one such approach that has been gaining increasing popularity worldwide since its conception. Specifically in the UK, where BRIEF became the first team to practice Solution-Focused Brief Therapy (SFBT) in the 1980’s ( 2 ). Solution-focused therapies are now being practiced in a wide variety of settings ( 3 ), including being recommended in the Nursing and Midwifery Council proficiency standards for newly qualified nurses ( 4 ) and in psychiatric practice ( 5 ).

The premise of a solution-focused approach was first described in 1974 by Watzlawick, Weakland, and Fisch in their Brief Therapy approach ( 6 ), where they described their belief that effective change can be brought about by enacting change in the present, without a need to necessarily understand “why” or the cause of a problem. They suggested the focus of therapy should be on investigation of previously attempted solutions to a problem to identify what is maintaining it, constructing clear concrete goals to define the change to be achieved, and finally formulating and implementing a plan to achieve such change. This approach was further developed in the 1980s, and most famously in de Shazer’s development of SFBT ( 7 ). SFBT builds on Watzlawick, Weakland and Fisch’s ( 6 ) approach, being oriented toward building solutions by identifying the client’s resources, and when something is found that works, the client should do more of it ( 8 ). It’s generic approach means that it is suitable for most therapeutic settings ( 5 ). De Shazer and Berg ( 7 ) outlined four characteristic features of SFBT, which they said should be present to ensure SFBT is taking place; (1) asking of the miracle question (a question that asks the client to describe how life might be different for them if something miraculous happened), (2) at one point in the session the client should be asked to scale something from 0–10, (3) the therapist should take a break, and (4) after returning from the break the therapist should provide a compliment and suggest a homework task. However, it is unclear how closely solution-focused approaches being practised today follow this original conceptualization, and whether these four features are still considered essential.

A review of SFBT controlled outcome studies by Gingerich and Peterson ( 3 ) found strong evidence for the effectiveness of SFBT across a large number of settings and populations, supporting de Shazer and Berg’s claims of widespread success. As a result of this review, the authors suggested there are six techniques core to the SFBT method: including specific goals, the miracle question, scaling questions, searching for exceptions, compliments, and homework. Of the 43 studies included in their review, they found 33 implemented all of these six techniques, and only three implemented three or fewer, concluding treatment fidelity is high. This demonstrates that since de Shazer and Berg outlined their characteristic features of SFBT, there has been some shift in what is considered to be integral to this approach.

While Gingerich and Peterson’s review provides recent evidence for the effectiveness of the techniques implemented within SFBT, SFBT is just one form of therapy within the wider solution-focused approach. There remains a need for a synthesis of the conceptualizations of the overall solution-focused approach in adult mental health research. Such conceptual work would allow common attributes of the approach to be identified by exploring the various ways in which this approach has historically been described. It would also uncover how the term “solution-focused” has been used, changed, and amended since its original conception and description. Moreover, building a conceptual framework of solution-focused approaches would provide clinicians and researchers with the theoretical underpinnings to enable a deeper understanding of the mechanism by which interventions based on a solution-focused approach function, and how key principles of the approach can be utilized.

Therefore, the aims of the current review are to undertake a conceptual review and narrative synthesis of solution-focused approaches in adult mental health research and to synthesize published concepts of solution-focused approaches into a systematic conceptual framework. The questions we aim to answer are:

(1) what are the common attributes defining interventions conceptualized as “solution-focused”? and, (2) how has the phrase “solution-focused” been used historically in adult mental health literature?

2. Materials and methods

For this review, we were not aiming to necessarily include every publication that cited a solution-focused approach, instead we were interested in including a breadth of papers from across the research literature to investigate widely whether the term “solution-focused” is applied similarly or understood differently by researchers representing distinct research areas and specialisms. As such, a conceptual review with narrative synthesis was deemed the most appropriate approach, with a systematic search to capture as many different publications as possible. We followed recommendations made by Lilford et al ( 9 ) which state rather than exhaustively searching for every publication, a wide and disparate source of evidence should be sought. We included several steps in our search process, described below, to ensure it was systematic, robust, and reflected an extensive range of the available literature.

The main review team consisted of three research assistants (LJ, NAH, KE), one senior researcher (PM), and one trainee clinical psychologist (JW). All authors had some exposure to training in solution-focused therapy and/or conducting research into interventions based on the principles of solution-focused therapy. The approach to this review and its emerging findings were discussed on several occasions with a wider group of roughly 30 researchers and clinicians, some of whom have clinical and/or research expertise in solution-focused approaches, and who have experience in conducting conceptual reviews.

2.1. Protocol and registration

In accordance with PRISMA guidelines, the methods of this paper were pre-specified in a registered protocol (PROSPERO: CRD42018090195). 1

2.2. Eligibility criteria

Full text papers, published in peer-reviewed scientific journals, were included if they included a detailed outline of a self-described “solution-focused” approach. “Self-described” here means either the name of the approach referred to “solution-focused” or “solution-focused” was cited as a descriptor or label. This was in order to better understand how “solution-focused” as a term and an approach was described in the literature, and to analyze what the key conceptual components of these approaches were. As such, the paper had to include sufficient detail to allow a succinct description of the approach to be extracted. Furthermore, the approach had to be delivered/described in the broad context of adult mental health care, including but not limited to primary care, inpatient, and/or community care. Primary studies were included if there were at least three participants with a self-described mental health issue, as were secondary research studies synthesizing existing literature. Only papers available in the English language were included. Any research involving a sample of mixed ages were included if over 50% of the sample were aged over 18.

Additionally, we included textbooks (where they were available) or guidelines, written by professionals working within a mental health context, describing the model, including original descriptions and characteristics of the model, when they were either recommended by key experts in the field or identified as commonly occurring in the reference lists of articles recommended by key experts.

Texts were excluded if they did not present a clear conceptualization of the solution-focused approach. Papers reporting on primary research with less than three participants were also excluded as the focus was on looking at general use and delivery of the approach, this exclusion criteria also applied to case studies and studies reporting first-person experiences or those using auto-ethnography. Further, papers reporting on solution-focused approaches applied to a non-mental health population were also excluded, as was grey literature, such as PhD theses and conference papers.

2.3. Data collection

First, key experts in the field were contacted to identify seminal publications. This was accompanied by a search of Google Scholar using broad search terms to identify relevant publications to act as marker papers in the subsequent systematic search.

Next, three electronic bibliographic databases, PsycINFO, EMBASE, and Web of Science, were searched from 1974, the year the first text on a solution-focused approach was published ( 6 ), to present. PubMed was also initially included however no additional unique publications were identified.

The following keywords were searched for terms characterizing:

• solution-focused approaches ((“solution-focus*” or “solution-orient*” or “solution-driven” or “solution-focus* brief”)) adj5 (therap* or psychotherap* or approach* or intervention*)) AND.
• mental health (mental disorders/or ((mental* or psych*) adj2 (health* or disorder* or disease* or deficien* or ill* or problem* or condition* or treat*).

After removing duplicates, titles and abstracts were screened for potentially relevant papers. The full texts of the remaining papers were then screened, and inclusion was based on the eligibility criteria described in section “Eligibility criteria.”

Finally, reference list screening and forward citation tracking was conducted for each significant paper identified by key experts, and each eligible publication to be included in the review, to identify additional relevant papers.

2.4. Data analysis

We conducted a three-stage narrative synthesis of the data following the guidance of Popay et al ( 10 ) to integrate the findings into a conceptual framework. As recommended by Lilford et al ( 9 ) these stages were part of an iterative process and had some overlap. Figure 1 provides an overview of the synthesis process.

Schematic providing an overview of the narrative synthesis process, and the specific techniques we utilized in this review.

First, a preliminary synthesis was developed using techniques described by Popay et al ( 9 ) to identify the main themes and subthemes in the publications.

• (1) Initially, textual descriptions of a variety of information from the publications were extracted and then tabulated to aid further analysis.
• (2) Vote counting was then performed to produce an initial description of patterns across the included publications, the findings of which were then further explored ( 9 ). Vote counting was performed on the following elements: the name of the approach; setting; theoretical background; and any key definitions and steps given. As there were a lot of unique concepts identified for theoretical background and key definitions/steps, any that could reasonably be grouped to aid further analysis were grouped under overarching categories; e.g., the miracle question, the tomorrow question, and asking the client to envisage their ideal situation, were all grouped under “focusing on the client’s future”. These categories were created deductively through discussions within the review team and our knowledge of the literature. All unique and distinct references to each category were classed as a vote, as such one paper may have multiple votes for the same category where they describe several different concepts that come under the same category.
• (3) A thematic analysis was then conducted to explore, in detail, the authors’ definition of solution-focused, the categories identified through vote counting the key definitions and steps, and practitioner characteristics. For the authors’ definition of solution-focused and the practitioner characteristics, the review team met in person and discussed the textual descriptions extracted for each paper for those elements, and wrote any concepts that were identified on post-it notes. As we progressed through the papers, post-it notes were grouped into themes. To analyze the categories identified from vote counting of key definitions and steps, the full descriptions of all the unique concepts grouped under each category were uploaded, by category, into NVivo 12. Two researchers analyzed each category by creating codes within NVivo. After all categories had been coded, the review team met to discuss their findings and assimilate their ideas into themes and subthemes. These findings were discussed in relation to the themes identified from the analysis of the definition of solution-focused, as there was a lot of overlap in the concepts identified.
• (4) In the final part of this preliminary synthesis, publications based on publication year and setting were grouped together in order to look for patterns within and across groups.

As analysis progressed, we began to develop our ideas of themes and subthemes present across the publications. Often we would return to concepts identified in analysis of a different element, or an earlier phase of analysis, and add further subthemes or depth to it, or disband themes entirely and re-establish new themes based on our ideas emerging from subsequent analyses. Many of our initial ideas merged into larger, overarching themes as analysis progressed and our ideas surrounding these concepts developed.

As well as synthesizing our findings into common themes and attributes, we were also interested in identifying negative cases, where a concept opposed those that were commonly identified. When we came across such cases, the review team discussed these and how they related to the themes we were developing. In the same way we would re-evaluate, disband and create new themes based on similar concepts identified, the themes were developed containing these opposing ideas.

Second, to explore relationships within and between studies, there was continuous discussion among the review team, other researchers and clinicians throughout the process. The initial findings that came from grouping publications were presented graphically to further explore the patterns found within and between the groups. Each member of the review team was involved in the preliminary synthesis, and in discussion of the identified themes, categories, and patterns within and between groups. The collaborative nature of our synthesis enriched our findings by ensuring we considered different views and interpretations, and contributed to the iterative nature of our analysis, as different insights developed our understanding of the concepts we identified. Finally, we created a conceptual map to highlight the key concepts and themes identified and the relationships between them. This final step brought together the results of our analysis and synthesized our ideas into one conceptual framework. This step also produced a visual representation of the concepts which further aided their definition, and established their relationships to one another.

Third, in order to assess the robustness of the synthesis we reflected critically on the synthesis process as we proceeded with our analysis. As we progressed through the analysis we considered how our knowledge of the literature, the analysis process we chose to use, and our individual preconceptions of solution-focused approaches may influence our identification of concepts and themes and how we synthesize them, and included this reflection in our discussions of the findings and our synthesis into the conceptual framework. We also shared our synthesis with a diverse range of researchers and clinicians, and with key experts, for feedback, to enable us to consider a range of views outside of the review teams.

We chose not to assess the quality of the included papers as we were interested in how approaches described as “solution-focused” are conceptualized in the literature, regardless of whether these approaches are then used in high quality research or not, we merely wanted to capture how the term is understood.

3.1. Publication characteristics

Figure 2 shows our search and selection process for the papers included in this review.

PRISMA 2020 flow diagram for new systematic reviews. From: Page et al. ( 11 ).

We included 56 papers published between 1993–2019. Thirty-five studies (65%) were therapeutic practice research papers, and twenty-one studies (35%) were interventional investigative research papers. Over half of the papers included in this review were published in the USA (52%), and the majority of the other included papers were published in Western countries. There were only two papers from non-western countries (Israel and Iran) included in the review ( 12 , 13 ). Regarding the study setting for the investigative research papers, eight studies were conducted within community mental health teams (38%), four studies occurred in primary care settings (19%), and three studies within an inpatient setting (14%). The remaining papers represent one study conducted in each of; a nursing home facility (5%), a web based SFBT chat room (5%), a non-profit community group (5%), an addiction service (5%), a school counseling team (5%), and a healthcare organization (5%). These findings demonstrate the wide applicability of solution-focused approaches in a number of different settings and contexts. A full and detailed list of all included papers is provided in Supplementary material S1 .

The papers included in this review describe clinicians from a variety of disciplines as delivering their solution-focused approach. For the purposes of this review for the remainder of our findings we will refer to the individual delivering the approach as the “practitioner,” which encompasses any individual delivering the approach, including but not limited to therapists, nurses, counselors etc., and the recipient of the approach as the “client.”

3.2. Descriptives

3.2.1. vote counting.

Vote counting the name of the approach used in the papers demonstrated that all except two papers called their approach some form of “solution-focused therapy,” usually reflecting the specific context of the approach, e.g., solution-focused nursing. One paper referred to their approach as the “strengths perspective” ( 14 ), and another as “empowerment based practice” ( 15 ). Although our search terms limited inclusion of papers to using the term “solution-focused,” so this finding is not a surprise, the ubiquity of the term was widespread.

Vote counting identified a number of different theoretical backgrounds described as the basis for the solution-focused approach. However, the most common theoretical background given ( n  = 18) was self-described as a “solution-focused” theory. This was followed by post-modern theories ( n  = 13), Ericksonian hypnotherapy ( n  = 4) the strengths perspective ( n  = 4), hope theory ( n  = 2), and the systems perspective ( n  = 2). The remaining 14 theories identified were unique, i.e., not described in any other paper, and many papers described more than one theory as influencing their approach. In contrast, 14 papers did not name any theoretical background for their approach. A full list of the theoretical backgrounds identified is in Supplementary material S2 .

Vote counting of the categories that derived from the key definitions and steps identified several key components that were consistently described in the included papers. Figure 3 shows the key components that we identified and how many times they were mentioned. Often multiple distinct concepts within a component were described within a paper, and so a paper could have more than one vote for a single component. Figure 3 also shows in contrast how many papers did not mention these components at all. Although some components were consistently mentioned more than others, none were mentioned in every paper. The identified components were explored further through thematic analysis, contributing to our resulting themes described in section “Themes.”

Graph showing key components identified from vote counting of the key definitions and steps described in the included papers. The number of times each component is mentioned is displayed, as well as the number of papers that do not mention each component at all.

3.2.2. Groupings

Grouping the included papers by their decade of publication identified some differences in how prevalent the key components, identified through vote counting, were presented in the included publications. The concepts of tasks, goals, scaling, a solution focus, and language were mentioned more often in more recent papers. In contrast, the concepts of compliments, exceptions, problems, pre-session work, beginning sessions, ending sessions, strengths, and collaborative working were mentioned less often in more recent papers. Compliments, for example, were mentioned an average of 1.1 times per included publication in those published between 1990 and 2000, compared to an average of 0.3 times in papers published from 2010 onwards. On the other hand, the concepts of a future focus and the views of others remained fairly consistent in their prevalence over time.

As we conducted the thematic analysis we were mindful of noticing any differences in how the themes we identified were presented over time, and whether any were particularly prevalent in one decade compared to another. In contrast to our findings from the categories identified from vote counting, described above, we did not identify any differences over time in our themes.

When comparing papers based on setting the concepts of beginning sessions, change, problems, a solution focus, strengths, collaborative working, scaling, exceptions and the views of others were mentioned more often in community settings than in other settings. In counseling settings, the views of others and scaling were not mentioned at all, and language was not mentioned in any papers in inpatient settings. However, there were very few papers in defined settings outside of community settings, and a number of papers did not clearly describe the setting their approach was conducted in, instead often just describing it as being conducted by a “therapist.” This limits the usefulness of grouping the papers by setting and these findings, as there were too few examples in the settings outside of community settings to make any confident conclusions.

3.3. Themes

In total, there were five themes that resulted from the thematic analysis of the descriptive elements of the extracted data. These themes encapsulated the key and distinctive aspects of solution-focused approaches that were described in the adult mental health literature. Some of the themes relate to the general philosophy of the approach (“Perceived as moving away from traditional approaches”; “problems vs. solutions”), one related to the specific techniques, tools and processes recommended (“Solution-Focused Tasks”), while others related to the role of key stakeholders in the process (“views of others”; “practitioner characteristics”). The themes will be outlined in full below with reference to the extracted data.

3.3.1. Perceived as moving away from traditional approaches

The idea that the main focus of therapy should be directed toward solutions rather than on problems was seen as a radical idea in the 1970s when first introduced by Watzlawick, Weakland and Fisch ( 6 ). This idea was then developed further still by de Shazer & Berg in the 1980s. Although it may no longer be viewed as so radical in contemporary discussion, many of the included papers still positioned solution-focused approaches as being non-traditional. The unique core tenet of shifting away from problems and instead centralising solutions in order to be proactive in mental health promotion, rather than reactive, was still viewed as distinguishing it from other major approaches in psychotherapy.

“An effort to reverse traditional psychotherapy practice by shifting the focus of treatment from problems to solutions” ( 16 , p. 455).

The shift from “traditional approaches” was not just limited to a focus on solutions, but also included the brevity and focus on achievable outcomes, as well as a shift from focusing on pathology to general mental health, particularly in regards to being less concerned with diagnostic criteria and specific symptoms.

“Traditionally, counselor and client are focused on pathology and dysfunction. From a solution-focused perspective, emphasis is placed on normalizing behaviors and ways of thinking as well as reframing the client’s situation and behaviors in ways that illuminate her or his strengths and resources” ( 17 , p. 155).

This non-specificity meant such approaches could be flexibly applied across differing clinical and cultural contexts. As a result, solution-focused approaches were often conceptualized as “contemporary,” with their generic yet coherent principles being seen as culturally compatible.

“The model sits well with the contemporary practice of empowerment and partnership and is, by definition, sensitive to differences of culture” ( 18 , p. 34).

Linked to this theme was the central principle within solution-focused approaches of “client knows best,” where the client is seen as an expert. This goes beyond traditional assumptions of expertise by experience and instead sees the client as an expert in all aspects of their lives while the practitioner adopts a “not knowing stance.”

“Clinicians do not assume they have an a priori expertise sufficient to objectively categorise and solve client problems. Clients are the only knowers and experts of their individual experiences, realities, and aspirations. Clients define the goals for treatment and thus are more likely to assume responsibility for working for a better and more satisfactory life” ( 19 , p. 37).

Only the client has the ability to proactively identify the problem/s to work on, with no input or assumptions from the practitioner about what the problem may actually be. The way the client understands the problem is ultimately how the practitioner should understand it too, with caution against too much interpretation or analysis by the practitioner. The practitioner’s key responsibility is to keep the therapeutic process on track, by “ leading from one step behind ” ( 5 , p. 298). Relatedly, it is assumed by the practitioner that the client is the only one who can find the solutions to the problem, apply them and eventually solve them.

3.3.2. Problems v. solutions

The second theme expands upon the central principle of shifting attention away from problems and onto solutions. The way problems and solutions are understood, defined and used within solution-focused approaches was a key principle. Within solution-focused approaches there was wide encouragement to minimize discussion of the problem and instead focus on solutions.

“Focus on solutions, strengths, and health. Solution-focused brief therapy focuses on what clients can do versus what clients cannot do. Instead of focusing and exploring clients’ problems and deficiencies, the focus is on the successes and accomplishments when clients are able to satisfactorily address their problems of living” ( 20 , p. 3).

In this vein, the client and practitioner should focus on personal strengths to build upon, rather than spending time finding a way to overcome specific problems. It was perceived to be more useful to conceive, understand and elaborate on solutions than on problems ( 21 ). However, authors differed in the amount of emphasis that should be put on “problem-talk,” with some advocating that a problem should be clearly defined in order for solutions to be found, while others argued that problem-focused talk should be avoided altogether. However, it is acknowledged that it would be difficult to completely avoid problem-talk, and clients should be given space to discuss the problem that brought them to therapy if they wish to;

“In theory, the past (and the problem bringing the person to therapy) does not need to be addressed (however, it usually is, especially during the beginning of the first session during the transition from problem talk to solution-talk)” ( 22 , p. 138).

Similarly, it was commonly suggested that a rapid or complete resolution of a client’s problems is unrealistic and instead the focus of therapy should be on the completion of small, obtainable goals in order to keep them moving forward. Some authors argued that it was still possible to reach a solution without fully understanding the problem, including how it is maintained or how it arose. And that solution-talk should far outweigh problem-talk.

“make a conscious effort to stay focused on solution-talk and deemphasize problem talk” ( 19 , p. 37).

Solving problems is not the goal in this therapeutic approach and sometimes the solutions identified are not necessarily directly related to a particular problem.

“the development of a solution is not necessarily related to the problem; the client is the expert; if it is not broken, do not fix it; if something works, continue with it; if something does not work, do something else” ( 23 , p. 88)

Overall, the client (and not the problem) should be at the center of the enquiry and this centralization should be maintained throughout the therapeutic process.

3.3.3. Solution-focused tasks

There were clear tasks, techniques and processes that were detailed in the literature for practitioners to use in order to be solution-focused. These seemed to cluster around temporal dimensions related to the client, namely the past, present and future. These have been described in three separate sub-themes below.

3.3.3.1. Past work

Past work primarily entailed identification of and reflection on existing strengths, and examples of exceptions to the identified problem. Exploring past successes and what the client has already done was seen to help clients identify their strengths and previous solutions that can be built upon or re-utilized. The identification of these existing strengths and resources related to the concept of client empowerment which was also present consistently in the included papers. Identifying existing client strengths contributes to a sense of resilience and hope, as solutions can be built using the strengths the client already possesses. This then empowers clients by reinforcing their sense of autonomy, increasing their confidence in dealing with the situation, and helping them to feel supported and optimistic about change and finding solutions.

The notion of searching for exceptions, i.e., identifying examples from the past of when the problem was not occurring, was an important component within the approach, being mentioned in most of the included papers.

“Search for ‘exceptions’; these are times when the problem could have occurred, but it did not or it was less severe than usual. The patient is encouraged to describe what was different when the problem did not occur, or what the client did differently that may, at least temporarily, have ameliorated the problem. The goal is for the client to repeat or do more of what has worked in the past and gain confidence in making improvements for the future” ( 24 , p. 328).

Practitioners may ask clients questions such as “how did you do that?”, fostering a sense of the client’s involvement in this change of situation. This helps to change the client’s perspective of the situation as they are able to see that there are times when the problem is absent or less severe, and realize that situations are not fixed but are fluid. “Positive blame” a technique to attribute the exception to the role the client played in this rather than some external factor, was also referenced ( 17 ). Exceptions can be explored to identify what skills and resources the client used, which can then be used in the present to amplify what works for the client and contribute to the construction of a solution.

3.3.3.2. Present work

Present work entails the practitioner using techniques to encourage the client to reflect and think about what can change in the present and to help them better understand their current situation. Perhaps one of the most integral aspects of this is the use of the scaling technique to quantify the client’s problems, with one article describing scaling questions as the “work horses” of solution-focused approaches due to the frequency in which the questions are asked and the ability to achieve a number of therapeutic ends ( 25 ). Scaling questions ask the client to rate a situation on a standardized scale, usually from 1 to 10, with 1 representing the worst that the situation could be and 10 representing the best ( 14 ). Scaling the clients desired outcome or how far they perceive themselves from their undesirable situation, provides a quantifiable measure of the current situation. It allows the practitioner and client to explore the client’s motivation to achieve their desired outcome as well as the level of control they possess over the current problems in their lives ( 26 ). This allows the client to take ownership over their current situation and identify what steps need to be taken to move forward to achieve their goal.

“Scaling - assigning a numeral value (typically between one and ten) to the individual’s perceived condition, improvement, mood, success, or other intangible (…) Scaling simplifies complex experiences by asking people to grade situations quantitatively” ( 27 , p. 46).

Questions posed by the practitioner encourage the client to take the lead in applying the skills and resources identified in “past work” to their current situation. Successfully applying these strengths in the present encourages the client to see themselves as an individual capable of creating positive change in their life. These strengths and resources must be utilized and amplified throughout the present work, and successful behavior that has worked in the past repeated to encourage improvement of the present situation.

The identification of these strengths will contribute to the overall hope and possibility for positive change, as the client can continuously build upon their existing strengths to formulate solutions. However, it is imperative to continuously discuss whether the solution has created change in the client and not to simply focus on the solution being a good solution.

The principle of “if it’s not working, do something different” highlights the danger of clients becoming stuck in cycles of continued problem patterns while attempting solutions that do not manifest into change ( 28 ). Additionally, the same risk is true for the practitioner, who can get caught in similar “vicious circles” of continued rigid therapeutic techniques that attempt to guide their clients. The practitioner and client must free themselves from these cycles by challenging themselves to look for novel and personalized methods to support the achievement of the client’s goals, which are worked toward in “future work.”

3.3.3.3. Future work

In addition to reflecting on the past and rating the present there was also a clear tradition within the selected research papers of orienting toward the future. This is used in a number of ways, but generally encapsulates thinking of a goal and then envisioning (and then generating) the solutions to achieve it. This makes up a large proportion of the time used within sessions, namely visualizing where the client wants to be and focusing on that preferred future.

Language plays an important role in envisioning this future and influencing the client’s perception of the goal. Language should be “ imaginative, positive, and creative ” ( 29 , p. 18), and the narrative act of solution development should be semantically different to the language of describing a problem.

“The language of solution development is different from that needed to describe the problem” ( 28 , p. 26).

As has been outlined earlier, questioning by the practitioner is key to helping the client work through these processes. The “miracle question” is a type of question that was referenced frequently and is described as a core technique used to help the client visualize and describe in some detail how they want things to be if the selected problem was absent. The “miracle question” can be framed in a variety of ways, but ultimately seeks to establish what a preferred future would be like for that individual. This is a way to immediately frame the therapy as solution-oriented and short-term.

“Inquire as to what will be happening in clients’ lives when the problem is no longer occurring. For example, [you] might ask, “Let’s say that while you are sleeping tonight a miracle occurs and your problem has disappeared. How would you notice that the problem was gone? What would you be doing differently? What would other people notice as different about you?” After a detailed description of change is developed, one that includes behavioral components (e.g., “How will you be acting differently?”), solution-focused [practitioners] and clients work together to “make the miracle happen” ( 30 , p. 301).

Relatedly, change is also a key expectation of the approach, and links to how practitioners orient toward the client’s goals. Solution-focused approaches view change as both continuous and inevitable within the therapeutic process, but also in everyday life. There is an assumption that the client cannot help but change, and the client should be encouraged to articulate what they want to change and then focus on the steps needed to achieve this.

“An assumption of solution-focused therapy is that change is so much a part of living that clients cannot prevent themselves from changing” ( 31 , p. 10).

Both the change-talk and the change processes are one of the most important goals within solution-focused approaches. But change needs to be iterative. Small, incremental changes inevitably lead to larger changes over time, so it is important that clients are not too ambitious in their aims. The focus should be on small, manageable and motivating steps and understanding what would be different if these more subtle changes occurred. Ultimately, these small steps will lead to more impactful change for the client.

“This principle leads us to seek small changes in therapy; changes which, albeit small, can lead to bigger changes in clients’ lives” ( 28 , p. 26).

3.3.4. Views of others

Another tool identified in our synthesis, used by solution-focused practitioners to encourage solution elaboration, was for the practitioner to use questioning to encourage the client to consider the views of others. The literature discusses several advantages to these conversations including the employment of a new lens with which to process situations, the development of new indicators of positive behavioral change, and enhanced future orientation.

“The person is asked to recall interactions with others and to assign significance to these interactions. The scales in this exercise are used to measure what others would observe about them from the past, the present, or future. The person, then, in theory, becomes more aware of the responses of others by envisioning their reactions, what others would want to see happen, and how the person could bring about the necessary change. Imagining how a third party would scale progress offers insights to the practitioner as well” ( 27 , p. 46).

Reflecting on the views of others (most often significant others) during sessions was most often described as the use of “relationship questions”, one of the key types of questions in solution-focused approaches. Such relationship questions can be used following the aforementioned miracle question, thereby inviting the client to describe how others would recognize that they had improved or reached a higher level on the scale.

“It is also helpful to ask clients what their significant others think or might think about their problematic situation and progress (…) Examples are: "What would your mother (or husband, friend, sister, etc.) notice different about you if they didn't know that a miracle has occurred?" ( 32 , p. 50).

Relationship questions encourage the client to assign significance to their interactions with others, and envision how to bring about the change necessary for others to notice they, or their situation, has improved ( 27 ). As the questions recognize the interactional aspect of client problems, the client is encouraged to offer contextually rich descriptions of how others would react to behavioral or situational improvements ( 20 ). The practitioner can also glean insights from the way in which the problem is defined and progress is scaled from a third-party perspective. Collaboratively, the practitioner and client are able to identify contextually relevant indicators of positive behavior that can be used to orient the client. These steps can then be used to move conversations from focusing on internal emotions to external manifestations of solution-focused behaviors and help clients move toward their preferred future.

3.3.5. Practitioner characteristics

The final theme orients around descriptions within the included papers of particular traits and characteristics practitioners should demonstrate while working within a solution-focused approach. These were grouped into four sub-categories: “personal virtues”; “communication techniques”; “generic therapeutic principles”; and “principles which are related to solution-focused approaches.”

“Personal virtues” were traits commonly described as pertaining primarily to the practitioner’s individual approach, such as being friendly or respectful. These were traits that were likely to be needed by any practitioner no matter the therapeutic approach but were nonetheless referenced as important within solution-focused approaches.

“When clients were asked why they placed the therapist where they did, there were a variety of responses; ‘the therapist was fair-minded’, ‘the therapist was honest’, ‘the therapist was trustworthy’” ( 33 , p. 41).

“Communication techniques” were also often listed as a key tool to ensure successful delivery of this approach. Although perhaps these could be seen as techniques used within all therapeutic approaches, such as active listening or selecting and tailoring language carefully, these techniques were also linked to the importance of ensuring a focus on solutions and strengths.

“A gentle, affirming, non-impositional but persistent listening style communicates empathic understanding, while also communicating a belief in the strengths of the client and in the possibility that they can make things different” ( 21 , p. 386).

Language was seen as key in working collaboratively, orienting toward solutions, and maintaining the therapeutic principles key to a solution-focused approach.

Conversely, the generic therapeutic principles that were outlined, like objectivity and avoiding confrontation, were viewed as general good practice that is required from practitioners, regardless of the therapeutic approach adopted.

Finally, some of the characteristics that were commonly described were seen to be less generic and more related to the specifics of working within a solution-focused approach. These included assumptions the practitioner should hold about the client, such as viewing the client as the expert, and taking a not knowing stance. Quick ( 34 , p. 532) describes the central tenet of the practitioner’s approach within a solution-focused model as:

“The model’ s overarching philosophy of `doing what works and changing what doesn’t’, applies not just to the client but also to the therapist as he or she proceeds with the work. When a technique or emphasis on a particular component of the model appears to be helpful, the therapist may well choose to continue it; when a certain kind of inquiry does not appear to be helpful, the therapist should probably `do something different.”

This demonstrates the specific requirement of solution-focused practitioners to apply the principles to their own work and practice. This appears fairly unique to this approach, with the practitioner expected to be willing to abandon their own preferred techniques in favour of doing what works for the client. This demonstrates the collaborative nature of the approach - that its philosophy applies equally to both clients and practitioners and they construct the progression through therapy together.

3.4. What makes an approach solution-focused?

As part of our critical reflection on the synthesis process we developed Table 1 , based on Waltz et al’s, Addis ( 35 ) model for assessing treatment distinctiveness. This helped us to organize our thoughts and understanding of what makes a solution-focused approach distinctive to other approaches, after having conducted the synthesis process. This was based on how the included papers’ authors described or presented the unique and distinctive components of the therapy, rather than direct comparisons with other therapeutic approaches.

Treatment distinctiveness assessment for solution-focused approaches.

3.5. Conceptual framework

Our synthesis and concept mapping resulted in the development of a conceptual framework (see Figure 4 ), showing our understanding of the conceptualization of solution-focused approaches in the adult mental health literature.

Conceptual framework resulting from our synthesis of the conceptualization of solution-focused approaches in the adult mental health literature.

4. Discussion

Using a narrative approach, we have identified the common, and distinct, attributes of solution-focused approaches as they are described in the adult mental health literature. Despite solution-focused approaches encompassing numerous therapeutic models, not just SFBT, and being implemented in a wide variety of settings, their overall conceptualization appears relatively consistent over time even though some of its originally important techniques, such as compliments, are scarcely mentioned in more recent literature. While we identified several key components, none were described in every single paper included in this review. Table 1 details some of the common concepts and techniques described in the literature that we believe appear to characterize the definition of an approach as “solution-focused.”

Across the included papers, there were several themes that demonstrated stability in how solution-focused approaches are conceptualized: perceived as moving away from traditional approaches; problems versus solutions; solution-focused tasks; views of others; and practitioner characteristics. The notion of the client being an expert and becoming empowered through the therapeutic process appears consistently across the included papers and throughout the themes we developed. Similarly, the importance of collaborative working was emphasized, as was the assumption of change being inevitable and essential for clients to progress. Although there was some disagreement between the included papers on the extent to which problems should be discussed, there was agreement overall that the client rather than the problem is the center of enquiry. The principle of focusing on client’s solutions rather than their problems was more radical at the time of the approach’s conception, with this and other concepts now integrated into other therapeutic approaches. However, solution-focused approaches are still seen as more contemporary and distinct from more traditional psychotherapeutic approaches.

Despite our themes being stable in the literature over time, comparing the papers based on year of publication identified some differences in the specific components commonly described. In particular, more recent publications cited task-based components more frequently, such as the use of scaling questions and goal setting, perhaps reflecting the current trend of mental health services being more outcomes-based and focused on tangible measures of progress and recovery. This may be particularly relevant in the UK and other countries where health services are publicly funded. Moreover, the absence of references to “taking breaks,” a core component of the original formulation, in the literature may be a reflection of demands on resource-limited mental health services, where the number of service users is high and time is limited. Taking breaks may be seen as an inefficient use of this limited time, despite being integral to the original conceptualization of the approach. Overall, the grouping and comparison of papers by setting and publication year illustrated a subtle evolution in the way that solution-focused concepts are described in the literature, or at least which key components are given the most salience. The current structure and capacity of modern healthcare services may underpin this subtle change over time.

The results of the vote counting identified one of the main areas of disparity to be the theoretical background ascribed to the solution-focused approach, with most papers either citing de Shazer’s original approach or giving no theoretical background at all. de Shazer’s original description of solution-focused therapy was so influential that perhaps it is considered a theoretical background in and of itself, despite contemporaneous criticisms that he was atheoretical and too pragmatic ( 36 ). The persistent influence of, and reference to, de Shazer’s approach could explain why there is so much consistency in how later solution-focused approaches are conceptualized. That post-modern theories were the second most commonly referenced theoretical background is unsurprising given the conceptualization of solution-focused approaches as centring on the client being the expert, the important use of language, and their perceived move away from more traditional approaches. The numerous theories uniquely identified in individual papers could be a result of the flexibility and applicability of solution-focused approaches to a variety of different settings, allowing for theories relevant to those specific settings to also be ascribed to their particular approach.

Vote counting of the key definitions and steps within the papers identified many unique descriptions that were grouped into overarching categories to aid analysis. These categories demonstrated the myriad ways key concepts were applied. For example, most papers discussed the concept of “focusing on the client’s future,” but prescriptions on how to do this varied. While some advised the use of the miracle question and its variations (i.e., the tomorrow question), others suggested the adoption of a general outlook which is forward-looking and focuses on the client’s desired future. The most frequent steps and definitions were linked in some way to the notion of the client being at the center of enquiry. These included identifying client strengths, focusing on the client’s desired future, and collaborative working between the client and practitioner. The variability of techniques to implement solution-focused concepts may contribute to the enduring conceptualization of solution-focused approaches as being adaptable and appropriate across a wide range of settings and practitioner roles.

This variability in techniques also demonstrates the distinction between concepts we identified which appear core to the underlying mechanism of change within solution-focused approaches and are consistent over time and setting, such as a focus on the future, and the specific techniques used to enact these concepts, which varied. Our themes explored these concepts, whereas previous reviews of solution-focused approaches often simply describe the presence or absence of techniques. Therefore, our conceptual framework provides a basis for understanding how solution-focused approaches achieve their desired outcomes, and the purpose of the techniques commonly used within them. Despite the wide range of settings of our included papers, the concepts explored in our themes were consistently present. This suggests these concepts are key to formulating a solution-focused approach, regardless of the specific techniques then used. While we cannot claim to have assessed which concepts are necessary for a successful solution-focused approach, the enduring presence of such concepts suggest their essentiality to these approaches, and our framework could provide a basis for further investigation in future research.

4.1. Strengths and limitations

The review provides a succinct overview of the understanding and use of solution-focused approaches utilizing a rigorous and novel form of analysis. The use of several analytic techniques, recommended by Popay et al ( 9 ), allowed a holistic approach to analyzing the data. The vote counting proved a useful tool to establish an initial description of patterns arising from the included studies. This initial analysis then allowed for a more thorough and rich exploration and thematic analysis of the extracted data. At each stage of the analysis, several multi-disciplinary researchers were involved, allowing for different views to be incorporated into the final analysis. Another strength of this review was the inclusion of papers from the last 29 years. To include research that stems from the first published study on solution-focused approaches to the present allowed us to establish a historical as well as conceptual perspective of the approach.

However, the review is limited by the fact it only included studies published in the English language. To broaden the search to include publications in different languages could have enhanced or changed certain findings of the review. Second, the review was limited to include papers which specifically used the phrase “solution-focused,” as this was one of the search terms, and so may have missed papers which broadly used a solution-focused approach but was described using a different name. This may account for the consistency we found in our results. Moreover, this could be considered tautological since we searched for the phrase “solution-focused,” it is unsurprising we only found approaches self-described as “solution-focused.” However, as we were interested in looking at how the term “solution-focused” is used and understood in the mental health literature this was deemed appropriate for this review. Third, our synthesis of the findings was limited to the knowledge and understanding of the approach and other therapeutic approaches within the review team. However, discussion of our emerging findings on several occasions with a wider team of researchers and clinicians was beneficial for considering and incorporating other views and interpretations into our final synthesis.

4.2. Comparison with existing literature

The influence of the identified core principles of solution-focused approaches are visible in newly developed therapeutic practices. For example, variants of cognitive behavioral therapy (CBT) which are specifically designed to engender resilience and identify strengths within clients. These include strength based cognitive behavioral therapy ( 37 ) which draws on several elements which are essential to solution-focused approaches such as client strengths identification, tactful use of metaphors and language, and even the use of compliments and smiling by the practitioner to further encourage the client. Another example being DIALOG+, a therapeutic intervention incorporating steps based on the principles of solution-focused therapy, which is used globally ( 38 ). While the specific language of therapeutic tools such as the “miracle question” seem to remain unique to solution-focused approaches, there is a clear persevering influence of solution-focused components in later therapeutic developments.

There have been numerous critiques of solution-focused approaches in the four decades since their development. For example, Walker, Froerer and Gourlay-Fernandez ( 39 ) argue that the approach ignores the importance of discussions of emotional experiences, and in particular the ways in which emotional language can mobilize behavior change within the client by allowing them to identify emotional strengths. However, the potential to emphasize behavioral and cognitive changes, potentially to the detriment of emotional change, was not explored in the literature reviewed. Within descriptions of the tools which must be mobilized to improve therapeutic outcomes, emotional change is reduced to a product of the cognitive change inherent to solution-focused approaches as opposed to a catalyst in its own right. Furthermore, while the articles broadly discuss the importance of language and metaphors, the specific importance of emotional language during therapeutic sessions is scarcely mentioned and its role in solution-focused approaches requires further discussion.

Further, Stalker, Levene and Coady ( 40 ) note that because solution-focused approaches do not provide broad based contextual assessments, it may not be appropriate for severe conditions, where important contextual factors within the lives of the client may be overlooked, in part, due to the brief nature of the therapy. While some articles provided approximate timelines for courses of treatment, other articles noted that the conclusion of solution-focused sessions was a decision that depended on the opinions of the client regarding whether it was necessary. While this may be true for SFBT, the more general widespread adoption of solution-focused approaches in a variety of settings demonstrates its applicability for more severe conditions and its ability to be implemented in a variety of contexts and formats, such as its use in emergency care with individuals who self-harm ( 41 ). However, while generally personalization of treatment is emphasized across the literature, it does not explicitly address whether “doing what works” should encompass the use of more comprehensive specific initial assessments, or how a solution-focused approach can be maintained while such assessments are being completed with the client.

Although the literature reviewed celebrates the cultural sensitivity of solution-focused approaches as one of its key strengths, feminist criticisms of the approach argue that problems experienced by clients are rarely contextualized within cultural conditions for oppression. Such critiques note that treatment of the client as an expert may prevent cultural myths held by the client, e.g., about gender roles, from being challenged. While the literature positions solution-focused approach’s emphasis on personal responsibility and actions as being empowering to clients, Dermer, Hemesath and Russell ( 42 ) note this can be unhelpful to clients who are grappling with larger systems of influence on their lives which are intangible and not prone to change through individual actions. It is argued that instead of empowerment, discussions of personal responsibility can lead to clients feeling responsible for conditions which are inflicted upon them, thus making them feel deserving of oppression. In such cases, Dermer, Hemesath and Russell ( 42 ) state that explanation-oriented approaches are preferable to action-oriented approaches as they permit the use of “blame” and can mobilize gradual and sustained change toward improved futures. Throughout the literature reviewed, the theoretical underpinnings of solution-focused approaches often include the prioritization of cultural sensitivity without further scrutiny into how false cultural narratives are meaningfully challenged, without compromising the notion that the client is an expert on their own experiences.

4.3. Implications

The conceptual framework and synthesis resulting from this review provides a significant contribution to the literature by providing a comprehensive understanding and analysis of solution-focused approaches to adult mental health care. Given solution-focused approaches’ widespread use, these findings will be of interest to researchers and clinicians working with such approaches, to better understand the mechanisms by which their approach works, and how the key principles are utilized. The conceptual framework developed will be useful to refer to when describing these approaches in future research and in clinical practice.

Future research could seek to establish how emotional language is used within solution-focused approaches and the impact this has on therapeutic outcomes. Moreover, the investigation of solution-focused approaches in cultures other than western, English-speaking ones would first uncover whether there are any differences in how it is conceptualized, and second, whether the conceptual framework we identified is maintained while also addressing the needs of other cultural conditions within adult mental health care. It may also be beneficial for future conceptual work to investigate how the key concepts outlined in this paper present in other psychotherapeutic and multimodal approaches. This could identify areas of overlap between approaches, and whether the shift in practice to fit modern healthcare services is common across psychotherapeutic approaches.

4.4. Conclusion

The findings of this conceptual review demonstrate the relatively stable and coherent understanding and use of solution-focused approaches within adult mental health research. Despite being applied across a range of different clinical and geographical contexts, over the 40 years or so since the original formulation of the approach the way solution-focused approaches are conceptualized have remained similar. Perhaps this is unsurprising given that one of the core assumptions of the solution-focused approach is to ensure it is generic and holistic. The findings of this conceptual review will be helpful in providing practitioners and clinicians, particularly those who are new to the approach, a deeper understanding of the core principles and active mechanisms through which solution-focused interventions work.

Author contributions

LJ ran the searches, removed duplicates, and collated the papers to be screened. LJ and JW performed both the title and abstract screening of texts, and full text screening. LJ, JW, PM, NA-H, and KE extracted data from the included papers and performed the analysis. LJ, PM, NA-H, and KE developed the conceptual map, the assessment of treatment distinctiveness, and wrote the final manuscript. All authors have approved the final manuscript.

This work was supported by the National Institute for Health Research (NIHR) [TACK, RP-PG-0615-20010]. The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care. The NIHR had no role in the study design, data collection, analysis, interpretation of data, writing of the report, or decision to submit for publication.

Conflict of interest

The reviewer PP declared a past co-authorship with the author KE to the handling editor.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Publisher’s note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Acknowledgments

The authors would like to thank our colleagues at the Unit for Social and Community Psychiatry, and the Youth Resilience Unit, for their helpful comments and feedback on this review and synthesis. We would also like to thank Priebe, Peterson, Kim, Franklin, Zhang, and Macdonald for their expert comments and key paper suggestions which were crucial to beginning and understanding this review. We are also grateful to Carlos Andre Santos who helped to formulate the original review question and was integral to writing the review protocol.

1 https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=90195

Supplementary material

The Supplementary material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyt.2023.1068006/full#supplementary-material

Discovering Theory in Clinical Practice pp 121–135 Cite as

Solution-Focused Brief Therapy: The Case of Jim

• Philip Miller 3  
• First Online: 30 November 2020

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A case is presented featuring a clinical social worker in a free medical clinic, utilizing solution-focused brief therapy (SFBT) while integrated into primary care. Jim, a 57-year-old black male, was referred by one of the clinic’s primary care physicians with concerns related to his alcohol and crack cocaine use. Application of the SFBT approach is demonstrated by conveying the successful moments and challenges while delicately navigating the unique aspects of this case such as the free medical clinic setting, primary care environment, Jim’s extensive history of substance use, and complicating biopsychosocial factors. Specific SFBT techniques such as presuppositional language, identifying pre-session change, recognition of exceptions, scaling questions, and collaborative goal setting are exhibited throughout treatment with Jim from the initial assessment to managing follow-up appointments. Applicability is relevant to both beginning and seasoned clinicians learning the SFBT approach and desiring to integrate into a healthcare setting such as primary care.

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6 SFBT in Action: Case Examples of School Social Workers Using SFBT

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• Published: April 2008
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This chapter presents five case studies which show how school social workers adapted solution-focused brief therapy (SFBT) to their school contexts. Using a variety of treatment modalities (family, small group, and macropractice), these school social workers demonstrate how flexible and powerful SFBT ideas can be in a school setting.

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What Is Solution Focused Brief Therapy (SFBT)?

Heather Murray

Counsellor & Psychotherapists

B.A.C.P., B.A.M.B.A

Heather Murray has been serving as a Therapist within the NHS for 20 years. She is trained in EMDR therapy for treating trauma and employs a compassion and mindfulness-based approach consistently. Heather is an accredited member of the BACP and registered with the HCPC as a Music Therapist. Moreover, she has been trained as a Mindfulness Teacher and Supervisor by BAMBA and is a senior Yoga Teacher certified by the British Wheel of Yoga.

Learn about our Editorial Process

Saul Mcleod, PhD

Editor-in-Chief for Simply Psychology

BSc (Hons) Psychology, MRes, PhD, University of Manchester

Saul Mcleod, PhD., is a qualified psychology teacher with over 18 years of experience in further and higher education. He has been published in peer-reviewed journals, including the Journal of Clinical Psychology.

Olivia Guy-Evans, MSc

Associate Editor for Simply Psychology

BSc (Hons) Psychology, MSc Psychology of Education

Olivia Guy-Evans is a writer and associate editor for Simply Psychology. She has previously worked in healthcare and educational sectors.

On This Page:

Take-home Messages

• Solution-Focused Brief Therapy (SFBT) is a therapeutic approach that emphasizes clients’ strengths and resources to create positive change, focusing on present and future goals rather than past problems. It’s brief, goal-oriented, and emphasizes solutions rather than delving into underlying issues.
• The focus is on the client’s health rather than the problem, strengths rather than weaknesses or deficits, and skills, resources, and coping abilities that would help reach future goals.
• Clients describe what they want to happen in their lives (solutions) and how they will use personal resources to solve their problems.
• Clients are encouraged to believe that positive changes are always possible and are encouraged to increase the frequency of current useful behaviors.
• Research has shown SFBT effectively decreases marital issues and marital burnout in women (Sanai et al. 2015). Research on children has shown an improvement in classroom behavioral problems in children with special educational needs after 10 SFBT sessions (Franklin et al. 2001).

What is Solution-Focused Therapy?

Solution-Focused Brief Therapy (SFBT), also referred to as Solution-Focused Therapy (SFT), is a form of psychotherapy or counseling.

This form of therapy focuses on solutions to problems or issues and discovering the resources and strengths a person has rather than focusing on the problem like more traditional talking therapies do.

Thus, instead of analyzing how the issue arose or interpretations of it and why it is there and what it really means for the person, SFBT instead concentrates on the issue in the here and now and how to move forward with a solution for it (De Shazer, 1988; De Shazer & Dolan, 2012).

Solution-Focused Therapy was created in the late 1970s and early 1980s in the Brief Family Therapy Center in Milwaukee by De Shazer and Berg (De Shazer et al. 1986).

The reason for its creation was that De Shazer and Berg noticed that clients would often speak about their problems and issues, seeming unable to notice their own inner resources for overcoming these problems and focusing on the future.

They also noticed that the client’s problems or issues showed inconsistency in the way that sometimes they were present and other times they were not, as the person did have moments in life where they could function without the problems being there.

Thus it was important to think about and explore these exceptions when the problem is not affecting the person (Iveson, 2002).

What is Solution-Focused Therapy used for?

Solution-Focused Therapy is currently used for most emotional and mental health problems that other forms of counseling are used to treat, such as:

• Self-esteem
• Personal stress and work-related stress
• Substance abuse/ addiction
• Relationship problems

SFBT is best used when a client is trying to reach a particular goal or overcome a particular problem.

While it is not suitable to use as a treatment for major psychiatric conditions such as psychosis or schizophrenia, it could be used in combination with a more suitable psychiatric treatment/ therapy to help alleviate stress and bring awareness to the person’s strengths and internal resources.

Research has shown that after a one-year follow-up, SFBT was effective in reducing depression, anxiety, and mood-related disorders in adults (Maljanen, et al., 2012).

A study on substance abuse in adults showed SFBT to be just as effective as other forms of talking therapy (problem-focused therapies) in treating addiction and decreasing addiction severity and trauma symptoms (Kim, Brook, & Akin, 2018).

A literature review showed SFBT to be most effective on child behavioral problems when it was used as an early intervention before behavioral issues became very severe (Bond et al. 2013).

Solution-Focused Therapy Techniques

In a solution-focused therapy session, the practitioner and client will work collaboratively to set goals and find solutions together, to overcome the problem or issue.

The practitioner will ask questions to gain an understanding of the client’s strengths and inner resources that they might not have noticed before.

The practitioner will also use complimentary language to bring awareness to and to support the strengths that the client does have, to shift the client’s focus to a more solution-oriented, positive outlook, rather than ruminating on the problem, unaware of the strengths and abilities that they do have.

Sessions usually will last between 50 – 90 minutes, but can be as brief as 15 – 20 minutes, usually once per week, for around 6 – 12 weeks, but are also given as one-off, stand-alone sessions.

There are lots of techniques used in SFBT to shift the client’s awareness onto focusing on the future and on a solution.

These techniques include the miracle question, coping questions, exceptions to the problem, compliments, and using scales, which are explained in more detail below:

1. The Miracle Question

This is where the practitioner will ask the client to imagine that they have gone to sleep and when they wake up in the morning, their problems have vanished.

After this visualization, they will ask the client how they know that the problems or issues have gone and what is in particular that is different.

For example:

‘Imagine that when you next go to sleep, a miracle occurs during the night, so that when you wake up feeling refreshed, your problem has vanished. I want to ask you how do you know that your problem has gone? What is different about this morning? What is it that has disappeared or changed in your life?’

This question can help to identify and gain a greater understanding of what the problem is and how it is affecting the person and can provide motivation to want to move forward and overcome it after imagining what it could be like to wake up without it (De Shazer et al., 1986).

2. Coping Questions

Coping questions are questions that the practitioner will use to gain an understanding of how the person has managed to cope.

When someone has been suffering from depression or anxiety for a long time, it often begs the question of how they have continued in their life despite the potentially degrading or depleting effects of such mental and emotional health problems.

Examples of coping questions include:

‘After everything you have been through, I am wondering what has helped you to cope and keep you afloat during all this?”;

‘I feel to ask you, what it is exactly that has helped you through this so far?’.

These questions cause the client to identify the resources they have available to them, including noticing the internal strength that has helped them make it thus far, which they might not have been consciously aware of before (De Shazer et al., 1986).

3. Exceptions to the Problems

Solution-focused therapy believes that there are exceptions or moments in a person’s life when the problem or issue is not present, or the problem is there; however, it does not cause any negative effects (De Shazer et al., 1986).

Thus, raising the question of what is different during these times. The practitioner can investigate the exceptions to the problem by asking the client to think about and recall moments in their life when the problem was not an issue; they can then inquire as to what was different about these moments.

This could lead to clues for helping to create a solution for the problem. It also will help the client to know that there are times when they are not affected by the problem, which could help lessen the power it has over their emotional and mental state.

As we can often be ‘clouded’ or consumed by our problems, it can be empowering to notice or be reminded of times when we were not.

4. Compliments

This involves the practitioner actively listening to the client to identify and acknowledge their strengths and what they have done well, then reflecting them back to the client whilst also acknowledging how difficult it has been for them.

This offers encouragement and values the strengths that the client does have. The practitioner will use direct compliments (in reaction to what the client has said), for example, ‘that’s amazing to hear!’, ‘wow, that’s great.’

Indirect compliments are also used to encourage the client to notice and compliment themselves, such as coping questions or using an appreciatively toned voice to dive deeper into something highlighting the positive strengths of the client.

For example, ‘How did you manage that?!’ with a tone of amazement and happy facial expressions.

The practitioner will ask the client to rate the severity of their problem or issue on a scale from 1-10. This helps both the practitioner and client to visualize whereabouts they are with the problem or issue.

Examples of scaling questions include:

• ‘On a scale of 1 to 10, where would you rate your current ability to achieve this goal?’;
• ‘From 1-10, how would you rate your progress towards finding a job?’;
• ‘Can you rate your current level of happiness from 1-10?’;
• ‘From 1-10, how much do you attribute your level of alcohol consumption to be one of the main obstacles or sources of conflict in your marriage?’.

They can be used throughout sessions to compare where the client is now, in comparison to the first or second session, and also to rate how far from or near their ideal way of being or to complete their goal.

This can help both practitioner and client notice if something is still left to be done to reach a 9 or 10, and can then start exploring what that is.

Scaling helps to give clarity on the client’s feelings, it also helps to give sessions direction and highlights if something is holding back the client’s ability to solve the problem still or not.

Critical Evaluation

• SFBT is a short-term therapy; on average, sessions will last for 6-10 weeks but can even be one stand-alone session, which helps it be more cost-effective compared to longer-term therapy that lasts for months or years (Maljanen et al. 2012).
• It can help clients to identify their problems and then find a goal to overcome them; the practitioner also offers the client support through compliments which gives them the motivation to notice their strengths, increase their self-esteem, and keep striving to achieve their goals.
• It is future-oriented, so it helps to motivate the client to move forward in life and not to feel stuck in their past; also, SFBT is positive in nature, so it gives the client the optimism needed to move forward into the future.
• It is non-judgmental and compassionate in its approach; the client chooses their own goals, not the therapist, and they are praised/ complimented for their strengths no matter how small; even if they fail at achieving their set goal, they are praised for showing their strengths in other ways in life, helping them not to lose sight of their inner resources and still feel encouraged.

Disadvantages

• Because it is short term, it is not a good fit for everyone, for example, clients with more severe problems that need more time and clients who are withdrawn or struggle to speak and open up fully to the therapist, who would naturally need more time to gain trust and feel comfortable, before being able to work towards a solution with the help of the practitioner.
• Has less importance placed on past traumas, giving less room during sessions to explore these significant events (sometimes of great complexity), and help the client to understand why something in their past happened and why it is still affecting them today.
• As it is solution-focused, it could minimize the client’s pain, making them feel like their past traumas have not been heard or felt by the counselor, which can and does affect the therapeutic alliance, as you are more likely to openly and honestly speak about something traumatic, if you feel the other person deems it important as well, and if they give you space for it. It is also a reason some people choose to see a counselor because they have not had the opportunity to speak about their problems or traumas with other people in their life.
• As the therapy is client-led, this could lead to a few problems. For example, if the client wishes to talk about and explore a past trauma or gain an understanding of a past issue, despite cues from the practitioner to focus on the near future in a solution-focused way, then it will be difficult for the practitioner to actually use this method at all with the client, as SFBT requires the client to actively be ready and want to find a solution and focus towards their near future.
• Also, the client-led approach means that the client can decide when their goals have been sufficiently reached. Therefore, they can end the therapy sessions early if they feel it’s enough, even if the practitioner is concerned about this.

Bond, C., Woods, K., Humphrey, N., Symes, W., & Green, L. (2013). Practitioner review: The effectiveness of solution focused brief therapy with children and families: A systematic and critical evaluation of the literature from 1990–2010 . Journal of Child Psychology and Psychiatry, 54 (7), 707-723.

De Shazer, S. (1988). Clues: Investigating solutions in brief therapy . New York: Norton & Co.

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(2): 207–221.

De Shazer, S., & Dolan, Y. (2012). More than miracles: The state of the art of solution-focused brief therapy . New York: Haworth Press

Franklin, C., Biever, J., Moore, K., Clemons, D., & Scamardo, M. (2001). The Effectiveness of Solution-Focused Therapy with Children in a School Setting. Research on Social Work Practice, 11 (4): 411-434.

Iveson, C. (2002). Solution-focused brief therapy . Advances in Psychiatric Treatment , 8(2), 149–157.

Kim, J, S., Brook, J., Akin, B, A. (2018). Solution-Focused Brief Therapy with Substance-Using Individuals: A Randomized Controlled Trial Study . Research on Social Work Practice, 28 (4), 452-462.

Maljanen, T., Paltta, P., Härkänen, T., Virtala, E., Lindfors, O., Laaksonen, M. A., Knekt, P., & Helsinki Psychotherapy Study Group. (2012). The cost-effectiveness of short-term psychodynamic psychotherapy and solution-focused therapy in the treatment of depressive and anxiety disorder during a one-year follow-up. Journal of Mental Health Policy and Economics. 15 (1), 13–23.

Sanai, B., Davarniya, R., Bakhtiari Said, B., & Shakarami, M. (2015). The effectiveness of solution-focused brief therapy (SFBT) on reducing couple burnout and improvement of the quality of life of married women. Armaghane danesh, 20 (5), 416-432.

Further Information

Solution-Focused Therapy Treatment Manual.

De Shazer, S., & Berg, I. K. (1997). ‘What works?’Remarks on research aspects of solution‐focused brief therapy. Journal of Family therapy, 19(2), 121-124.

Dermer, S. B., Hemesath, C. W., & Russell, C. S. (1998). A feminist critique of solution-focused therapy. American Journal of Family Therapy, 26(3), 239-250.

Trepper, T. S., Dolan, Y., McCollum, E. E., & Nelson, T. (2006). Steve De Shazer and the future of solution‐focused therapy. Journal of Marital and Family Therapy, 32(2), 133-139.

De Shazer, S., Berg, I. K., Lipchik, E. V. E., Nunnally, E., Molnar, A., Gingerich, W., & Weiner‐Davis, M. (1986). Brief therapy: Focused solution development. Family process, 25(2), 207-221.

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Kevin Greene

Case study: solution focused therapy (sft).

• August 30, 2019
• , Solution Focused Therapy (SFT) , Therapeutic Approaches

Updated: September 17, 2020 | Original Post: August 30, 2019

If you are not familiar with Solution Focused Therapy (SFT), click here for a quick overview.

I was working with a student who was feeling increased anxiety over their school work, and as they got closer to their deadlines they procrastinated more and found that their stress skyrocketed. We quickly agreed to use a SFT-based approach and focused our first session on the specifics of what they were feeling and thinking. Once we have an idea of what was holding them back from a cognitive point of view, we explored technology and lifestyle. This individual made limited usage of their phone’s calendar and had never been taught how to approach their work.

Our first step was to put all deadlines into their calendar so that they were now known and easy to find. Then I walked them through how to take an assignment and break it up into smaller components. This helped them get a little bit done each day rather than having to do the entire project over a weekend. It also helped them see what they knew and what they needed help with so they could ask their teacher for help. The result was more assignments handed in on time and overall lowered anxiety.

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7 Solution-Focused Therapy Techniques and Worksheets (+PDF)

It has analyzed a person’s problems from where they started and how those problems have an effect on that person’s life.

Out of years of observation of family therapy sessions, the theory and applications of solution-focused therapy developed.

Let’s explore the therapy, along with techniques and applications of the approach.

Before you read on, we thought you might like to download our three Positive Psychology Exercises for free . These science-based exercises will explore fundamental aspects of positive psychology including strengths, values, and self-compassion, and will give you the tools to enhance the wellbeing of your clients, students, or employees.

This Article Contains:

5 solution-focused therapy techniques, handy sft worksheets (pdf), solution-focused therapy interventions, 5 sft questions to ask clients, solution-focused brief therapy (sfbt techniques), 4 activities & exercises, best sft books, a take-home message.

Solution-focused therapy is a type of treatment that highlights a client’s ability to solve problems, rather than why or how the problem was created. It was developed over some time after observations of therapists in a mental health facility in Wisconsin by Steve de Shazer and Insoo Kim Berg and their colleagues.

Like positive psychology, Solution Focused Therapy (SFT) practitioners focus on goal-oriented questioning to assist a client in moving into a future-oriented direction.

Solution-focused therapy has been successfully applied to a wide variety of client concerns due to its broad application. It has been utilized in a wide variety of client groups as well. The approach presupposes that clients have some knowledge of what will improve their lives.

The following areas have utilized SFT with varying success:

• relationship difficulties
• drug and alcohol abuse
• eating disorders
• anger management
• communication difficulties
• crisis intervention
• incarceration recidivism reduction

Goal clarification is an important technique in SFT. A therapist will need to guide a client to envision a future without the problem with which they presented. With coaching and positive questioning, this vision becomes much more clarified.

With any presenting client concern, the main technique in SFT is illuminating the exception. The therapist will guide the client to an area of their life where there is an exception to the problem. The exception is where things worked well, despite the problem. Within the exception, an approach for a solution may be forged.

The ‘miracle question’ is another technique frequently used in SFT. It is a powerful tool that helps clients to move into a solution orientation. This question allows clients to begin small steps toward finding solutions to presenting problems (Santa Rita Jr., 1998). It is asked in a specific way and is outlined later in this article.

Experiment invitation is another way that therapists guide clients into solution orientation. By inviting clients to build on what is already working, clients automatically focus on the positive. In positive psychology, we know that this allows the client’s mind to broaden and build from that orientation.

Utilizing what has been working experimentally allows the client to find what does and doesn’t work in solving the issue at hand. During the second half of a consultation with a client, many SFT therapists take a break to reflect on what they’ve learned during the beginning of the session.

Consultation breaks and invitations for more information from clients allow for both the therapist and client to brainstorm on what might have been missed during the initial conversations. After this break, clients are complemented and given a therapeutic message about the presenting issue. The message is typically stated in the positive so that clients leave with a positive orientation toward their goals.

Here are four handy worksheets for use with solution-focused therapy.

• Miracle worksheet
• Exceptions to the Problem Worksheet
• Scaling Questions Worksheet
• SMART+ Goals Worksheet

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Compliments are frequently used in SFT, to help the client begin to focus on what is working, rather than what is not. Acknowledging that a client has an impact on the movement toward a goal allows hope to become present. Once hope and perspective shift occurs, a client can decide what daily actions they would like to take in attaining a goal.

Higher levels of hope and optimism can predict the following desirable outcomes (Peterson & Seligman, 2004):

• achievement in all sorts of areas
• freedom from anxiety and depression
• improved social relationships
• improved physical well being

Mind mapping is an effective intervention also used to increase hope and optimism. This intervention is often used in life coaching practices. A research study done on solution-focused life coaching (Green, Oades, & Grant, 2006) showed that this type of intervention increases goal striving and hope, in addition to overall well-being.

Though life coaching is not the same as therapy, this study shows the effectiveness of improving positive behavior through solution-focused questioning.

Mind mapping is a visual thinking tool that helps structure information. It helps clients to better analyze, comprehend, and generate new ideas in areas they might not have been automatically self-generated. Having it on paper gives them a reference point for future goal setting as well.

Empathy is vital in the administration of SFBT. A client needs to feel heard and held by the practitioner for any forward movement to occur. Intentionally leaning in to ensure that a client knows that the practitioner is engaged in listening is recommended.

Speaking to strengths and aligning those strengths with goal setting are important interventions in SFT. Recognizing and acknowledging what is already working for the client validates strengths. Self-recognition of these strengths increases self-esteem and in turn, improves forward movement.

The questions asked in Solution-Focused Therapy are positively directed and in a goal-oriented stance. The intention is to allow a perspective shift by guiding clients in the direction of hope and optimism to lead them to a path of positive change. Results and progress come from focusing on the changes that need to be made for goal attainment and increased well being.

1. Miracle Question

Here is a clear example of how to administer the miracle question. It should be delivered deliberately. When done so, it allows the client to imagine the miracle occurring.

“ Now, I want to ask you a strange question. Suppose that while you are sleeping tonight and the entire house is quiet, a miracle happens. The miracle is that the problem which brought you here is solved. However, because you are sleeping, you don’t know that the miracle has happened. So, when you wake up tomorrow morning, what will be different that will tell you that a miracle has happened and the problem which brought you here is solved? ” (de Shazer, 1988)

2. Presupposing change questions

A practitioner of solution-focused therapy asks questions in an approach derived way.

Here are a few examples of presupposing change questions:

“What stopped complete disaster from occurring?” “How did you avoid falling apart.” “What kept you from unraveling?”

3. Exception Questions

Examples of exception questions include:

1. Tell me about times when you don’t get angry. 2. Tell me about times you felt the happiest. 3. When was the last time that you feel you had a better day? 4. Was there ever a time when you felt happy in your relationship? 5. What was it about that day that made it a better day? 6. Can you think of a time when the problem was not present in your life?

4. Scaling Questions

These are questions that allow a client to rate their experience. They also allow for a client to evaluate their motivation to change their experience. Scaling questions allow for a practitioner to add a follow-up question that is in the positive as well.

An example of a scaling question: “On a scale of 1-10, with 10 representing the best it can be and one the worst, where would you say you are today?”

A follow-up question: “ Why a four and not a five?”

Questions like these allow the client to explore the positive, as well as their commitment to the changes that need to occur.

5. Coping Questions

These types of questions open clients up to their resiliency. Clients are experts in their life experience. Helping them see what works, allows them to grow from a place of strength.

“How have you managed so far?” “What have you done to stay afloat?” “What is working?”

3 Scaling questions from Solution Focused Therapy – Uncommon Practitioners

The main idea behind SFBT is that the techniques are positively and solution-focused to allow a brief amount of time for the client to be in therapy. Overall, improving the quality of life for each client, with them at the center and in the driver’s seat of their growth. SFBT typically has an average of 5-8 sessions.

During the sessions, goals are set. Specific experimental actions are explored and deployed into the client’s daily life. By keeping track of what works and where adjustments need to be made, a client is better able to track his or her progress.

A method has developed from the Miracle Question entitled, The Miracle Method . The steps follow below (Miller & Berg, 1996). It was designed for combatting problematic drinking but is useful in all areas of change.

• State your desire for something in your life to be different.
• Envision a miracle happening, and your life IS different.
• Make sure the miracle is important to you.
• Keep the miracle small.
• Define the change with language that is positive, specific, and behavioral.
• State how you will start your journey, rather than how you will end it.
• Be clear about who, where, and when, but not the why.

A short selection of exercises which can be used

1. Solution-focused art therapy/ letter writing

A powerful in-session task is to request a client to draw or write about one of the following, as part of art therapy :

• a picture of their miracle
• something the client does well
• a day when everything went well. What was different about that day?
• a special person in their life

2. Strengths Finders

Have a client focus on a time when they felt their strongest. Ask them to highlight what strengths were present when things were going well. This can be an illuminating activity that helps clients focus on the strengths they already have inside of them.

A variation of this task is to have a client ask people who are important in their lives to tell them how they view the client’s strengths. Collecting strengths from another’s perspective can be very illuminating and helpful in bringing a client into a strength perspective.

3. Solution Mind Mapping

A creative way to guide a client into a brainstorm of solutions is by mind mapping. Have the miracle at the center of the mind map. From the center, have a client create branches of solutions to make that miracle happen. By exploring solution options, a client will self-generate and be more connected to the outcome.

4. Experiment Journals

Encourage clients to do experiments in real-life settings concerning the presenting problem. Have the client keep track of what works from an approach perspective. Reassure the client that a variety of experiments is a helpful approach.

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These books are recommended reads for solution-focused therapy.

1. The Miracle Method: A Radically New Approach to Problem Drinking – Insoo Kim Berg and Scott D. Miller Ph.D.

The Miracle Method by Scott D. Miller and Insoo Kim Berg is a book that has helped many clients overcome problematic drinking since the 1990s.

By utilizing the miracle question in the book, those with problematic drinking behaviors are given the ability to envision a future without the problem.

Concrete, obtainable steps in reaching the envisioned future are laid out in this supportive read.

Available on Amazon .

2. Solution Focused Brief Therapy: 100 Key Points and Techniques – Harvey Ratney, Evan George and Chris Iveson

Solution Focused Brief Therapy: 100 Key Points and Techniques is a well-received book on solution-focused therapy. Authors Ratner, George, and Iveson provide a concisely written and easily understandable guide to the approach.

Its accessibility allows for quick and effective change in people’s lives.

The book covers the approach’s history, philosophical underpinnings, techniques, and applications. It can be utilized in organizations, coaching, leadership, school-based work, and even in families.

The work is useful for any practitioner seeking to learn the approach and bring it into practice.

3. Handbook of Solution-Focused Brief Therapy (Jossey-Bass Psychology) – Scott D. Miller, Mark Hubble and Barry L. Duncan

It includes work from 28 of the lead practitioners in the field and how they have integrated the solution-focused approach with the problem-focused approach.

It utilizes research across treatment modalities to better equip new practitioners with as many tools as possible.

4. More Than Miracles: The State of the Art of Solution -Focused Therapy  (Routledge Mental Health Classic Editions) – Steve de Shazer and Yvonne Dolan

It allows the reader to peek into hundreds of hours of observation of psychotherapy.

It highlights what questions work and provides a thoughtful overview of applications to complex problems.

Solution-Focused Therapy is an approach that empowers clients to own their abilities in solving life’s problems. Rather than traditional psychotherapy that focuses on how a problem was derived, SFT allows for a goal-oriented focus to problem-solving. This approach allows for future-oriented, rather than past-oriented discussions to move a client forward toward the resolutions of their present problem.

This approach is used in many different areas, including education, family therapy , and even in office settings. Creating cooperative and collaborative opportunities to problem solve allows mind-broadening capabilities. Illuminating a path of choice is a compelling way to enable people to explore how exactly they want to show up in this world.

Thanks for reading!

We hope you enjoyed reading this article. Don’t forget to download our three Positive Psychology Exercises for free .

• de Shazer, S. (1988). Clues: Investigating solutions in brief therapy. New York, NY: W.W. Norton and Co.
• Green, L. S., Oades, L. G., & Grant, A. M. (2006). Cognitive-behavioral, solution-focused life coaching: Enhancing goal striving, well-being, and hope. The Journal of Positive Psychology, 1 (3), 142-149.
• Miller, S. D., & Berg, I. K. (1996). The miracle method: A radically new approach to problem drinking. New York, NY: W.W. Norton and Co.
• Peterson, C., & Seligman, M. E. P., (2004).  Character strengths and virtues: A handbook and classification (Vol. 1). New York, NY: Oxford University Press.
• Santa Rita Jr, E. (1998). What do you do after asking the miracle question in solution-focused therapy. Family Therapy, 25( 3), 189-195.

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Solution-Focused Documentation

Embedding solution-focused documentation templates within electronic health records could help build solution-focused fluency, sustain solution-focused practices within organizations, and improve care coordination, communication, and client outcomes.  Thank you for reading this article on solution-focused documentation, which I would venture to say is not the most exciting topic. How did you decide to take the time while working tirelessly on the front lines of the mental health pandemic, given how staying up to date on notes is the miserable bane of our daily grind?  As my colleagues used to say, a “note is just a note” and “a done note is a good note,” but notes (documentation) now serve so many additional purposes, including accountability to reimbursing third parties, accreditation agencies, legal records of care, informing clinical decision supports and creating a repository of information for clinical research and quality improvement initiatives. Medical and mental health professionals are required to complete all sorts of documentation such as comprehensive psychological intake assessments and ongoing documentation to determine whether a client is appropriate for counseling,  what types of treatment are indicated, formulating treatment plans, coordinating care with multiple providers, documenting when clients are ready to complete or  “graduate” from discrete treatment episodes, and whether a higher level of care is indicated, such as in emergency and crises. However, little empirical attention has been given to this intake and subsequent paperwork (Richmond et al., 2014), and there is little evidence in the literature to guide the selection of specific data entry methods according to the type of data documented (Wilbanks 2018).  

Primary care and behavioral health clinicians often differ in their reporting requirements, codes, regulations, and language. Working with clinical teams to create solution-focused customized shared templates that are unique to each practice context is essential. Providing practitioners within organizations the opportunity to review their current documentation forms, get input directly from clinicians, and test out the forms with practitioners is essential for successful implementation.  Incorporating solution-focused questions within semi-structured data entry by creating text narratives and structured data entry could harness positive aspects of electronic records ( Janett & Yeracaris 2020) . 

At the end of this article, there are solution-focused documentation examples for an intake evaluation, a progress note with a case example, and a solution-focused safety assessment (SFSA).

How Solution-Focused Documentation Can Help Sustain This Evidenced-Based Practice (EBP)

Solution-Focused Brief Therapy entails a paradigm, order, and language shift. These components can be easily integrated into documentation templates to enhance practitioner fluency and assist in sustaining the solution-focused brief therapy approach within organizations. 

Documentation is considered static and unchanging; however, what questions are asked, how they are asked, and when they are asked all make a difference in the narrative created.  The solution-focused practitioner harnesses hope by assisting clients in developing a narrative in which they can recognize their agency and resources while developing an action plan moving forward. Solution-focused documentation can help clinicians and clients develop a hopeful report while making record keeping a little more tolerable and bearable for practitioners. 

Solution-focused brief therapy (SFBT) is fundamentally a linguistic therapeutic approach. Questions are constructed to convey confidence in the client while simultaneously recognizing their agency, strengths, and resources and creating a collaborative treatment plan with the client.  Questions are formulated to help clients articulate what has worked, what is working, and what their best hopes are so they will be confident and have the necessary “good enough” skills to graduate from defined treatment episodes.  The solution-focused practitioner attempts to highlight positive language while simultaneously conveying a belief and confidence in their client. Solution-focused documentation templates can provide friendly reminders and cues for clinicians to ask hopeful questions.  What questions we ask, what we listen to, what we ignore, how we construct questions, and what order we ask questions matter. 

Imagine if the following questions were part of an electronic record semi-structured document. 

• “What are your best hopes?” : conveys the assumption that they do have best hopes.
• “What has been better since we last met? : conveys something has been better and looks for positive differences/exceptions.
• “What has been happening that you want to continue to happen?” conveys some things have been working.
• “What do you know about your condition?” : conveys that they do have knowledge and expertise. 
• “What do you know about your child that they will succeed in life?”:  conveys a belief that they do know their child will succeed. 
• “Supposing ten is you are confident that your skills are good enough to graduate from this treatment episode, and 1 is the opposite; where are you now?”: conveys clients have the capabilities to develop skills and graduate from discrete treatment episodes.

How Solution-Focused Documentation Differs from Problem-Focused Documentation

Traditional intake and follow-up paperwork have relied on a medical model that requires a detailed description of the client’s problems. Problem-oriented approaches require a complete understanding of all the symptoms to make a diagnosis and then treat the client. Solution-focused brief therapy (SFBT)  stands in sharp contrast. SBFT is the only therapeutic modality not requiring a complete understanding of the problem for clients to move forward with their goals. SFBT starts by revealing a detailed understanding of the client’s best hope for their future and collaboratively looks for client-related resources, actions, and agency that build this outlook. The focus is on detailing what a client will do when their problem is solved rather than diagnosis and symptom exploration. Based on the premise that people have the necessary resources to solve their problems, SFBT amplifies these strengths and abilities by building a shared dialect that focuses on what has worked and is working in a client’s life.  

Resource activation and therapeutic interventions that reinforce the client’s agency and abilities play a central role during successful treatment (Gassmann & Grawe 2006).   Therapists who create an environment where clients perceive themselves as well-functioning and activate their resources early in the session have more successful outcomes (Gassmann & Grawe 2006). Research was done to test problem-focused versus solution-focused intake questions on pre-treatment change and compared a standard written intake form with problem-focused questions to a solution-focused brief therapy intake form (Richmond 2014). Clients answering the solution-focused questions described significantly more solutions and fewer problems than the comparison group. Clients in the SFBT intake interview improved significantly on the Outcome Questionnaire before their first therapy session, whereas those in the traditional diagnostic intake did not. This study demonstrated that intake procedures are not neutral information gathering and that strength-based questions have advantages (Richmond 2014). 

Solution-Focused Documentation Clinical Case Example:

The following is a brief example of a case and one possible way to incorporate solution-focused documentation. Of course, there are many different mandates and requirements; this example only provides one. All documentation templates need input from staff and organizations to ensure they meet requirements.

Karl is an 18y/o transgender male (preferred pronoun is he) who presented to the emergency department following a motor vehicle accident. He reportedly was texting his friends about meeting to hang out with them while driving when he didn’t realize the car in front of him had stopped. The car was totaled. Karl sustained a broken leg and back injury. He was hospitalized due to the severity of his injuries and the need for surgery on his leg. While awaiting surgery, Karl was reporting suicidal thoughts and wanting to die. Karl’s father was out of town caring for his elderly parents on the car accident day and had not yet arrived back home. Karl had a difficult time when his father was away and had a prior overdose attempt six months ago while his father was caring for his elderly parents. Karl’s mother died from cancer when Karl was 12 years old, and Karl spent much of his youth witnessing her treatments, decline, and death. The following is an excerpt from Karl’s crisis evaluation while in the hospital medical unit.

Tx: Hello Karl – is that how you like to be called? Karl: Yes Tx: Thank you for taking the time to meet with me. My hope is that I will be helpful to you. I will do my best. Would it be ok if I asked you a few questions in hopes of being helpful for you? Some questions may be a bit challenging. Karl: Ok Tx: Thank you. It must be difficult for you to be here; how have you been holding up these past few days? Karl: It’s been hard. It’s loud, and I can never get any rest. I just want to go home. Tx: Of course. It must be so frustrating for you to be here. What do you know has helped make things even a little bit bearable while you are here? Karl: Getting pain medication. Tx: How has getting pain medication been helpful for you? Karl: It was bad after the accident. I was in so much pain. All I could think of was killing myself just to relieve my agony.

Discussion: Tone Setters and Activating Resources:

The therapist sets the tone by thanking Karl and confirming how he wants to be called, as well as providing consent for the conversation to follow. The therapist also provides plenty of “for you” responses followed by coping questions that activate Karl’s individual resources early in the conversation.

Tx: I’m glad the medications are being helpful for you. How well would you say you are tolerating your pain from 1-10 (10 being the best)? Karl: Probably a 5. Tx: What would be a good enough number? Karl: A 7. Tx: What keeps the number from being lower than a 5? Karl: I’m able to get some sleep. Tx: What else keeps it from being lower? Karl: It’s gone up from a one, and I’m hoping the surgery will help even more. Tx: What have you done that has helped the medication work, even a little bit? Karl: I just try and distract myself by playing video games. The nurses have brought me some games, and that helps a bit.

Discussion: Scaling Pain Tolerability

The therapist attends to his pain and how well he is tolerating it demonstrating concern about his wellbeing. Scaling how well Karl is tolerating the pain and how helpful the medications are from 1-10 is a more constructive way to assess pain. It promotes his agency in managing his pain.

Tx: I’m impressed with how you are handling this. I wonder if you know whose idea it was for me to come and see you today? Karl: I think it was the nurse. Tx: What do you know the nurse was concerned about that asking me to come to see you would be helpful for you?

Discussion: Exploring External VIPs

Asking Karl whose idea it was for the therapist to come and framing this as concern can be helpful in exploring important VIPs in Karl’s immediate social context. Notice that the therapist did not ask “why” rather instead what the nurse was concerned about guiding the narrative to one of care and compassion.

Karl: I don’t know. (Pause) Probably because I said I wanted to die and couldn’t take it anymore. Tx: What do you mean by “take it anymore”? Karl: My father is in Arizona, and when he comes back, he will be furious with me. I know he will take away my driving privileges, and driving to see my friends is the only thing that helps me feel any better.

Discussion: Exploring the client’s language

Karl was able to identify the reason for the consultation – that he wanted to die. Exploring the meaning of his words provided more about Karl’s concerns and his reasons for distress. Although, it may seem to slow the conversation down, exploring the clients’ meaning often paradoxically moves the conversation forward more quickly as the therapist and client negotiate a shared understanding.

Tx: That must be very difficult for you to think about while also dealing with your pain and upcoming surgery. How have you been enduring all of this? Karl: It’s been hard. My father is still in Arizona and won’t be home until tomorrow. Tx: Of course, this must be hard for you. Is your father an important person in your life? Karl: Yes. I don’t know what I would do without him. Tx: What do you most appreciate about your father? Karl: He’s always there for me – even when I do stupid things. He doesn’t give up on me. Tx: What has he done to always be there for you? Karl: He and I are close. After my mother died, we went through a lot. We helped each other. Tx: It sounds like your father loves you a lot. Suppose I were to ask him what he most appreciates about you, what would he say? Karl: That I’m strong, and I can deal with a lot. Tx: What do you mean by “deal with a lot”? Karl: My mother died when I was 12 years old, and it was so hard. Tx: That sounds incredibly challenging. What would your father say you have done to deal with this? Karl: He’d say that I kept going to school and kept caring about people – that I am strong. Tx: What would he say you have done that you are strong? Karl: That I care about people. Tx: You both sound very strong. I’m wondering, who else are the important people in your life? Karl: My mother. Even though she died, I think of her a lot and know she is with me. Tx: What do you suppose your mother most appreciates about you? Karl: She knows how much my father and I care and help each other. She would be proud of that. Tx: What else would she say she appreciates about you? Karl: That I don’t give up.

Discussion: Exploring VIPs

Taking the time to ask who the most important people in Karl’s life and what they most appreciate about him is critical in highlighting his relationship resources. It is often these meaningful relationships that are protective and stop people from acting on thoughts of suicide.

Tx: Supposing I asked your mother and father what their best hopes would be for you so they would know you are safe to go home, what would they say? Karl: My father would want to make sure I don’t do anything unsafe. Tx: What would he hope you do instead? Karl: He would want me to let him know if I was upset and reach out for support. Tx: What else would tell him you can keep yourself safe? Karl: That I wouldn’t be driving and getting into accidents and wanting to end my life. I don’t want to die; it’s just sometimes I get so upset that all I can think of is the relief of being together with my mother. Tx: Of course. These are very intense emotions you are experiencing. I’m wondering, what are your reasons for living? Karl: I want to go to college and become a nurse. Tx: Wow. That is impressive. Have you always wanted this, or is this different? Karl: I’ve wanted to be a nurse for a long time. Ever since seeing how they helped my mother and our family. Tx: Wow – you are strong. Where do you get this determination from? Karl: Probably my father. He doesn’t give up. He keeps trying to help his parents and me.

Discussion: Exploring Best Hopes

Often clients experiencing intense emotions are more able to answer what their best hopes are from the perspectives of their VIPs. This is another reason to have some knowledge of who are the most important people in your clients’s life. Karl was able to answer what his parents’ best hopes were quite easily – to stay safe. Following this, every question or response was focused on activation of his resources including exploring his reasons for living. This is in contrast to exploring why he wants to die. Exploring his reasons for living uncovered additional resources and opportunities to compliment Karl and explore positive differences with him.

Tx: Sometimes, I ask number of questions to help me help you. Would that be ok? Karl: Ok Tx: Suppose ten is you are confident that you can keep yourself safe and one is the opposite; where are you now? Karl: about a 5. Tx: And what would be a good enough number? Karl: A 6 Tx: What keeps the number from being lower than a 5? Karl: Knowing that my father will be here soon. Tx: What do you know about your father being here for you soon is helpful? Karl: I just need to have him nearby. He knows how to calm me down. Tx: What else keeps the number from being lower? Karl: That I wouldn’t do anything. I wouldn’t want to hurt my father. It would kill him. Tx: Suppose I asked your father how confident he is in terms of your ability to keep yourself safe from 1-10; what would he say? Karl: I don’t know. Tx: You know your father best. There is no right answer. I’m just wondering what you think? Karl: Probably a 3 Tx: What do you think is the reason your number is a 5 and not a 3? Karl: I think he would say he’s scared that I had another accident and did the same thing a few months back. He would probably say he’s scared that I could’ve died. Tx: of course – I’m sure that must be frightening for him to know you could have died. What do you suppose keeps his number from being lower than a 3? Karl: That I’m here and getting help. Tx: What else do you think keeps his number from being lower? Karl: That he’s on his way and will be here soon. Tx: I’m wondering, Karl, what would you be doing when your confidence is just a bit higher, at a 6? Karl: I would have a plan for when I leave the hospital. Tx: What do you mean by a plan? Karl: That my father and I would talk, and I would have someone to talk to.

Discussion: Scaling Confidence in Ability to Stay Safe

Scaling confidence in Karls’ ability to stay safe and “working the scale” is an effective way to develop a collaborative safety plan. Even though his parents were not present in the session, their perspectives could easily be incorporated into the conversation. Numbers limit language confusion and allow for a clear plan moving forward in small manageable steps. Numbers often help clients manage the intensity of their experiences safely, as working the scale provides further opportunities to highlight their agency and a plan. And Hope = agency + plan!

Documentation Examples

These document examples are provided as PDFs.

Karl Progress Note case example

Solution-Focused Progress Note

Solution-Focused Adult Intake Questionnaire

Solution-Focused Safety Assessment Tool

Beyebach, M., Neipp, M. C., Solanes-Puchol, Á., & Martín-del-Río, B. (2021). Bibliometric Differences Between WEIRD and Non-WEIRD Countries in the Outcome Research on Solution-Focused Brief Therapy. Frontiers in Psychology , 4926.

Gardner, C. L., & Pearce, P. F. (2013). Customization of electronic medical record templates to improve end-user satisfaction. CIN: Computers, Informatics, Nursing , 31(3), 115-121.

Gassmann, D., & Grawe, K. (2006). General change mechanisms: The relation between problem activation and resource activation in successful and unsuccessful therapeutic interactions. Clinical Psychology & Psychotherapy , 13 (1), 1–11.

Janett, R. S., & Yeracaris, P. P. (2020). Electronic Medical Records in the American Health System: challenges and lessons learned. Ciencia & saude coletiva , 25, 1293-1304.

Richmond, C. J., Jordan, S. S., Bischof, G. H., & Sauer, E. M. (2014). Effects of solution-focused versus problem-focused intake questions on pre-treatment change. Journal of Systemic Therapies , 33(1), 33.

Wilbanks, B. A., & Moss, J. (2018). Evidence-based guidelines for interface design for data entry in electronic health records. CIN: Computers, Informatics, Nursing , 36(1), 35-44.

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Solution Focused Therapy Case Study Examples

Our present state of life is very tough because of the way people are used to working and living. Our routine of work may consist of more than eight hours a day. Most of us spend less than nine hours in bed.

Solution focused therapy case studies often find people dealing with grief or depression. They spend their time or work in an environment where they have to put up with a lot of hostility. People tend to get into that place because they feel powerless.

A solution focused therapy case study will examine how to get past that area. It usually deals with how to face the obstacle head on. It doesn’t involve treating the depression, but how to recognize it and how to deal with it.

People will think back to childhood and discover what kind of things made them feel that way. That can help them when they enter adulthood. If a problem is based on a way of thinking, it can manifest itself in many ways.

In any therapy case study, a solution focused approach is sometimes the best way to go. When a person believes in a problem and seeks to take the necessary steps to solve it, that will often make the situation better. It’s sometimes better to say that a person has a solution than to say that a person has no solution.

One might feel happy because she can get rid of a problem, or she might feel sad because her life is not goingso well. The good news is that there is hope. A solution focused approach can be the key to getting out of that situation.

People should try to learn what is going wrong in their lives and why. Sometimes, a problem can lie deeper than others may seem. It is sometimes necessary to look at the whole picture rather than just one symptom.

A solution focused therapy case study might be about addressing the symptoms of depression, but it might also be about addressing the core issue that is causing the depression. It might also be about finding solutions to anxiety or phobias. The answer can often be the same.

A solution focused therapy case study will look at other factors that contribute to the depression. They can include the person’s job, his/her family, his/her social circle and so on. In many cases, it is the number of people in a social circle that contributes to depression.

A solution focused therapy case study might be about treating depression in women. While some men can experience this condition, there are few women who experience this type of problem. It might also be about treating feelings of failure, for example.

A solution focused therapy case study will have solutions to all these problems. It can also involve education. There are a lot of tools and methods that can be helpful.

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