Recently the radio was on at home and I was drawn to an item on Woman’s Hour. A studio discussion was taking place concerning a new play that was about to be performed. The subject matter caught my attention, as it concerned the famous case of twins June and Jennifer Gibbons, who were committed to Broadmoor Hospital in 1982 for various offences including arson. Their case is fascinating: born in 1963 to parents from Barbados, they were brought up in England and Wales and experienced isolation and racism and, from the age of 14, they stopped talking to anyone but each other. On the day they were released, in 1993, Jennifer died from inflammation of the heart. June is still alive today.

The discussion centred on the attempts that were made to communicate with the twins in hospital, and ranged further into a general discussion about elective mutism. Then the presenter suddenly asked the billion dollar question of Annabel Burns, a Speech and Language Therapist from Hackney who was present:

How do you break into that circle of people not talking?

I stopped what I was doing to listen closely to the ‘expert advice’ that would be forthcoming, and this is what Burns said:

With children with elective mutism the emphasis is usually on developing their self esteem, their confidence, and working with the people, using what’s positive, so working with their parents, working alongside psychologists and Speech and Language Therapists, to build on the skills that they do have. So if they talk with maybe a sibling, perhaps bringing the sibling into school, gently, very slowly building their confidence.

I was astounded. Here, at first glance (so to speak), was a slice of solution focused thinking in action! I wondered what  people listening to the programme would have made of that ‘advice’ – surely they would have expected something that was about ‘treating the condition’ rather than a ‘positive’, systemic approach?

This then led me to reflect on how solution focused Annabel Burn’s response actually was.  I have no idea if Annabel Burns sees herself as a solution focused practitioner. What she said would resonate with many practitioners: it sounds right. However, It would also be reasonable to say that what Burns described is a ‘strengths based approach’ rather than solution focused.

In practice I think solution focused work involves more than what she was saying. At BRIEF, we ground our approach on what people want, looking to build on people’s strengths and skills to achieve their own preferred future. Burns makes no mention of discovering what a client wants from the work. Instead, it seems from the use of the phrase ‘self esteem’ that an assessment is made of the young person’s level of confidence and that is then the focus of clinical attention. Nothing too wrong there, but it’s not quite solution focused practice.

Hoowever, given that in cases of elective mutism it may be difficult to establish early on what the client actually wants, then a focus on strengths and skills makes perfect sense. Solution focused and strengths based – there is a difference.

Harvey Ratner
4 December 2011

Having spent the last 20 years talking about the solution focused approach all over the UK, Europe and further afield Chris, Harvey and I know what sorts of questions people coming across the solution focused approach for the first time tend to ask. And one of the most common is ‘does it work with . . . ?’ Naturally when asking the question people do not stop there. They fill in the gap. And they fill in the gap variously. Sometimes they add a diagnostic description – depression, manic-depression, personality disorder, PTSD or psychosis. Sometimes they add one of a number of life experiences – people who have been sexually abused, the bereaved, people with a terminal diagnosis, people who are addicted to drugs, alcohol, self-harm or people who have chosen the path of elective mutism. Sometimes they add a context. ‘Does it work in’ schools, in groups, in organisations, in foster care, in residential units or in a ward setting? And sometimes they describe categories of people – the young, the old, adolescents, people from ethnic minority backgrounds, people with learning difficulties, people who are less articulate (at least in the context of therapeutic conversation).

Superficially therefore the question can appear to vary, even if fundamentally it is always the same. However the answer never varies. And the answer has two parts.
1. There is nothing that we can discover about the client that will tell us that a solution focused approach is not going to work. Diagnosis, life experience, context or ‘person type’ – none of these will determine the outcome, and none of these therefore will determine whether or not solution focused work should be attempted. We know that the approach works, based on clinical evidence, with a good percentage of people, 70% – 80% typically, but we have no idea about how come it works for some and not for others.
2. And the second part of the answer is just as important as the first. The question ‘does it work with . . .’ should not be thought in this approach to be a question about the client. It is rather a question about the worker. It is a question that challenges the worker’s capacity to find a fit, to find a way of doing solution focus with this particular person at this particular time. So although the approach does not vary a session with a 5 year old and a session with an adolescent and a session with an adult may look different just because the worker is packaging the same questions differently.

And that brings us to Therese Steiner. Therese is a solution focused child psychiatrist based near Zurich in Switzerland. She is co-author, with Insoo Kim Berg, of Children’s Solution-Talk. Her work takes her all over the world and last week BRIEF was lucky enough to have her spend two days with us and a group of 45 participants. And what she worked on for two days was in essence the question ‘so does this work with children’? What she showed us was that of course solution focus works with children. However the worker has to be imaginative. The worker has to find ways of connecting with the client that fit with the child’s world and the child’s preferred ways of communicating. If we sit in a room face-to-face with the child and demand speech then no therapy, let alone solution focus is likely to work. But if we draw cartoons, allow silence, walk scales, use soft toy/puppet supporters and consultants, are prepared to play backgammon with children, engage in squiggle games, make collages of life at 25, paint hands and tell stories – then of course children are likely to engage and once engaged are likely to make changes. Those of us in the group with less confidence in working directly with children may have felt a little daunted by Therese’s endless imagination, flexibility and sheer courage, but at the same time many of us will have been inspired. Therese – thank-you.

Evan George

(Before finishing might I just add the ‘does it work’ question that most baffled (and pleased) me. When working with a group of professionals much of whose work was done in people’s homes I was asked the question ‘How does solution focus work with people who won’t open the door?’ Having spent a moment in mute surprise at the nature of the question I suddenly realised that the approach is useful, even in these circumstances. Think about it.)

The other day I, Evan, received an email from an ex-client who had attended BRIEF some 5 years previously. Her reason for contacting me was to ask if I could meet with a friend of hers – a friend who was going through a difficult time. In addition she mentioned that some time earlier she had written an article about her experience of depression and her recovery from it and that the article mentioned Brief Therapy and me. She attached the article. Naturally I read through the article, quite quickly the first time, looking for the reference to our work together, well to be honest, for the reference to my work with her. And this is what I read:

“The Psychiatric ward was no Victorian ‘bedlam’ and yet I knew that I would not be helped there. It was a place of containment. A therapeutic environment it was not. Many of the psychiatric nurses confirmed this. There was no therapeutic activity. I was allowed to vegetate in my room all day. Thank goodness for my visitors – even though I did not feel like speaking to them!

My sincere thanks to Jane for allowing me to publish this and may I say that my most powerful memory of Jane and Bill is of two lovely people. I looked forward to each and every meeting. Bill looked after the plants in our waiting room and Jane, on our finishing, left me with a CD of her singing which I have listened to with pleasure. The story of her recovery from depression was an inspirational story, each episode of which left me feeling humble and reminding me of just how extraordinary human beings can be.“

Having read this piece Jane responded as follows.

“Oh Evan – I’m sorry if my description of you left you slightly disappointed! I do understand your reaction – as if all your experience and skills might take second place to your loveliness! But you have to accept that I found you lovely and that’s that!

Jane“

If you would like to read the whole of Jane’s account of her recovery from depression you can find a pdf copy named ‘Being invisible in therapy . . . or not’ in our download section.

In 2005 I was invited to give a day’s workshop for social care staff entitled ‘Working with Hostile and Aggressive Clients’. The topic was one which interested me and would require me to pull together my thinking about an area of practice with which I had experience. I agreed, thought about how to present my ideas, delivered the day and was pleased with the results. The commissioner was also pleased and very soon asked me to repeat the day. And yet I had real misgivings. What worried me wasn’t the material or the delivery. What worried me was the title of the workshop. Agreeing to talk about clients as ‘hostile’ or ‘aggressive’ removed any hint of context. The person to whom the client behaved in a ‘hostile’ or ‘aggressive’ manner disappeared. The interactional patterns were obscured while the client’s implied pathology was highlighted. The description was totalising – did the client always behave in a hostile and aggressive manner or were there times when the client behaved in a cooperative way? Was the client hostile and aggressive with every professional or only with some? These (interesting) questions were harder to access if I thought of the client as hostile and aggressive. And so having given the matter some consideration I asked the commissioner if I could change the title of the workshop. Could I call it ‘Building cooperation and engagement with reluctant clients’? Of course I was not quite comfortable with the phrase ‘reluctant client’ but that at any rate was better. The commissioner agreed and this has been the title of the programme ever since.

‘Hostile’ and ‘aggressive’ are not the only words that get us into trouble when we use them to describe the people with whom we work. What about ‘unmotivated’ or ‘resistant’? Are these terms useful to us in our thinking about people? Describing people as ‘unmotivated’ suggests that this is an inherent, permanent state. It is internal; it is part of the other’s make-up; it is part of their personality. Even if we make the very small shift to thinking ‘my relationship with this person is peculiarly unmotivated’ new possibilities open up. We begin to see a possible direction for purposeful activity. We can start to ask ourselves the question ‘what can I do differently so that motivation grows in this relationship?’ Putting ourselves into the frame makes it easier to consider what action we can take. The other’s motivation becomes my issue just as much as it remains their’s. I can no longer sit back if there is no progress in the work and comfort myself with a recitation of the client’s failings – unmotivated, resistant, uninsightful, inarticulate. It becomes clearer now to me that it is part of my job to work with people in a way that builds motivation, builds cooperation and fits with what people can do. Of course this thought is uncomfortable for us to live with. If the client continues to behave in a ‘hostile’ and ‘aggressive’ way we have to ask ourselves the question ‘what could I have done differently that might have led to more cooperation?’ Facing up to our responsibilities clearly is not easy but at least it increases the odds that we might do a better job next time!

Evan George
13 July 2011