Over the course of the summer I, and many others I am sure, read and was inspired and moved by Paul Kalanithi’s book ‘When breath becomes air’. As a Solution Focused practitioner it would be hard not to have smiled a collegial smile of recognition when we read the following lines where he is referring to a patient coming to him with a hugely difficult decision to make:
‘She would likely refuse surgery if I launched into a detached spiel detailing all the risks and possible complications. I could do so, document her refusal in the chart, consider my duty discharged, and move on to the next task. Instead, with her permission, I gathered her family with her, and together we talked through the options. As we talked, I could see the enormousness of the choice she faced dwindle into a difficult but understandable decision. I had met her in a space where she was a person, instead of a problem to be solved. She chose surgery. The operation went smoothly. She went home two days later, and never seized again.’ (p 90)
Paul Kalanithi’s words ‘I had met her in a space where she was a person, instead of a problem to be solved’ leapt off the page as I read. They slowed me down and invited me to reflect. They brought to mind a couple of lines of Athar Yawar (2009) writing in The Lancet:
‘We rarely have the time, or encouragement, to treat patients according to their story, rather than our diagnosis; outcome measures are too coarse to consider whether the patient has been allowed to preserve and fulfill his or her humanity.’
But of course Paul Kalanithi’s words also brought me back to Steve de Shazer. I recalled the number of times that I heard Steve during presentations making the same point. Workshop attenders would, understandably, ask him questions along the lines of ‘can you use SFBT with psychosis, with depression, with anxiety, with bereavement, with trauma . . . ?’ And Steve would often answer ‘no’ to each and every one of these enquiries. This would puzzle the enquirers since they had come to the workshop assuming that you could and were merely asking for confirmation. And then of course, later on and at a point of his choosing, Steve would add that SFBT does not work with psychosis or depression, or anxiety, or trauma or bereavement or people who have been abused, SFBT works with people who want something and the challenge for the worker is to find out what the person does indeed want.
One of the aspects of the Solution Focused approach that attracted me to the model was precisely the foundational assumption, often unarticulated, that ‘the person is more than the problem that they bring’. When we allow ourselves to describe people as if they are coterminous with the problem, for example ‘he is an alcoholic’, we reduce and limit people, describing them in relation to just one small part of who that person is. Of course we all ‘know’ that the person is more, much more than anxiety, much more than self-harm or anorexia or bulimia or adjustment disorder, but when we allow ourselves these descriptive short-cuts, there is the risk that we might forget. We might come to believe our ‘jargon’ and very soon we could find ourselves ‘treating’ disorders rather than getting alongside people and working with them to make the changes that they want to make in their lives. Diagnostic language empowers and centralizes the worker and the worker’s thinking and disempowers clients and their thinking. Diagnostic language makes workers the experts on the people with whom they work, and before long that can slip and slide to ‘the people on whom they work’.
Paul Kalanithi puts it beautifully. We must always aspire to meet people in those spaces where they are people and not problems to be solved. Judging from his lovely book Paul’s death is a loss not just to his family and friends but also to his patients and to his profession. The world needs more people like Paul.
Kalanithi, Paul. (2016) When Breath becomes Air. The Bodley Head. London
Yawar, Athar. (2009) The Fool on the Hill. The Lancet. February 21 2009 Volume 373 Number 9664 p621-622 (This piece can be found on-line.)