Therapists enter the therapy room with framework of beliefs and values not as a blank slate. Before a therapist ever enters the therapy room, there is the development of a framework (theoretical orientation) to help organize client information and how to use that information to help clients reach their goals. This framework is the lens through which the therapist views client information, the process of change and how the therapist interacts with the client.
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Karlson and Kermott (2006) noted that research continues to struggle with how best to define what constitutes therapeutic change and effective treatment. In fact, these authors further note that comparative studies consistently find that all treatments are more effective than no treatment. If all treatments are effective, then why is a theoretical orientation important? Sperry (2010) argues that having a conceptual framework is a therapists most basic competency.
Theoretical orientation provides the context for effectively all the clinical decisions made by the therapist. Entering the therapy room with a client allows the client the theoretical orientation provides the information needed for the client to know who the therapist is and what to expect out of therapy. Theoretical orientation also provides the therapist with the strategies used, the development of the treatment plan, and a way to measure change in the therapeutic process. Brammer and MacDonald (1999) write the theoretical orientation is a way to ground the therapist and give them a base to work from and that without this base there is limited ability to measure client progress. Additionally, the theoretical orientation helps the therapist to connect with the client and for the client to determine if the theoretical style is a good match.
Regardless of the theoretical orientation the role and purpose of the therapist are similar. The common role of the therapist is to establish a working therapeutic relationship with the client and to facilitate progress toward change (Brammer & MacDonald, 1999). Theoretical orientation is adopted over time with many influencing factors. Adopting a theoretical orientation develops over time as a therapist finds their own therapeutic voice by examining and matching values and worldview with an orientation.
This writer, having been exposed and practiced may approaches to therapy settled on a theoretical orientation initially out of necessity then out of personal identification with the orientation. Working clinically for a large healthcare organization with long wait times does not afford the opportunity for traditional weekly, long-term therapy approaches. A theoretical orientation that is brief and change focused was critical. Solution-Focused Brief Therapy (SFBT) is an orientation that focuses not only on brief intervention but also on creating efficient change. In addition, SFBT can be integrated with other approaches to help facilitate change. Cepeda and Davenport (2006) note that SFBT may hold different assumptions regarding the therapists’ role in facilitating change than other approaches, SFBT techniques can be compatible with other approaches. For example, they note the integration of person-centered therapy with its focus on the here and now and SFBT focus on the future and potentials.
Traditionally, clinical approaches have focused on what is wrong with the client resulting in communication around the problem. Steve de Shazer, credited with the development of SFBT, created a paradigm shift from traditional psychotherapy focused on problem formation to problem resolution (Trepper, Dolan, McCollum, & Nelson, 2006). The paradigm shift is away from an examination of the client’s inner world, thoughts, feelings and past events to the client’s abilities, strengths, achievements, and success in the present and the future (Winbolt, 2011). Steve de Shazer and his team at the Brief Family Therapy Family Center in Milwaukee built on the works of other innovators to shift away from problem formation to client strengths and resiliencies through the examination of both solutions and exceptions.
SFBT provides a structured, short-term approach which enable the therapist and client to establish a collaborative relationship to create a plan of action constructing solutions to clients’ problems. The collaborative relationship is a shift from the therapist as an expert to a view of the therapist as a nonexpert creating a conversation toward change (Shilts, Filippino, & Nau, 2007). McKergow (2016) writes that solution focused practice is about engaging the client in first person rather than third person.
SFBT is a collaborative and creative process requiring the expertise of both the therapist and client to identify and amplify client skills and resources, empowering the client to think about their goals (Winbolt, 2011). de Shazer (1988) observed that there are times when a client’s problems are absent or appear less often. de Shazer found that exploration of how clients managed during these times helps a client identify some of their own resources and strengths they used in solving their own problems. It is through solution focused conversations with a client involving the creative use of questions to discover what is working in their lives to produce change (Winbolt, 2011). Winbolt (2011) writes that through solution talk conversations marked by genuine curiosity, warmth, respect, and humor and solutions are uncovered demonstrating client is resourceful.
The main assumptions of SFBT include (Cepeda & Davenport, 2006; Winbolt, 2011):
- Clients have strengths and resources
- The relationship between therapist and client has therapeutic value
- Change happens all the time
- A small change will generate larger change
- Rapid change is possible
- The focus is on the present and the future
- Clear goals are essential
- The attempted solution may be part of the problem
- The focus is on people not problems
- Resistance is a function of the relationship
- Knowing the cause of the problem is not necessary to do effective therapy
As previously stated, it is through solution focused conversations with a client involving the creative use of questions that build on client competencies. SFBT questions facilitate the co-constructive process of client goal setting and facilitate identification of solutions (Franklin, Bolton, & Guz, 2019). By asking the client to define, identify, or reflect on what went well, the client is provided with strengths-based skill building opportunities (Franklin, Bolton, & Guz, 2019).
Examples of SFBT questions include (Franklin, Bolton, & Guz, 2019):
- Exception questions to explore times in the client’s life in which the problem could have occurred but did not
- Relationship questions that allow the client to reflect on how others in their life perceive them
- Miracle question allowing the client to reconstruct their story by identifying a preferred future without the problem
- Goal setting questions to establish goals based on how the client wants their life to be different
- Scaling questions to examine and evaluate progress toward identified goals
In conclusion, this writer identifies with SFBT due to its ability to target specific goals in collaboration with clients and demonstrated effectiveness with producing rapid change. Franklin, Bolton, and Guz (2019) note SFBT as being evaluated and recognized as an evidenced-based practice currently being included in the National Registry of Evidenced-Based Programs and Practices (NREPP).
Case Conceptualization and Intervention
The client (L) is a 24-year-old Hispanic, single, female. L is a student living with biological mother, maternal aunt, and maternal grandfather. She was self-referred to the behavioral health clinic with the chief complaint of anxiety wanting to better manage overall stress in order to reenter a nursing program. At intake L endorsed symptoms of anxiety to include difficulty controlling worry, decreased sleep, restlessness, shortness of breath, decreased appetite, difficulty with concentration and heart palpitations.
L is an only child to parents who never married. Mother was born in Columbia and has lived in the USA for 40 years. Father is Caucasian moving between southwest states. L was primarily raised by her mother with her father being present for the first three years of her life moving out of state when she was 9 years old. L then visited here father once a year and reports feeling close to her father. L lived with mother, aunt, and grandfather until age 23.
L reports a childhood characterized by maternal chaos and seeking support from extended family. Her mother has been diagnosed with Post-Partum Depression with 5150 after L’s birth, Obsessive Compulsive Disorder and Bipolar Disorder. L reports three significant events in early childhood that have resulted in avoiding close relationships. First, mother had a psychotic episode running out into traffic with L in her arms when she was a toddler. Second, states that mom does not have a sense of responsibility never being employed and briefly spent time in jail for child neglect. Third, she when was Between the ages of 9 and 10 L reports mother’s boyfriend touched her inappropriately. L noted that these experiences have also resulted in not feeling good enough and “too broken to be loved”.
L reports a history of depression and anxiety and participated in psychiatric treatment from ages 15 to 19 to include individual therapy and medication management. Previous therapy focused on early attachment and trauma. L reports treatment was helpful with challenging negative beliefs about herself, maintaining positive relationships in her life, and reports depression is not a current concern.
Prior to entering treatment with this writer L participated in individual therapy to address childhood traumas. During current treatment L has re-engaged in her education enrolling in nursing school and has bene in a long-term significant relationship. Although still living with mother and aunt, L has been able to establish healthy boundaries and focus on self-care. She currently focuses on identifying strengths and resources that she is finding within. She does continue to struggle with focus and concentration at school but applies solution focused self-talk to identify solutions rather than getting stuck in the problem. She has also begun to apply this to her relationship when feeling unsure and overwhelmed with feelings of “being too broken to be loved”.
Suitt, Franklin, & Kim, (2016) found that studies of SFBT with Latinos across multiple setting and ages revealed positive outcomes on standardized measures and participant goals. SFBT appeared suitable for L. In addition, due to L’s previous work addressing childhood traumas those were not a focus of current treatment.
Initial focus in therapy was to focus an understanding L from her perspective and the creation of a therapeutic relationship due to the relationship between therapist and client having therapeutic value. She was very distressed and anxious, which both motivated her to want to change and to work toward her desired changes. Cepeda and Davenport (2006) noted the integration of person-centered therapy with its focus on the here and now and SFBT focus on the future and potentials. Using a person-centered framework, the initial focus is in on allowing her the ability to find her own way and believed that she had within herself the necessary resources for personal growth to help build the therapeutic relationship. SFBT questions to facilitate this process included asking open ended questions and affirming patient’s perceptions. This process is not focused on knowing the cause of the problem but to clearly understand the problem from her perspective, begin using solution talk and to facilitate goal setting. Goal setting questions were used to establish goals based on how the client wants her life to be different and to identify how we would know it is time to terminate treatment.
Subsequent sessions followed de Shazer clinical model (de Shazer, et al., 1986):
- Problem-free talk (solution talk) building rapport and locating strengths
- Statement of the problem pattern, although not necessary to have detail some discussion of the problem is required
- Exploration of solutions patterns by eliciting and amplifying exceptions to the problem
- Small steps of change keeps the therapy focused on change talk and creates the expectation that change possible and inevitable
- The break and the message/homework
Professional Clinical Development Plan
Goals in treatment:
Develop the therapeutic alliance
Reduce overall anxiety by increasing management of stress
Objectives in treatment:
Develop the therapeutic alliance: Each session includes the Therapeutic Alliance Scale to assess alliance strength (see appendix A). Given importance of alliance, anything less than perfect is discussed (as well as perfect scores). Questions help assess the alliance include – Is there anything else I could have done, something I should have done more of or less of, some question or topic I should have asked?
Increase self-confidence and reduce overall anxiety by increasing management of stress: The
miracle question was used allowing the L to identify a preferred future without the problem. L
identified that her if she was feeling more confident, she would be more prepared for the day by
having more structure and routine. L identified that increased self-confidence would result in
feeling reduced overall stress. Scaling questions were used to examine and evaluate progress
toward identified goals. L initially placed herself at a 2 on a scale from 1 to 10 with 10 being
best. L expressed that she would feel successful in treatment if she reached a 7 on the
scale. Solution talk was then used to identify what is already doing that results in a rating of 2
rather than a 1. In addition, exception questions were used to explore times in her life in which
she already felt confident. L was able to recognize that she excelled academically and had
completed two degrees simultaneously.
Recommendations: Due to history of depression and trauma this writer will continue to assess for
these symptoms and needed referral for medication.
- Brammer, L. & MacDonald, G. (1999). The Helping Relationship: Process and Skills. Boston, MA: Allyn and Bacon.
- Cepeda, L. M. and Davenport, D. S. (2006). Person-Centered Therapy and Solution-Focused Brief Therapy: An Integration of Present and Future Awareness. Psychotherapy: Theory, Research, Practice, Training, 43(1), 1-12.
- de Shazer, S. (1988). Clues: Investigating Solutions in Brief Therapy. New York, NY: Norton.
- 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.
- Franklin, C., Bolton, K. W., & Guz, S. (2019). APA Handbook of Contemporary Family Therapy and Training, Vol. 3. Washington DC: American Psychological Association.
- Karlson, R. & Kermott, A. (2006). Reflective-Functioning During the Process in Brief Psychotherapies. Psychotherapy: Theory, Research, Practice, Training, 43(1), 65-84.
- McKergow, M. (2016). Solution Focused Practice: Engaging with the Client as a First-Person, Rather than a Third-Person. InterAction: The Journal of Solution Focus in Organisations, 8(1), 31-44.
- Shilts, L., Filippino, C., & Nau, D. S. (1994). Client-Informed Therapy. Journal of Systematic Therapies, 13(4), 39-52.
- Sperry, L. (2016). Teaching the Competency of Family Case Conceptualizations. The Family Journal, 24(3), 279-282.
- Suitt, K. G., Franklin, C., & Kim, J. (2016). Solution-Focused Brief Therapy with Latinos: A Systematic Review. Journal of Ethnic & Cultural Diversity in Social Work: Innovation in Theory, Research & Practice, 25(1), 50-67.
- Trepper, T. S., Dolan, Y., McCollum, E. R., & Nelson, T. (2006). Steve de Shazer and the Future of Solution-Focused Therapy. The Journal of Marital and Family Therapy, 32(2), 133-137.
- Winbolt, B. (2011). Solution Focused Therapy for the Helping Professions. Philadelphia, PA: Jessica Kingsley Publishers. Retrieved from: https://eds-a-ebscohost-com.ezproxy.snhu.edu/eds/ebookviewer/ebook/bmxlYmtfXzM4Nzk0OV9fQU41?sid=21418143-a185-458d-878c-704f2df4f193@sessionmgr4007&vid=0&format=EB&rid=6
Therapeutic Alliance Scale
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