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Solution-Focused Therapy (SFT) in Primary Care

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Sommaire : Many primary care patients present with chronic issues, or challenging problems with emotional and/or behavioural aspects such as anxiety, depression, grief, or chronic medical issues. Standard medical, problem-based interviewing are good for acute issues, but may be less effective for these types of issues. Solution-focused therapy (SFT) is an extremely powerful approach for these types of patients and is suitable for a primary care setting. SFT is a form of brief therapy which presupposes that patients have the ability to bring about the changes they need. SFT concentrates on a patient’s strengths, abilities and resources thus empowering the patient to overcome their own obstacles with hope and optimism. Solution-focused strategies are ideal for primary care settings because they can be used in any clinical encounter, whether it is a standard 15-minute appointment or a 15-30 minute counselling session.
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Case: Linda, Part 1

You are seeing Linda, a 40-year old ish woman for chronic pain. Unfortunately, she continues to have chronic pain, despite having seen numerous specialists, and trying numerous medications and treatments. It really does seem like all the diagnostic and treatment options have been exhausted. You ask her: “What brings you here today?” She responds, “My pain! I want to try a new medication to see if it will be better.”

You know that she has tried every possible medication… You decide that during today’s visit, you will try something different...

What is Solution-Focused Therapy (SFT)?

Solution-focused therapy (SFT) is a form of brief therapy which emerged in the 1970s1. It was initially used by family therapists to shift the focus of therapy from problems to solutions2. SFT presupposes that patients have the ability to bring about the changes they need3. The patient knows what the best solution is and how to achieve this solution4. SFT concentrates on a patient’s strengths, abilities and resources thus empowering the patient to overcome their own obstacles with hope and optimism1. There is a strong focus on the present and future, rather than the past5. Various techniques can be integrated into SFT provided the core principles are preserved4.

What is the Evidence for SFT?

Evidence supports SFT6,7 for various issues and conditions such as stress reduction8-9, anxiety10-11, depression12-14, postpartum depression15, psychotic disorders16, self-injurious behaviour17-19, coping with personal illness or disability20-22, coping with illness or disability in a family member23-26, grief reactions27-28, marital discord29, chronic pain30, substance use31-37, adherence to treatment plans38, obesity39-41 , diabetes control42, increasing physical activity42.43and other health behaviours44.

Evidence suggests that SFT can be rapidly effective, often in as little as 3-8 sessions45-48. Furthermore, SFT compares well to other forms of brief psychotherapy including psychodynamic therapy48-49, and cognitive behavioural therapy51.

Benefits of SFT include:

  • Rapidly effective, often in as little as 3-8 sessions45-48.
  • Efficacy is comparable to other forms of brief psychotherapy including psychodynamic therapy48-49, and cognitive behavioural therapy51.
  • Using the SFT approach may have a positive impact on the SFT provider19,47, 52-54. This may be due to the positive, empowering atmosphere created by the therapy or perhaps due to the shift of responsibility for finding solutions from physician to patient47.
  • May be more cost-effective compared to other psychotherapies55.

Indications for SFT

SFT is appropriate for patients who:

  • Are well known to the physician and have an established therapeutic alliance;
  • Present with a chronic medical issue  (where acute issues have been explored and appropriately investigated);
  • Are coping well enough that they can talk rationally about their problem(s) and possible solution(s).

Relative Contra-Indications for SFT

There are no absolute contraindications for SFT, however there will be situations where SFT is less appropriate, or patients are too overwhelmed to be able to use SFT such as: 

  • Acute medical issues. If you are seeing a patient in the walk-in clinic with a sprained wrist, it would probably not be appropriate to ask them about goals. Its obvious they want their wrist fixed! And if you are in the emergency room seeing someone with a cardiac arrest, similarly it is not necessary to ask about their best hopes for the visit. 
  • Patients too overwhelmed to think about goals. If you ask a patient about goals, and they are completely unable articulate any, then perhaps switch back to standard medical, problem-based interviewing. For example, you might be working with a patient who is a survivor of trauma and abuse. You ask them about their goals, but they are so overwhelmed, they cannot imagine any other goals. In this case, do further work with them, and later on, you might suggest your ideas about goals. 

Do not pressure patients into giving goals, or answering SFT questions -- otherwise, it becomes solution "forced" therapy.

Doing SFT

At the beginning of a visit, start by asking your patient's goals for the visit 5:

  • Setting expectations for the visit: 
    • "We have 15-minutes for our visit."
  • Examples of goal questions: 
    • "What is your best hope from coming here today?"
    • "How can we make this a helpful visit for you?"

Continue with asking various questions used in SFT, as in the mnemonic MECSTAT -- questions can be asked in any order or combination 1,65


M)iracle Questions
  • Often one starts with the miracle question which helps the patient identify a goal or something that can be improved. This question enables patients to envision the future and what the “solution picture” or "ideal future" would look like.
  • Example: "Imagine that tonight while you are sleeping, a miracle occurs which causes your problem to disappear. What will be the first sign you notice that tells you a miracle has happened?"
E)xception questions
  • These types of questions aim to amplify the patient’s strengths . These questions presume that there are times when the identified problem is less intense. It helps to draw attention to the fact that the problem is not always present.
  • Example: "Can you think of any times when the problem is less severe? When and why does this happen? How could you get this to happen again?"
C)oping questions
  • Patients often feel hopeless to overcome their problem. By asking coping questions, the physician is able to acknowledge the patient’s perceived hopelessness or sense of crisis and identify the patient’s strengths.
  • Example: "Despite the problem, you were able to get up this morning and get yourself to this appointment. How did you manage to make this possible?"
S)caling questions
  • These questions are helpful for clearly defining and measuring the problem and progress towards the solution. Scaling questions briefly acknowledge the problem, without shifting the focus away from solution.
  • Example: 
    • "On a scale of 1-10, where 10 represents your problem being solved, how bad is the problem today?"
  • Compare the score today to last visit. Subsequent questions should aim to identify the reason behind the better of the two scores (i.e. the less severe score).
T)ime-out
  • This component might not be feasible in all settings (depending on space and time constraints). Taking a time out can be useful to allow both the patient and physician to reflect on the session. It is helpful to ask the patient to use this time to consider what goals they would like to set. Time-outs may be as short as 1-2 minutes.
  • Example: "I need to just step out a minute or two. In the meanwhile, can you think about what goals you'd like to set? I'll be back."
A)ccolades

  • Highlight positives to reinforce positive feelings such as through:
    • Compliments
    • Positive observations about the patient’s progress or commitment achieving their solution. 
    • This is helpful to reinforce the positive feelings created during SFT.
      • Example:
        • "It is impressive, that despite your having to cope with ___, you managed to come here today." 
T)ask
  • Depending on how motivated the patient is, the task can be delivered differently. For a patient who is not very sure what they want to get from therapy, it may be best for the physician to assign a goal/task. For patients who are more certain/confident, they may wish to devise their own task.
  • Example: "Between now and our next visit, how about working on making the exceptions we discussed earlier happen more often..."

Follow-up

When a patient returns for a follow-up SFT session, a useful first question is a “pre-therapy change question”. These questions presuppose that change is inevitable and that change has occurred, prompting the patient to identify positive progress rather than dwell on negatives. 

For example:

  • "Since you made this appointment, what have you done that has made a difference in your problem?"
  • "How has the problem changed since our last visit? What do you think was responsible for the change?"

Case: Linda, Part 2 

You decide to try out some different strategies, as opposed to your usual approach with her.

You: “If we could make today a helpful visit, what would be your best hope from coming to see me?”

Goals for the visit, helpful when faced with more chronic issues (as opposed to acute medical issues)

Linda: “I just wish the pain could go away, and I could have my old life back.”

You: “You’d like the pain to go away, and your old life back… I hear you.”

Reflecting back, validation

You: “I have a question for you… Imagine that you go to bed tonight, and while you are asleep, a miracle happens… Tomorrow you wake up… What would tomorrow look like?”

Miracle question

Linda: “Well, if that could happen… If it was a weekend, I’d wake up, I’d go for a walk with the dog. And then I’d hang out with my best friend at her place and help her with her kids. Afterwards, I’d swing by the library, and get some books to read for the evening. And then I’d have a nice long warm bath with candles before reading in bed.”

You: “That sounds like a really wonderful day. Walking the dog… Hanging out with a friend… Helping out with her kids… Going to the library… Having a nice bath with candles… Reading in bed…”

Highlighting positive, healthy behaviours

You: “Just out of curiosity… I know that some of those things might not be possible right now with you, but I’m guessing some of them might… Which of those might be possible these days with you?”

Asking about possible behavioural goals

Linda: “Hanging out with my friend isn’t going to work, because the pain is so bad. But I guess I could call her…”

You: “Anything else that might be possible?”

Linda: “I could have a nice long bath with candles… And read in bed…”

Linda commits to trying some of these behaviours and seeing if they might be helpful. She leaves your office, feeling more hopeful, knowing that there are some practical strategies she might try that might be helpful…

Practice Your Skills!

Try these conversation simulations to practice your skills.

Additional Resources

Motivational Interviewing article

https://www.cfp.ca/content/53/12/2117#T1

Halifax Brief Therapy Centre

http://www.hbtc.ca/resources

University of Toronto SFT guide

https://dfcmopen.com/item-topic/solution-focused-therapy/

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About this Document

Written by Tara Hilton, Family Medicine Resident, Class of 2020. Reviewed by Mireille St-Jean (Family Physician, CCFP), Michael Cheng (Psychiatrist, FRCP(C)). Conflicts of Interest: None declared. 

Disclaimer

Information in this pamphlet is offered ‘as is' and is meant only to provide general information that supplements, but does not replace the information from a qualified professional.

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Affichée le : Jan 8, 2020
Date de la dernière modification : Jan 14, 2020
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