Keeping It Brief

Here are some popular misconceptions about brief therapy:

• It sacrifices a real therapeutic alliance.
• It is only popular because insurance companies love it. 
• It doesn’t work long term. 

Many counselors with in-depth training in brief therapy models are quick to dispel these myths and contend that brief therapy can help clients zero in on real causes for problem issues without getting lost in detail and old history. Others emphasize the way that brief therapy, often known as solution-focused brief therapy (SFBT), helps clients build substantial solutions rather than just resolve specific problems. Rooted in the 1950s work of Milton Erickson and further developed by the husband-and-wife team of Steve de Shazer and Insoo Kim Berg in the 1980s, the brief therapy model highlights and activates a client’s strengths to help change a situation.

Studies have shown the model’s effectiveness in working with clients with depression, antisocial adolescents, prison populations and even parenting skills groups. Its proponents say that, with less time spent on history taking and diagnoses, the SFBT approach is well suited to the new realities of limited insurance benefits and the increasing need for community mental health outreach.

Mike Kozlowski, an American Counseling Association member who works at Columbia River Mental Health Services in Vancouver, Wash., is one clinician who has witnessed the misconceptions that often swirl around SFBT. He says he appreciates the opportunity to set the record straight.

“Many counselors who favor long-term approaches often think brief and solution-focused approaches are invalidating to the client’s experience because they only concern themselves with understanding enough of the problem to find a solution to it,” he says. “I think counselors feel this way because they walk around with the assumption that the problem needs to be completely known in order to solve it. This means diving into client histories trying to understand how problems began.”

Clients may harbor some of these false impressions as well. “Sometimes clients also have the perception that they need long-term work in order to feel better,” Kozlowski says. “I think this is due to the portrayal of counseling in popular culture. This has created the client assumption that the counselor needs to completely understand the past in order to help the client in the present.”

Counselors who practice brief therapy emphasize understanding the problem within the immediate moment, Kozlowski explains. “I think this approach is becoming more and more necessary [because] research in psychotherapy and counseling is suggesting that the number of sessions attended by most clients is one,” he says.

Mat Trammel, cofounder of the Fort Worth Brief Therapy Center in Fort Worth, Texas, gravitated toward SFBT after exploring the client-centered, Rogerian approach and the interpersonal process style. “The premise behind brief therapy models is that change can take place suddenly,” he says. “Through creative questioning aimed at discovering exceptions to when, how and where a problem occurs, SFBT practitioners also rely heavily on a client’s personal strengths, creativity and expertise with [his or her] own life as opposed to assuming a directive role or expertly telling clients how they should solve their problems.”

Trammel notes that, rather than emphasizing childhood and early life experiences, counselors applying brief therapy models often follow their curiosity to help clients recognize the “here and now” situations in which the identified problems do not have influence. “Understanding the nature of a problem is not typically the focus of brief therapy models and is not always necessary before forward progress can take place,” he says. “While solution-focused therapy may utilize genograms, family history or childhood experience, they are not considered prerequisites to positive change.”

Trammel also points out that SFBT is not the sole model he uses. “I employ rational emotive behavior therapy as well and cognitive behavioral therapy to some extent. In dealing with facets of personality disorders, use of some aspects of dialectal behavior therapy is also beneficial,” he says. “I endeavor to use whatever approach or model works best for the client. I find that [SFBT] combines nicely with other forms of counseling.”

Kozlowski concurs. “Skilled brief counselors know clients don’t always fit nicely into our psychotherapeutic boxes,” he says. “[These counselors] make adjustments to include techniques from other theories … in the spirit of ‘doing what works.’”

Looking for exceptions

The Solution-Focused Brief Therapy Association, a group affiliated with de Shazer and Berg that promotes counselor education and consultation, describes the approach simply as being brief and focusing on solutions rather than on problems. The client and counselor collaborate in “becoming curious” about the times when the client’s identified issue is not present or feels less powerful. They work to enhance awareness of these moments, with the client growing more confident as a result. Instead of teaching a client an entire new set of behaviors, this model helps the client recognize and build on his or her existing strengths. The theory supposes that, because the client’s strengths already exist, it may take less time to put them to use in addressing the presenting problem.

Looking for exceptions to the client’s perceived problem is a hallmark technique of SFBT and one that many clients don’t expect when beginning the counseling process, Kozlowski says. “I specifically remember one client suffering from crippling anxiety whom I asked, ‘So, tell me about the times where you are not anxious.’ She was so surprised that she almost fell out of her chair,” he says. “She told me that all of her other counselors had only talked to [her about] triggers to anxiety, and no one had ever asked her about when the problem wasn’t occurring.”

SFBT practitioners may apply other interventions, including “problem-free” talk to build rapport and learn about the client’s other resources. They may also ask clients to rate their feelings about the problem on a scale of 1 to 10 and inquire about coping skills. Another classic technique, although not unique to SFBT, is asking the “miracle question,” which invites the client to consider how life would change if the presenting problem miraculously disappeared. Used together, these interventions may help clients stop focusing on what is wrong and instead move toward naming what is going well and considering how to enhance the positive.

The brief therapy model also uses homework and taps into community resources to help clients, notes Mira Mullen, a licensed professional counselor and ACA member in Juneau, Alaska. “I often use handouts from [Kate Cohen-Posey’s] More Brief Therapy Client Handouts for anxiety, depression, mindfulness breathwork, relationships, etc. I have resources available in my office for community supports, 12-step groups and other agencies because, frequently, patients are eager to accept help from food banks and charitable organizations,” she says.

Kozlowski recalls working with a client with posttraumatic stress disorder who assumed she would need years of counseling to overcome a sexual assault and an abusive childhood. “When we were discussing the problems in therapy, it turns out her main problem was actually dealing with her musician boyfriend who was out late, and she assumed he was being unfaithful, even though he hadn’t been. So, she would yell at him when he would come home, and he would react by yelling at her, which reminded her of the emotional abuse she had experienced in the past.”

“By probing for exceptions and punctuating her solutions to the problems,” Kozlowski continues, “we discovered she was actually very good at communicating her needs to her boyfriend during other times in their relationship. After a little coaching and practice in applying her already existing skills to her conversation with her boyfriend when he came home late from a concert, she felt well enough to terminate counseling. To my knowledge, she hasn’t returned for services since.”

Kozlowski acknowledges that a psychodynamic or trauma-oriented counselor might recommend a different path for this client and cites this as the fundamental difference between long-term and brief therapy models. “Brief models focus specifically on resolving the chief complaint,” he says. “Solution-focused, as I understand and practice it, focuses on finding a solution that works well enough for the client to function in [his or her] day-to-day life without the need of the therapist.”

The appeal of brief therapy

It’s natural to ask what type of client benefits from SFBT. Because of the model’s flexibility and positive approach, its proponents suggest a better question might be what type of client wouldn’t find SFBT beneficial. “I haven’t met a client yet where this approach hasn’t been … helpful,” Kozlowski says, adding that competent supervision is a must for those seeking to incorporate SFBT into their practices.

Kozlowski admits that at the clinic where he works, some clients come in thinking they need long-term counseling. To those clients, he offers an analogy: “People are like oceans. They are vast, complicated and not always easy to understand. When people come to counseling, they often think we need to spend the time exploring every oceanic canyon, classifying every kind of fish and mapping every current in order for things to be different. While this can be true for some, others just want to figure out how to get from London to New York. I’m the guy who can help you get from London to New York. Is that something you would like?”

Trammel agrees. “I think any person may find a nice fit with solution-focused work. It seems to be a good fit for court-ordered clients, possibly due to the externalizing of the problem and unconditional acceptance of how they have attempted to resolve the issues in the past.”

Brief therapy models hold appeal for other reasons too. Namely, insurance companies tend to be more willing to reimburse for these sorts of services because they often involve fewer sessions and provide quantifiable outcome measures. “The techniques in solution-focused therapy, as well as its brief design, lend it to fit well within [the insurance] process,” says Kozlowski, who adds that a large managed care company in his part of the country strongly favors SFBT. “I work in community mental health, which primarily bills Medicaid and Medicare for its services. Some counties here in the Northwest have adopted solution-focused therapy as an evidence-based practice billable for psychotherapy.”

Outside the box

The use of brief therapy models is not limited to the traditional counseling office. In fact, some counselors contend that brief therapy models lend themselves to unusual practice locations because of their flexibility and emphasis on goal achievement. Mullen works as a behavioral health consultant in a tribal Indian Health Service-funded clinic in frontier Alaska that uses the family home medical model. The model brings behavioral health workers such as counselors and social workers into medical clinics, thus incorporating mental health support into the traditional medical approach. The model lends itself to SFBT because the clients are referred as part of a larger medical diagnosis — for example, to consider the mental health side of a medical diagnosis such as cancer.

Mullen gives an example of what she does when one of the clinic’s primary care doctors gives her a referral. “A doctor will come see me [and] give the age, name, social circumstances, presenting problem and co-occurring medical issues [of the patient]. Then we will walk together to the assessment room the patient is in, and the doctor will introduce me and exit to quickly continue seeing other patients. I will sit with a patient and do active listening and validate [his or her] experience in order to build rapport and improve affect regulation. From there, we can at times move to my office for an additional 20 minutes or so and begin the process of problem identification and brief therapy.”

Mullen will conduct between one and four visits with clients, after which she may make referrals to a separate behavioral health department within her facility. She explains that a few sessions with her can help clients solidify their goals before launching into longer-term therapy.

Mullen concedes that it can be challenging when clients resist the short-term approach necessary in her clinical work environment. She has had clients say they like working with her and do not want to “change horses midstream.” In these situations, she has found herself reframing the purpose of the sessions as a way to teach clients what is expected in therapy and how to use the time to their advantage.

Getting started

For those wanting to learn more about integrating SFBT into a counseling practice, Trammel recommends reading the works of de Shazer, Erickson, Berg and Bill O’Hanlon. In addition, many continuing education opportunities are available online and through the Solution-Focused Brief Therapy Association (sfbta.org).

Kozlowski notes that some counselors may be surprised to find they are already familiar with some of the positive psychology components of the SFBT model. He started learning about SFBT during a clinical internship, assuming it would sit alongside cognitive behavior therapy (CBT) and motivational interviewing in his counseling toolkit. Instead, he found himself inspired by SFBT’s emphasis on client strengths.

“Where CBT assumes erroneous thought processes and schemas, SFBT assumes clients have the strengths, skills and resources to solve their own problems — but they either forgot their skills or need guidance in applying those skills to their specific situations,” he says.

Today, Kozlowski uses only SFBT with clients, but he insists that choice does not make him rigid in his practice. “We have a saying in solution-focused brief counseling: ‘If it isn’t broken, don’t fix it. If it works, do more of it. If it doesn’t work, stop doing it. Do something different.’ Under this motto,” he says, “it’s possible to integrate almost any approach within a brief model.”

Contributing writer Stacy Notaras Murphy is a licensed professional counselor and certified Imago relationship therapist practicing in Washington, D.C. To contact her, visitstacymurphyLPC.com.

Letters to the editor: ct@counseling.org

This article originally ran in the July 2013 issue of Counseling Today magazine.