Reflections from the other side of the SF computer desk (or, what's like to be on the receiving end of Solution Focused therapy).

I’ve been a committed Solution-Focused therapist for more than three decades and have been described (perhaps criticised!) by some as something of a purist. I have been sceptical of many of the common ways of seeing and thinking in mental health and openly critical of many of the more prevalent therapeutic approaches. Imagine my surprise … or severe cognitive dissonance … when a few close colleagues, who are mental health professionals and thoroughly Solution-Focused in their own work, told me they were concerned about me and encouraged me to seek psychiatric assistance!

I was sceptical; however, I was also suffering. The only way I can describe it is that I felt like I was falling down a HUGE, deep hole, getting further and further away from the light and the things that keep my life stable. I had no control over the falling and sometimes felt desperate. I could see the bottom of the hole and thought, “Well, hitting the bottom will be painful; but at least I will stop falling and maybe I can start to figure how to climb my way out”. Good plan — but every time I nearly reached the bottom, it simply disappeared and was replaced by more hole, more nothingness. I was not suicidal, but I CAN see exactly how tempting it would be to want to do ANYTHING to stop what was happening. Bugger the consequences!

So, I did what felt like Solution-Focused apostacy. I went to see a psychiatrist (I chose him carefully!). After a detailed conversation, his conclusion was that various difficult events in my life were insufficient to explain the deterioration in my mood (there were various other symptoms, which had made life very difficult for at least a few years; however, I do not need to go into those here) and that I was suffering Major Depression. That kind of made sense … certainly my attempts to focus on exceptions or small successes weren’t working, so maybe some biological condition would explain what I had been experiencing and why I couldn't shake it.^{Go to note 1}

He prescribed SSRI medication, outlined the process that might occur before I experienced any great improvement and described in detail the possible side effects. Well, the last bit was certainly correct and I was able to “tick off” each potential side effect over the next month or so. A few weeks later, I told him that I was tired because of insomnia (possible side-effect #27) but otherwise no improvement. “That’s okay. Quite often the first antidepressant doesn’t work and we have to try one or two others.” Great! Trial and error psychiatry! So, we changed to an SNRI, which came with its own set of side effects. A couple of months later, I told him I had experienced a small improvement, but nothing really very significant. (A “small” improvement … wishful thinking perhaps?). He suggested that, rather than changing to a different drug, we continue the SNRI but add an additional drug which can increase the effect of the first one. Of course, the new drug comes with its own few pages of possible side effects!

I’ve got lethargy but have kind of moved through that, dry mouth means my teaching work is seriously affected,  night sweats — I wake in the middle of the night with the bed sheets literally soaked, and the sheets are washed two or three times more often than normal. Libido — forget it! And even if I somehow become aroused, even Viagra and the like don’t help anything get up!

It’s been a year of various side effects (which are pretty bloody depressing in themselves). Life is by no means always awful; however, it is also not substantially better and I was feeling frustrated and stuck. I talked with a few close friends/colleagues, who all recommended that I should try therapy.

Dilemma: Solution-Focused or other?

So … I’ve decided (perhaps reluctantly) to see a therapist. Who the hell do I see? If I see a Solution-Focused therapist here in Australia, particularly one who is experienced, he or she is most likely to be either a close colleague or someone whom I have trained. I have good friends who are Solution-Focused therapists (hey, I’m married to one!) and friendly conversations with them, where they may use some Solution-Focused questions, can be helpful and enjoyable. However, they are clearly NOT therapy. Would Solution-Focused therapy be helpful, or would I find it hard to get into it because I knew what the next question would be? So, maybe not a Solution-Focused person. However, if I were to see someone who comes from a CBT or ACT stance (that’s 90% of the therapists in private practice here), I know that much of what she/he might say would drive me absolutely crazy! So, maybe not a non-Solution-Focused person.

Dilemma: friend or stranger?

As I said above, any Solution-Focused therapist I might see is most likely to be either a close colleague or someone whom I have trained. However, I have worked in a major hospital and taught therapy in two universities. I am also mildly well-known within broader psychology and therapy circles. So, even if I were to see a non-SF person, the chances are fairly high that we might already have SOME sort of collegial or friend connection.

One of the ethical principles that was drummed into me was the importance of avoiding dual relationships. I was fairly confident that, whoever I ended up seeing wouldn’t be someone I was sleeping with and wouldn’t be someone who had the power to pass or fail me academically. However, the psychologists’ Code of Ethics specifically cautions against a therapist seeing a personal friend professionally.

Stepping into the known unknown

In the course of these discussions, one colleague said to me discreetly, “If you wanted to meet for a bit of SFBT I'd be more than happy. I would talk with you as with any other client and be nosey about only those things SFers get nosey about. It would be totally private and when we'd done we'll go back to our old relationship. This is an offer I'm pleased to be able to make but will be totally okay about it not being the right thing for you.”

This therapist — let’s call him Alan (that is NOT his name!) — is a Solution-Focused therapist. I know him reasonably well but do not see him often. I regard him as highly skilled and absolutely ethical and trustworthy. Maybe I should take him up on his offer?

Pros — He is one of the best; seeing an SF therapist who is less skilled than me will be frustrating; having a non-SF therapist telling me what it really is that I feel or what I should do will drive me crazy. Either way, I’m likely to be fairly critical.

Cons — How will it feel next time I’m sitting on the other side of a restaurant table from him? Won’t the Solution-Focused questions be less effective if I already know what the next question will be?

Yvonne Dolan, one of the more prominent SF therapists and a close friend and collaborator of SFBT founders, Steve de Shazer and Insoo Kim Berg, wrote a paper some years ago about using Solution-Focused Brief Therapy on herself (Dolan, 1997). Presumably, she knew absolutely what question her “therapist” was about to ask, yet the process clearly provoked new thoughts and a sense of possibility which seemed to lead to her desired change. 

So, I decided to step into the “known unknown” and take Alan up on his offer — seeing a therapist I know, who would be using an approach that is like my day-to-day language, but with absolutely no idea where it would head!

Body language — what body?

As with lots of interaction in these COVID-19 lockdown days, our meetings are online. This raises a number of interesting issues in terms of what we think we’ve always “known” about therapeutic interaction.

All we can both see is the other’s head on a screen. Alan could be in the next room or at the North Pole — and it makes absolutely no difference (except I’m not sure about the wi-fi signal at the North Pole!). I can see his head (and maybe part of his shoulders, but often not) and I am MUCH closer to his head (maybe 30 cm/12 in) than I would be if we were sitting face-to-face (even before “social distancing”). So, I can see his head and face, larger than they would be in “real” life. Depending on the camera angle, I can see up his nose. However, I have absolutely no idea whether he is wearing pants or not! I can see facial expressions (indeed, they are almost exaggerated because of the size of the screen) but I can see almost nothing from the neck down. I don’t know for sure if he is sitting or standing; I can’t see whether he takes notes or not; I can’t see his hands move and I can’t tell for sure if he shrugs. Because, for most people, the image of the other person’s face is in the centre of the screen but the camera is actually at the top of the screen, it is almost impossible to maintain direct eye contact. In fact, what is slightly disconcerting, is NOT that Alan does not have eye contact with me; it is that it is almost impossible for me to tell whether he does or not! (Computer nerd, Joe Kissell, has written a fairly technical but quite readable piece about this problem with video conversations; Kissell, 2018).

As therapists, we were taught to be aware of “body language”. When I show videos of Steve de Shazer’s therapy sessions in my training, one or more participants always comments on how his body language is “quite off-putting”. Some even say that there is no way they could be the client of that man, because his communication skills are all wrong! I can remember sitting across from Steve in a restaurant and him asking me about my children. I would often be aware that he was looking searchingly at the ceiling or seeming unattentive, and this could have been quite off-putting. However, once I realised that he was actually 237% focused on ME, then not only did his strange “body language” no longer concern me — I actually no longer even noticed it!

Some therapists talk (or write) as if body language is somehow more “real” than other kinds of language and, indeed, that body language can reveal when spoken language is not true or real. Language and communication researcher Janet Bavelas (Terni, 2011) talks about “the widespread myth that there is a separate, secretly read ‘body language,’ so you can learn to read someone’s emotions and ‘real feelings’ from their posture or face, seeing things not revealed in their words”. My experience suggests to me that "body language" may or may not exist but is certainly not more real than spoken communication nor is a consideration of it even necessary. Certainly, I did not think about Alan’s body language, because largely it was hidden from me.

Chris Iveson, from BRIEF in London, recounts how one of his clients commented, “when you ask the right questions, you disappear” (George et al, 1999). This fits with my experience with Alan. He would ask me a question (even a question I knew was coming!) and I was prompted to think about myself and my life and my interactions, sometimes to think in new ways, and I would think for some timeless period. I might then catch a glimpse of Alan on the screen, and it was almost like, “Oh … you’re still here? Sorry … I’d forgotten.”

Into the fire

At the appointed time, I logged into Skype and there was Alan’s smiling face. He said hello, I think he may have asked me how I was (I forget), but within about 30 seconds of our connecting, he asked me, "So … what are your best hopes from this meeting?”^{Go to note 2}

Absolutely predictable. I knew 100% that that is the way he would begin. In fact, I had spent some of the day rehearsing how I might answer that question. However, suddenly all the answers I’d thought of were irrelevant (or I’d forgotten them!) because this question, in this context, was a completely new question for me.

A few seconds of idle chit-chat, and then, “Right … let’s get into it. So … what are your best hopes from this meeting?”. That was it. No introduction, no putting me at ease. Straight to work!

Alan did not spend any time establishing rapport with me, putting me at ease or discussing the context. You might argue, “Well, you already have a relationship with him, so he didn’t have to establish rapport”. True; however, I haven’t seen him for quite some time and I don’t have a therapist/client relationship with him. Indeed, there could be an argument that because I already had a relationship with Alan, it is even MORE important the he spends time establishing this "different" relationship. Also, the video conversation relationship is largely unknown territory for me. As time went on, it confirmed what I have believed for some time – rapport is created through the Solution-Focused conversation rather than being something that we “create first” in a separate “phase” of the conversation.

Similarly, he asked me ABSOLUTELY NOTHING about the problem. Nothing. In fact, I don’t think he even acknowledged the existence of the problem and he certainly never used the word "problem"! Similarly, he didn't ask me what it was that I wanted to talk with him about (which is really another version of "What's the problem?"). He had some very general information that I had sent in an email to a few close friends; however, this was not as detailed as your average doctor’s referral letter might be. Now, I’m a Solution-Focused therapist. I know all about the problem-solution logical discontinuity(!!). I know the importance of a SF clinician’s discipline in resisting the temptation to explore the problem. Nonetheless, in that moment, I was mildly taken aback. While I knew that Solution-Focused therapists don’t explore the problem; I was also acutely aware that the whole reason we were having this conversation was because I was having some sort of difficulty (or problem) and that biological psychiatry apparently hadn’t been able to fix it!. If it wasn’t there, we wouldn’t be having this conversation. (Although, it is interesting that I have been using the phrase “the problem” — as if were something with its own identity. If you asked me now to describe the problem in detail, I’m not sure that I could!)

“What are your best hopes from this meeting?”

[thinking] "Um … maybe that I start to get some clarity about where I’m heading."

I'm not sure I know what that means, so I’m sure Alan doesn’t. However, he asks NO clarification questions, because (I realise as I reflect on it), he doesn’t need to understand!

“Okay, so how will you know that you’ve got some clarity about where you’re heading? What will be the first sign?”

He continues to ask me how I will know, what other people will notice, how they might respond, and so on. Almost endlessly, it seems. I can imagine, if I was showing the video in training, a number of people would say, “but it’s SO repetitive. If I was there, it would drive me crazy!”. I can understand why they might say that, but that was NOT my experience. My experience was that I kept “discovering” new things about myself and my life and my abilities (except … they were not new … they were already there. However, either I’d never really thought about them before … or, I’d never thought about them in that particular way before.)

Sorry to keep jumping around, but let me share an example from our third session. Alan began our third session by asking, “So … what’s better?” I can’t remember if it was immediately or it was later, but at some point I said, “And … I haven’t had a drink for more than a month!”. Alan’s immediate reply was, “Really … ?”.

My wife, and my GP, had both said they thought it would be good if I had an alcohol-free period (one said it more forcefully that the other!). I had probably been self-medicating in the past; although my GP was clear that he did not think my drinking was the primary issue. I wasn’t averse to the idea df an extended alcohol-free period, but I also wasn’t convinced how important that was; however, I agreed (willingly) to go along with that idea. My wife and I had talked about three “dry” months but, after five weeks, we agreed to resume drinking but do so consciously and carefully. Interestingly, I had not mentioned this to Alan in our previous sessions.

He asked me if it had been difficult and I replied, “No … actually it wasn’t that hard … it was actually easier than I had expected”. Alan’s choice of focus in his following questions was interesting. I had expected he might focus on the achievement of four or five dry weeks and ask me how I had done it, how I had managed any “cravings”, what difference it had made, and so on. But he didn’t. He focused on the fact that somehow I had found it relatively easy. There was some exploration of “How did you make it easy?”, but a lot more exploration of “What do you think other people noticed that showed you were making it easy?”, “How did your wife notice that you were making it easy?", "How did she respond to that?"."How did you respond to that?", "What was the first thing YOU noticed that told you that SHE was noticing that you were finding it easier than you had thought it would be?".

Also, “So how did that make a difference to you?”; “I think it helped me see that I could really achieve whatever I put my mind to … that I was more confident.” “So, how did being more confident show itself?”, “How did you wife notice that you were more confident?", “How did she respond to that”, “How did you respond to that?”, “What was the first thing you noticed that told you she was noticing that you were more confident?”

Some therapists would have taken a “history” and then advised me to cut down on my drinking. Alan didn’t do that, In fact, “cutting down on my drinking” was NEVER a focus of our discussion. However, Alan made WHATEVER change I had already made important — not important to him (“well done; let me congratulate you.”) but important to me, in my context. Further, the end point of this discussion was me recognising/feeling that I had DONE something (made it easy) rather than just that I had managed to NOT do something for four or five weeks (NOT drinking). A HUGE difference. The difference between feeling that I have managed to NOT do something compared to recognising that I HAVE been able to achieve something is enormous. And, of course, if I had made not drinking easy, maybe I could make other changes easy!

Sorry … let me go back to the first session. I had talked about “maybe that I start to get some clarity about where I’m heading.” And Alan had said, “Okay, so how will you know that you’ve got some clarity about where you’re heading? What will be the first sign?”

We were talking on a Friday night. Alan asked, “So tomorrow morning, what will your wife notice?” I told him we have a kind of Saturday morning ritual, where the alarm goes off at 8.30, and we immediately start to listen to ABC radio (ABC is the government radio network … probably like some BBC or NPR). Saturday at 8.30, they have reports from the fresh food markets about the best buys of the week, then a well-known Sydney chef talks about what he or she would cook with the best ingredients from the markets. It is a tiny part of our week … however, after asking, “So what is the first thing you will do tomorrow morning”?, Alan managed to spend at least 30 minutes asking about that 10 minutes of radio. “So, when the alarm goes off, how will your wife know that you’ve got some clarity?”, and then “What else will she notice?”, “How will she respond to that?” … and so on. After 40 minutes, we had a rich description of things between my wife and I being different.

Some would say — “Oh, see … it was a marriage problem — now we’ve figured how to solve the marriage problem, the depression has also gone!”. I would say that this completely misses the point. I don’t think it was a marriage problem. I don’t know (and, maybe I don’t care). Alan did not ask or do ANYTHING to identify where the problem was located. Rather, the “solution”, or better “my preferred future”, or even better “how I wanted things to be in my life”, was able to be located within the relationship that is most important to me. The PROBLEM was not necessarily in my marriage; however, a DIFFERENT FUTURE was something I could begin to imagine in the context of waking up tomorrow next to my wife and being different.

I walked out of my first session with Alan, and my wife said I looked different!

After three sessions, Alan asked me if I wanted to set another time, and I said, “Let’s leave it a while and see what happens”. I KNOW I could talk to Alan next Friday if I felt I needed to (or just wanted to!), and I will check in with him in two or three weeks from now. I know that some people in my life (mentioning NO people specifically, my darling) are a little worried that perhaps I’m finishing my therapy prematurely.

However, I think that the main thing my talks with Alan have done is help me realise that I have some control over this. MY falling down the depression hole involved a series of events I had NO control over whatsoever. I felt helpless with various things in my life happening to me and I felt helpless with this gradually all-encompassing dread, which it seemed to me I could do nothing about. My decision to talk to Alan, my ability to be more talkative about the recipe while we were listening to the radio in bed on Saturday morning, my ability to be a bit more interested in what my wife was doing the rest of Saturday, my ability to stop drinking alcohol for five weeks — these became clear as things I had DONE; things I had (or could have) control over. As I began to see myself as someone who had control over these things … then maybe I wasn’t helpless and hopeless … then maybe I could take control over some other things … and so on.

I am NOT out-of-the-woods yet. My mood is still probably more subdued than it was a few years ago. However, I would say that I feel MUCH better and actually think/feel that I have some control over my future … in marked contrast to when I could only see all this stuff happening to me!

My wife says that the difference in me since I started my sessions with Alan is remarkable. She says it is in marked contrast to the twelve months when I was only on anti-depressant medication and where she saw ZERO improvement. I have told my psychiatrist this; and he assures me he is not offended.

Postscript

I had another session with Alan. It was useful and probably helped me be clearer about what I have managed to do. However, we kind of ran out of steam in questions and answers. I am clear that I have achieved the changes thus far and that it is up to me from here. I know that Alan is there if I feel like I need to talk. I also think I am much better at being able to talk honestly with my wife, and with one or two other close friends, about what I'm feeling and what I'm going through; although, I know I need to practice this — quite deliberately — more!

I saw my psychiatrist, who was pleased with what I told him, and suggested we should try coming off medication. Yep ... not reducing it, but coming OFF it. He gave me a timetable for reducing the medication, step-by-step, over five weeks. He told me of all the possible side-effects of coming OFF the medication (funny they don't tell you that at the beginning!). The side effects of coming off are worse than the side-effects of being on it. Every time I have come down a step, I have had 24-48 hours of acute physical and neurological reaction. One day, I accidentally missed a dose completely and, a day or so later, I thought I was going to die. At my pharmacist's suggestion, I resumed at a slightly higher dose and then tapered off more slowly. This coming Saturday, I am OFF medication completely ...  after seventeen months. That feels like quite an achievement!

I know that much of the literature concludes that a combination of medication AND psychotherapy is a more effective treatment for depression than either on their own. My sense is the I'm not convinced that the medication made any difference (although it's hard to judge, since I wasn't able to have a control condition!) Whilst feeling AWFUL, for a year or more, I was able to maintain a business and personal life ( to a greater or lesser extent — "lesser", many of my colleges would argue), so maybe the medication helped that. Certainly, Alan and I achieved MUCH more and MUCH more quickly!

Notes:

1. When I received a diagnosis of a mental health condition, I decided not to seek to be secretive about it. I wouldn't go to the extent of proclaiming it on Facebook (!) but I did share it fairly widely with my professional network. This was my contribution towards fighting the stigma that somehow often attracts to mental health difficulties. This blog post is offered in the same spirit.^{Back to text}
2. Asking about “best hopes” … the Solution-Focused world is probably moving into two “schools” — although these are not necessarily in opposition or competition with each other. Towards the end of his career, Steve de Shazer would begin every first session with some version of, “How will you know — when we finish here — that coming here to see me today has been useful?” This question has been discussed extensively by Harry Korman and he coined the term "the Common Project" (Korman, 2004). This question then often leads into the Miracle Question. My colleagues from BRIEF in London have developed a variant where their opening question is, “What are your best hopes from this meeting?”, which often leads to the question, “so when is [any part of] that already happening?”. In the past, I have had various esoteric discussions about the relative pros and cons of the two questions and, as a therapist, I lean towards the de Shazer/Korman side. However, as a client, I’m not convinced it made a substantial difference.^{Back to text}

 

 

Dolan, Y. (1997). I'll start my diet tomorrow: A Solution-Focused approach to weight loss, Contemporary Family Therapy, 19,41–48.

George, Evan, Iveson, Chris and Ratner, Harvey (1999) Problem to Solution: Brief therapy with individuals and families (2^nd edition). London: BT Press.

Kissell, J. (2018). Eye-to-eye video: Solving the eye contact problem, Interesting Thing of the Day, Oct 2018. Downloaded from https://itotd.com/articles/5279/eye-to-eye-video/

Korman, Harry. (2004). The common project. Downloaded from www.sikt.nu

Terni, P. (2011). Interview with Janet Beavin Bavelas, Ph.D., Sacramento, CA: Brief Coaching Solutions. Downloaded from http://www.briefcoachingsolutions.com/interview-with-janet-beavin-bavelas-ph-d/