Solution-Focused Therapy: Theory, Research & Practice

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Alasdair J. Macdonald

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    Copyright

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    Dedication

    With thanks to Celia and my colleagues

    About the Author

    Alasdair has been a Consultant Psychiatrist in the NHS since 1980. He currently holds a part-time contract with Children's Services in Dorset County Hospital Foundation Trust, and has experience in all aspects of psychiatry including secure care. Alasdair's psychotherapy training includes psychodynamic, group and systemic approaches and he is registered as a family therapist and supervisor with the United Kingdom Council for Psychotherapy. He has been the Medical Director of two Trusts and Project Director of the Mental Health Institute at St Martin's College in Carlisle and Lancaster, and is Research Coordinator and former President and Secretary of the European Brief Therapy Association. Alasdair works as a trainer and supervisor and as a management consultant. Training workshops include solution-focused therapy, solution-focused approaches to mental health and organisational skills for finding cooperation in the workplace. He is the Service Director of Dorset Child and Family Counselling Trust and a Trustee of the Dorset Trust for Counselling and Psychotherapy, both local charities.

    Teaching and training in solution-focused brief therapy has been Alasdair's chief interest for 20 years. He has taught in the USA, South Africa, China, Singapore and Australia, as well as most of the countries of Europe. He has special experience in the application of these ideas within the mental health setting and with offenders. Alasdair's main research interest is the study of process and outcomes in therapy and he has over 40 peer-reviewed publications and numerous other published pieces. His book Solution-focused Therapy: Theory, Research and Practice was published in 2007, and he is on the editorial boards for a forthcoming book on solution-focused approaches and for two journals. Alasdair is also the Scientific Advisor for the Helsinki Psychotherapy Institute.

    For further information see http://www.solutionsdoc.co.uk

    Praise for the Book

    ‘Ideally, every clinician, supervisor and trainer who aspires to excellence would have unlimited access to a wise, supportive mentor or colleague with a wealth of practical clinical experience balanced by extensive knowledge of all the most pertinent research. This eminently useful and satisfying book comes close to approximating that experience! Macdonald provides a generous spectrum of practical solution-focused techniques that readers will be able to readily apply to a wide range of clinical, supervisory, coaching and educational settings balanced by a clear and satisfying overview of the solution-focused approach in the context of current, state of the art research.’

    Yvonne Dolan, Director of the Institute of Solution-Focused Brief Therapy, Chicago, Illinois

    ‘Whether you are an experienced practitioner in solution-focused therapy or an absolute beginner, this scholarly, yet accessible, text has everything you need. It explains not only what solution-focused therapy is but where it comes from, how it differs from other therapies, where it can be used, when to use it and when not to, and how and why it works. This revised edition has all the hallmarks of a classic text.’

    Judith Milner, solution-focused practitioner (http://www.judithmilner.co.uk)

    ‘The second edition of Alasdair's book is a must for both introductory courses in solution-focused approaches to therapy and for those established practitioners interested in the developing research from this field. Solution-focused skills are usefully illustrated with therapist–client vignettes that bring the practice of therapy to life for the reader. The updated research chapter offers a very helpful and contemporary critique of SFBT's growing evidence base, raising awareness of strengths, limitations and potential direction for future studies.’

    Fred Ruddick, Senior Lecturer (Mental Health Studies) RMN, RGN, Adv Dip Counselling, MA Counselling, University of Cumbria

    ‘Alasdair Macdonald's book is the go-to source for research and insights into solution-focused approaches. This new edition includes all the latest research studies and analysis, along with concise and usable ways to use SF in a huge range of situations from severe mental illness to workplace performance. The new chapters on ethics, commonly posed questions and future prospects are concise and sharply observed. Anyone interested in evidence, research and application of the SF approach should have a copy to hand. Really.’

    Mark McKergow PhD MBA, author of The Solutions Focus: Making coaching & change SIMPLE, co-founder of SFCT and SOLWorld

    ‘This is a well structured and meaty text that presents SFT authoritatively, in a way that has to be taken seriously. It covers all the areas one would expect – a description and history of the model; ethics; research, settings and issues – and is an all-round excellent text.’

    Colin Feltham, Emeritus Professor of Critical Counselling Studies, Sheffield Hallam University

  • Appendix I Useful Links and Addresses

    The author's website includes information about the author, the European Brief Therapy Association therapy research manual and an annotated bibliography of published outcome and evaluation studies. Some otherwise unobtainable papers are provided there in full. http://www.solutionsdoc.co.uk

    The Solution-Focused Brief Therapy Association (SFBTA) of America was founded in 2002. They have acquired copyright to the teaching materials developed by Steve de Shazer and Insoo Kim Berg Family Therapy Center in Milwaukee. The website provides extensive information about solution-focused therapy in the North American continent, including details of the annual conference. Programmes and training events are also listed. The site provides mail order facilities to obtain teaching tapes and literature. http://www.sfbta.org

    The European Brief Therapy Association (EBTA) is a worldwide group that has provided an annual world conference since 1993. It sponsors research and publicises matters of interest to solution-focused therapists in all countries. http://www.ebta.nu

    The Swedish SIKT website provides teaching information and access to the STF-L discussion list as well as to the list archives. The STF-L list members provide a wide range of knowledge and advice. Harry Korman of Sweden is the STF-L listmaster. http://www.sikt.nu

    The Dutch speaking network of solution-focused workers, Netwerk Oplossingsgericht Werkenden, is open to interested parties. http://www.solution-focused.nl

    Fredrike Bannink is a widely experienced negotiator and international trainer. She has published several books and articles in English and Dutch. http://www.fredrikebannink.com

    Coert Visser at the Solutions Centre in Amsterdam works mainly in management consultancy; however, he provides many resources through his website. http://www.solutions-centre.org

    The SOLWorld organisation for solution-focused approaches to organisations began in the UK. There is a discussion list for members. Their website provides details of their annual world conference and their Summer University. http://www.solworld.org

    The Association for the Quality Development of Solution Focused Consulting and Training has close links with SOLWorld. Their German-based group review solution-focused work and approve it when the criteria are met. http://www.asfct.org

    Mark McKergow and Jenny Clarke use a solution-focused approach with organisations. The Centre for Solutions Focus at Work website provides information on the foundations of their work and training events along with an interesting collection of articles, tips and examples. http://www.sfwork.com

    Paul Jackson and Janine Waldman at The Solutions Focus provide workplace training in solution-focused approaches. http://www.thesolutionsfocus.co.uk

    The United Kingdom Association for Solution Focused Practice (UKASFP) was founded in 2003. There is an annual UK conference and the Association maintains a directory of members. There is a discussion list on the Internet for members and a website. The UKASFP publishes an online newsletter Solution News, which attracts a substantial readership from outside the UK. http://www.ukasfp.co.uk, http://www.solution-news.co.uk

    Bill O'Connell established the former four-year MA course in solution-focused therapy at the University of Birmingham. He has also written a number of influential textbooks. His training and supervision agency Focus on Solutions' website provides details of available courses. http://www.focusonsolutions.co.uk

    BRIEF is the largest solution-focused training agency in the UK. It provides a full range of trainings in solution-focused brief therapy ranging from one-day introductory courses to a one-year Diploma course. http://www.brieftherapy.org.uk

    Brief Therapy North East (BTNE) is an influential group of practitioners and learners within the North-east of England. They arrange study days and international presenters every year. They have close links with Andrew Turnell and the ‘Signs of Safety’ approach. http://www.btne.org

    The website of John Wheeler, one of the founding members of BTNE. John's site includes a list of his publications, some of which will be downloadable in the near future, along with details of the solution-focused training, supervision and consultation he offers. http://www.johnwheeler.co.uk

    The website for Ioan Rees et al. provides information on training events and workshops, mostly in Wales, conducted by their company Sycol Ltd. http://www.sycol.org

    Yorkshire Solution Focused Brief Therapy Group is a professional interest group whose aim is to assist in the spreading of SFT skills as widely as possible around the Yorkshire region. http://www.yorkshiresolutions.org.uk

    Professor Wally Gingerich was an early member of the Brief Family Therapy Center in Milwaukee. His homepage offers useful links and research reviews. http://www.gingerich.net

    Michael Durrant was one of the original exponents of solution-focused brief therapy within education in Australia. The website of the Brief Therapy Institute of Sydney is an outstanding source of useful links. http://www.briefsolutions.com.au

    Professor Ron Warner was instrumental in the development of solution-focused practice in Canada. The Canadian Council of Professional Certification offers recognition to courses and therapists from Canada and other countries. http://home.oise.utoronto.ca/~rewarner/www.ccpcprofessionals.com

    The Brief & Narrative Therapy Network (BNTN) is a Canadian network for solution-focused practitioners. This ever-growing website includes a useful collection of articles and interviews. http://www.brieftherapynetwork.com

    The Institute for Therapeutic Change in Chicago is one of the leaders in the ‘Common Factors’ movement in psychotherapy. Solution-focused practice is one of the key elements in their development and the Heart & Soul of Change Project website offers useful information to the interested practitioner. Research tools, an American-based discussion list and book sales are accessible through the site. http://heartandsoulofchange.com/

    Ben Furman and Tapani Ahola's Helsinki Brief Therapy Institute website illustrates the various adaptations of ‘solution talk’ and ‘reteaming’. Child workers will find Ben's ‘Kids’ Skills' to be of particular relevance, along with ‘THE STEPS OF RESPONSIBILITY: How to Deal with the Wrongdoings of Children and Adolescents in a Way That Builds Their Sense of Responsibility’. http://www.benfurman.com, http://www.kidsskills.org

    Bill O'Hanlon's website explains his particular slant on solution-focused work and includes a section with various handouts and lists. http://www.billohanlon.com

    In Poland, Tomasz Switek has contributed to the solution-focused world by producing his Deck of Trumps, which can be found on this website. The site also includes research into the personal impact of becoming a solution-focused practitioner. http://www.centrumpsr.eu

    Appendix II Hyperventilation: A Curable Cause for ‘Anxiety’ Symptoms

    (Macdonald, A.J., Journal of Primary Care Mental Health and Education, 2004, 7: 105–8. Reproduced with permission)

    Abstract

    Hyperventilation has been recognised as a cause of anxiety-like symptoms for many years. The diagnosis can easily be made in the consulting room but is often missed. Such patients benefit from breathing exercises but not from psychological or pharmacological treatments. If untreated these symptoms are a cause of much distress and lead to increased demands on the general practitioner. Hyperventilation can be a factor in the onset of many common physical disorders. Advice on diagnosis and treatment is included, with a handout of breathing techniques for patient use.

    Introduction

    Walton1 asks if anxiety symptoms will overwhelm the NHS. In 1979 a senior colleague introduced us to the idea of hyperventilation as a cause of unexplained ‘anxiety’ symptoms. This placed my medical training in competition with the teaching which I received as a psychotherapist, in which all ‘neurotic’ phenomena were ascribed to hidden unconscious motives.

    Medical textbooks2 and psychiatric textbooks3 describe hyperventilation as a feature of ‘panic disorder’. However, in some patients hyperventilation may itself be the cause of the panic and may respond to direct management. Lum4 gives an account of the physiology of hyperventilation and of the historical background to its association with anxiety.

    Physiology

    Hyperventilation lowers pCO2 thus producing a variety of physical changes. These can include dizziness, being lightheaded, feeling faint; headaches; tension in the head; trouble thinking clearly; being easily tired; ringing in the ears; blurred vision; dry mouth; ‘a lump in the throat’; sweating; shortness of breath; tachycardia; palpitations; vague chest pain; shaking hands; numbness or tingling of the hands, feet or face; aches and pains in the limbs; apprehension, tension, agitation. Rarely carpo-pedal spasm will occur. Many of these frightening physical changes mimic those produced by epinephrine release and by other states of heightened emotional arousal.

    The condition is easily diagnosed in the acute episode and a history of overbreathing is often available from the patient or onlookers. However, it is less recognised that chronic hyperventilation can also occur, producing similar symptoms in a more insidious way.

    Respiratory rate is controlled mainly by pCO2 with pO2 as a secondary driver. Those who habitually overbreathe maintain their pCO2 at a lower level than is usual. A small increase in respiration lowers pCO2 rapidly, and recovery to a stable level is delayed. Infusions of sodium lactate or inhalation of carbon dioxide produce panic symptoms, which has been taken as evidence of a biological sensitivity in those with panic disorder. However, these interventions also increase respiratory rate in those with low pCO2 so that their sensitivity may have been acquired through habitual overbreathing rather than being an inherited characteristic. A low venous phosphate level is identified by Klein5 as being both a sign of chronic hyperventilation and a powerful predictor of panic attacks.

    Frequent sighing or yawning can add to the problem. If aerophagy is present then bloated stomachs, vomiting, pains in the stomach, diarrhoea, and chronic flatulence can be present.

    Clinical Features

    I expect to see at least 8–10 such patients every year. I have found the same proportion while working in several different parts of the UK. The rate does not seem to be affected by the availability or otherwise of psychological treatment services.

    Referrals are made when a clinician is puzzled by a patient who describes ‘panic attacks’ with no evident precipitant, or recurrent physical symptoms for which no physical cause can be found. The patient does not show signs of anxiety at other times. They have often been stable and competent previously. They feel out of control and ask ‘Am I going mad?’

    The disorder sometimes follows a bereavement or a major social stress. It is more common in women. One hypothesis is that pregnancy encourages thoracic breathing, which is more likely to induce excessive ventilation. Those accustomed to abdominal breathing through training in music or meditation are less likely to present with symptoms.

    The patient is often pale, with frequent sighing respirations or yawns. Speech is fast and accessory muscles of respiration may be visibly in use. Specific enquiry will reveal some of the symptoms listed above. Aerophagy may have led to bowel symptoms and sometimes a diagnosis of irritable bowel syndrome. Disturbed childhoods and features of emotional disorder are usually absent. However, you may be told that ‘my mother (or father) was just the same’.

    Diagnosis

    Measurement of arterial or capillary pCO2 is not convenient in general practice or in the psychiatric clinic. However, a voluntary provocation test is almost invariably diagnostic.

    The patient is asked to sit comfortably and to breathe deeply through the mouth for 20 breaths. They are overbreathing successfully if their pulse rises, they become pale and sweaty and their pupils dilate. Severe cases will destabilise within a few breaths and persisting to 20 breaths is unnecessary (and unpopular with the patient!). The patient is then asked to breathe slowly through the mouth until their pulse settles and their colour improves. Because reducing pCO2 produces cerebral vasoconstriction and therefore impairs cognition, you must wait until their pulse settles before asking for or giving information. They should not speak until their pulse has settled to a near-normal level.

    The test is positive if the patient recognises that the symptoms induced by the experience are similar to the early stages of their attacks. The test is both diagnosis and treatment since it demonstrates that the symptoms can be summoned and removed by voluntary actions. I tell them briefly about the effects of overbreathing, reassure them that they can learn to deal with their symptoms and give them the handout reproduced at the end of this article. (See also Clark, Salkovskis and Chalkley6.)

    A second consultation is rarely necessary. A few fail to carry out the recommended slow breathing exercises properly; asking them for a brief demonstration will clarify this. A common error is to take a long slow breath and then hold it in inspiration. If patients wish to pause in their breathing they should do so at the end of expiration, not inspiration. If there is a long history then the patient may achieve improvement but not recovery. Even if the patient also has genuine anxiety disorder, the ability to control some aspects of their symptoms is a comfort to them. Paper bag rebreathing may help with the exercises initially or can be used in acute attacks. (The NHS Medium Dressing Bag is an ideal size.) One of my patients complained that the bag was unhelpful. Asking him for a demonstration revealed that his fear of asphyxia had led him to make a large hole in the bag as a precaution, thus reducing its effectiveness.

    Physiotherapists have skills in the treatment of hyperventilation but not all departments of physiotherapy have the capacity to undertake this task. Psychological services provided by non-medical staff often fail to recognise the role of hyperventilation. As a consequence, ineffective treatments are offered, which leads to a waste of valuable resources.

    Comments

    Some patients become briefly tearful when the diagnosis is made. This may be relief at having a clear diagnosis. However, it has been proposed that overbreathing is learned in childhood as a means of suppressing negative emotions of which the child's carers disapprove. It is a common observation that a child who is rebuked briskly for crying will inhale deeply or hold their breath briefly. Bioenergetic psychoanalysis encourages healthy breathing patterns; emotional release through tears is a common part of this process.

    It has been suggested (Klein5) that hyperventilation is an oversensitive response by a biological system which exists to protect against the threat of suffocation. However, suffocation as a form of child abuse was described by Oliver7 in 1988. It has been confirmed by many other workers since. So a fear of suffocation may be acquired rather than inherited.

    Hyperventilation leading to vasoconstriction may be the final common pathway in migraine attacks, transient ischaemic episodes, epileptic fits and cardiac ischaemia. Asthmatic episodes may also be triggered by hyperventilation. Perhaps the characters in nineteenth century novels who have an apoplexy on receiving bad news are experiencing the effects of hyperventilation induced by emotion?

    In sports medicine some fit and highly motivated individuals overbreathe before competitive events. This can lead to cognitive impairment and physical symptoms. Training Red Cross workers at public events to say ‘Breathe slowly’ instead of ‘Breathe deeply’ would make a useful difference. Many of the benefits of relaxation training and meditation may be due to the slow breathing component rather than the other aspects.

    Smokers who overbreathe often report transient improvement on lighting a cigarette, possibly because of the high carbon dioxide level in the inhaled smoke. Chronic hyperventilators who smoke can be recognised in public areas because they inhale the first puff very deeply. Their metabolism readjusts after a few minutes of smoke-laden air and symptoms may reappear.

    Diazepam reduces respiratory rate and initially may relieve symptoms due to hyperventilation. However, tolerance to the effect soon develops, followed by requests for dose increases. Beta-blockers relieve some of the symptoms but most patients do not find this enough. Fatigue induced by beta-blockers is common and can make matters worse. Certain antidepressants have been recommended for panic disorder. Naturally, research by pharmaceutical companies has focused on presumed biological mechanisms rather than on psychological features.

    Conclusion

    Symptoms provoked by hyperventilation are common in general and psychiatric practice. They are a cause of much distress and contribute to a variety of general medical conditions. These symptoms are easy to identify. They are straightforward and cheap to treat, with a consequent saving of time and resources. This is satisfying for the busy practitioner.

    References
    1. Walton, I.Will anxiety be the downfall of the NHS?Journal of Primary Care Mental Health2003; 7: 26–28.
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    6. Clark, D.M., Salkovskis, P.M., Chalkley, A.J.Respiratory control as a treatment for ‘panic attacks’. Journal of Behaviour Therapy and Experimental Psychiatry1985; 16: 23–30. http://dx.doi.org/10.1016/0005-7916%2885%2990026-6
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    Overbreathing

    Overbreathing (medical name ‘hyperventilation’) means a habit of breathing incorrectly and excessively. It can result from emotional stress and can cause tension or anxiety. Overbreathing upsets the chemistry of the body and can lead to many physical and emotional symptoms. Frequent sighing, yawning or swallowing air can add to the problem.

    Symptoms

    Dizziness, lightheaded, feeling faint; headaches; tension in your head; being easily tired; ringing in the ears; blurred vision; dry mouth; hard to swallow; sweating; shortness of breath; heart beating faster; palpitations; shaking hands; numbness or tingling of hands, feet or face; aches and pains in your limbs; bloated stomach; nausea; diarrhoea; passing wind up or down; apprehension; tension; agitation.

    You can learn better breathing habits which will reduce many of these symptoms. However, it is not always easy to change habits and it may take some time. The actions outlined below have been useful to other people with this problem.

    Treatment

    Step 1 Breathe as slowly as you can using your stomach and not your chest. If possible, breathe only through your nose; in while counting 5 to yourself and then out while counting 5 to yourself.

    Step 2 Sit or lie in a quiet place where you will not be interrupted and breathe like this for 5 minutes several times a day. Most people find this uncomfortable at first until the body is used to it.

    Step 3 When you can do this easily then lengthen the time spent each day. Start to practise slow breathing when sitting quietly, for example watching TV or on a bus. Practise by speaking more slowly or by reading out loud.

    Step 4 Eventually you will be able to breathe slowly all the time unless upset or frightened by something. Prepare for such times by breathing slowly beforehand and afterwards.

    Interrupted Breathing

    Try taking a breath, then hold your nose with your mouth closed and push your breath as if you are trying to breathe out or are ‘popping’ your ears. Delaying your breathing in this way will calm your heart and your breathing within a few moments.

    Rebreathing

    If you find it difficult to start the above exercises or if you cannot control your breathing in certain situations, hold a paper bag (big enough for a loaf of bread) over your mouth and nose. Breathe as deeply as you like but only breathe the air inside the bag. You will begin to feel better after a few minutes of this. (It is not safe to use a plastic bag!)

    Sighing, Yawning or Swallowing Air

    If you become aware of any of these habits try to take a single ordinary breath instead or hold your breath for five seconds.

    Relaxation, yoga, tai chi or meditation may also help you to slow your breathing.

    (Thanks to Helene Dellucci of Lyon for advice)

    Dr A.J. Macdonald – 2010

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