Tag Archives: Psychotherapy

Is Solution-Focused Therapy as Powerfully Effective as Solution-Focused Therapists Would Have Us Believe?

[This Blog is adapted from a previous blog posted on psychotherapy.net]

Solution-focused therapy is very popular. But is it effective?

Beginning in the 1980s, solution-focused therapy hit the mainstream and many mental health providers (and third-party payers) continue to sing the praises of its brevity and effectiveness. For example, in a 2009 book chapter Sara Smock claimed, “. . . there are numerous studies, several reviews of the research, and a few meta-analyses completed that showcase [solution-focused therapy’s] effectiveness.”

Really?

Solution-focused counseling and psychotherapy has deep roots in post-modern constructive theory. As Michael Hoyt once famously articulated, this perspective is based on “the construction that we are constructive.” In other words, solution-focused therapists believe clients and therapists build their own realities.

Ever since 2003, my personal construction of reality has been laced with skepticism. That was the year President George W. Bush included 63 references to “weapons of mass destruction” in his State of the Union address (I’m estimating here, using my own particular spin, but that’s the nature of a constructive perspective). As it turned out, there were no weapons of mass destruction, but President Bush’s “If I say it enough, it will become reality” message had a powerful effect on public perception.

From the constructive or solution-focused perspective, perception IS reality. Remember that. It applies to the solution-focused therapist’s view of solution-focused therapy effectiveness.

I recall hearing many presenters tell me that solution-focused therapy is powerful and effective. Or maybe it was powerfully effective. And I recall reading books and articles that similarly referred to the power and effectiveness of solution-focused therapy. Now we could just take their word for it, but I still can’t help but wonder: “What does the scientific research say about the efficacy of solution-focused therapy anyway?”

Here’s a quick historical tour of scientific reality.

  • In 1996, Scott Miller and colleagues noted: “In spite of having been around for ten years, no well-controlled, scientifically sound outcome studies on solution-focused therapy have ever been conducted or published in any peer-reviewed professional journal.”
  • In 2000, Gingerich & Eisengart identified 15 studies and after analyzing the research, they stated: “. . . we cannot conclude that [solution-focused brief therapy] has been shown to be efficacious.”
  • In 2008, Johnny Kim reported on 22 solution-focused outcomes studies. He noted that the only studies to show statistical significance were 12 studies focusing on internalizing disorders. Kim reported an effect size of d = .26 for these 12 studies [this is a rather small effect size].
  • In 2009, Jacqueline Corcoran and Vijayan Pillai concluded: “. . . practitioners should understand there is not a strong evidence basis for solution-focused therapy at this point in time.”

Now don’t get me wrong. As a mental health professional and professor, I believe solution-focused techniques and approaches can be very helpful . . . sometimes. However, my scientific training stops me from claiming that solution-focused approaches are highly effective. Although solution-focused techniques can be useful, psychotherapy often requires long term work that focuses not only on strengths, but problems as well.

So what’s the bottom line?

While in a heated argument with an umpire, Yogi Berra once said: “I wouldn’t have seen it if I hadn’t believed it!” This is, of course, an apt description of the powerful confirmation bias that affects everyone. We can’t help but look for evidence to support our pre-existing beliefs . . . which is one of the reasons why even modernist scientific research can’t always be trusted.  But this is why we bother doing the research. We need to step back from our constructed and enthusiastic realities and try to see things as objectively as possible, recognizing that absolute objectivity is impossible.

Despite strong beliefs to the contrary, there were no weapons of mass destruction. And currently, the evidence indicates that solution-focused therapy is NOT powerfully effective.

 

John Dreams About Counseling and Psychotherapy Theories

One morning, long ago, John woke up in the midst of a dream about having written a theories book. Over breakfast, John shared his dream with Rita. Rita said, “John go sit down, relax, and I’ll sit behind you as you free associate to the dream” (see Chapter 2, Psychoanalytic Approaches).

As John was free-associating, Rita tried to gently share her perspective using a two-person, relational psychotherapy model. She noted it had been her lived experience that, in fact, they had already written a theories text together and that he must have been dreaming of a 2nd edition. John jumped out of his seat and shouted, “You’re right! I AM dreaming about a 2nd edition.”

This profound insight led to further therapeutic exploration. Rita had John look at the purpose of his dream (see Chapter 3, Individual Psychology); then he acted out the dream, playing the role of each object and character (see Chapter 6; Gestalt therapy). When he acted out the role of Rita, he became exceedingly enthusiastic about the 2nd edition. She, of course, accused him of projection while he suggested that perhaps he had absorbed her thoughts in a psychic process related to Jung’s idea of the collective unconscious. Rita noted that was a possibility, but then suggested we leave Jung and the collective unconscious online where it belongs (see the Jungian chapter in the big contemporary collective unconscious of the internet online at ** ).

For the next week, Rita listened to and resonated with John as he talked about the 2nd edition. She provided an environment characterized by congruence, unconditional positive regard, and empathic understanding (see Chapter 5, Person-Centered approaches). John flourished in that environment, but sneakily decided to play a little behavioral trick on Rita. Every time she mentioned the word theories he would say “Yesss!,” pat her affectionately on the shoulder and offer her a piece of dark chocolate (see Chapter 7, Behavior therapy). Later he took a big risk and allowed a little cognition into the scenario, asking her: “Hey, what are you thinking?” (see Chapter 8, Cognitive-behavioral therapy).

Rita WAS still thinking it was too much work and not enough play. John responded by offering to update his feminist views and involvement if she would only reconsider (see Chapter 10, Feminist therapy); he also emphasized to Rita that writing a second edition would help them discover more meaning in life and perhaps they would experience the splendor of awe (see Chapter 4, Existential therapy). Rita still seemed ambivalent and so John asked himself the four questions of choice theory (see Chapter 9, Choice theory and reality therapy):

  1. What do you want?
  2. What are you doing?
  3. Is it working?
  4. Should you make a new plan?

It was time for a new plan, which led John to develop a new narrative (see Chapter 11, Narrative therapy).  He had a sparkling moment where he brought in and articulated many different minority voices whose discourse had been neglected (see Chapter 13; Multicultural therapy). He also got his daughters to support him and conducted a short family intervention (see Chapter 12, Family systems therapy).

Something in the mix seemed to work: Rita came to him and said . . . “I’ve got the solution, we need to do something different while we’re doing something the same and approach this whole thing with a new attitude of mindful acceptance” (see Chapter 11, Solution-focused therapy and Chapter 14, Integrational approaches). To this John responded with his own version of radical acceptance saying: “That’s a perfect idea and you know, I think it will get even better over a nice dinner.” It was at that nice dinner that they began to articulate their main goals for the second edition of Counseling and Psychotherapy Theories in Context and Practice.

The Efficacy of Solution-Focused Therapy

The Efficacy of Solution-Focused Therapy

For years I’ve wondered about what the research says about the efficacy of solution-focused therapy. While revising our theories text, I reviewed some of the literature. If you’re interested, I published a short blog about it on psychotherapy.net. Check it out. http://www.psychotherapy.net/blog/title/the-miraculous-or-not-efficacy-of-solution-focused-therapy

Reflections on Listening to Irvin Yalom at the ACA Conference

After a few hectic and overstimulating days at the ACA World Conference in San Francisco, I’ve now secured the back table at a Starbucks in Vancouver, WA for brief written reflection. This reflection weaves quotations (and paraphrases) from the great Irvin Yalom into my own personal conference experiences.

My formal conference highlight was watching and listening as NPR’s Craig Windham interviewed Yalom onstage for the keynote. After listening to Yalom’s keynote six years ago, I think the interview format was an ingenious method for capturing a more personal glimpse into Yalom and his writing than a stand and deliver keynote speech.

I especially enjoyed listening to Yalom reflect on his early years. Two statements stand out:

On his career decision-making as a child of Russian immigrants: “We had two choices: We could become a doctor or a failure.”

On his unparalleled greatness within the field of group psychotherapy: “My wife thinks it’s rather ironic that I became an expert in group psychotherapy, because I’m really quite uncomfortable in groups.”

Early in his “speech” Yalom emphasized the importance of counselors to the field of psychotherapy. In several ways he made curiously stimulating statements emphasizing (I’m paraphrasing now) that counselors are the future of psychotherapy. As a hybrid counselor and psychologist, I wonder if he would have made the same statements had he been keynoting at the annual American Psychological Association meeting.

My reactions to Yalom’s claim about counselors being the future of psychotherapy are free-ranging like the chickens in our backyard, but here are two:

Yes, I think counselors will be the future of psychotherapy, but only if we’re able to stop getting in our own way . . . And psychologists will undoubtedly be the future of measuring psychotherapy efficacy . . . if they (or we) can manage to focus on issues more meaningful than pharmacology and neuroscience.

For those curious about where Yalom finds his writing inspiration, in response to Windham’s questioning, he disclosed that as a Californian he has mastered the evening hot tub experience. Subsequently, he’s able to write most productively in the morning about “what I’ve learned in the hot tub.” I suspect there’s a bit more to it than that . . . but for those of us aspiring toward more writing greatness it makes for a solid rationale for nightly inspirational hot-tubbing.

On the popularity of his Group Psychotherapy text, Yalom stated: “I suspect it’s because of the stories in the book that I smuggled in . . .”

On his personal experience of fame (keep in mind that about 4K of us had to line up like rock concert fans to see him), he shared his own sort of dissociated imposter feelings:

“There’s a part of this that is very unreal. I don’t have any foundation. My parents were uneducated. They had very little schooling. I don’t have any foundation behind me. It’s a little shaky for me. I compare it to a lily growing in a swamp. There’s no foundation underneath. No matter how successful I am, I question . . . is this really me. Am I really successful?”

As an existential psychotherapist, it’s not surprising that Yalom believes deeply in helping clients pursue meaning. This is where it gets personal for all of us. He said, “Cancer cures psychoneurosis” and that “Life cannot be postponed.” Over the years he has helped many clients focus on their regrets—which often translate into moments when they weren’t able to face life and life fully in the moment. But we shouldn’t mistake Yalom’s live-in-the-moment philosophy for old-fashioned California hot-tub hedonism.  Yalom’s version of living in the moment is at once emotional AND intellectual; it is inspirational AND intentional.

Yalom also said that “Storytelling . . . may be the very best way I can teach.” Lucky for me I’ve gathered a few teaching stories over the years. Sometimes a combination of reality and my own constructive fiction, at this ACA I had a chance to share many stories. First, in a six hour pre-conference Learning Institute on Wednesday attended by 32 fabulous counselors, and later in an ACA-sponsored Friday session on Connecting and Working Effectively with Challenging Youth attended by about 200. In terms of reaping my own share of attention and praise, this was perhaps my best ACA conference ever.

But then Sunday morning comes. And when I awaken, what grand thoughts trickle into my consciousness? Do I think of the 25 people who lined up to have me sign copies of “Tough Kids, Cool Counseling?” Do I lie on the floor of my high-school educated parents home—where I’ve stopped for a short visit—feeling smug satisfaction about the glory I felt when Craig Windham of NPR fame also stood in line to have me sign a book FOR HIM. Do I reflect on the sweet and ego-boosting comments he shared with me about my work?

Nope. Nothing so grand knocks on the door of my early morning awareness. Instead, I’m transported back to a moment when, immediately after speaking to 200 conference attendees and spontaneously signing a couple books and receiving repeated praise from participants, a bold young woman approached me. She had attended BOTH my six hour workshop AND my 90 minute talk . . . and so forgive me my anticipation of praise as I looked into her eyes. But instead, she tells me that she’s not sure she learned anything from the six hour workshop. My well-practiced response is to welcome the criticism, while fending off disappointment and defensiveness. I feel precariously situated on my own lily pad. She goes on to explain that she’d “accidentally” gotten stuck in the 90 minute presentation and that based on what I’d talked about in there she thought I’d want the constructive feedback. “Of course I do,” I say . . . “Of course I do . . . and thank you very much for that.”

This is the stinging mantra to which I awaken this lovely and cloudy Sunday morning. A mantra of self-doubt . . . of possible regret . . . of wondering what I did wrong . . . of how I might improve myself.

Which brings me back to one of my favorite Yalom quotations (from his Group Psychotherapy text) about universality:

“During my own 600-hour analysis I had a striking personal encounter with the therapeutic factor of universality . . . I was very much troubled by the fact that, despite my strong positive sentiments, I was beset with death wishes for [my mother], as I stood to inherit part of her estate. My analyst responded simply, “That seems to be the way we’re built.” That artless statement offered not only offered considerable relief but enabled me to explore my ambivalence in great depth.” (p. 7)

Thank you Dr. Yalom for helping me and many others more deeply understand ambivalence, regret, self-doubt, personal meaning, death, and many of the other interesting ways the human psyche is built. And thank you, bold young woman, for providing me with hot-tub-free grist for my morning therapeutic writing mill.