Term Paper: Managed Care Solution Focused Therapies

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Managed Care, Solution-Focused Therapies

Some of the most important changes that have taken place in therapy over the last 10 to 15 years, is movement from ecosystemic to solution-focused brief therapy has occurred. The former approach builds on themes in Milton Erickson's (Erickson, Rossi, & Rossi, 1976) uncommon therapy and the systems approach of the Mental Research Institute (Watzlawick, Weakland, & Fisch, 1974). It emphasizes how clients' lives and troubles are embedded in social systems that must be changed if the troubles are to be remedied. Solution-focused therapy, on the other hand, is a radically constructivist approach to personal troubles which emphasizes how troubles and solutions are socially constructed realities. Central to this process is clients and therapists' use of language to create troubled and untroubled lives. That is, clients use language to portray their lives as dominated by troubles, and act in ways that affirm their portrayals. Solution-focused therapists' major responsibility, then, is to help their clients literally talk themselves out of their troubles by encouraging them to describe their lives in new ways (Miller, 1997).

Kingsbury (1997) stated that solution-focused treatment begins from the observation that most psychological problems are present only intermittently. People with panic disorder obviously do not spend every minute of every day in a panic; even depression fluctuates in severity. Solution-focused therapy tries to help the patient notice when symptoms are diminished or absent and use this knowledge as a foundation for recovery. If a patient insists that the symptoms are constant and unrelieved, the therapist works with him or her to find exceptions and make the exceptions more frequent, predictable, and controllable. In other words, therapy builds on working solutions already available to the patient. As a corollary, the therapeutic dialogue is often deliberately diverted from a discussion of the problems themselves.

Solution-focused therapy has an emphasis on competence and strength, solution focused therapy tends to overlook gender and power differences (Dermer, Hemesath, & Russell, 1998, p. 239). Issues such as domestic violence work with sexual abuse survivors, and gender issues are addressed in solution focused therapy along with other important topics.

Ecosystemic therapists assume that the troubles that bring clients to therapy are the result of clients and others in their social systems having become "stuck." They are temporarily unable to adapt to ongoing changes in their environments. One indicator that clients are stuck is their primary focus on the troubled aspects of their lives. This focus makes it impossible for them to interpret their lives in positive ways. Thus, a major responsibility of ecosystemic therapists is to help their clients use their already developed skills at managing their lives to get "unstuck." Small changes that disrupt clients' existing trouble-focused patterns of action, thought, and/or relationships are often sufficient to achieve this goal (Miller, 1997).

Dermer et al. (1998) reported that solution based therapy represents a systematic, strengths-based, collaborative approach to supporting individuals, couples and families. Since systems are interrelated, change in one-domain influences connected domains. Therefore, the slightest change may lead to a considerable difference. There are a few assumptions that the theory is based on. Change is constant, emphasis on solutions, positives, and possibilities facilitate change. There is always an exception to the problem, families are competent and are experts in their choices of goals, and solutions, solutions evolve through conversation (social reality is co-created through language). There is no right way to view things, because different views may be equally valid and fit the facts equally well; and one need not know a lot about a problem in order to solve it (Dermer et al., p.240).

Becoming solution-focused involves entering a new discourse that provides brief therapists with new assumptions about social reality and therapeutic relationships, new practical concerns about therapeutic processes and therapists' responsibilities within them, and new strategies for constructing change in clients' lives. Thus, while traces of the ecosystemic approach are still evident in solution-focused therapy, the significance of these apparent continuities is different in solution-focused therapy. For example, solution-focused discourse involves a reflexive orientation that is not associated with the practice of ecosystemic therapy. Therapists adopt a reflexive orientation by treating their interactions with clients as sites for self-consciously constructing social realities, not just for describing them. Indeed, from a reflexive standpoint, the descriptions are themselves reality-creating activities (Miller, 1997).

A standard solution-focused interview would consist of the following: asking about the problem, setting goals (miracle question), exploring what happens when the problem does not exist (exception questions), and determining where they stand currently in regard to the problem as well as what action they think would represent a small change that might show some progress (scaling questions). Occasionally a team member may call the therapist and ask a question or observe that the therapist might have missed. Finally, the therapist asks the family whether there is anything that was left out of the interview that would be important for a better understanding of their situation. Then the team and couple (along with the therapist) exchange positions in relation to the mirror (Johnson, Waters, Webster, & Goldman, 1997).

Miller (1997) reported that scaling questions are the "back-bone" of solution-focused therapy because they are frequently asked, and solution-focused therapists use them to achieve a variety of therapeutic ends. Scaling questions may be used to elicit information about whether clients believe their lives are getting better or worse. Scaling questions are also helpful in constructing exceptions. For example, when clients rate other times of their lives as less troublesome than in the present, the rating provides a justification for therapists to ask about the details of the previous times and how clients were able to manage their troubles better then.

Solution-focused therapists subscribe to circular causality while simultaneously subscribing to the idea of personal responsibility. Clients are encouraged to concentrate on their own behavior, and everyone in the therapeutic system, including the therapist, is held responsible for change (Dermer et al., 1998).

In solution-focused therapy, the therapists ask the person to focus on his or her own behavior instead of blaming problems on other people. Solution focused therapists do not believe the concept of blame to be useful or necessary. Therapist think that being bogged down in questions blame keeps people stuck in their problems instead of promoting change. Solution focused perspective recognizes that nonproductive blaming is not therapeutic and shines its light on accepting responsibility (Dermer et al., 1998).

Dermer et al. (1998) reported that solution -focused therapists have been said to take a pluralist perspective when they identify the goals of each person and encourage him or her to share his or her needs and wants. This style of therapy focuses on the needs and wants of all parties involved no matter how unrealistic it may seem.

Juhnke (1996) remarked that the solution-focused approach emphasizes competence, strengths, and possibilities rather than deficits, weaknesses, and limitations (de Shazer, 1991; Huber & Backlund, 1991; Littrell, Malia, & Vanderwood, 1995; Murphy, 1994; O'Hanlon & Weiner-Davis. 1989). Counselors using a solution-focused approach respect a client's abilities and encourage the use of existing personal resources to bring about change (O'Hanlon & Weiner-Davis, 1989). An expectation of successful resolution to presenting concerns is fostered within this approach, and significant emphasis is placed on a client's potential to bring about change (Bubenzer & West, 1993; O'Hanlon & Weiner-Davis, 1989). The no pathological underpinnings of the solution-focused approach match well with professional counseling's philosophical premise of focusing and building on client strengths (Brooks & Gerstein, 1990). Both view individuals as healthy and as possessing an ability to address challenges (Brooks & Gerstein, 1990; de Shazer, 1991; O'Hanlon & Weiner-Davis, 1989; Vacc & Loesch, 1994).

Quick (1998) stated that therapists who practice strategic solution focused therapy often discover that they are emphasizing different components of the model in different clinical situations. This raises the question of how the therapist: decides what to emphasize and when to shift the focus. Some general guidelines can assist the therapist: in deciding 'when to do what'.

The model's overarching philosophy of 'doing what works and changing what doesn't' applies not just to the client but also to the therapist as he or she proceeds with the work. When a technique or emphasis on a particular component of the model appears to be helpful, the therapist may well choose to continue it; when a certain kind of inquiry does not appear to be helpful, the therapist should probably 'do something different'. The therapist must remain flexible; speaking in a way the client is most likely to 'hear' (Quick, 1998).

Solution-focused therapists take a neutral stance in therapy. Choosing sides is in essence causing resistance. Therapists are supposed to refrain from putting their personal views on any of the clients in therapy (Dermer et al., 1998). As beneficial as the solution-focused reflecting team is to clients, it has proven to be equally advantageous for the therapists participating in the process. The process requires that team members increase their focus on what is going on in the therapy room. There is… [END OF PREVIEW]

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