As physicians shift care from a disease-centered to a patient-centered clinical method, there is a need for a compatible counseling paradigm. Solution-focused therapy is a competency-based model that minimizes emphasis on past problems and failings and instead focuses on patient strengths and resources. The solution-focused approach often results in briefer lengths of treatment and thus is an essential skill for physicians, and in particular for psychiatrists, whose services are in short supply and high demand.
A solution-focused conversation begins with problem-free talk inviting patients to discuss parts of their life that are going well, the strengths and talents that contributed to this, the people they most appreciate in their life, and what they most appreciate about them. These people are critical relationship resources through which patients develop their solutions.
Compliments are used frequently and function to support what is working well in the patient’s life, thereby setting up the expectation for future success. Direct compliments such as “Wow!” candidly praise patients on something they have said or done. Indirect compliments such as “How did you do that?” are in the form of a question and allow patients to describe their own successes.
Diagnosing and amplifying positive differences, also known as exceptions, are other tools used in the solution-focused approach. Paying attention to times that patients are doing things differently, in a positive way when the problem did not occur or was less severe, are called positive differences or exceptions. These positive differences require the closest attention and signify solutions already occurring within the patient’s experience. For example, pausing the conversation when a patient identifies a time when he or she was sober, felt happier, or got along better with a spouse by asking “Was this different?” “How was it different?” “Was it helpful?” “How was it helpful?” and “How did they do it?” will amplify the patient’s success.
Solution-focused scaling questions ask patients to rate their goals, satisfaction, coping strategies, successes, motivation for change, and confidence on a numerical scale from 1 to 10. They help to formulate goals and measure myriad patient issues from a multitude of perspectives. They are constructed in such a way that the number 10 highlights a positive aspect such as satisfaction that their problem is solved. The use of scales can further amplify a patient’s success by asking what makes the number not lower. Asking patients what it would take to raise the number by one point helps formulate realistic small next steps toward achieving their goals.
The miracle question is a unique solution-focused question that helps patients construct a vision of their future. The following is a description of the miracle question. “Suppose that tonight after you have done your usual things and have fallen asleep, a miracle happens. The miracle is that the problems that brought you here are solved, but because you were sleeping, you didn’t know that it happened. When you wake up in the morning, what do you suppose would be the first thing you would notice that would tell you a miracle has happened and the problems that brought you here are solved?”
This question transforms the patient’s attention from the presenting problem to a problem that is solved. It enables patients the freedom to think beyond the problems that seem insurmountable and allows them to identify resources that they may not remember or recognize when their minds are clouded by the problem.
Consider the following case and what solution-focused questions you might ask:
Maria is a 65-year-old Hispanic woman diagnosed with diabetes mellitus, cardiovascular disease, hypertension, and depression. She is on a “boatload” of medications including insulin, multiple heart medications, and sertraline for depression. She is morbidly obese and interested in weight-reduction surgery but cannot get her diabetes under enough control to be a surgical candidate. The surgeons told her that her hemoglobin A1C would have to be at 7 for her to be a surgical candidate. She brought it from 14.9 to 8.5, but was told that this was not good enough. She likes to take drug holidays from all her medications.
Here are some possible questions: Managing all these medications must be very challenging; how have you been able to do this? How else have you managed? There must be a “good reason” for you to take drug holidays? Is it different for you to be interested in weight reduction? How did you come to this decision? What have you tried so far to reduce your weight that has worked for you? You managed to get your HgBA1C down from 14.9 to 8.5; how did you do this? Supposing 10 reflects that you are confident that you will be able to get the surgery, and 1 the opposite, where would you say things are now? What makes it not lower? What would it take to raise it by one point?
Solution-focused therapy is a brief therapy model that is uniquely adapted and easily integrated into patient-centered clinical care. Its language is both hopeful and optimistic. Solution-focused therapy puts ownership of patients’ health back into their hands, reminding them of the control, authority, and responsibility they have over their lives. This feels good to patients and physicians alike.